Health Plan Manifesto
Introduction
The healthcare industry is rapidly evolving, and mental and behavioral health services are central to this transformation. Historically, these services have operated under a fee-for-service (FFS) model, compensating providers based on the volume of services rendered rather than the quality of outcomes. This model has proven inefficient and increasingly unsustainable in today’s healthcare environment. With rising costs and growing emphasis on outcome-based care, Pay-for-Performance (P4P) models present a viable solution.
Health plans are facing legislative pressures, particularly from initiatives such as Oregon’s Sustainable Healthcare Growth Target Program and the Oregon Value-Based Payment Compact, which mandate a shift from FFS to value-based models. These initiatives aim to control costs while improving care outcomes and equity. This memo outlines how we, as a health plan, are not only meeting these legislative requirements but are also preparing for the future in a way that ensures collaboration with providers who are willing to engage.
Legislative Pressures and Program Requirements
In Oregon, the Sustainable Healthcare Growth Target Program and the Oregon Value-Based Payment Compact require that 70% of payments transition to value-based models by 2024. These initiatives are designed to rein in the growth of healthcare costs while ensuring that providers deliver high-quality care that improves patient outcomes.
As a health plan, our responsibility is to align our payment models with these mandates. This means moving away from FFS structures and implementing P4P models that prioritize the quality of care provided. Providers have not taken an active role in shaping this transition, and there has been little resistance or feedback from the provider community. As such, we are moving forward with our implementation based on the available guidance and data, which we believe will meet both the requirements of the legislation and the needs of our members.
The Necessity of Aggressive Implementation
The aggressive timelines of state and federal programs compel us to move quickly. Federal guidelines initially proposed a phased transition, beginning with pay-for-measurement and moving gradually toward full pay-for-performance. However, given the urgency to meet state-mandated deadlines, we are required to proceed directly into P4P models.
In this environment, providers have not provided organized feedback, and we have not seen active participation in shaping these performance measures. It is important to emphasize that without clear input from the provider community, health plans are not in a position to predict what providers want or need. We are, therefore, designing our models based on legislative requirements and our own understanding of how to best meet patient needs and deliver high-quality care.
If providers are interested in playing a more active role in this transition, we encourage engagement in discussions around performance metrics and contract terms. Without such participation, we will continue to design and implement models that align with legislative timelines and goals.
Ethical and Legal Considerations
As we transition into P4P models, we are mindful of the ethical and legal responsibilities that accompany such a shift. Our goal is to set performance benchmarks that are achievable yet challenging enough to improve care outcomes. We understand that some providers may find these benchmarks difficult, but it is essential that we design metrics that reflect the realities of cost control and care improvement.
While some may perceive tactics such as performance audits and reviews as financially challenging for smaller practices, we are complying with all legislative mandates to ensure that payments are tied to performance. Delays in payments may occur due to necessary reviews of performance data, but these are integral to ensuring that the system is transparent and based on merit.
We are also committed to ensuring that contracts reflect both parties' interests. Providers are encouraged to review their contracts and offer feedback, but without active engagement, it becomes difficult to anticipate their concerns. Our contracts are designed to be as fair as possible under the current regulatory framework, but adjustments can only be made when providers proactively engage with us.
Why Providers Are Not Engaging
It is apparent that many providers remain focused on short-term gains from the FFS model, believing they can adapt to value-based care later. However, this transition is already well underway, and providers who delay in adapting may face challenges in meeting the new performance metrics.
Additionally, the mental and behavioral health provider community is highly fragmented, with many independent practitioners lacking centralized leadership or advocacy groups. This disorganization has led to minimal feedback or resistance regarding the transition to P4P models.
As a health plan, we are not obligated to guess at what providers need or might object to in these models. We have offered opportunities for engagement and discussion, but without input from providers, we will continue to design systems that meet our obligations under the law.
The Myth of Out-of-Pocket Services
Some providers have suggested that they can avoid value-based contracts by transitioning to out-of-pocket services. However, this model is not sustainable for most practices. Patients increasingly rely on insurance coverage, and few can afford to pay out-of-pocket for services that would otherwise be covered by their health plans.
Health plans are working to ensure that value-based care models incentivize in-network care, which aligns with patient preferences and affordability. Out-of-pocket models may work for certain niche practices, but for the vast majority of mental and behavioral health providers, engaging with health plans will remain the most viable option.
Providers Are Signaling They Will Not Push Back
Providers are, in effect, signaling to health plans that they will not push back against new policies until it is too late to change the standards. This lack of engagement leaves health plans in a position where they must proceed with implementing P4P models without the benefit of provider input.
While providers may raise concerns later, health plans cannot be expected to predict those concerns in advance. The standards we are setting now will form the foundation of value-based care in the future, and any adjustments can only be made through collaboration and engagement from the provider community.
Gathering, Aggregating, Analyzing, and Reporting Quality Metrics
As we move into the value-based care model, providers are encouraged to proactively participate in the process of gathering and analyzing performance data. Providers should consider joining group practices or forming collective organizations of sufficient size to negotiate contracts effectively and meet the reporting requirements of P4P models.
A key component of successful participation in value-based care is the adoption of common online measurement technologies. These systems should include tools for screening, tracking progress, monitoring the therapeutic alliance, assessing patient satisfaction, and measuring outcomes. Our health plan provides online measurement systems that providers may use to track and analyze these metrics effectively.
Health plans may require groups to independently analyze and report their data, or in some cases, require the use of third-party analysis to ensure transparency and accuracy. By embracing these systems, providers can better position themselves to meet performance benchmarks and succeed in a value-based payment landscape.
Branding the Transition: Value-Based Payment
While Pay-for-Performance is an accurate description of the model, branding this transition as Value-Based Payment offers a more favorable message to stakeholders, including providers, members, and purchasers. This terminology highlights our commitment to improving care quality and aligning payments with patient outcomes, which resonates with broader healthcare trends.
"Value-Based Payment" also underscores our role as leaders in healthcare innovation, positioning us as forward-thinking and patient-focused. Providers are encouraged to view this shift as an opportunity to improve care delivery while maintaining financial sustainability.
Health Plans Must Lead
As the healthcare industry transitions to value-based care, health plans must take the lead in implementing these changes. Legislative mandates require us to move forward aggressively, and while provider feedback is always welcome, we cannot afford to wait for providers to engage. Providers don't want or expect to be coddled. It is their responsibility to organize and advocate for their concerns.
We encourage providers to participate in shaping the future of value-based care. However, without their active involvement, health plans will continue to meet legislative requirements and design models that prioritize patient outcomes and care quality. In this evolving landscape, health plans must remain at the forefront, ensuring that the transition to Pay-for-Performance benefits both providers and patients alike.
DISCLAIMER and PURPOSE: This discussion document is intended for training, education, and or research purposes only. 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