Moda Health's Termination of Contract Negotiations After Moda Negotiators Agreed to Ensure they Had a Certified Internal Auditor and an Ethics Point Portal
A Discussion Paper
In 2024, Moda Health abruptly terminated negotiations for a value-based payment contract, despite nearly a decade of collaboration with a group of providers and Mentor Research Institute (MRI). Moda's behavior demonstrated that MODA almost certainly intended to turn a blind eye to practices which violated state and federal guidelines, and potentially contravened laws designed to prevent fraud and antitrust violations. Moda initially agreed but then did not respond to concerns and recommendations for implementing a secure ethics point portal with independent oversight and fair auditing processes (widely accepted industry standards) which would ensure contractual integrity, safeguard patient and public health, and uphold ethical and lawful business practices.
For more information see:
Signs of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contract
Ethics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefits
Ethics-Point Portals Overseen by Independent Certified Internal Auditors (CIA):
A Resource to Serve Stakeholders and the Public.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditor
While companies generally retain the right to withdraw from negotiations before finalizing a contract, such actions must be conducted with fairness and in good faith. The circumstances surrounding Moda’s abrupt withdrawal provides further evidence of Moda breaches of good faith, antitrust violations, and deceptive practices that merit closer examination under federal and state law. By withholding essential information necessary for fair contracting, Moda acted in bad faith, undermining the transparency and accountability required for ethical value-based payment agreements. By refusing to review the results of a risk-impacting objectives analysis and risk-control matrix, Moda declined to consider evidence of concerns which concluded that the MODA value-based payment contract had probable to almost certain risk of moderately severe to catastrophic impact on public health and the public health system.
For more information see:
Controls, Tests of Design (TOD) and Tests of Effectiveness (TOE) in Measurement and
Value-Based Contracting For Mental and Behavioral Health Services.
https://www.mentorresearch.org/tests-of-design-and-tests-of-effectiveness
Core Psychotherapy Values and the Erosion by Healthplan Practices.
https://www.mentorresearch.org/core-psychotherapy-values-and-the-erosion-by-healthplan-practices
Substantial evidence supports these concerns, including a comprehensive document library consisting of papers, years of emails, recorded conversations and negotiations, and multiple written proposals reflecting significant investments of time and financial resources by providers. Those efforts were dedicated to creating the administrative framework and technological infrastructure necessary to support sustainable value-based payments. While there are appropriate reasons and procedures for terminating negotiations, Moda’s actions raise serious legal and ethical questions about their commitment to fair dealing, good faith, and responsible contracting practices.
There are several potential reasons why Moda might have decided to terminate negotiations for a value based contract, even after initially agreeing to evaluate a proposal that Moda establish an ethics point portal over seen by an independent auditor. Here are some plausible explanations that might be considered:
Risk Management and Liability Concerns:
Moda may have re-evaluated the potential legal or reputational risks associated with establishing an ethics point portal. Independent auditing could expose them to scrutiny or highlight issues they were not prepared to address, leading to concerns about liability or regulatory repercussions.Internal Strategic Shifts:
Changes in internal leadership, priorities, or strategic direction could prompt a shift in negotiation goals. If key decision-makers at Moda have altered their stance on ethical oversight mechanisms or independent auditing, this may have led them to retract previous commitments.Cost and Resource Considerations:
Implementing an ethics portal and maintaining regular independent audits involves both financial and human resource investments. Moda might have reassessed these costs and determined that the expenditures were not justifiable relative to their expected benefits, especially if the perceived value of these measures was lower than initially estimated.Concerns About Operational Complexity:
Introducing an independent auditing system can complicate existing workflows and increase operational burdens. If Moda believed that these additional processes might hinder efficiency or lead to slower decision-making, they might have opted out of the negotiations to preserve a leaner operational model.Negotiation Leverage and Contractual Flexibility:
It is possible that Moda saw the ethical oversight measures as a negotiation tactic rather than an essential component of the contract. If they believed that the inclusion of these terms could reduce their negotiating leverage or introduce constraints that might limit future contractual flexibility, terminating the negotiations could be a strategic move.Differences in Ethical Philosophies or Expectations:
The disagreement might stem from a fundamental difference in how both parties view ethical oversight and transparency. Moda might have reservations about the proposed framework's effectiveness or its alignment with their internal ethics policies, leading to a breakdown in negotiations when these differences became too significant to reconcile.
Moda Health’s abrupt termination of negotiations regarding implementation of ethics point portal and independent auditing has raised significant concerns about contractual integrity, ethical business practices, and potential legal violations. While companies generally have the right to withdraw from negotiations before finalizing a contract, the circumstances surrounding Moda’s give more weight to allegations of bad faith, fraud, antitrust violations, and deceptive practices that warrant further examination under federal and state law.
Freedom of Contract vs. Good Faith Obligations
Under contract law, parties are generally free to negotiate and withdraw before reaching a binding agreement. However, many jurisdictions recognize an implied duty of good faith and fair dealing, which requires honest and fair engagement. If Moda’s termination was based on legitimate reassessments of cost, risk, or strategic shifts, their actions may be legally justifiable. However, if they withdrew in bad faith—such as to avoid transparency or oversight—there may be legal grounds for a claim of breach of good faith.
Moda’s failure to review documented concerns and follow through on prior commitments raises serious ethical questions. If MRI and other provider groups relied on Moda’s assurances and incurred significant costs in the expectation of a fair negotiation, there may be legal claims based on promissory estoppel or detrimental reliance. In such cases, if a party makes a promise that another party reasonably relies upon to their detriment, the withdrawing party could be held liable for damages.
For more information see:
Contract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-fail
Potential Antitrust Violations
Beyond contract law, Moda’s actions may raise red flags under federal and state antitrust laws.
The Sherman Act (15 U.S.C. §§ 1-7) prohibits agreements that restrain trade or limit competition. If Moda’s decision was part of a broader strategy to suppress competition or restrict transparency in value-based contracting, their conduct could be subject to antitrust enforcement.
The Clayton Act (15 U.S.C. § 12, et seq.) prohibits business practices that unfairly disadvantage competitors. If Moda leveraged its dominant position to prevent fair negotiations, it could be engaging in anti-competitive conduct.
By withholding key information and avoiding accountability, Moda may be manipulating the market to the detriment of provider groups and patients. Their refusal to engage with independent auditing or discuss critical contractual concerns suggests an effort to maintain an unfair advantage in negotiations, raising concerns about monopolistic behavior.
FTC and Consumer Protection Implications
The Federal Trade Commission Act (15 U.S.C. §§ 41-58) empowers the FTC to investigate unfair methods of competition and deceptive trade practices. Moda’s refusal to engage in good faith negotiations, failure to review documented concerns, and misleading conduct could qualify as unfair and deceptive business practices under FTC regulations. If evidence emerges that Moda intentionally misled provider groups or engaged in predatory contracting behavior, federal enforcement actions could follow.
At the state level, Moda’s actions almost certainly violate consumer protection laws. The Oregon Unlawful Trade Practices Act (ORS 646.045 and ORS 646.055) prohibits unfair or deceptive business conduct. If Moda knowingly withheld critical information or engaged in misleading contracting practices that harmed provider groups and the broader healthcare system, they could face legal challenges from the Oregon Attorney General’s Office. Given that these negotiations impact provider groups across multiple states, this case may warrant multi-state enforcement actions coordinated among attorneys general.
For more information see:
Timeliness and Compliance in Mitigating Antitrust Violations for Healthplans.
https://www.mentorresearch.org/timeliness-and-compliance-in-mitigating-antitrust-violations-for-health-plans
What is a Rule of Reason Analysis?
https://www.mentorresearch.org/what-is-a-rule-of-reason-analysis
Key Antitrust Implication to Protect the Public, and Mental and Behavioral Health Provider.
https://www.mentorresearch.org/key-antitrust-acts-in-the-united-states
Manipulation of Provider Groups Through Asymmetric Power
Moda Health’s unethical contracting behavior has had widespread consequences, affecting up to 128 provider groups across multiple states. MRI has over a decade of experience in value-based contracting, giving it the expertise to ask critical questions and perform risk assessments—questions that many provider groups lack the knowledge to pose.
The absence of available information means providers are making decisions without a full understanding of the risks involved. Had Moda disclosed all relevant contractual risks, many provider groups might have chosen not to participate. By withholding critical details and failing to engage in transparent discussions, Moda has effectively manipulated provider groups into agreements that they may not have otherwise accepted.
This dynamic exemplifies the use of asymmetric power in healthcare contracting. Moda’s position as a dominant entity allows it to dictate terms while limiting access to crucial information. This behavior not only harms providers but also endangers patients, stakeholders, and public health. Ethical contracting demands fairness and full disclosure—principles that Moda has actively undermined.
