Exposing the Loopholes! How Moda Health and Other Health Plans Exploit Regulatory Gaps
Reports and Evidence of Fraud and Antitrust Violations in Mental and Behavioral Health Contracting by Health Plans which Involve Commercial and Taxpayer Dollars have No Risk of Consequence in Oregon.
A Discussion Document
The healthcare industry is (at least in theory) built on values of trust, fairness, and accountability. However, in practice, health plans operate within systems which allow them to commit fraud, manipulate markets, and violate antitrust laws with small risk of significant consequences. Such unchecked power threatens the public, professionals who provide care and successful development of a value-based care system Oregon has committed to create.
Governor Kotek, Oregon’s Legislature, and the Oregon Health Authority are so insulated from care providers’ concerns and complaints that they cannot diffuse ticking bombs until after they explode.
Regulatory Gaps Shield Health Plans from Accountability
For more than a decade, Mentor Research Institute (MRI) has studied processes that could ensure ethical value-based payment contracting, particularly for mental and behavioral health care. Those processes would include investing substantial resources in oversight mechanisms such as outcome measurement technology, ethics point portals, and independent audits of contracts and policies.
After their request in 2019, MRI presented Moda with research papers examining the necessary breadth and depth of policies and processes required to support equitable value-based payment structures for mental and behavioral health.
In late 2022, discussions began between Moda and MRI focused on MRI’s concern related to the problematic “value-based payment” contract addendum Moda had begun offering over 125 groups of mental and behavioral providers in Oregon and other states. Those discussions continued in 2023 and into late 2024. In October, 2024, Moda terminated discussion with MRI after a meeting in which MRI asked whether Moda employs an independent auditor.
MRI came to a troubling realization months ago: Oregon health plans are shielded from meaningful accountability. Despite repeated efforts to file complaints and trigger investigations, providers have no effective legal channels in Oregon to report a health plan’s unethical or illegal behavior to any entity other than the health plan management responsible for the misconduct.
MRI did, in 2022, 2023 and 2024, submit concerns to a number of state agencies including the Oregon Department of Justice, the Department of Consumer and Business Services (DCBS), the Oregon Health Authority (OHA), and had communication with legislative offices including those of Representative Jason Kropf, Representative Rob Nosse, and the Governor’s Office. Those efforts resulted in pass-the-buck responses. Officials and agencies pointed the providers to one regulatory entity and another and another, a continuous loop, each entity asserting that the questions and challenges being made about Moda’s supposedly “value-based payment” proposition have no legal and regulatory oversight inside Oregon. This lack of oversight exposes a legislative void that prevents meaningful investigation, accountability or enforcement when a challenge is made by care providers.
Following guidance from U.S. Senator Jeff Merkley’s office, MRI submitted a well-documented complaint to the United States Office of the Inspector General (OIG) in late 2024. That complaint has been acknowledged. No action has yet been taken. In January we learned that the Inspector General for US Health and Huma Services, and much of their staff, were fired by President Trump.
In Oregon, health plans are, effectively, not accountable for unethical or illegal behavior which impacts patients, employers, purchasers, and public health.
Oregon has legislative voids and regulatory gaps which allow health plans to engage in undetected fraudulent behavior and violation of antitrust principles.
Health Plans Operate with Impunity Even After They are Clearly Exposed
Unlike employees and consumers, for whom there are established complaint mechanisms with enforceable whistleblower protections, providers are left in regulatory limbo. Health plans can effectively investigate themselves, dismissing or covering up complaints without oversight. This lack of accountability allows blatant manipulation of provider groups, forcing them into contracts with undefined or ill-defined policies, metrics, penalties, controls, and unilateral changes in performance benchmarks. Worse, providers usually lack the background and knowledge to ask the right questions and perform adequate risk analyses. This means they enter agreements based on incomplete or misleading information. If accurate information were fully available, many provider groups would likely opt out of participation.
