Healthy Contracts - Discussion Papers
Below is a library of discussion papers intended for training and education of providers, Healthplan managers, legislators, attorneys and regulators. The library is organized by topic.
Legislation
Healthy Contracts Legislation Proposal
https://www.mentorresearch.org/healthy-contracts-legislation-proposal
Definitions
Definitions For Healthy Contract Design
https://www.mentorresearch.org/healthy-contracts-bill-definitions
Proposals to Moda Health
Moda Outcome-Informed Behavioral Healthcare Proposal (January 14, 2022) By Mentor Research Institute For IMHPA
The proposal outlines a collaborative initiative between the Mentor Research Institute (MRI), the American Mental Health Alliance - Oregon (AMHA-OR), and Moda Health to enhance mental health services in Oregon through Value-Based Care (VBC), Value-Based Reimbursement (VBR), and Measurement-Based Care (MBC). It addresses Oregon's mental health crisis, emphasizing workforce shortages and service demand, while proposing solutions aligned with Oregon’s mental health parity law (HB 3046).
Key recommendations include adopting MBC with standardized assessments like the PHQ9 and GAD7, creating unique CPT codes for these measures, and tying provider reimbursement to CMS rates adjusted for Oregon's healthcare market. The Behavioral Health Incentive Program (BHIP) would reward providers through performance-based bonuses linked to clinical outcomes and participation.
The proposal stresses transparent, fair contracts respecting provider autonomy, clinical judgment, and patient confidentiality. It critiques industry practices driven by venture capital models and advocates for an ethical, provider-centered approach that balances financial sustainability with quality care delivery..
Mentor Research Institute Collaboration with Moda Health
The paper discusses a proposed collaboration between mental health providers and a health plan to implement value-based care (VBC) and measurement-based care (MBC). It outlines contract requirements, reimbursement models, and implementation challenges, emphasizing fair compensation, transparent data practices, and reducing administrative burdens. The discussion also addresses antitrust concerns, provider retention, and ethical contracting practices to enhance service access, care coordination, and treatment effectiveness.
Articles
Systemic Health Plan Problems
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 of 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 indicates 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 - A Whistleblower Complaint
The article details a whistleblower complaint filed against Moda Health, alleging deceptive contracting practices, fraud, and antitrust violations. It highlights concerns that Moda Health's value-based contracts unfairly shift financial risks onto providers while securing financial advantages for the insurer. Key allegations include a lack of transparency in incentive calculations, manipulation of risk adjustment scores, and the use of coercive, non-negotiable contracts. The complaint argues that these practices undermine provider trust, restrict competition, and could lead to reduced access to care. The article calls for regulatory oversight and legal intervention to ensure fair and ethical contracting in healthcare.
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-violationsOregon Health Authority’s Value-Based Payment (VBP) Roadmap as an Example of Solutionism
The article critiques the Oregon Health Authority's (OHA) Value-Based Payment Roadmap, arguing that it exemplifies "solutionism", the oversimplification of complex healthcare issues through technical fixes without addressing underlying systemic problems. It contends that the Roadmap's emphasis on value-based contracts overlooks critical concerns such as contract transparency, equitable financial risk distribution, and the administrative burdens placed on providers. The article warns that without addressing these foundational issues, the VBP Roadmap may lead to unintended consequences, including provider burnout, reduced care quality, and the perpetuation of existing power imbalances in the healthcare system.
https://www.mentorresearch.org/the-oregon-health-authoritys-valuebased-payment-vbp-roadmap-as-an-example-of-solutionismAnalysis of Moda Health's Code of Conduct and Allegations of Violations
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, which may contravene the organization's commitments to honesty and fairness. These actions potentially undermine provider trust and raise concerns about Moda Health's adherence to its own ethical standards.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violationsExposing Asymmetric Power: Moda Health's Unethical Approach to Value-Based Contracting
This article examines Moda Health's abrupt termination of contract negotiations with the Mentor Research Institute (MRI), highlighting a pattern of unethical behavior that includes misleading rationales and potential violations of federal and state laws, such as antitrust statutes and consumer protection regulations. The piece underscores the detrimental impact of Moda's actions on MRI and up to 128 provider groups across multiple states, emphasizing the broader risks posed to ethical value-based contracting and the integrity of healthcare negotiations.
https://www.mentorresearch.org/exposing-asymmetric-power-moda-healths-unethical-approach-to-valuebased-contractingCritique of Oregon's Value-Based Payment 2023 Roadmap
The article critiques Oregon's Value-Based Payment (VBP) 2023 Roadmap, highlighting concerns about its implementation and potential impact on healthcare providers and patients. It argues that the roadmap may impose significant administrative burdens on providers without adequate compensation, potentially leading to reduced access to care and provider burnout. The critique emphasizes the need for transparent contracting practices, equitable risk-sharing arrangements, and meaningful stakeholder engagement to ensure that the VBP initiatives achieve their intended goals without unintended negative consequences.
https://www.mentorresearch.org/critique-of-oregons-valuebased-payment-2023-roadmapBreaking 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-consequencesAnnouncement in Response to Moda Health’s NCQA Compliance Addendum
The announcement addresses Moda Health's NCQA compliance addendum, critiquing it as a superficial attempt to meet accreditation requirements without addressing underlying issues. It discusses concerns that the addendum may obscure ongoing unethical practices, such as restrictive contracting and anti-competitive behavior. The paper emphasizes the need for genuine compliance efforts that prioritize transparency, fair competition, and the well-being of providers and patients.
https://www.mentorresearch.org/announcement-in-response-to-moda-healths-ncqa-compliance-addendumWho are the Stakeholders When Contracting for Mental and Behavioral Health Services?
This discussion article identifies the key stakeholders involved in health plan contracting and their roles in shaping agreements. It categorizes stakeholders such as providers, health plans, patients, and regulators, outlining their interests and influence on contract terms. The article also discusses how the priorities of each group can sometimes conflict, impacting the negotiation process and the implementation of value-based care models. Strategies for balancing these interests to create fair and effective contracts are also presented.
https://www.mentorresearch.org/who-are-stakeholders-in-contractingWhy do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers tend to avoid conflicts with health plans, even when facing unfavorable contract terms. It highlights contributing factors such as fear of losing patient referrals, concerns over being excluded from networks, and the time-consuming nature of disputes. The paper also discusses the negative impact this avoidance can have on both care quality and provider autonomy. Recommendations for creating a more balanced environment, including stronger legal protections and transparent dispute resolution mechanisms, are also presented.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplansAsymmetrical Information - Mitigating Adverse Effects
This discussion examines strategies to mitigate asymmetrical information between health plans and providers in value-based care contracts. It discusses how unequal access to data and unclear contract terms can lead to imbalanced negotiations and poor alignment of incentives. The discussion outlines approaches such as transparency in performance metrics, clear definitions, and standardized reporting requirements to promote fairer contracting practices and improve trust between parties. Potential impacts on care quality and provider autonomy are also explored.
https://www.mentorresearch.org/mitigating-asymmetrical-informationAddressing Asymmetric Power Dynamics and Ethical Concerns in Health Plan Contracts
This discussion paper addresses asymmetric power dynamics and ethical concerns in health plan contracts. It analyzes how imbalances in negotiation power can lead to unfair contract terms, impacting provider autonomy and patient care. The paper explores strategies to create more equitable contracting, such as incorporating standardized definitions, ethical oversight, and ensuring transparency in contract negotiations. It also highlights the importance of including safeguards to protect against coercive practices and unethical contracting behavior.
https://www.mentorresearch.org/addressing-asymmetric-power-dynamics-and-ethical-concerns-in-health-plan-contractsContracts Shall Include Complete Descriptions of Reimbursement Algorithms Such that Another Auditor Following the Instructions Would Achieve the Same Results
This discussion article examines the importance of including complete descriptions of reimbursement algorithms in health plan contracts. It outlines how vague or incomplete algorithm descriptions can lead to confusion, billing disputes, and financial uncertainty for providers. The article recommends incorporating transparent and detailed language to clarify how reimbursement is calculated, ensuring that providers fully understand payment terms and reducing the risk of misinterpretation. Approaches for negotiating clearer contract language are also discussed.
https://www.mentorresearch.org/complete-descriptions-of-reimbursement-algorithms-in-contractsSuccessful 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-contractsWhy do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers often avoid conflicts with health plans despite facing unfavorable contract terms. It outlines factors such as fear of retaliation, potential exclusion from networks, and the administrative burden of disputes. The paper discusses how these dynamics can undermine providers’ ability to advocate for better conditions and impact care quality. Recommendations for addressing these challenges include stronger legal protections and transparent dispute resolution processes.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplansWhat Can Happen if Unfair, Bad Faith, Ambiguous, Ill-Defined, Unethical, or Voidable Provisions in Fee-For-Service and Value-Based Contracts Go Unchallenged?
This discussion paper examines the risks associated with voidable provisions in health plan contracts. It explains how these clauses allow one party to unilaterally alter or terminate key terms, creating instability and potential legal risks for providers. The paper outlines strategies for identifying and addressing voidable provisions, advocating for clearer contract language and mutual consent when changes are made. Recommendations for promoting more transparent and reliable contracting practices are also provided.
https://www.mentorresearch.org/contracts-with-voidable-provisionsIMHPA and Moda Health Collaboration for Measurement-Based Care
In December 2022, the Independent Mental Health Practices Alliance (IMHPA) initiated a collaboration with Moda Health to develop a measurement-based care (MBC) contract, aiming to transition to a value-based payment (VBP) model over three years. IMHPA provided detailed recommendations, including necessary CPT codes, technology requirements, administrative protocols, and data-sharing practices, along with cost estimates for implementing MBC. However, concerns arose regarding Moda Health's contracting approach, which IMHPA found to be potentially misleading and lacking in transparency. An analysis suggested that the proposed contract posed significant risks to provider practices and public health, leading to IMHPA's conclusion that the agreement offered minimal value to providers while disproportionately benefiting Moda Health. The article emphasizes the need for fair and transparent negotiations to ensure ethical and effective VBP contracts.
https://www.mentorresearch.org/-imhpa-and-x-health-collaboration-for-mbcFiduciary Responsibility in Health Plan Contracting: A Critical Examination
This article delves into the fiduciary duties of health plans, emphasizing their obligation to act in the best interests of stakeholders, including patients, providers, and the public. It highlights the importance of transparency, honesty, and fairness in contracting practices, especially with the shift towards value-based payment models. The piece warns against misrepresentation and unethical behavior, such as inflating compliance metrics or providing misleading contracts, which can breach fiduciary duties and lead to legal consequences. The article advocates for independent oversight by certified internal auditors who report directly to the Board of Directors or an Audit Ethics Committee to ensure compliance with ethical and legal standards. It also underscores the necessity for health plans to conduct regular ethical and legal reviews of their practices to maintain trust and integrity in the healthcare system.
https://www.mentorresearch.org/fiduciary-responsibility-in-healthplan-contracting-a-critical-examination
Transforming Fee-for-Service to Value-Based Payment Contracts
Creating 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 and Behavioral Health
The paper examines value-based payment models for behavioral health services, focusing on their design, implementation, and impact on care quality. It discusses how these models aim to align financial incentives with patient outcomes while addressing unique challenges in mental health care, such as measuring clinical effectiveness and ensuring equitable access. The analysis highlights potential benefits and risks, emphasizing the need for thoughtful policy design to support sustainable, high-quality behavioral health services.
https://www.mentorresearch.org/value-based-payment-for-behavioral-healthTransition from Fee-for-Service Step-Wise to Alternative Payment Contracts and then Value-Based Payment Contracts: The Good and the Bad
The paper outlines a framework for transitioning traditional fee-for-service psychotherapy models to value-based payment contracts. It discusses the key principles of value-based care, including outcome measurement, quality improvement, and the alignment of financial incentives. The content highlights challenges and strategies for integrating these principles into practice, emphasizing the importance of adapting clinical workflows and ensuring fair reimbursement structures. The discussion also addresses potential pitfalls and offers recommendations for successful implementation.
https://www.mentorresearch.org/transforming-feeforservice-psychotherapy-to-valuebased-payment-contractTransforming Mental Health Services From Fee-for-Service to Value-Based Contracts: A Closer Look
The paper examines the complexities of transforming mental health services by analyzing current barriers and proposing actionable strategies for improvement. It contrasts traditional care models with modern approaches, emphasizing the need for integrated care, evidence-based practices, and enhanced provider collaboration. Key points include addressing service fragmentation, optimizing care coordination, and promoting patient-centered models. The content provides insights on how to achieve meaningful reform in mental health delivery systems.
https://www.mentorresearch.org/transforming-mental-health-services-a-closer-lookBehavioral Health Quality Framework: A Roadmap For Using Measurement To Promote Joint Accountability and Whole-Person Care
This paper outlines a behavioral health quality framework aimed at improving care for individuals with mental health and substance use conditions. It focuses on enhancing measurement, care coordination, and health outcomes through better integration of physical and behavioral health, promoting person-centered care, and addressing social determinants of health. The paper also highlights the importance of data systems, standardized measures, and value-based care models to support these efforts.
https://www.ncqa.org/wp-content/uploads/2021/07/20210701_Behavioral_Health_Quality_Framework_NCQA_White_Paper.pdfMeasurement and Value-based Payment Contracting
The paper examines value-based payment models for behavioral health services, focusing on their design, implementation, and impact on care quality. It discusses how these models aim to align financial incentives with patient outcomes while addressing unique challenges in mental health care, such as measuring clinical effectiveness and ensuring equitable access. The analysis highlights potential benefits and risks, emphasizing the need for thoughtful policy design to support sustainable, high-quality behavioral health services.
Measurement-Based Care: Enhancing and Undermining Mental Health Treatment Values
Discussion paper describes the concepts of measurement-based and outcome-informed care, focusing on how these approaches use standardized tools to track patient progress and inform treatment decisions. It outlines the benefits of incorporating structured assessments, such as improved clinical outcomes and more personalized care. The content contrasts these methods with traditional clinical judgment and discusses practical challenges in implementation, including provider training and integrating data into clinical workflows.
https://www.mentorresearch.org/what-is-measurement-based-and-out-come-informed-careOutcome Informed Care And Measurement-Based Care Adoption - Challenges in Oregon
This discussion addresses the challenges associated with adopting measurement-based care in mental health settings. It examines common barriers such as provider resistance, lack of standardized measures, and integration issues with electronic health records. The content highlights the need for training, data management support, and leadership engagement to ensure successful implementation. The discussion also explores how overcoming these obstacles can lead to better clinical outcomes and a more structured approach to treatment planning.
https://www.imhpa.org/measurement-based-care-adoption-challengesPatient Reported Outcomes & Performance Measures (PROM-PM)
This discussion explores the role of patient-reported outcomes and progress measures in enhancing psychotherapy services. It outlines how these tools capture patient perspectives on treatment effectiveness and track changes over time, providing valuable insights for clinicians. The discussion contrasts these measures with traditional clinician assessments and emphasizes their impact on treatment planning, therapeutic alliance, and overall care quality. Practical considerations for implementation, including selecting appropriate tools and integrating feedback into clinical practice, are also discussed.
https://www.mentorresearch.org/patient-reported-outcomes-progress-measures
Contract Negotiation Issues
Contract 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-plansUnfair Financial Risks in Healthcare: Challenges for Providers in Public and Private Contracts.
The paper examines unfair financial risks imposed on healthcare providers through contracting practices. It discusses how certain value-based payment models and contract terms shift excessive financial burdens onto providers, jeopardizing their financial stability. The analysis highlights the impact of these risks on small and independent practices, emphasizing the need for equitable contract structures that balance financial accountability with sustainable operations.
https://www.mentorresearch.org/unfair-financial-risks-in-healthcareAsymmetrical Information - Mitigating Adverse Effects
This discussion examines strategies to mitigate asymmetrical information between health plans and providers in value-based care contracts. It discusses how unequal access to data and unclear contract terms can lead to imbalanced negotiations and poor alignment of incentives. The discussion outlines approaches such as transparency in performance metrics, clear definitions, and standardized reporting requirements to promote fairer contracting practices and improve trust between parties. Potential impacts on care quality and provider autonomy are also explored.
https://www.mentorresearch.org/mitigating-asymmetrical-informationAddressing Asymmetric Power Dynamics and Ethical Concerns in Health Plan Contracts.