For more information see:
Asymmetrical Information - Mitigating Adverse Effects.
https://www.mentorresearch.org/mitigating-asymmetrical-information
Addressing Asymmetric Power Dynamics and Ethical Concerns in Health Plan Contracts.
https://www.mentorresearch.org/addressing-asymmetric-power-dynamics-and-ethical-concerns-in-health-plan-contracts
Moda Health Violation of Their OWN Code of Conduct
Moda Health’s contract negotiations have been characterized by intimidation, misleading information, and the misuse of market power, all of which violate Moda’s published Code of Conduct. This code emphasizes ethical behavior, respect, and transparency—standards that Moda has clearly failed to uphold in these negotiations.
By refusing to engage in meaningful discussions, ignoring critical risk concerns, and leveraging its power to limit oversight, Moda has demonstrated willful negligence and a disregard for fair business practices. Their actions create financial, operational, and reputational harm to provider groups that have invested significant time and money into developing value-based contracts.
For more information see:
Analysis of Moda Health's Code of Conduct and Allegations of Violations.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violations
Regulatory and Legal Scrutiny is Warranted
Given the evidence of unethical contracting behavior, lack of good faith negotiations, potential violations of federal antitrust laws, FTC regulations, and Oregon consumer protection statutes, regulatory and legal scrutiny of Moda Health’s actions is both necessary and urgent.
Government agencies should investigate whether Moda’s refusal to engage in independent auditing and transparent contracting discussions constitutes bath faith, fraud, and or anti-competitive behavior. Provider groups and health plans affected by Moda’s actions should consider legal recourse, including potential claims for fraud, misrepresentation, and unfair business practices.
Conclusion
Moda Health’s decision to abruptly terminate negotiations is not merely a contractual setback—it is a calculated evasion of responsibility that harms provider groups, patients, and the integrity of the healthcare market. The stark contrast between MRI’s commitment to ethical value-based contracting and Moda’s deceptive contracting practices highlights the urgent need for greater transparency and accountability in healthcare negotiations.
If Moda’s withdrawal was motivated by a desire to avoid ethical scrutiny, suppress competition, or mislead providers into agreements based on incomplete information, they may be in violation of multiple federal and state laws. Given the potential harm to providers and patients, regulatory authorities should conduct a full investigation into Moda Health’s contracting behavior and take appropriate enforcement action to restore fairness in healthcare negotiations.
Proposed Legislation
Healthy Contracts Legislation Proposal
https://www.mentorresearch.org/healthy-contracts-legislation-proposal
References
Exposing Loopholes: How Health Plans Can Exploit Regulatory Gaps
This discussion document examines how health plans, such as Moda Health, exploit regulatory gaps in Oregon to engage in unethical practices with minimal risk of consequences. Despite efforts by organizations like the Mentor Research Institute (MRI) to promote ethical value-based payment contracting, health plans often operate without substantial oversight. MRI's attempts to address these issues through state agencies and legislative offices have highlighted the lack of effective legal channels for reporting and investigating health plan misconduct. The document emphasizes the need for substantial investments in oversight mechanisms, including outcome measurement technology, ethics point portals, and independent audits, to ensure ethical value-based payment contracting.
https://www.mentorresearch.org/exposing-loopholes-how-health-plans-can-exploit-regulatory-gaps-1Moda Health's Termination of Contract Negotiations After Moda Negotiators Agreed to Ensure they Had a Certified Internal Auditor and an Ethics Point Portal
The article discusses the abrupt termination of contract negotiations by Moda Health with the Mentor Research Institute (MRI). Despite initial agreements to evaluate proposals for establishing an ethics point portal overseen by an independent auditor, Moda Health ceased discussions without clear justification. Since the State of Oregon will not investigate provider evidence and complaints regarding fraud or violations state and federal antitrust laws, this action raises concerns about Moda's commitment to ethical oversight, transparency, and good faith negotiations. The article suggests that such behavior may indicate a reluctance to implement independent auditing mechanisms, potentially to avoid external scrutiny of their contracting practices. This termination not only undermines trust between the parties involved but also highlights broader issues within healthcare contracting, where power imbalances and lack of accountability can adversely affect provider practices and patient care.
https://www.mentorresearch.org/moda-health-termination-of-contract-negotiations-with-mentor-research-instituteAllegations of Bad Faith, Fraud and Antitrust Violations by Moda Health Submitted to the Oregon Health Authority - Whistleblower Complaint
This paper discusses whistleblower allegations against Moda Health, including claims of bad faith contracting, fraud, and antitrust violations. It details how Moda allegedly uses deceptive contract terms and restrictive policies to limit competition and undermine independent practices. The article also compares these practices with legal standards to highlight potential breaches of antitrust and healthcare regulations, supporting the need for legal intervention.
https://www.mentorresearch.org/whistleblower-complaint-allegations-of-bad-faith-fraud-and-antitrust-violations-by-moda-healthAnalysis of Moda Health's Code of Conduct and Allegations of Violations - Appendix 1
The article examines discrepancies between Moda Health's publicly stated Code of Conduct and its actual contracting practices with healthcare providers. Allegations include mid-contract changes to performance metrics, retroactive penalties, and a lack of transparency in financial calculations, which contradict Moda’s commitments to fairness and integrity. These actions have led to provider mistrust and raise concerns about whether Moda Health is adhering to its own ethical standards. The article underscores the need for independent oversight and regulatory intervention to ensure accountability and fairness in Moda’s business practices.
https://www.mentorresearch.org/analysis-of-moda-health-code-of-conduct-and-allegations-of-violationsProtecting Minorities and Underserved Populations: Value-Based Contract Challenges
The article discusses the need for safeguards in value-based contracts to protect minority and underserved populations from systemic inequities. It emphasizes the importance of standardized definitions, clear language, whistleblower protections, and independent oversight to prevent exploitation and ensure transparency. Without these measures, providers serving vulnerable communities may face financial instability, limiting patient access to care. The article advocates for equitable contracting practices that promote health equity and sustainable care models.
https://www.mentorresearch.org/value-based-contracts-protecting-minorities-and-underserved-populationCreating 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-servicesEmpowering 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-behaviorsHow 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-auditorsSuccessful and Failed Case Studies of Measurement-Based Care and Value-Based Payment Contracts: Recommended Requirements
This discussion article compares successful and failed value-based contracts in healthcare. It analyzes the key factors that contribute to each outcome, such as clear performance metrics, aligned incentives, and effective care coordination. The article highlights common pitfalls in failed contracts, including poor communication, misaligned goals, and inadequate data sharing. Lessons learned from these case studies are presented to guide the development of value-based contracts that can achieve better clinical and financial results.
https://www.mentorresearch.org/successful-and-failed-valuebased-contractsWhistleblower Protections in Oregon: Rights, Incentives, and the Role of Public and Private Funding
This discussion paper examines the varying degrees of legal safeguards and financial incentives available to whistleblowers in Oregon, contingent upon the nature of the funding involved—public or private. It highlights that individuals reporting misconduct related to public programs, such as Medicaid, Medicare, or the Oregon Health Plan, benefit from robust protections and potential financial rewards under statutes like the False Claims Act. Conversely, those disclosing issues within commercial health plans encounter more limited protections and lack financial incentives. The paper underscores the importance of consulting legal resources, including the Oregon Bureau of Labor and Industries (BOLI) or specialized attorneys, to navigate the complexities of whistleblower protections effectively, tailored to the specific funding context of the reported misconduct.
https://www.mentorresearch.org/whistleblower-protections-in-oregon-rights-incentives-and-the-role-of-public-and-private-fundingBreaking the Cycle of Unfunded Health Plan Mandates
The article discusses the challenges posed by health plans that impose administrative tasks on providers without offering corresponding compensation or support. This practice leads to operational inefficiencies, erodes trust between providers and payers, and hampers the effective implementation of value-based care models. The author advocates for health plans to invest in necessary infrastructure and collaborate with providers to ensure sustainable healthcare reform.
https://www.mentorresearch.org/breaking-the-cycle-of-unfunded-mandatesModa Health: Nine Actions and Their Consequences
The article examines nine specific actions taken by Moda Health in its contracting practices, highlighting the negative consequences for healthcare providers and the broader healthcare system. These actions include imposing non-negotiable contracts, utilizing ambiguous terms, retroactively altering performance metrics, and enforcing unfunded mandates. Such practices have led to increased administrative burdens, financial instability for providers, erosion of trust, and potential declines in patient care quality. The article advocates for transparent contracting, equitable risk-sharing, and independent oversight to mitigate these adverse effects and promote ethical value-based care.
https://www.mentorresearch.org/moda-health-9-actions-and-the-consequencesContract Negotiation Tactics Used by Health Plans
The article examines strategies employed by health plans during contract negotiations that can undermine mental health services by limiting providers' ability to negotiate effectively. These tactics include presenting non-negotiable, "take-it-or-leave-it" contracts; using strategic ambiguity to leave critical terms undefined; implementing contract ratcheting by progressively increasing administrative demands; maintaining network secrecy by withholding information about participating providers; and imposing unfunded mandates that require providers to absorb additional costs without reimbursement. By identifying these practices, providers can better anticipate potential risks and advocate for fairer contract terms during negotiations.
https://www.mentorresearch.org/contract-negotiation-tactics-used-by-health-plansThe Fallacy of Better, Cheaper, Faster: How Health Plans Shift Risk to Providers
The article examines how health plans promote value-based contracts under the premise of delivering better, cheaper, and faster healthcare services. In reality, these contracts often transfer significant financial and operational risks onto providers. Tactics include imposing rigid service caps, reducing payment rates, and increasing administrative burdens, all of which can lead to inadequate patient care and provider burnout. The article calls for greater transparency, fair contract terms, and regulatory oversight to ensure that health plans share financial risks equitably and invest in genuine improvements in care quality.
https://www.mentorresearch.org/the-fallacy-of-better-cheaper-faster“Solutionism” in Healthcare: Moda Health’s Contracting Approach and Consequences
The article critiques Moda Health's reliance on "solutionism" the belief that complex healthcare issues can be resolved through technical solutions without addressing underlying systemic problems. Moda's implementation of measurement-based care, incentive-based payments, and administrative streamlining is seen as superficial, failing to consider deeper issues such as unethical contracting practices, lack of transparency, and provider burnout. This approach may lead to unintended consequences, including reduced care quality and erosion of trust between providers and payers.
https://www.mentorresearch.org/solutionism-in-healthcare-moda-healths-contracting-approach-and-consequencesThe Dangers of Using an Ombudsman for Fraud and Antitrust Violations: Undermining Accountability and the Legal Process.
The paper discusses the risks of relying on ombudsmen to address cases of fraud and antitrust violations. It argues that ombudsmen may lack the authority and independence necessary to enforce accountability, potentially delaying or undermining legal actions. The discussion highlights how this approach can create conflicts of interest, allowing fraudulent practices to persist while giving a false impression of oversight. The paper advocates for stronger, independent regulatory mechanisms to handle such violations effectively.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrustContract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
This discussion paper analyzes various forms of contract gaming that can undermine the success of value-based contracts. It describes tactics such as manipulating patient risk scores, selective reporting of outcomes, and redefining performance metrics to skew results. The paper explains how these practices can distort the intended goals of value-based care, leading to mistrust and reduced effectiveness. Strategies to identify and prevent contract gaming, including stronger oversight and clearer definitions, are also discussed.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-failEthics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
This paper defines ethics point portals and outlines their benefits in health plan contracting. It explains how these portals provide a secure and confidential way for stakeholders to report unethical practices, compliance concerns, or contract violations. The paper highlights how ethics point portals promote transparency, accountability, and ethical conduct within organizations. Recommendations for implementing effective portals, including ensuring independence and accessibility, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefitsEthics-Point Portals Overseen by Independent Certified Internal Auditors (CIA): A Resource to Serve Stakeholders and the Public.
This discussion paper emphasizes the importance of having ethics point portals overseen by an independent certified internal auditor (CIA). It explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper highlights the benefits of this structure, such as increased trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for maintaining auditor independence and promoting transparent investigations are also included.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditorControls in Fee-For-Service, Alternative and Value-Based Payment Contracting.
This discussion paper defines the concept of a "control" in the context of health plan contracting and compliance. It explains how controls are mechanisms put in place to ensure that operations align with established policies, prevent unethical behavior, and detect potential issues. The paper outlines different types of controls, such as preventative, detective, and corrective controls, and discusses their role in promoting accountability and reducing risk. Strategies for implementing effective controls within contracting frameworks are also provided.
https://www.mentorresearch.org/what-is-a-controlSigns of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans.
This discussion paper outlines signs of a bad faith value-based payment contract. It describes indicators such as vague performance metrics, unilateral changes to terms, and excessive administrative requirements that disadvantage providers. The paper also highlights how these contracts can undermine trust and compromise care quality. Strategies for identifying and avoiding bad faith contracts, as well as recommendations for promoting more transparent and equitable agreements, are also discussed.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contractHigh Case-Mix Severity Must be Considered in Value-Based Contracting.
This discussion paper addresses the importance of considering high case mix severity in value-based contracting. It explains how failing to account for complex patient populations can lead to unfair performance evaluations and inadequate reimbursement for providers. The paper highlights the need for risk adjustment methods that accurately reflect patient severity to ensure that value-based contracts are equitable and do not penalize providers who treat high-risk patients. Strategies for implementing effective risk adjustment measures are also discussed.
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
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