Moda Health’s termination of contract negotiations was both a breach of good faith, and appears to be a calculated move to maintain market control and avoid scrutiny. This was bad business practice with systemic consequences. In creating their provider networks, Moda misrepresents provider availability, misleads public purchasers including the Oregon Education Benefits Board (OEBB), the Public Employee Benefits Board (PEBB), and Oregon Health Science University (OHSU) as it steers taxpayer dollars into their contracts under false pretenses. This is believed to be a reasonable conclusion.
Care Providers who file complaints with state agencies will be ignored, not because their complaints are without merit. They are ignored because contract controls that ensure there is accountability and investigative responsibility for misuse of commercial and tax payer dollars do not exist.
Legislative and Regulatory Failure
MRI has consulted with a number of attorneys and legislators. A response from the office of Representative Jason Kropf confirmed what MRI suspected: the Department of Consumer and Business Services (DCBS), Oregon’s largest regulatory and consumer protection agency, overseeing areas including insurance, banking, and financial services, does not support or protect healthcare providers raising concerns. DCBS authority is narrowly focused on consumer protection, leaving providers to rely on contract law rather than regulatory enforcement. The legislative solution suggested, expanding DCBS oversight to include provider protections, is deemed costly and politically unfeasible.
Even though nearly every health plan doing business in Oregon has entered a formal agreement, a “Compact”, to move toward value-based payment, there are no legal definitions providers can use to understand or challenge badly crafted health plan contracts or Oregon Health Authority (OHA) initiatives. Representative Rob Nosse, before the 2025 legislative session, confirmed that his committee has too many bills to manage, that he did not sufficiently understand the problem, and that he did not have necessary resources or time to address MRI’s legislative concerns and proposals.
Without standardized terms and requirements, defined by statute and statutory support, providers and purchasers will continue to be confused by contract requirements. Without standardized terms, providers inability to challenge payers’ unfair practices or to report violations will continue. Now, providers are prevented from protecting patients, insurance purchasers and public health.
Examples of terms which need legislated definitions:
Legal Clarity & Enforcement: Health plans have used terms like “medically necessary cand appropriate care” allowing the health plans to define what is appropriate. Recognizing this, the centers for Medicare and Medicaid changed the definition to "medically necessary care and reasonable care" which prevents arbitrary denials. Without better definitions, providers are unable to challenge wrongful claim rejections. Health plans continue to use old definitions because they define what is appropriate, focused on profit rather than reasonable care.
Accountability & Whistleblower Protection: Statutory definitions of "bad faith actions" can allow providers to document violations and prevent health plans from dismissing complaints as subjective.
Preventing Manipulation: Health plans shift financial risks by redefining contract terms mid-agreement. Clear definition of "plain language contracts" would prevent confusing and deceptive terms from being hidden in complex language, ensuring fair and transparent agreements.
Ethics Point Portals: If an "ethics point portal" does not have a standard definition, a health plan can establish a system that is neither independent nor secure, discouraging providers from reporting fraud or contract violations. Statutory definitions would ensure accessible, third-party oversight to protect whistleblowers and hold health plans accountable.
Without uniform definitions, health plans maintain unfair advantage. Legislators might act to codify clear terms so providers can negotiate contracts, challenge unethical practices, report violations, and protect public health.
Gaps in oversight harms providers and weakens Oregon’s transition to value-based care models. Without clarifying statutes it is impossible for care providers to negotiate fair value-based contracts or sustain ethical practices. Without legislative intervention, Oregon risks reinforcement of a system where health plans dictate terms, suppress competition, and erode care providers’ ethical autonomy.
Based on several years to experience, and thought recommendations made to Moda and other health plans, MRI drafted several legislative act, documented in the most recent Health Contracts Proposal.
Urgent Action Recommendations
It is wise to diffuse a bomb before it goes off. In Oregon, providers need to increase their awareness of ticking bombs.
Legislative Reform Must
Mandate independent oversight of health plan contracts to prevent unilateral changes and deceptive business practice.
Mandate that Health plans have readily available, trustworthy, useful, and accountable ways for providers to register contract or policy questions, or to report evidence of problems, bad faith, service delivery failures, discrimination, unethical conduct, fraud, etc.
Create comprehensive definitions and controls which will allow independent auditors to audit contracts, review provider concerns or complaints such that the auditor might reach the same or a different conclusion than health plan management.
Federal and State Antitrust Investigations
The FTC should investigate Moda Health for anticompetitive behavior, fraudulent contract practices, and market manipulation.
The Oregon Department of Justice should open a formal inquiry into health plans’ contracting practices that mislead providers and public purchasers.
Whistleblower Protections and Reporting Mechanisms
Providers should have the same legal protections as employees and consumers when reporting fraud and contract violations. If DCBS authority cannot be expanded, health care contract law might protect care providers who blow the whistle.
Establish an independent provider complaint system that bypasses health plan management and ensures external review.
Transparency in Value-Based Payment Models
Require full disclosure of contract terms, performance metrics, and financial risks before providers can be bound to agreements.
Prohibit retroactive penalties and unilateral contract modifications, which have been used to manipulate providers into financial losses.
The Costs of Inaction
Failure to hear the whistle has already harmed providers and negotiations undertaken in good faith. The moral injury of providing healthcare under the circumstances of poorly crafted value-based contracts will erode health care outcomes and undermine value-based payment initiatives. This is less important than providers' analysis and conclusion that the Moda contract has a moderate to almost certain negative impact on public health and providers. Providers are likely to be blamed when the bomb goes off.
The current system is unsustainable. If the Oregon Legislature, Governor Kotak, and the Oregon Health Authority fail to act, they will only address the crisis after more damage is done. Without intervention, health plans will continue to manipulate markets, restrict provider autonomy, and undermine the principles of ethical healthcare contracting.
Unless decisive actions are taken, corruption will expand across Oregon’s healthcare system, harming providers, patients, and public health for years to come.
References
Exposing Loopholes: How Health Plans Can Exploit Regulatory Gaps
This discussion document examines how health plans cab exploit regulatory gaps in Oregon to engage in unethical practices with minimal risk of consequences. Despite efforts by organizations like Mentor Research Institute (MRI) to promote ethical value-based payment contracting, health plans operate without substantial oversight. MRI's attempts to address these issues through state agencies and legislative offices have highlighted the lack of effective legal channels for reporting and investigating health plan misconduct. The document emphasizes the need for substantial investments in oversight mechanisms, including outcome measurement technology, ethics point portals, and independent audits, to ensure ethical value-based payment contracting.
https://www.mentorresearch.org/exposing-loopholes-how-health-plans-can-exploit-regulatory-gaps-1Moda Health's Termination of Contract Negotiations After Moda Negotiators Agreed to Ensure they Had a Certified Internal Auditor and an Ethics Point Portal
The article discusses the abrupt termination of contract negotiations by Moda Health with the Mentor Research Institute (MRI). Despite initial agreements to evaluate proposals for establishing an ethics point portal overseen by an independent auditor, Moda Health ceased discussions without clear justification. Since the State of Oregon will not investigate provider evidence and complaints regarding fraud or violations state and federal antitrust laws, this action raises concerns about Moda's commitment to ethical oversight, transparency, and good faith negotiations. The article suggests that such behavior may indicate a reluctance to implement independent auditing mechanisms, potentially to avoid external scrutiny of their contracting practices. This termination not only undermines trust between the parties involved but also highlights broader issues within healthcare contracting, where power imbalances and lack of accountability can adversely affect provider practices and patient care.
https://www.mentorresearch.org/moda-health-termination-of-contract-negotiations-with-mentor-research-instituteAllegations of Bad Faith, Fraud and Antitrust Violations by Moda Health Submitted to the Oregon Health Authority - Whistleblower Complaint
This paper discusses whistleblower allegations against Moda Health, including claims of bad faith contracting, fraud, and antitrust violations. It details how Moda allegedly uses deceptive contract terms and restrictive policies to limit competition and undermine independent practices. The article also compares these practices with legal standards to highlight potential breaches of antitrust and healthcare regulations, supporting the need for legal intervention.
https://www.mentorresearch.org/whistleblower-complaint-allegations-of-bad-faith-fraud-and-antitrust-violations-by-moda-healthAnalysis of Moda Health's Code of Conduct and Allegations of Violations - Appendix 1
The article examines discrepancies between Moda Health's publicly stated Code of Conduct and its actual contracting practices with healthcare providers. Allegations include mid-contract changes to performance metrics, retroactive penalties, and a lack of transparency in financial calculations, which contradict Moda’s commitments to fairness and integrity. These actions have led to provider mistrust and raise concerns about whether Moda Health is adhering to its own ethical standards. The article underscores the need for independent oversight and regulatory intervention to ensure accountability and fairness in Moda’s business practices.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violationsProtecting Minorities and Underserved Populations: Value-Based Contract Challenges
The article discusses the need for safeguards in value-based contracts to protect minority and underserved populations from systemic inequities. It emphasizes the importance of standardized definitions, clear language, whistleblower protections, and independent oversight to prevent exploitation and ensure transparency. Without these measures, providers serving vulnerable communities may face financial instability, limiting patient access to care. The article advocates for equitable contracting practices that promote health equity and sustainable care models.
https://www.mentorresearch.org/value-based-contracts-protecting-minorities-and-underserved-populationEmpowering Providers to Report Suspicious, Unethical, and Illegal Behaviors
The article highlights the importance of supporting healthcare providers in reporting unethical, illegal, or suspicious practices within value-based contracts and broader healthcare systems. It discusses barriers to reporting, such as fear of retaliation, lack of clear reporting channels, and contractual restrictions imposed by health plans. The article advocates for stronger whistleblower protections, independent oversight, and transparent reporting mechanisms to ensure providers can expose fraud, coercion, and unethical practices without jeopardizing their careers. Strengthening these safeguards is essential for maintaining ethical healthcare delivery and protecting both providers and patients.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviorsSuccessful and Failed Case Studies of Measurement-Based Care and Value-Based Payment Contracts: Recommended Requirements
This discussion article compares successful and failed value-based contracts in healthcare. It analyzes the key factors that contribute to each outcome, such as clear performance metrics, aligned incentives, and effective care coordination. The article highlights common pitfalls in failed contracts, including poor communication, misaligned goals, and inadequate data sharing. Lessons learned from these case studies are presented to guide the development of value-based contracts that can achieve better clinical and financial results.
https://www.mentorresearch.org/successful-and-failed-valuebased-contractsWhistleblower Protections in Oregon: Rights, Incentives, and the Role of Public and Private Funding
This discussion paper examines the varying degrees of legal safeguards and financial incentives available to whistleblowers in Oregon, contingent upon the nature of the funding involved—public or private. It highlights that individuals reporting misconduct related to public programs, such as Medicaid, Medicare, or the Oregon Health Plan, benefit from robust protections and potential financial rewards under statutes like the False Claims Act. Conversely, those disclosing issues within commercial health plans encounter more limited protections and lack financial incentives. The paper underscores the importance of consulting legal resources, including the Oregon Bureau of Labor and Industries (BOLI) or specialized attorneys, to navigate the complexities of whistleblower protections effectively, tailored to the specific funding context of the reported misconduct.
How and Why Should the Independence of Certified Internal Auditors be Ensured?
This discussion paper addresses the importance of maintaining the independence of internal auditors in health plan contracting. It explains how independent auditors can objectively evaluate compliance, detect unethical practices, and provide unbiased recommendations without external influence. The paper highlights common threats to auditor independence, such as conflicts of interest and management pressure, and offers strategies for preserving impartiality, including clear reporting structures and adherence to professional standards.
https://www.mentorresearch.org/maintaining-independence-of-internal-auditorsBreaking the Cycle of Unfunded Health Plan Mandates
The article discusses the challenges posed by health plans that impose administrative tasks on providers without offering corresponding compensation or support. This practice leads to operational inefficiencies, erodes trust between providers and payers, and hampers the effective implementation of value-based care models. The author advocates for health plans to invest in necessary infrastructure and collaborate with providers to ensure sustainable healthcare reform.
https://www.mentorresearch.org/breaking-the-cycle-of-unfunded-mandatesModa Health: Nine Actions and Their Consequences
The article examines nine specific actions taken by Moda Health in its contracting practices, highlighting the negative consequences for healthcare providers and the broader healthcare system. These actions include imposing non-negotiable contracts, utilizing ambiguous terms, retroactively altering performance metrics, and enforcing unfunded mandates. Such practices have led to increased administrative burdens, financial instability for providers, erosion of trust, and potential declines in patient care quality. The article advocates for transparent contracting, equitable risk-sharing, and independent oversight to mitigate these adverse effects and promote ethical value-based care.
https://www.mentorresearch.org/moda-health-9-actions-and-the-consequencesContract Negotiation Tactics Used by Health Plans
The article examines strategies employed by health plans during contract negotiations that can undermine mental health services by limiting providers' ability to negotiate effectively. These tactics include presenting non-negotiable, "take-it-or-leave-it" contracts; using strategic ambiguity to leave critical terms undefined; implementing contract ratcheting by progressively increasing administrative demands; maintaining network secrecy by withholding information about participating providers; and imposing unfunded mandates that require providers to absorb additional costs without reimbursement. By identifying these practices, providers can better anticipate potential risks and advocate for fairer contract terms during negotiations.
https://www.mentorresearch.org/contract-negotiation-tactics-used-by-health-plansThe Fallacy of Better, Cheaper, Faster: How Health Plans Shift Risk to Providers
The article examines how health plans promote value-based contracts under the premise of delivering better, cheaper, and faster healthcare services. In reality, these contracts often transfer significant financial and operational risks onto providers. Tactics include imposing rigid service caps, reducing payment rates, and increasing administrative burdens, all of which can lead to inadequate patient care and provider burnout. The article calls for greater transparency, fair contract terms, and regulatory oversight to ensure that health plans share financial risks equitably and invest in genuine improvements in care quality.
https://www.mentorresearch.org/the-fallacy-of-better-cheaper-faster“Solutionism” in Healthcare: Moda Health’s Contracting Approach and Consequences
The article critiques Moda Health's reliance on "solutionism" the belief that complex healthcare issues can be resolved through technical solutions without addressing underlying systemic problems. Moda's implementation of measurement-based care, incentive-based payments, and administrative streamlining is seen as superficial, failing to consider deeper issues such as unethical contracting practices, lack of transparency, and provider burnout. This approach may lead to unintended consequences, including reduced care quality and erosion of trust between providers and payers.
https://www.mentorresearch.org/solutionism-in-healthcare-moda-healths-contracting-approach-and-consequencesThe Dangers of Using an Ombudsman for Fraud and Antitrust Violations: Undermining Accountability and the Legal Process.
The paper discusses the risks of relying on ombudsmen to address cases of fraud and antitrust violations. It argues that ombudsmen may lack the authority and independence necessary to enforce accountability, potentially delaying or undermining legal actions. The discussion highlights how this approach can create conflicts of interest, allowing fraudulent practices to persist while giving a false impression of oversight. The paper advocates for stronger, independent regulatory mechanisms to handle such violations effectively.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrustContract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
This discussion paper analyzes various forms of contract gaming that can undermine the success of value-based contracts. It describes tactics such as manipulating patient risk scores, selective reporting of outcomes, and redefining performance metrics to skew results. The paper explains how these practices can distort the intended goals of value-based care, leading to mistrust and reduced effectiveness. Strategies to identify and prevent contract gaming, including stronger oversight and clearer definitions, are also discussed.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-failEthics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
This paper defines ethics point portals and outlines their benefits in health plan contracting. It explains how these portals provide a secure and confidential way for stakeholders to report unethical practices, compliance concerns, or contract violations. The paper highlights how ethics point portals promote transparency, accountability, and ethical conduct within organizations. Recommendations for implementing effective portals, including ensuring independence and accessibility, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefitsEthics-Point Portals Overseen by Independent Certified Internal Auditors (CIA): A Resource to Serve Stakeholders and the Public.
This discussion paper emphasizes the importance of having ethics point portals overseen by an independent certified internal auditor (CIA). It explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper highlights the benefits of this structure, such as increased trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for maintaining auditor independence and promoting transparent investigations are also included.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditorControls in Fee-For-Service, Alternative and Value-Based Payment Contracting.
This discussion paper defines the concept of a "control" in the context of health plan contracting and compliance. It explains how controls are mechanisms put in place to ensure that operations align with established policies, prevent unethical behavior, and detect potential issues. The paper outlines different types of controls, such as preventative, detective, and corrective controls, and discusses their role in promoting accountability and reducing risk. Strategies for implementing effective controls within contracting frameworks are also provided.
https://www.mentorresearch.org/what-is-a-controlSigns of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans.
This discussion paper outlines signs of a bad faith value-based payment contract. It describes indicators such as vague performance metrics, unilateral changes to terms, and excessive administrative requirements that disadvantage providers. The paper also highlights how these contracts can undermine trust and compromise care quality. Strategies for identifying and avoiding bad faith contracts, as well as recommendations for promoting more transparent and equitable agreements, are also discussed.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contractHigh Case-Mix Severity Must be Considered in Value-Based Contracting.
This discussion paper addresses the importance of considering high case mix severity in value-based contracting. It explains how failing to account for complex patient populations can lead to unfair performance evaluations and inadequate reimbursement for providers. The paper highlights the need for risk adjustment methods that accurately reflect patient severity to ensure that value-based contracts are equitable and do not penalize providers who treat high-risk patients. Strategies for implementing effective risk adjustment measures are also discussed.
https://www.mentorresearch.org/high-case-mix-severity-must-be-considered-n-valuebased-contractingCreating a Value-Based Payment Model: A Stepwise Approach to Success
This discussion paper outlines a structured approach to developing and implementing value-based payment (VBP) models in mental and behavioral health services, transitioning from traditional fee-for-service to performance-based contracting. The paper emphasizes the necessity of a deliberate framework to align provider incentives with patient outcomes, enhance transparency, ensure legal compliance, foster collaboration, and mitigate financial and operational risks.
Key Steps:
Establish Clear Objectives and Shared Values: Define common goals such as improving patient outcomes, enhancing care coordination, reducing costs, and maintaining access to services.
Develop Transparent Contracts: Craft agreements in plain language, clearly outlining service scope, performance benchmarks, risk-sharing mechanisms, and quality assurance protocols to prevent misunderstandings and disputes.
Define Measurement and Performance Metrics: Implement measurement-based care with key performance indicators, including clinical outcomes, patient satisfaction, and service utilization rates, to objectively assess provider performance.
Implement Data Infrastructure and Analytics: Invest in technology systems capable of collecting, analyzing, and reporting data to support informed decision-making and continuous quality improvement.
Provide Training and Support: Offer education and resources to providers and staff to ensure understanding and effective participation in VBP models, fostering a culture of continuous improvement.
Establish Continuous Monitoring and Feedback Mechanisms: Regularly review performance data, provide feedback, and adjust strategies as needed to maintain alignment with objectives and respond to emerging challenges.
The paper concludes that a methodical, collaborative approach is essential for the successful adoption of VBP models, ultimately leading to improved patient care and more efficient healthcare delivery systems.
https://www.mentorresearch.org/creating-a-contracts-agreements-and-policy-for-value-based-mental-and-behavioral-health-servicesValue-Based Payment Contracting for Psychotherapy Services: Requirements and Challenges
This draft discussion paper, dated April 2024, provides a comprehensive overview of the complexities involved in implementing value-based payment (VBP) models within psychotherapy services. It emphasizes the shift from traditional fee-for-service models to VBP, which focuses on quality and patient outcomes rather than service volume. The paper outlines the high risks and complexities associated with VBP contracting, highlighting the need for provider practices to possess significant experience, resources, and strategic approaches to navigate these intricacies effectively.
Key Points:
High-Level Guidance and General Challenges: The transition to VBP in psychotherapy demands expert knowledge, appropriate business structures, financial resources, and experience in contract administration, internal auditing, and risk management. Providers must meet health plan targets while negotiating contracts that allow for reasonable profit and manage the probable risk of financial loss.
Requirements for Successful Implementation: Effective VBP implementation necessitates significant investment by health plans, technology adoption, knowledge of psychotherapy, data analytics, and ethical practices. Provider groups need extensive experience in measurement-based care (MBC) and the capability to gather, aggregate, and analyze data to establish baselines and benchmarks for successful contract negotiation and management.
Opportunities and Challenges with VBP: VBP presents opportunities for improving treatment adherence, patient-centric care models, quality improvement, and incentivization of effective providers. However, challenges include the rarity of independent psychotherapists in VBP arrangements, lack of standardized outcome measures, separation from physical health care systems, undervaluation by payers, complexity of mental health conditions, ethical considerations, risk of adverse selection, and resource limitations.
Negotiating VBP Contracts: The paper outlines strategies for negotiating VBP contracts, emphasizing the importance of assessing provider practice capabilities, understanding the value proposition, identifying measurable outcomes, evaluating legal terms and financial risks, and fostering collaboration and partnership with payers.
Potential Pitfalls and Challenges: Participating in a VBP contract can lead to loss of control over patient care, fragmentation of services, challenges with performance metrics, financial risks, and potential for increased administrative burdens.
The document serves as a living resource, subject to revision as new information and perspectives emerge, aiming to guide providers through the evolving landscape of value-based payment in psychotherapy services.
https://www.mentorresearch.org/value-based-payments-psychotherapy
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Comprehensive Library
The Mentor Research Institute offers a comprehensive library of discussion papers aimed at educating providers, health plan managers, legislators, attorneys, and regulators on the design and implementation of ethical and effective healthcare contracts. These papers are organized by topic to facilitate targeted learning and address various aspects of healthcare contracting. Key categories include:
Definitions: Clarifying essential terms and concepts related to healthy contract design.
Proposals to Health Plans: Detailed proposals outlining collaborative initiatives between mental health providers and health plans to enhance services through value-based care and measurement-based care.
Systemic Health Plan Problems: Analyses of issues such as abrupt termination of contract negotiations by health plans, highlighting the need for ethical and lawful contracting practices.
Each category contains in-depth discussions that emphasize the importance of transparency, fairness, and mutual accountability in healthcare contracts. The library serves as a valuable resource for stakeholders aiming to promote ethical contracting and improve the quality of care in the healthcare system.
https://www.mentorresearch.org/healthy-contracts-categorized
Moda Health Discussion Papers
Key Oregon Legislators
Representative Rob Nosse
Democrat - District 42 - Portland
(A nurse, labor organizer, vice-chair of the House Behavioral Health Care Committee
Capitol Phone: 503-986-1442
Capitol Address: 900 Court St. NE, H-277, Salem, Oregon 97301
Email: Rep.RobNosse@oregonlegislature.gov
Website: https://www.oregonlegislature.gov/nosse
Representative Shannon Isadore
Democrat - District 33 - Portland
(A psychotherapist, and healthcare clinic executive)
Capitol Phone: 503-986-1433
Capitol Address: 900 Court St. NE, H-276, Salem, Oregon 97301
Email: Rep.shannonisadore@oregonlegislature.gov
Website: https://www.oregonlegislature.gov/isadore
Representative Jason Kropf
Democrat - District 54 - Bend
(Personal injury attorney, Co-chair of the House Judiciary Committee)
Capitol Phone: 503-986-1454
Capitol Address: 900 Court St. NE, H-491, Salem, Oregon 97301
Email: Rep.JasonKropf@oregonlegislature.gov
Website: https://www.oregonlegislature.gov/kropf
Senator Lisa Reynolds, MD
Democrat - District 17 - Northeast Washington County
Capitol Phone: 503-986-1717
Capitol Address: 900 Court St. NE, S-409, Salem, Oregon 97301
Email: Sen.LisaReynolds@oregonlegislature.gov
Website: https://www.oregonlegislature.gov/reynolds
Senator Kathleen Taylor
Democrat - District 21 - Milwaukie, Oak Grove, SE & NE Portland
Capitol Phone: 503-986-1721
Capitol Address: 900 Court St. NE, S-209, Salem, Oregon 97301
Email: sen.kathleentaylor@oregonlegislature.gov
Website: https://www.oregonlegislature.gov/taylor
Published: February 2025
DISCLAIMER and PURPOSE: This discussion document is intended for training, education, legislation, and or research purposes. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose