Moda Health Discussion Papers
Exposing Loopholes: How Health Plans Can Exploit Regulatory Gaps
This article examines how health plans, such as Moda Health, can exploit regulatory gaps to engage in unethical practices with minimal risk of consequences. It highlights the lack of effective legal channels in Oregon for healthcare providers to report unethical or illegal behavior by health plans, leading to unchecked power and potential harm to patients and providers. The article 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. It also calls for legislative action to address these regulatory gaps and hold health plans accountable for their actions.
https://www.mentorresearch.org/exposing-loopholesModa Health's Termination of Contract Negotiations When Asked to Ensure Ethical and Lawful Contracts and Policies
The article discusses the abrupt termination of contract negotiations by Moda Health with the Mentor Research Institute (MRI). Despite initial agreements to evaluate proposals for establishing an ethics point portal overseen by an independent auditor, Moda Health ceased discussions without clear justification. Since the State of Oregon will not investigate provider evidence and complaints regarding fraud or violations state and federal antitrust laws, this action raises concerns about Moda's commitment to ethical oversight, transparency, and good faith negotiations. The article suggests that such behavior may indicate a reluctance to implement independent auditing mechanisms, potentially to avoid external scrutiny of their contracting practices. This termination not only undermines trust between the parties involved but also highlights broader issues within healthcare contracting, where power imbalances and lack of accountability can adversely affect provider practices and patient care.
https://www.mentorresearch.org/moda-health-termination-of-contract-negotiations-with-mentor-research-instituteAllegations of Bad Faith, Fraud and Antitrust Violations by Moda Health Submitted to the Oregon Health Authority - Whistleblower Complaint This paper discusses whistleblower allegations against Moda Health, including claims of bad faith contracting, fraud, and antitrust violations. It details how Moda allegedly uses deceptive contract terms and restrictive policies to limit competition and undermine independent practices. The article also compares these practices with legal standards to highlight potential breaches of antitrust and healthcare regulations, supporting the need for legal intervention.
https://www.mentorresearch.org/whistleblower-complaint-allegations-of-bad-faith-fraud-and-antitrust-violations-by-moda-healthAnalysis of Moda Health's Code of Conduct and Allegations of Violations - Appendix 1
The article examines discrepancies between Moda Health's publicly stated Code of Conduct and its actual contracting practices with healthcare providers. Allegations include mid-contract changes to performance metrics, retroactive penalties, and a lack of transparency in financial calculations, which contradict Moda’s commitments to fairness and integrity. These actions have led to provider mistrust and raise concerns about whether Moda Health is adhering to its own ethical standards. The article underscores the need for independent oversight and regulatory intervention to ensure accountability and fairness in Moda’s business practices.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violationsProtecting Minorities and Underserved Populations: Value-Based Contract Challenges
The article discusses the need for safeguards in value-based contracts to protect minority and underserved populations from systemic inequities. It emphasizes the importance of standardized definitions, clear language, whistleblower protections, and independent oversight to prevent exploitation and ensure transparency. Without these measures, providers serving vulnerable communities may face financial instability, limiting patient access to care. The article advocates for equitable contracting practices that promote health equity and sustainable care models.
https://www.mentorresearch.org/value-based-contracts-protecting-minorities-and-underserved-populationEmpowering Providers to Report Suspicious, Unethical, and Illegal Behaviors
The article highlights the importance of supporting healthcare providers in reporting unethical, illegal, or suspicious practices within value-based contracts and broader healthcare systems. It discusses barriers to reporting, such as fear of retaliation, lack of clear reporting channels, and contractual restrictions imposed by health plans. The article advocates for stronger whistleblower protections, independent oversight, and transparent reporting mechanisms to ensure providers can expose fraud, coercion, and unethical practices without jeopardizing their careers. Strengthening these safeguards is essential for maintaining ethical healthcare delivery and protecting both providers and patients.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviorsIs 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-lawOregon 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-contractingValue-Based Contracts: Protecting Minorities and Underserved Populations
The article discusses the critical need for incorporating standardized definitions, plain language requirements, whistleblower protections, and independent oversight into value-based contracts to safeguard minority and underserved populations. Without these provisions, systemic inequities may persist, leading to reduced access to care and financial instability for providers serving these communities. The article advocates for clear contractual terms to prevent exploitation, ensure transparency, and promote health equity.
https://www.mentorresearch.org/value-based-contracts-protecting-minorities-and-underserved-populationIMHPA Collaboration with Moda Health for VBC, VBP, VBR, MBC, OIC (2022)
This discussion paper reviews the collaboration between MRI, AMHA (now IMHPA), and Moda Health to implement measurement-based care (MBC). It discusses the goals of the partnership, including enhancing care quality, improving patient outcomes, and integrating standardized outcome measures into clinical practice. The paper outlines the challenges encountered during the collaboration, such as aligning stakeholders and managing data integration, while highlighting strategies that were used to overcome these barriers and promote successful implementation of MBC.