This discussion paper addresses asymmetric power dynamics and ethical concerns in health plan contracts. It analyzes how imbalances in negotiation power can lead to unfair contract terms, impacting provider autonomy and patient care. The paper explores strategies to create more equitable contracting, such as incorporating standardized definitions, ethical oversight, and ensuring transparency in contract negotiations. It also highlights the importance of including safeguards to protect against coercive practices and unethical contracting behavior.
https://www.mentorresearch.org/addressing-asymmetric-power-dynamics-and-ethical-concerns-in-health-plan-contractsNavigating Value-Based Contracting in Mental Health Services: Risks, Mitigation Strategies, and Consequences
This article explores the complexities of value-based contracting (VBC) in mental health services, highlighting the financial risks, operational burdens, and potential consequences for providers. It emphasizes the importance of negotiating clear contract terms, implementing robust data management systems, and fostering collaborative relationships with payers to mitigate these challenges. The article also provides a checklist to help providers assess whether health plans are engaging in good faith negotiations, aiming to ensure that VBC models enhance patient care without compromising provider sustainability.
https://www.mentorresearch.org/navigating-value-based-contracting-in-mental-health-services-risks-mitigation-strategies-and-consequencesCollaboration Agreements For Value-Based Payment Services and Contracts
This article discusses the role of collaboration agreements in value-based payment contracting. It outlines how these agreements can help define shared responsibilities, financial arrangements, and performance expectations between providers and health plans. The article emphasizes the importance of clear communication, mutual trust, and alignment on care goals to support successful partnerships. Key considerations include structuring agreements to balance risk, ensuring compliance with regulatory requirements, and promoting long-term sustainability.
https://www.mentorresearch.org/collaboration-agreements-for-valuebased-payment-contractingMedically Necessary and Reasonable Psychotherapy Services
This paper examines the concepts of "medically necessary" and "reasonable" within the context of health plan policies and coverage decisions. It contrasts how different definitions and interpretations can lead to variability in service authorization and reimbursement, often causing confusion for both providers and patients. The paper discusses the impact of these terms on care access and outlines recommendations for clearer, standardized definitions to reduce ambiguity and ensure equitable treatment decisions.
https://www.mentorresearch.org/medically-necessary-reasonableWho are the Stakeholders When Contracting for Mental and Behavioral Health Services?
This discussion article identifies the key stakeholders involved in health plan contracting and their roles in shaping agreements. It categorizes stakeholders such as providers, health plans, patients, and regulators, outlining their interests and influence on contract terms. The article also discusses how the priorities of each group can sometimes conflict, impacting the negotiation process and the implementation of value-based care models. Strategies for balancing these interests to create fair and effective contracts are also presented.
https://www.mentorresearch.org/who-are-stakeholders-in-contractingRisk Pools: How can they be Manipulated by Healthplans?
This discussion paper analyzes how health plans can manipulate risk pools in value-based payment models. It describes tactics such as selective patient inclusion, skewing risk scores, and using narrow definitions to shift financial risk onto providers. The paper outlines the impact of these practices on provider reimbursement and care quality, emphasizing the need for transparency and standardized criteria to prevent misuse. Recommendations for safeguarding against these manipulations are also discussed.
https://www.mentorresearch.org/risk-pools-how-can-they-be-manipulated-by-healthplansHigh 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-in-valuebased-contractingPlain Language Collaboration Agreement and Use Case Example
This discussion article explores the importance of using plain language in health plan contracts and provides a use case example to illustrate its application. It highlights how complex legal jargon can create misunderstandings, hinder compliance, and obscure critical terms for providers. The article outlines strategies for drafting clear agreements, emphasizing readability, transparency, and the use of standardized definitions. The use case example demonstrates how adopting plain language can facilitate better communication and improve trust in contractual relationships.
https://www.mentorresearch.org/plain-language-contract-agreement-and-use-case-exampleProvider Practice and Value-Based Payment Contracting for Psychotherapy Services: Requirements and Challenges.
This article discusses the implementation of value-based payments in psychotherapy and its implications for clinical practice. It outlines how traditional fee-for-service models differ from value-based approaches that tie reimbursement to treatment outcomes and patient satisfaction. The article explores the benefits and challenges of transitioning to these models, including issues related to outcome measurement, data reporting, and aligning clinical practices with value-based goals. Strategies for integrating value-based principles into psychotherapy settings are also highlighted
https://www.mentorresearch.org/value-based-payments-psychotherapyWhy do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers tend to avoid conflicts with health plans, even when facing unfavorable contract terms. It highlights contributing factors such as fear of losing patient referrals, concerns over being excluded from networks, and the time-consuming nature of disputes. The paper also discusses the negative impact this avoidance can have on both care quality and provider autonomy. Recommendations for creating a more balanced environment, including stronger legal protections and transparent dispute resolution mechanisms, are also presented.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplansRisks, Reasons, and What to Do When Healthplan Measurement and Value-Based Payment Contracts are a Contract of Adhesion
This discussion article examines the risks associated with contracts of adhesion in health plan agreements, where one party has significantly more power in setting the terms. It outlines how these contracts can impose unfair conditions, limit provider options, and create ethical concerns. The article discusses strategies to recognize and address such imbalances, including negotiating for fairer terms, advocating for clearer definitions, and considering legal options when faced with coercive clauses. Recommendations for ensuring more equitable contracting practices are also included.
https://www.mentorresearch.org/risks-reasons-and-what-to-do-with-contracts-of-adhesionThe Problem When Contracts of Adhesion are Offered to Mental and Behavioral Health Providers
This discussion article addresses the problems that arise when contracts of adhesion are offered by health plans. It describes how these take-it-or-leave-it agreements can place providers at a disadvantage by limiting their ability to negotiate terms or opt for alternative arrangements. The article highlights the ethical and practical concerns associated with these contracts, including reduced provider autonomy and increased financial risk. Strategies for managing these challenges, such as advocating for clearer contract language and seeking independent legal review, are also discussed.
https://www.mentorresearch.org/problem-when-contracts-of-adhesion-are-offeredTransition from Fee-for-Service Step-wise to Alternative Payment Contracts and then Value-Based Payment Contracts: The Good and the Bad
This discussion paper outlines a framework for transitioning fee-for-service psychotherapy to value-based payment contracts. It discusses key principles of value-based care, such as outcome measurement, quality improvement, and aligning financial incentives with patient outcomes. The paper highlights challenges related to implementing these changes, including workflow adjustments and reimbursement fairness, and offers strategies for successful adoption. Recommendations for providers and health plans to collaborate in restructuring service delivery models are also presented.
https://www.mentorresearch.org/transforming-feeforservice-psychotherapy-to-valuebased-payment-contractHealthy Contracts: Ensuring Ethical and Collaborative Agreements in Mental Health Services
This discussion article explores how to create healthy contracts that promote ethical and collaborative agreements in mental health services. It emphasizes the importance of fairness, transparency, and mutual respect in contracting to ensure that both providers and health plans can meet patient care goals effectively. The article outlines key elements of ethical contracts, such as clear terms, balanced responsibilities, and mechanisms for addressing disputes. Strategies for fostering trust and collaboration between contracting parties are also discussed.
https://www.mentorresearch.org/healthy-contracts-ensuring-ethical-and-collaborative-agreements-in-mental-health-servicesContracts Shall Include Complete Descriptions of Reimbursement Algorithms Such that Another Auditor Following the Instructions Would Achieve the Same Results
This discussion article examines the importance of including complete descriptions of reimbursement algorithms in health plan contracts. It outlines how vague or incomplete algorithm descriptions can lead to confusion, billing disputes, and financial uncertainty for providers. The article recommends incorporating transparent and detailed language to clarify how reimbursement is calculated, ensuring that providers fully understand payment terms and reducing the risk of misinterpretation. Approaches for negotiating clearer contract language are also discussed.
https://www.mentorresearch.org/complete-descriptions-of-reimbursement-algorithms-in-contractsContracts and Policies Shall be Written in Plain, Understandable Language
This discussion paper advocates for health plan contracts and policies to be written in plain language. It explains how complex legal jargon can create misunderstandings, hinder compliance, and lead to disputes between providers and health plans. The paper emphasizes the benefits of using clear, straightforward language, including improved communication, enhanced trust, and easier contract implementation. Recommendations for adopting plain language standards and examples of effective contract language are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-be-written-plain-languageContracts and Policies Shall Include Transparent and Shared Values, Objectives, Controls, and Key Indicators Of Success
This discussion paper addresses the importance of incorporating transparent and shared values, objectives, controls, and key performance indicators in health plan contracts. It explains how aligning these elements can promote accountability and trust between providers and health plans. The paper outlines strategies for defining common goals, measuring performance, and ensuring both parties are committed to shared standards. Potential benefits include improved collaboration, enhanced service quality, and more effective management of contractual relationships.
https://www.mentorresearch.org/including-transparent-and-shared-values-objectives-controls-and-key-indicators
“Take-It-Or-Leave-It” Unenforceable and Voidable Contracts
Problems When Contracts of Adhesion are Offered to Mental and Behavioral Health Providers
This discussion article examines the challenges posed by contracts of adhesion in health plan agreements. It describes how these non-negotiable contracts can create power imbalances, limit providers’ ability to advocate for fair terms, and increase their exposure to financial risk. The article highlights ethical concerns and potential legal implications, while also suggesting strategies for negotiating better terms or avoiding these contracts altogether. Solutions such as enhanced legal protections and clearer contract standards are discussed to promote more equitable agreements.
https://www.mentorresearch.org/problem-when-contracts-of-adhesion-are-offeredWhat Can Happens if Voidable Provisions in Value-Based Contracts Go Unchallenged?
This discussion paper explores the implications of voidable provisions in health plan contracts. It explains how these clauses can be used to unilaterally alter or terminate key terms, creating uncertainty and potential legal risks for providers. The paper discusses strategies for identifying and addressing voidable provisions during contract review, advocating for clearer language and mutual consent when changes are made. Recommendations for ensuring more stable and transparent contracting practices are also included.
https://www.mentorresearch.org/contracts-with-voidable-provisionsPreventing the Problems Created by “Take It or Leave It” Contracts in Mental and Behavioral Health Services?
This discussion paper addresses strategies for preventing contracts of adhesion that negatively impact public health. It explains how these one-sided agreements can undermine provider autonomy, restrict patient access to care, and prioritize financial interests over health outcomes. The paper outlines policy recommendations, such as enforcing fair contract standards, promoting transparency, and establishing legal safeguards to protect against coercive practices. The broader implications for health equity and quality of care are also discussed.
https://www.mentorresearch.org/preventing-contract-of-adhesion-that-harm-public-healthEnforceable and Unenforceable Mental and Behavioral Health Contract Requirements
This discussion paper outlines key requirements for making health plan contracts enforceable. It explains how clear terms, mutual consent, and adherence to legal standards are essential for creating binding agreements that protect both parties. The paper discusses common pitfalls, such as vague language or hidden clauses, that can render contracts unenforceable and increase the risk of disputes. Recommendations for ensuring contract compliance and promoting fair, transparent agreements are also provided.
https://www.mentorresearch.org/enforceable-contract-requirementsWhat Problems are Created When Healthplans Offer Providers “Take it or Leave it” Contracts of Adhesion?
This discussion article examines the impact of take-it-or-leave-it contracts in healthcare. It describes how these contracts, which offer no room for negotiation, can disadvantage providers by imposing unfavorable terms and limiting their ability to advocate for better conditions. The article highlights the ethical concerns and financial risks associated with these agreements and offers strategies for resisting or renegotiating such terms. Policy solutions to promote more balanced contracting practices are also discussed.
https://www.mentorresearch.org/take-or-leave-contract-in-healthcare
Risk of Contract Success and Failure
Navigating Value-Based Contracting in Mental Health Services: Risks, Mitigation Strategies, and Consequences
This article explores the complexities of value-based contracting (VBC) in mental health services, highlighting the financial risks, operational burdens, and potential consequences for providers. It emphasizes the importance of negotiating clear contract terms, implementing robust data management systems, and fostering collaborative relationships with payers to mitigate these challenges. The article also provides a checklist to help providers assess whether health plans are engaging in good faith negotiations, aiming to ensure that VBC models enhance patient care without compromising provider sustainability.
https://www.mentorresearch.org/navigating-value-based-contracting-in-mental-health-services-risks-mitigation-strategies-and-consequencesBreaking 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-healthplan-mandatesThe Fallacy of Better, Cheaper, Faster: How Health Plans Shift Risk to Providers
This article examines how health plans promote value-based contracts under the guise 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-fasterImportance of Clear and Accountable Contract Requirements for Value-Based Payment Contracts
This discussion paper emphasizes the importance of having clearly written and accountable contracts in healthcare. It explains how well-defined terms and transparent accountability measures can reduce misunderstandings, prevent disputes, and promote trust between providers and health plans. The paper outlines best practices for drafting contracts that include precise language, mutual responsibilities, and enforceable provisions, thereby supporting more effective and ethical business relationships.
https://www.mentorresearch.org/importance-of-clearly-written-and-accountable-contractsUnethical Tactics in Pay-for-Performance: How Health Plans Manipulate Provider Contracts in Value-Based Care
This discussion paper examines unethical tactics used by health plans in pay-for-performance contracts. It describes practices such as manipulating performance metrics, using misleading contract language, and setting unrealistic benchmarks to reduce provider reimbursement. The paper discusses the impact of these tactics on care quality, provider trust, and patient outcomes, while offering recommendations for identifying and addressing unethical behaviors. Strategies for ensuring fair performance evaluations and promoting ethical contracting are also included.
https://www.mentorresearch.org/unethical-health0plan-tactics-in-pay-for-performanceSuccessful 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-contractsWhy do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers often avoid conflicts with health plans despite facing unfavorable contract terms. It outlines factors such as fear of retaliation, potential exclusion from networks, and the administrative burden of disputes. The paper discusses how these dynamics can undermine providers’ ability to advocate for better conditions and impact care quality. Recommendations for addressing these challenges include stronger legal protections and transparent dispute resolution processes.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplansWhat Can Happen if Unfair, Bad Faith, Ambiguous, Ill-Defined, Unethical, or Voidable Provisions in Fee-For-Service and Value-Based Contracts Go Unchallenged?
This discussion paper examines the risks associated with voidable provisions in health plan contracts. It explains how these clauses allow one party to unilaterally alter or terminate key terms, creating instability and potential legal risks for providers. The paper outlines strategies for identifying and addressing voidable provisions, advocating for clearer contract language and mutual consent when changes are made. Recommendations for promoting more transparent and reliable contracting practices are also provided.
https://www.mentorresearch.org/contracts-with-voidable-provisionsThe 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-antitrustUnreasonable Constraints on Healthcare Professionals - Doe v. U.S. Health Care Systems
This discussion paper addresses the impact of unreasonable constraints imposed on healthcare professionals through restrictive contract terms. It explains how such constraints—such as excessive administrative requirements, non-compete clauses, and limitations on clinical decision-making—can reduce provider autonomy, increase burnout, and negatively affect patient care. The paper provides strategies for negotiating more balanced agreements and advocates for regulatory reforms to protect healthcare professionals from coercive contract practices.
https://www.mentorresearch.org/unreasonable-constraints-on-healthcare-professionalsCan Providers Legally Boycott a Healthplan? - Ethical Reasons to Legally Boycott a Healthplan
This discussion paper outlines ethical reasons for healthcare providers to consider boycotting a health plan. It discusses situations where health plans engage in unethical practices, such as manipulating contract terms, misrepresenting coverage, or undermining patient care. The paper highlights how participating in such contracts can compromise professional integrity and harm patient outcomes. Strategies for organizing a boycott, including legal considerations and advocacy efforts, are also discussed as a means to promote fairer contracting practices.
https://www.mentorresearch.org/ethical-reasons-to-boycott-a-healthplanWill Healthplans Support the Healthy Contracts Legislation
This discussion article examines whether health plans are likely to support healthy contract legislation designed to promote fairer agreements with providers. It analyzes health plans’ potential motivations for opposing or endorsing such reforms, including concerns over profitability, administrative burden, and public image. The article outlines the benefits of adopting transparent and ethical contract standards and suggests strategies for engaging health plans in meaningful dialogue to gain their support.
https://www.mentorresearch.org/will-healthplans-support-the-healthy-contracts-legislationWill Value-Based Payments Harm Public Health and Provider Practices? Case Example
This discussion paper reviews the implementation of value-based contracts in Oregon’s healthcare market. It highlights key initiatives, such as the Oregon Value-Based Payment Compact, and examines how these contracts aim to improve care quality and control costs. The paper discusses the challenges providers face, including adapting to new performance metrics and managing financial risk. Strategies for enhancing the effectiveness of value-based contracts in the state, such as improved data sharing and stronger care coordination, are also presented.
https://www.mentorresearch.org/value-based-contracts-in-oregonCore Psychotherapy Values and the Erosion by Healthplan Practices
This discussion paper explores how certain health plan practices can erode core psychotherapy values, such as patient autonomy, confidentiality, and the therapeutic alliance. It examines tactics like limiting session duration, restricting treatment options, and prioritizing cost over clinical need, which can undermine ethical care. The paper advocates for policies that protect the integrity of psychotherapy and offers strategies for resisting practices that conflict with core professional values.
https://www.mentorresearch.org/core-psychotherapy-values-and-the-erosion-by-healthplan-practicesChallenges in Implementing Value-Based Payment Contracts Using W-2 Mental and Behavioral Health Professionals
This discussion article examines the challenges of implementing value-based payment contracts using W-2 mental health professionals. It discusses how employment structures, such as W-2 versus independent contractor arrangements, impact the ability to align performance incentives and manage clinical outcomes. The article highlights issues like reduced flexibility, administrative burdens, and potential conflicts between financial goals and clinical practice. Recommendations for adapting value-based models to suit W-2 employee structures are also provided.
https://www.mentorresearch.org/challenges-in-implementing-value-based-payment-contracts-using-w-2-mental-health-professionals
Good Faith and Fair Dealing
Signs 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-contractGood Faith and Fair Dealing in Healthcare Contracting for Fee-For-Service, Alternative and Value-Based Payment Models
This discussion paper examines the principles of good faith and fair dealing in health plan contracts. It explains how these concepts are meant to ensure honest communication, transparency, and mutual respect between contracting parties. The paper discusses common contract practices that violate these principles, such as hidden terms and deceptive language, and offers strategies for promoting ethical contracting through clearer definitions and enforceable standards. The broader impact on provider relationships and patient care is also considered
https://www.mentorresearch.org/good-faith-and-fair-dealingPlain Language Contract and Use Case Example
This discussion article emphasizes the importance of using plain language in health plan contracts and provides a use case example to illustrate its application. It explains how complex legal jargon can lead to misunderstandings, compliance issues, and power imbalances between providers and health plans. The article outlines strategies for creating clear, accessible agreements, highlighting benefits such as improved communication and trust. The use case demonstrates how plain language can simplify contract terms and promote more ethical contracting practices.
https://www.mentorresearch.org/plain-language-contract-agreement-and-use-case-exampleHow Can Mental and Behavioral Health Provider Practices Recognize They are Being “Taken for a Ride”?
This discussion paper examines how mental and behavioral health provider practices can be exploited through unfair health plan contracting practices. It describes tactics such as deceptive reimbursement structures, excessive administrative requirements, and restrictive network agreements that can diminish provider revenue and autonomy. The paper outlines the impact of these practices on service quality and sustainability, offering strategies for identifying and resisting exploitative contracts to protect provider interests.
https://www.mentorresearch.org/in-what-ways-are-mental-and-behavioral-health-provider-practices-being-taken-for-a-rideThe Problems When Contracts of Adhesion are Offered to Mental and Behavioral Health Providers
This discussion article addresses the problems associated with contracts of adhesion in healthcare agreements. It explains how these non-negotiable contracts can create power imbalances, limit providers’ ability to advocate for fair terms, and increase their financial and legal risks. The article highlights the ethical and practical issues that arise from these agreements and offers strategies for negotiating more balanced terms or avoiding such contracts altogether. Recommendations for fostering fairer contracting practices are also discussed.
https://www.mentorresearch.org/the-problem-when-contracts-of-adhesion-are-offeredThe Quadruple Aim: What Should Healthplans Do? & What Some Healthplans Say They're Doing
This discussion paper explores the concept of the Quadruple Aim in healthcare, which extends the traditional Triple Aim by adding the goal of improving the work life of healthcare providers. It discusses how achieving the Quadruple Aim—enhancing patient experience, improving population health, reducing costs, and supporting provider well-being—requires addressing systemic issues such as burnout, administrative burden, and inefficient care models. The paper outlines strategies for aligning organizational practices with these objectives to create a more sustainable and effective healthcare system.
https://www.mentorresearch.org/the-quadruple-aimThe Macroeconomic Patterns which Ensure Profitable Failure of Value-Based Contracts in Oregon
The implementation of value-based payment (VBP) contracts in Oregon has encountered systemic failures due to cultural, economic, and regulatory dynamics that begin with unfair and bad-faith negotiations, blocking important changes in mental and behavioral health practice. This cycle, controlled by health plans, undermines providers, patients, other stakeholders, and the broader healthcare system. Addressing these failures requires legislation mandating that health plans establish independent oversight mechanisms within the organization, overseen by the Board of Directors, to ensure internal accountability and achieve sustainable healthcare reform. Without such measures, the current practices of solutionism, erosion of trust, and lack of accountability will continue to impede the success of VBP contracts in Oregon.
https://www.mentorresearch.org/the-macroeconomic-patterns-which-ensure-profitable-failure-for-health-plans
Gaming, Fraud and Antitrust
Contract “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-failDescription of Healthcare Fraud in Measurement and Value-Based Care Contracting
This discussion paper examines how healthcare fraud can manifest in value-based payment contracts. It outlines common fraudulent practices such as inflating performance metrics, misrepresenting patient data, and manipulating risk scores to maximize financial gains. The paper discusses the challenges of detecting and preventing fraud in these complex payment models and emphasizes the need for transparent data reporting and robust compliance measures. Strategies for minimizing fraud risk and promoting accountability in value-based contracts are also presented.
https://www.mentorresearch.org/healthcare-fraud-measurement-an-valuebased-payment-contractsRule of Reason Analysis Using Prima Facie Evidence
This discussion paper examines Moda Health's contracting practices through a rule-of-reason analysis, utilizing prima facie evidence to assess potential fraud and antitrust violations. The analysis highlights concerns such as manipulation of risk adjustment scores, lack of transparency, and coercive contract terms that may suppress competition and harm providers. The paper advocates for legislative reforms, regulatory oversight, and provider advocacy to promote transparency, fairness, and accountability in value-based contracting, ultimately protecting providers and patients from unethical practices.
https://www.mentorresearch.org/rule-of-reason-analysis-using-primafacia-evidenceBait and Switch Tactics - A Hypothetical Contract Recruitment Scenario?
This discussion paper explores bait-and-switch tactics used in healthcare contracting. It explains how health plans may initially offer favorable contract terms or reimbursement rates, only to change them unilaterally after providers have committed to the agreement. The paper highlights the impact of these tactics on provider revenue, care delivery, and trust in contracting relationships. Strategies for identifying and resisting bait-and-switch practices, along with recommendations for promoting fair and transparent contracts, are also discussed.
https://www.mentorresearch.org/bait-and-switch-tacticsRisk Pools: How can they be Manipulated by Healthplans?
This discussion paper analyzes how health plans can manipulate risk pools in value-based payment models. It outlines tactics such as selectively including or excluding certain patients, skewing risk scores, and using narrow definitions to shift financial risk onto providers. The paper discusses the impact of these manipulations on provider reimbursement, care quality, and overall contract fairness. Strategies for increasing transparency and implementing standardized criteria to prevent misuse are also provided.
https://www.mentorresearch.org/risk-pools-how-can-they-be-manipulated-by-healthplansDescription of Healthcare Fraud by using Provider Practices as a Proxy
This discussion paper examines how healthcare fraud can occur within measurement and value-based contracting. It details fraudulent activities such as falsifying data, manipulating patient outcomes, and misrepresenting performance to achieve financial incentives. The paper explains how these actions undermine the integrity of value-based models and erode trust between providers and health plans. Strategies for identifying, preventing, and addressing fraud, including robust auditing and clearer performance metrics, are also discussed.
https://www.mentorresearch.org/healthcare-fraud-in-measurement-and-value-based-contractingPreventing Healthplan Fraud on Mental Health Professionals
This discussion paper addresses strategies for preventing health plan fraud, particularly in the context of value-based contracts. It describes common fraudulent practices, such as manipulating quality measures, inflating costs, and misrepresenting patient data, which can undermine care quality and financial stability. The paper emphasizes the importance of transparency, standardized reporting, and independent audits to detect and deter fraud. Recommendations for creating more robust anti-fraud policies and promoting ethical contracting practices are also provided.
https://www.mentorresearch.org/preventing-healthplan-fraudIs Moda Health Violating Antitrust Law?
This discussion paper examines whether Moda Health’s contracting practices may violate antitrust laws. It analyzes how certain behaviors, such as limiting provider networks, restricting competition, and using exclusionary tactics, could create unfair market advantages. The paper outlines the potential antitrust implications of Moda Health’s actions and discusses how these practices may impact market pricing, provider autonomy, and patient access to care. Recommendations for further investigation and strategies to address potential antitrust violations are also included.
https://www.mentorresearch.org/is-moda-health-violating-antitrust-lawValue-Based Payment Fraud: When Heathplan Misrepresentation Turns into Conspiracy
This discussion paper explores strategies to prevent health plan fraud, particularly in value-based payment models. It outlines common forms of fraud, such as inflating performance metrics, misclassifying patients, and falsifying outcome data, which can distort reimbursement and undermine trust. The paper emphasizes the need for transparent data reporting, independent audits, and standardized performance measures to detect and deter fraudulent behavior. Recommendations for strengthening compliance and promoting ethical practices in health plan contracting are also provided.
https://www.mentorresearch.org/preventing-healthplan-fraudWhat can Happen if Unfair, Bad Faith, Ambiguous, Ill-Defined, Unethical, or Voidable Provisions in Fee-For-Service and Value-Based Contracts go Unchallenged?
This discussion paper examines the risks posed by voidable provisions in health plan contracts. It explains how these clauses allow one party to unilaterally modify or cancel key terms, creating legal and financial uncertainty for providers. The paper discusses strategies for identifying voidable provisions and negotiating clearer, mutually enforceable terms. Recommendations for promoting more transparent and stable contracting practices are also presented.
https://www.mentorresearch.org/contracts-with-voidable-provisionsCollaboration Agreements For Value-Based Payment Contracting
This article discusses the role of collaboration agreements in value-based payment contracting. It explains how these agreements define shared responsibilities, financial arrangements, and performance expectations between providers and health plans. The article emphasizes the importance of trust, clear communication, and aligning care goals to support successful partnerships. Key considerations for structuring collaboration agreements, such as risk-sharing and compliance with regulatory requirements, are also highlighted.
https://www.mentorresearch.org/collaboration-agreements-for-valuebased-payment-contractingIntersection of Mental Health, Value-Based Payment Contracts, and the Law: A Case Study of Moda Health.
This discussion paper presents a case study on integrating mental health services into value-based contracts. It examines the unique challenges of applying value-based models to mental health care, such as measuring outcomes, managing risk, and coordinating care between behavioral and physical health. The paper provides insights into successful strategies for overcoming these challenges, including establishing clear performance metrics and aligning incentives to support both clinical and financial goals.
https://www.mentorresearch.org/intersection-of-mental-health-and-value-based-contracts-a-case-studyHealthy Versus Toxic Contracts
This discussion paper contrasts healthy and toxic contracts in healthcare and examines how contract conversations and audits can either strengthen or undermine provider-health plan relationships. It outlines the characteristics of healthy contracts, such as clear terms, mutual accountability, and ethical safeguards, compared to toxic agreements that impose unfair conditions and lack transparency. The paper discusses the role of audits in ensuring contract compliance and offers strategies for fostering constructive dialogue to promote ethical contracting.
https://www.mentorresearch.org/healthy-toxic-contracts-conversations-and-auditsInformed Consent Motivates Patients to Game Outcome Measures
This discussion paper examines how informed consent requirements can unintentionally encourage gaming of outcome measures in value-based contracts. It explains how the transparency needed for patient consent might lead some providers to manipulate data or selectively report outcomes to align with performance benchmarks. The paper discusses the ethical dilemmas this creates and offers strategies to mitigate gaming, including clearer metrics, better oversight, and adjustments to consent processes.
https://www.mentorresearch.org/informed-consent-motivates-gaming-outcome-measuresEthics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services
This discussion paper defines an ethics point portal and explores how these portals provide a secure and anonymous way for providers to report unethical practices, compliance issues, or contract violations. The paper highlights the role of ethics point portals in promoting transparency, accountability, and trust within organizations. Recommendations for implementing effective portals, including ensuring accessibility and independence from management, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefitsEthics-Point Portals Overseen by Independent Certified Internal Auditor's: A Resource to Serve Stakeholders and the Healthplans
This discussion paper explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper outlines the benefits of this structure, including enhanced trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for establishing and maintaining independent audit oversight are also provided.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditorThe Results of Audits and Mitigation Options Should be Posted on a Public Electronic Platform Webpage
This discussion paper explains how publicly accessible information can enhance transparency, reduce misunderstandings, and allow for greater accountability in contract negotiations. The paper discusses how this practice supports ethical contracting by enabling providers and stakeholders to review and compare contract terms easily. Strategies for implementing public posting while protecting sensitive information are also outlined.
https://www.mentorresearch.org/posted-on-a-public-electronic-platform-webpageContracts And Policies Shall Undergo 90 To 120-Day Review Period To Gather Stakeholder Feedback
This discussion paper advocates for requiring health plan contracts and policies to undergo a 90- to 120-day review period to gather stakeholder feedback. It explains how this extended review process allows providers, patients, and other stakeholders to assess terms, identify potential issues, and suggest improvements before agreements are finalized. The paper highlights how this approach promotes transparency, prevents misunderstandings, and leads to more balanced and effective contracts. Recommendations for structuring the review period to maximize stakeholder input are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-undergo-90-to-120day-review-period-to-gather-stakeholder-feedbackBreaking 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-healthplanmandates
Independent Certified Internal Auditor
Independent Certified Internal Auditor – Example Job Description
This discussion paper defines the role of an independent certified internal auditor (CIA) in health plan contracting and governance. It explains how having an independent auditor ensures that compliance reviews and investigations into unethical practices are conducted impartially. The paper highlights the benefits of using certified internal auditors, including increased trust, transparency, and accountability in health plan operations. Recommendations for integrating independent CIAs into organizational oversight structures are also discussed.
https://www.mentorresearch.org/independent-certified-internal-auditorA Case For The Value and Importance Of Independent Internal Auditors In Contracting For Fee-For-Service, Alternative, and Value-Based Mental And Behavioral Health Services
This discussion paper examines the value and importance of independent internal auditors in health plan contracting. It explains how independent auditors provide objective oversight, detect compliance issues, and ensure that contract terms are upheld fairly. The paper highlights the role of independent internal auditors in promoting ethical practices, reducing fraud, and enhancing trust between providers and health plans. Recommendations for implementing effective audit processes and ensuring auditor independence are also provided.
https://www.mentorresearch.org/value-and-importance-of-independent-internal-auditorsHow Can an Independent Certified Internal Auditor Support Mental and Behavioral Health Contracting
This discussion paper explores how an independent certified internal auditor (CIA) can support health plan contracting and compliance. It explains how CIAs provide objective oversight by identifying unethical practices, ensuring adherence to contractual terms, and enhancing transparency. The paper discusses the benefits of using independent auditors, such as improved accountability, reduced fraud risk, and increased trust between health plans and providers. Strategies for integrating independent auditors into governance frameworks are also outlined.
https://mentorresearch.org/how-can-an-independent-certified-internal-auditor-supportHow 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-auditorsIndependent Certified Internal Auditor: The Bridge Between Stakeholder and the Healthplan
This discussion paper advocates for independent auditors to serve as a point of contact for stakeholders in health plan contracts. It explains how having auditors in this role enables stakeholders to report concerns about unethical practices or contract violations safely and confidentially. The paper outlines benefits such as improved transparency, enhanced trust, and more effective resolution of compliance issues. Strategies for maintaining auditor independence and ensuring that stakeholder input is addressed impartially are also discussed.
https://www.mentorresearch.org/auditor-shall-be-a-point-of-contact-for-stakeholdersThe Independent Certified Internal Auditor Shall Audit Reports Registered in the Online Ethics Point Portal that Pertain to Mental and Behavioral Health Service Contracts and Policies
This discussion paper explores the role of independent auditors in reviewing reports registered through health plan ethics portals. It explains how auditors can verify the accuracy of these reports, identify patterns of unethical behavior, and ensure that concerns are addressed transparently. The paper highlights how independent audits promote accountability and reduce the risk of retaliation against those who report issues. Recommendations for structuring audit processes and maintaining auditor impartiality are also provided.
https://www.mentorresearch.org/auditor-shall-audit-reports-registeredThe Independence of Healthplan Auditors Must Comport with Standards Set the U.S. Office of Inspector General (OIG)
This discussion paper outlines the value of using Office of Inspector General (OIG) standards in health plan contracting and compliance. It explains how OIG standards provide a framework for preventing fraud, waste, and abuse through clear guidelines on ethics, accountability, and internal controls. The paper discusses how adopting these standards can promote transparency, enhance oversight, and build trust between providers and health plans. Recommendations for integrating OIG standards into organizational policies and practices are also included.
https://www.mentorresearch.org/why-use-oig-standardsWhat Can Certified Internal Auditors Do That Will Prevent Healthplans From “Gaming” Providers, Purchasers, and The Public?
This discussion paper examines how value-based contracts can be manipulated through gaming tactics. It describes strategies such as selectively choosing patients, inflating risk scores, and misrepresenting outcomes to maximize financial incentives while undermining the contract’s intent. The paper discusses the impact of these practices on care quality, provider trust, and the effectiveness of value-based models. Recommendations for preventing gaming, including implementing clearer performance metrics and stronger oversight, are also provided.
https://www.mentorresearch.org/gaming-a-valuebased-contractWhy is Hiring an Independent Certified Internal Auditor a Good Idea?
This discussion paper highlights the benefits of hiring an independent certified internal auditor (CIA) in health plan contracting. It explains how CIAs provide objective oversight, identify compliance issues, and ensure that contractual obligations are met fairly. The paper discusses how using independent auditors can promote transparency, reduce fraud risk, and build trust between contracting parties. Recommendations for selecting and integrating independent auditors into organizational governance are also included.
https://www.mentorresearch.org/why-hiring-an-independent-certified-internal-auditor-is-a-good-idea
Value, Objectives, Controls, Tests of Design and Effectiveness, Key Indicators of Success
Controls 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-controlWhat is a Control Library?
This discussion paper explains the purpose and benefits of maintaining a control library in health plan contracting. It describes how a control library serves as a centralized repository of all policies, procedures, and compliance measures used to monitor and manage contract performance. The paper highlights how a well-organized control library supports transparency, standardizes practices, and ensures that all stakeholders are aligned on compliance expectations. Recommendations for building and maintaining an effective control library are also discussed.
https://www.mentorresearch.org/control-libraryControls, Tests of Design (TOD) and Tests of Effectiveness (TOE) in Measurement and Value-Based Contracting For Mental and Behavioral Health Services
The paper outlines the distinction between tests of design and tests of effectiveness in healthcare programs and interventions. It contrasts how design tests assess whether an intervention is implemented as intended, while effectiveness tests evaluate the outcomes and impact on target populations. The discussion emphasizes the importance of using both types of assessments to ensure interventions are not only well-constructed but also achieve meaningful results in real-world settings.
https://www.mentorresearch.org/tests-of-design-and-tests-of-effectivenessCore Psychotherapy Values and the Erosion by Healthplan Practices
This discussion paper explores the concepts of tests of design and tests of effectiveness in health plan contracting. It explains how tests of design evaluate whether a control is appropriately structured to meet its objectives, while tests of effectiveness assess whether the control is functioning as intended in practice. The paper highlights the importance of using both types of tests to ensure robust compliance and reduce risks. Recommendations for implementing these tests and addressing deficiencies are also provided.
https://www.mentorresearch.org/core-psychotherapy-values-and-the-erosion-by-healthplan-practicesImportance of Transparent Shared Values, Objectives, Controls, Key Indicators of Success, Tests of Design, and Tests of Effectiveness in Value-Based Payment Contracts for Mental and Behavioral Health Services
This discussion paper examines the importance of shared values, objectives, and indicators of success in health plan contracting. It explains how aligning these elements between providers and health plans promotes mutual trust, enhances collaboration, and supports long-term success. The paper outlines strategies for defining common goals and establishing clear performance metrics to ensure that all parties are working toward the same outcomes. Recommendations for maintaining alignment and addressing conflicts are also included.
https://www.mentorresearch.org/importance-of-shared-values-objectives-indicators-of-success
Ethics Point Portal
Ethics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services
This discussion 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-auditorThe Results of Audits and Mitigation Options Should be Posted on a Public Electronic Platform Webpage
This discussion paper advocates for posting health plan contracts and policies on a public electronic platform or webpage. It explains how public access to these documents can enhance transparency, reduce misunderstandings, and allow for greater accountability in contract negotiations. The paper highlights the benefits of this approach, such as enabling stakeholders to review and compare contract terms more easily. Strategies for implementing public posting while protecting sensitive information are also provided.
https://www.mentorresearch.org/posted-on-a-public-electronic-platform-webpageThe Independent Certified Internal Auditor Shall Audit Reports Registered in the Online Ethics Point Portal that Pertain to Mental and Behavioral Health Service Contracts and Policies
This discussion paper examines the role of independent auditors in reviewing reports registered through health plan ethics portals. It explains how auditors can verify the accuracy of these reports, identify patterns of unethical behavior, and ensure concerns are addressed transparently. The paper highlights how independent audits promote accountability and reduce the risk of retaliation against those who report issues. Recommendations for structuring audit processes and maintaining auditor impartiality are also discussed.
https://www.mentorresearch.org/auditor-shall-audit-reports-registeredEmpowering Providers to Report Suspicious, Unethical, and Illegal Behaviors
The paper discusses strategies for empowering healthcare providers to report unethical, illegal, and suspicious behaviors. It emphasizes the importance of establishing clear reporting channels, protections against retaliation, and education on recognizing misconduct. The discussion highlights how fostering a culture of accountability and transparency can encourage providers to act without fear, ultimately improving the integrity and quality of healthcare services.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviorsContracts And Policies Shall Be Written In Plain, Understandable Language
This discussion paper advocates for health plan contracts and policies to be written in plain language. It explains how complex legal jargon can create confusion, hinder compliance, and lead to disputes between providers and health plans. The paper highlights the benefits of using clear and straightforward language, including improved communication, enhanced trust, and more efficient contract implementation. Strategies for adopting plain language standards and examples of effective contract language are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-be-written-plain-language
Audits
Medically Necessary and Reasonable Psychotherapy Services
This discussion paper explores the definitions and implications of the terms “medically necessary” and “reasonable” in health plan contracts. It explains how varying interpretations of these terms can impact service authorization, reimbursement, and patient access to care. The paper highlights how unclear definitions can lead to disputes between providers and health plans and recommends adopting standardized language to ensure consistent decision-making and promote fair coverage practices.
https://www.mentorresearch.org/medically-necessary-reasonableFive Types of Psychotherapy Audits
This discussion paper explores the purpose and impact of psychotherapy practice audits in health plan contracting. It describes how audits assess clinical practices, adherence to contract terms, and billing accuracy. The paper highlights both the potential benefits, such as enhancing care quality and ensuring compliance, and the risks, including the possibility of being used to reduce provider reimbursements or impose punitive measures. Recommendations for navigating audits and maintaining practice integrity are also provided.
https://www.mentorresearch.org/psychotherapy-practice-audits
Healthplan and Medicare Advantage Risk Scores and “Clawbacks”
This discussion paper examines Medicare Advantage risk adjustments and clawback practices. It explains how health plans use risk adjustments to modify payments based on the health status of enrollees and how clawbacks are implemented to recover funds when risk scores are later adjusted. The paper highlights concerns about the potential for manipulation, which can lead to financial instability for providers. Strategies for managing risk adjustments and ensuring fair reimbursement practices are also discussed.
https://www.mentorresearch.org/medicare-advantage-risk-adjustments-and-clawbacks
Employee Retirement Income Security Act (ERISA)
ERISA and The History Of Conflict With Psychotherapy Practice
This discussion paper examines the history of conflict between the Employee Retirement Income Security Act (ERISA) and psychotherapy practice. It explains how ERISA’s preemption of state regulations has led to challenges in enforcing mental health parity and fair reimbursement practices. The paper outlines the impact of ERISA on psychotherapy services, including limitations on provider protections and patients’ ability to appeal denied claims. Strategies for addressing these conflicts, such as legislative reforms and enhanced provider advocacy, are also discussed.
https://www.mentorresearch.org/erisa-and-the-history-of-conflict-with-psychotherapy-practiceAlignment of ERISA with Healthy Contracts Legislation: Supported by Federal Regulations
This discussion paper explores how aligning ERISA with healthy contracts legislation is supported by federal regulations. It explains how recent regulatory changes aim to enhance transparency, accountability, and fairness in health plan contracting. The paper discusses how aligning ERISA provisions with these goals can address historical conflicts, improve provider protections, and support more equitable contract practices. Strategies for leveraging federal regulations to promote healthy contracts in psychotherapy and other healthcare services are also outlined.
https://www.mentorresearch.org/aligning-erisa-with-healthy-contracts-legislation-is-supported-by-federal-regulationsUnderstanding and Overcoming ERISA Preemption Doctrine using Healthy Contracts
This discussion paper explores how providers can address the challenges of ERISA by implementing healthy contract principles. It explains how ERISA’s preemption of state laws creates barriers to enforcing fair reimbursement and provider protections. The paper outlines strategies such as using clear contract language, advocating for federal compliance, and leveraging recent regulatory changes to improve fairness in ERISA-governed health plans. Recommendations for aligning contracts with healthy practices to protect provider interests and ensure ethical contracting are also discussed.
https://www.mentorresearch.org/understanding-and-overcoming-erisa-using-healthy-contracts
Legislative Opportunities
3 Ways to Improve House Bill 4069.
https://www.mentorresearch.org/3-ways-to-improve-house-bill-4069Fiduciary Responsibility in Healthplan Contracting: A Critical Examination
https://www.mentorresearch.org/fiduciary-responsibility-in-healthplan-contracting-a-critical-examinationWill Healthplans Support the Healthy Contracts Legislation?
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-fail
Healthplan Waste
Charting Requirements are Not Patient-Centered
This discussion paper critiques how standard charting requirements in health plan contracts can be misaligned with patient-centered care. It explains how these requirements often prioritize administrative needs, such as billing and compliance, over clinical relevance and patient engagement. The paper highlights how excessive documentation can burden providers and detract from the therapeutic process. Recommendations for creating charting practices that better support patient-centered care, while still meeting regulatory and contractual obligations, are also discussed.
https://www.mentorresearch.org/charting-requirements-are-not-patient-centeredWhat is the Value of Charting in Psychotherapy Practice?
This discussion paper examines the value of psychotherapy charting in the context of health plan requirements. It explains how detailed and meaningful documentation can support treatment planning, demonstrate clinical effectiveness, and justify the medical necessity of services. The paper contrasts this with the risks of over-documentation, which can increase administrative burden and reduce time for patient care. Strategies for balancing thorough charting with efficiency and maintaining alignment with value-based care principles are also provided.
https://www.mentorresearch.org/value-psychotherapy-chartingPsychotherapy Treatment Plans & Progress Notes can Have Chilling Effects on Patients, Outcomes, Satisfaction and Dropout
This discussion paper explores the "chilling effect" that excessive charting requirements can have on patient outcomes in psychotherapy. It explains how overemphasis on documentation for compliance and billing purposes can undermine the therapeutic relationship, reduce patient trust, and shift the focus away from patient-centered care. The paper discusses how these practices may discourage open communication, impacting the quality of care and treatment effectiveness. Strategies for minimizing the negative impact of charting requirements while maintaining necessary compliance are also provided.
https://www.imhpa.org/charting-chilling-effect-on-patients-outcomesMeasurement-Based and Outcome Informed Care: Enhancing Mental Health Treatment Outcomes
This discussion paper explores the "chilling effect" that excessive charting requirements can have on patient outcomes in psychotherapy. It explains how overemphasis on documentation for compliance and billing purposes can undermine the therapeutic relationship, reduce patient trust, and shift the focus away from patient-centered care. The paper discusses how these practices may discourage open communication, impacting the quality of care and treatment effectiveness. Strategies for minimizing the negative impact of charting requirements while maintaining necessary compliance are also provided.
https://www.mentorresearch.org/comparing-measurement-basedcare-and-feedback-informed-treatmentMedically Necessary and Reasonable Psychotherapy Services
This discussion paper explores the definitions and implications of the terms “medically necessary” and “reasonable” in health plan contracts. It explains how varying interpretations of these terms can influence service authorization, reimbursement, and patient access to care. The paper highlights how unclear definitions can lead to disputes between providers and health plans, impacting clinical decision-making and coverage determinations. Recommendations for adopting standardized language to ensure consistency and fairness in medical necessity determinations are also provided.
https://www.mentorresearch.org/medically-necessary-reasonable
Practice Models and Considerations
The End of Fee-for-Service.
https://www.mentorresearch.org/the-end-of-feeforservicePractice Opportunities for Early and Mid-Career Psychotherapists. (5 models & 3 Ways to Get Paid)
https://www.mentorresearch.org/practice-opportunities-for-early-and-midcareer-psychotherapistsThe Future of Independent Private Practice Mental Health Services Requires Legislation to Protect Stakeholders.
https://www.mentorresearch.org/the-future-of-independent-private-practice-mental-health-servicesPsychotherapist Employment Type and Tax Consequences.
https://www.mentorresearch.org/psychotherapist-employment-type-and-tax-consequencesWhat do Healthplans Want from Psychotherapists?
https://www.mentorresearch.org/what-do-healthplans-want-from-psychotherapistsOrganization Advantages and Disadvantages of Being a Member of an IPA vs. a Group Practice.
https://www.mentorresearch.org/advantages-and-disadvantages-of-being-a-ipa-or-group-practiceFinancial Advantages and Disadvantages of IPAs and Group Practices.
https://www.mentorresearch.org/financial-advantages-and-disadvantages-of-ipas-and-group-practicesSole Proprietor, W-2 and 1099: Psychotherapy Practice Employment Options.
https://www.mentorresearch.org/sole-proprietor-w2-and-1090-counseling-and-psychotherapy-practiceFormation of Independent Practice Associations to Protect Private Psychotherapy Practice.
https://www.mentorresearch.org/formation-of-an-independent-practice-associationFinancial Advantages and Disadvantages of IPAs and Group Practices.
https://www.mentorresearch.org/financial-advantages-and-disadvantages-of-ipas-and-group-practices
Venture Capital Competition with Independent Private Practice
What do Healthplans and Venture Capital Want Independent Psychotherapists to Do?
https://www.mentorresearch.org/what-do-healthplans-want-from-independent-psychotherapistsHeadway Business Model - Mental Health.
https://www.mentorresearch.org/headway-business-model-mental-healthSpring Health Business Model - Mental Health.
https://www.mentorresearch.org/spring-health-business-model-mental-healthCerebral Business Model - Mental Health
https://www.mentorresearch.org/healthy-contracts-bill-definitions
Antitrust and Federal Trade Commission (FTC) - Background
Timeliness and Compliance in Mitigating Antitrust Violations for Healthplans.
https://www.mentorresearch.org/timeliness-and-compliance-in-mitigating-antitrust-violations-for-health-plansWhat is a Rule of Reason Analysis?
https://www.mentorresearch.org/what-is-a-rule-of-reason-analysisKey Antitrust Implication to Protect the Public, and Mental and Behavioral Health Provider.
https://www.mentorresearch.org/key-antitrust-acts-in-the-united-statesThe Antitrust Laws. The Antitrust Division. U.S. Department of Justice.
https://www.justice.gov/atr/antitrust-laws-and-youDealings with Competitors.
https://www.ftc.gov/advice-guidance/competition-guidance/guide-antitrust-laws/dealings-competitorsCompetition in the Health Care Marketplace.
https://www.ftc.gov/advice-guidance/competition-guidance/industry-guidance/competition-health-care-marketplace
Healthplan Discussion Papers
DISCLAIMER and PURPOSE: These discussion documents are intended for training, education, and 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