https://www.mentorresearch.org/mri-amha-x-collaboration-for-mbcBreaking 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-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-mandatesPrima-Facie Evidence of Moda Health Fraud and Violation of Antitrust Laws: The Need for Guardrails and Firewalls
This article outlines allegations of fraud and antitrust violations involving Moda Health. It presents prima facie evidence that Moda manipulated contracts and engaged in deceptive practices that could undermine fair competition and inflate healthcare costs. The analysis includes specific contract clauses, patterns of behavior, and the impact on independent providers. The content discusses how these practices may violate both state and federal laws, emphasizing the need for regulatory oversight and legal accountability.
https://www.mentorresearch.org/prima-facie-evidence-of-moda-health-fraud-and-violation-of-antitrust-lawsAnnouncement 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-addendumContract 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-plansRule of Reason Analysis Using Prima-Facia Evidence of Fraud and Violations of Antitrust and Federal Regulations
The paper presents a rule-of-reason analysis framework applied to prima facie evidence in cases of antitrust violations. It explains how this legal approach evaluates whether a practice unreasonably restrains trade by considering its intent, impact, and potential justifications. The discussion highlights the application of this framework to healthcare contracts, emphasizing its role in identifying anti-competitive behaviors and ensuring fair market practices.
https://www.mentorresearch.org/rule-of-reason-analysis-using-primafacia-evidenceWhy Teachers, Counselors and Legislators Should Support the Healthy Contracts Legislation.
This discussion article outlines the need for healthy contract legislation to protect teachers, counselors, and other public sector employees from unfair health plan agreements. It explains how such legislation can promote transparency, prevent coercive practices, and ensure that contract terms prioritize employee well-being and access to care. The article highlights key legislative components, including standardized contract language, ethical oversight, and enforceable protections, to support fair and sustainable agreements in public sector employment.
https://www.mentorresearch.org/why-teachers-counselors-and-legislators-healthy-contract-legislationBait 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-tacticsIs Moda Health Violating Antitrust Law?
This discussion paper explores whether Moda Health’s contracting practices may violate antitrust laws. It analyzes behaviors such as limiting provider networks, restricting competition, and employing exclusionary tactics, which could create unfair market advantages. The paper discusses potential antitrust implications, including impacts on market pricing, provider autonomy, and patient access to care. Recommendations for further investigation and strategies to address potential antitrust violations are also provided.
https://www.mentorresearch.org/is-moda-health-violating-antitrust-lawWill the Moda Measurement and Value-Based Payment Contract for Mental and Behavioral Services Fail?
This paper analyzes why Moda Health’s value-based contract is likely to fail. It highlights issues such as poorly defined performance metrics, misaligned incentives, and an inadequate understanding of patient complexities that can undermine contract success. The paper discusses how these shortcomings can lead to ineffective care, provider disengagement, and financial instability. Recommendations for addressing these pitfalls and improving contract design to support meaningful value-based outcomes are also provided.
https://www.mentorresearch.org/why-the-moda-value-based-contract-will-almost-certainly-failMODA Behavioral Health Incentive Program (BHIP): Bold and Reckless?
This discussion article analyzes why Moda Health’s value-based contract is likely to fail. It highlights issues such as poorly defined performance metrics, misaligned incentives, and an inadequate understanding of patient complexities that can undermine contract success. The paper discusses how these shortcomings can lead to ineffective care, provider disengagement, and financial instability. Recommendations for addressing these pitfalls and improving contract design to support meaningful value-based outcomes are also provided.
https://www.mentorresearch.org/moda-behavioral-contract-bold-or-recklessFiduciary Responsibility in Healthplan Contracting: A Critical Examination.
This paper critically examines the concept of fiduciary responsibility in health plan contracting. It explains how fiduciary duties, such as acting in the best interest of beneficiaries and maintaining transparency, are often overlooked or undermined in health plan agreements. The paper discusses common violations, including conflicts of interest and prioritizing cost savings over patient care. Strategies for strengthening fiduciary accountability and ensuring that contracts align with ethical obligations are also provided.
https://www.mentorresearch.org/fiduciary-responsibility-in-healthplan-contracting-a-critical-examinationIMHPA and X 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-mbc
Fiduciary 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.
Technology for Advancing Behavioral Health Integration
The article discusses the critical role of technology in enhancing behavioral health integration (BHI) within healthcare systems. It identifies key challenges in BHI, such as care fragmentation, limited access, and persistent stigma surrounding mental health services. To address these issues, the article advocates for the adoption of various technological solutions:
Centralized Data Integration: Utilizing electronic health records (EHRs) and health information exchanges (HIEs) to facilitate seamless communication among providers.
Digital Tools: Implementing mobile applications, telehealth platforms, and patient portals to increase patient engagement and convenience.
Advanced Technologies: Employing artificial intelligence (AI) and predictive analytics to identify at-risk patients, customize treatment plans, and predict outcomes.
The article highlights the benefits of these technological adoptions, including improved care coordination, personalized patient care through remote monitoring and real-time feedback systems, operational efficiencies via automation, and expanded access to services for remote or underserved populations. However, it also acknowledges barriers to implementation, such as resource limitations for smaller practices and provider resistance to adopting new technologies. The article concludes by emphasizing the need for strategic planning, investment, and training to overcome these challenges and fully realize the potential of technology in advancing BHI.
https://www.mentorresearch.org/technology-for-advancing-behavioral-health-integration
Value-Based Payment Contracting for Psychotherapy Services: Requirements and Challenges
This draft discussion paper, dated April 2024, provides a comprehensive overview of the complexities involved in implementing value-based payment (VBP) models within psychotherapy services. It emphasizes the shift from traditional fee-for-service models to VBP, which focuses on quality and patient outcomes rather than service volume. The paper outlines the high risks and complexities associated with VBP contracting, highlighting the need for provider practices to possess significant experience, resources, and strategic approaches to navigate these intricacies effectively.
Key Points:
High-Level Guidance and General Challenges: The transition to VBP in psychotherapy demands expert knowledge, appropriate business structures, financial resources, and experience in contract administration, internal auditing, and risk management. Providers must meet health plan targets while negotiating contracts that allow for reasonable profit and manage the probable risk of financial loss.
Requirements for Successful Implementation: Effective VBP implementation necessitates significant investment by health plans, technology adoption, knowledge of psychotherapy, data analytics, and ethical practices. Provider groups need extensive experience in measurement-based care (MBC) and the capability to gather, aggregate, and analyze data to establish baselines and benchmarks for successful contract negotiation and management.
Opportunities and Challenges with VBP: VBP presents opportunities for improving treatment adherence, patient-centric care models, quality improvement, and incentivization of effective providers. However, challenges include the rarity of independent psychotherapists in VBP arrangements, lack of standardized outcome measures, separation from physical health care systems, undervaluation by payers, complexity of mental health conditions, ethical considerations, risk of adverse selection, and resource limitations.
Negotiating VBP Contracts: The paper outlines strategies for negotiating VBP contracts, emphasizing the importance of assessing provider practice capabilities, understanding the value proposition, identifying measurable outcomes, evaluating legal terms and financial risks, and fostering collaboration and partnership with payers.
Potential Pitfalls and Challenges: Participating in a VBP contract can lead to loss of control over patient care, fragmentation of services, challenges with performance metrics, financial risks, and potential for increased administrative burdens.
The document serves as a living resource, subject to revision as new information and perspectives emerge, aiming to guide providers through the evolving landscape of value-based payment in psychotherapy services.
https://www.mentorresearch.org/value-based-payments-psychotherapy
Erosion of Trust in Moda Health Value-Based Contracts
The article examines how Moda Health's value-based contracts for psychotherapy services have led to a breakdown in trust between providers and the insurer. Key issues include ambiguous contract terms, lack of transparency in data handling, unfair financial risk distribution, and administrative burdens placed on providers without adequate support. These practices have resulted in providers feeling deceived and exploited, undermining the intended goals of value-based care and potentially destabilizing the mental health ecosystem. The article emphasizes the need for transparent contract terms, equitable financial arrangements, and independent oversight to rebuild trust and ensure the success of such healthcare initiatives.
https://www.mentorresearch.org/erosion-of-trust-in-moda-health-value-based-contracts
Comprehensive Library
Health Contracts - Discussion Papers
The Mentor Research Institute offers a comprehensive library of discussion papers aimed at educating providers, health plan managers, legislators, attorneys, and regulators on the design and implementation of ethical and effective healthcare contracts. These papers are organized by topic to facilitate targeted learning and address various aspects of healthcare contracting. Key categories include:
Definitions: Clarifying essential terms and concepts related to healthy contract design.
Proposals to Health Plans: Detailed proposals outlining collaborative initiatives between mental health providers and health plans to enhance services through value-based care and measurement-based care.
Systemic Health Plan Problems: Analyses of issues such as abrupt termination of contract negotiations by health plans, highlighting the need for ethical and lawful contracting practices.
Each category contains in-depth discussions that emphasize the importance of transparency, fairness, and mutual accountability in healthcare contracts. The library serves as a valuable resource for stakeholders aiming to promote ethical contracting and improve the quality of care in the healthcare system.
https://www.mentorresearch.org/healthy-contracts-categorized
DISCLAIMER and PURPOSE: This discussion document is intended for training, education, legislation or research purposes. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose