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Healthy Contracts Legislation; Measurement & Value-Based Payment Contracting: Online Screening & Outcome Measurement Software

503 227-2027

Successful and Failed Case Studies of Measurement-Based Care and Value-Based Payment Contracts: Recommended Requirements

Brief Summary

This article provides a comprehensive overview of the crucial elements required for successful measurement and value-based payment contracts in mental and behavioral healthcare. Results of nine implemented contracts were published by SAMHSA, The National Counsel, and the Advanced Health CCO. Those results emphasize the importance of transparency in contract terms and open data sharing to ensure all parties have clear understanding of performance terms and outcome objectives. The results emphasize the need for fair and achievable performance metrics that reflect clinical realities and prioritize patient care. They underline the significance of balanced risk sharing and the inclusion of support mechanisms to protect providers from excessive losses.

This overview highlights the necessity of adequate administrative support and streamlined processes to reduce burdens on providers. Ethical contracting practices, continuous provider education, and robust data analytics are essential to monitor and improve patient care and meet contract objectives. A focus on patient-centered care ensures that quality and patient outcomes are prioritized over cost savings. Regular review and adjustment of contracts, compliance with legal and regulatory standards, and maintaining high ethical standards are also discussed as vital components. By understanding these elements, readers may gain valuable insight into creation of effective value-based payment contracts that improve healthcare quality and ensure financial sustainability.

The unmistakable conclusion, based on these case reviews, is that measurement-based and value-based payment contracting is currently an uncontrolled experiment that has probable to almost certain moderate to catastrophic impacts such that a contract will fail to achieve objectives shared between stakeholder and Payers. Healthplans do not have common operational definitions of values, objectives, controls, tests of effectiveness, tests of design, or key indicators of success. This makes comparison of what went right and what is going wrong unreliable. Provider practices should strongly consider that there is a probable to almost certain moderate to catastrophic risk-impacting objectives such that a contract’s objectives may not achieve the values in the contract, and that 4 out of 5 contracts may fail.

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Healthy Contract Definitions.
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Successful Case Studies in Measurement-Based Care and Value-Based Payment

Companion Benefit Alternatives (CBA)

Companion Benefit Alternatives (CBA), a behavioral health plan, successfully integrated measurement-based care (MBC) to enhance clinical outcomes and reduce overall care costs. The challenges included a lack of standardized patient progress measures and difficulty engaging providers and members in outcomes data collection. The proposed solution involved adopting MBC tools to systematically track patient-reported outcomes and using this data to inform clinical decisions and enhance patient engagement. The solution was implemented by integrating MBC tools into routine practice, training providers on their use, and collaborating on utilizing outcomes data for continuous improvement. As a result, CBA saw improved clinical outcomes, reduced total care costs through efficient and effective treatment plans, and enhanced patient engagement and satisfaction. The critical factors for success included robust infrastructure for data collection and analysis, adequate financial incentives to motivate providers, and strong engagement by both providers and patients. To address initial resistance from providers, it was recommended to enhance training and support efforts.

  • Values: Quality of care, patient outcomes, cost efficiency.

  • Objectives: Implementing standardized MBC tools, provider training, and robust data systems.

  • Auditing Controls: Performance dashboards, regular data audits, and patient feedback mechanisms.

Veterans Affairs (VA) Measurement-Based Care Initiative

The VA's Measurement-Based Care in Mental Health Initiative aimed to standardize care practices and improve patient outcomes. Challenges included fragmented care and inconsistent use of outcome measures across the VA system. The proposed solution was to standardize the use of MBC across VA mental health clinics to ensure consistent tracking of patient outcomes and support data-driven clinical decisions. The initiative involved nationwide implementation of MBC tools, continuous training for clinicians, and development of a centralized system for data collection and analysis. Outcomes included consistent improvement in patient outcomes due to regular monitoring and adjustments in treatment plans, increased clinician engagement and confidence in using data to guide treatment decisions, as well as significant cost savings through reduced hospitalizations and better management of comorbid conditions. Key success factors were comprehensive training programs, a centralized data collection system, and strong leadership support from the VA. Initial fragmentation in data systems was addressed by investing in integrated data systems.

  • Values: Quality of care, patient outcomes, cost efficiency.

  • Objectives: Implementing standardized MBC tools, provider training, and robust data systems.

  • Auditing Controls: Performance dashboards, regular data audits, and patient feedback mechanisms.

North Carolina Medicaid

North Carolina Medicaid implemented a value-based payment (VBP) model for behavioral health, focusing on integrated care and outcomes measurement. Challenges included integrating physical and behavioral health care and adapting providers to VBP models. The proposed solution involved developing a VBP model that incentivized providers based on patient outcomes and care integration. This was implemented by establishing metrics for performance-based payments, providing technical assistance to providers, and implementing a robust data collection system. Outcomes included improved integration of care between physical and behavioral health providers, enhanced patient outcomes, and positive feedback from providers. The program's success was attributed to clear performance metrics, adequate financial incentives, and strong technical support. To overcome resistance to new payment models, ongoing provider education and support were recommended.

  • Values: Integrated care, provider engagement, cost efficiency.

  • Objectives: Developing VBP models, providing technical assistance, and robust data systems.

  • Auditing Controls: Performance dashboards, financial audits, and provider performance reviews.

Beacon Health Options

Beacon Health Options, a managed behavioral health organization, implemented a VBP model to improve care quality and reduce costs. Challenges included provider resistance to the new payment model, difficulties in data collection, and ensuring consistent care quality across different providers. The proposed solution was to establish a VBP model that rewarded providers for achieving specific quality and outcome metrics. This involved providing training and resources to help providers transition to the new model, implementing robust data collection and analysis systems, and establishing clear performance metrics and financial incentives. Outcomes included improved care quality, reduced costs through more effective treatment plans, and increased provider engagement and satisfaction with the new payment model. The success was due to comprehensive training programs, clear performance metrics, and strong financial incentives. Initial resistance from providers was addressed through frequent communication and support.

  • Values: Quality of care, patient outcomes, provider engagement.

  • Objectives: Establishing VBP models, training and resources for providers, and clear performance metrics.

  • Auditing Controls: Feedback mechanisms, outcome analysis, and patient satisfaction surveys.

Blue Cross Blue Shield of Michigan's Collaborative Care Model

Blue Cross Blue Shield of Michigan integrated behavioral health into primary care settings through a collaborative care model. Challenges included fragmentation between physical and behavioral health services and difficulties in coordinating care across different providers. The proposed solution involved developing a care model that integrated behavioral health services into primary care practices, supported by a value-based payment structure. Implementation included training primary care providers, integrating care coordination systems, and establishing performance metrics tied to financial incentives. Outcomes included improved patient outcomes, better care coordination, and reduced healthcare costs. The success was attributed to an integrated care model, strong provider engagement, and adequate financial incentives. Initial coordination challenges were mitigated by enhancing communication tools for providers.

  • Values: Integrated care, quality of care, patient outcomes.

  • Objectives: Integrating care coordination systems, training primary care providers, and financial incentives.

  • Auditing Controls: Compliance monitoring, regular data audits, and patient feedback.

 Common Values, Objectives, and Auditing Controls Among Case Examples of Success

Common Values

  1. Quality of Care: Ensuring that patients receive high-quality, evidence-based mental and behavioral health services.

  2. Patient Outcomes: Improving clinical outcomes for patients through consistent tracking and management of their health status.

  3. Cost Efficiency: Reducing overall healthcare costs by avoiding unnecessary treatments and hospitalizations.

  4. Provider Engagement: Encouraging active participation and buy-in from providers in the care process.

  5. Data-Driven Decisions: Utilizing data to inform clinical decisions and policymaking.

  6. Integrated Care: Promoting the integration of physical and behavioral health services to provide comprehensive care.

Common Objectives to Achieve Common Values

  1. Implementing Standardized Measures: Use standardized tools for measuring patient outcomes, such as patient-reported outcome measures (PROMs) and clinical assessments.

  2. Training and Support for Providers: Provide continuous training and technical support to help providers adapt to new models and use data effectively.

  3. Financial Incentives: Design payment structures that reward providers for meeting quality and outcome metrics.

  4. Robust Data Systems: Develop and maintain robust data collection and analysis systems to support outcome tracking and reporting.

  5. Patient Engagement Strategies: Implement strategies to engage patients actively in their care, such as regular feedback and involvement in treatment decisions.

  6. Integrated Care Models: Foster collaboration between physical and behavioral health providers through integrated care models and coordinated care systems.

Common Auditing Controls to Measure and Detect Deviations from Values and Objectives

  1. Performance Dashboards: Develop dashboards that display key performance indicators (KPIs) for quality of care, patient outcomes, and cost efficiency.

  2. Regular Data Audits: Conduct regular audits of collected data to ensure accuracy, completeness, and compliance with standards.

  3. Feedback Mechanisms: Implement mechanisms for continuous feedback from both providers and patients to identify areas for improvement.

  4. Compliance Monitoring: Establish protocols for monitoring compliance with established guidelines and protocols.

  5. Outcome Analysis: Perform regular analysis of patient outcomes to detect any deviations from expected performance and identify trends.

  6. Financial Audits: Regularly review financial performance to ensure that financial incentives are aligned with quality and outcome goals.

  7. Provider Performance Reviews: Conduct periodic performance reviews for providers to assess their adherence to MBC and VBP protocols and their impact on patient outcomes.

  8. Patient Satisfaction Surveys: Use patient satisfaction surveys to gauge the effectiveness of care and identify areas for improvement.

Analysis of Failed Case Studies

Vermont's Mental Health Payment Reform

Vermont's attempt to expand its successful "hub and spoke" model for addiction treatment to mental health services faced significant challenges. The primary issues included inadequate infrastructure for data collection, provider resistance due to increased administrative burden and perceived risk, and insufficient financial incentives. These problems hindered the initiative's ability to collect and utilize data effectively, resulting in limited success. Providers were reluctant to adopt new payment methodologies due to the additional workload and financial uncertainty. This resistance, coupled with the lack of robust data systems, led to partial adoption and minimal impact on overall care quality and cost reduction. What had worked in for behavioral healthcare in Vermont did not translate into the more generic “mental health” arena. Perhaps for the new diversity of “target outcomes?”

Reasons for Failure:

  1. Inadequate Infrastructure: The lack of a robust data collection system made it difficult to track patient outcomes and measure the effectiveness of the new payment models.

  2. Provider Resistance: Providers were hesitant to adopt the new payment models due to increased administrative tasks and perceived financial risks.

  3. Insufficient Financial Incentives: The financial incentives offered were not substantial enough to motivate providers to change their existing practices.

Recommendations:

  1. Invest in Robust Data Systems: Developing a comprehensive data collection and analysis infrastructure is crucial for tracking patient outcomes and the effectiveness of the payment models.

  2. Increase Financial Incentives: Offering more substantial financial rewards can help mitigate the perceived financial risks and encourage providers to adopt new models.

  3. Enhance Provider Support and Training: Providing ongoing training and support can help providers manage the administrative burden and understand the benefits of the new payment models.

New York’s Behavioral Health VBP Readiness Program

New York's program aimed to help providers transition to VBP models by forming networks and adopting new payment structures. However, the initiative faced high initial costs and complexity in forming networks, inconsistent provider engagement, and difficulties integrating physical and behavioral health services. Despite providing significant financial support and technical assistance, the program resulted in mixed outcomes. Some providers transitioned successfully, while others struggled with the complexity and cost, highlighting the need for ongoing support and clearer pathways for providers to achieve successful integration and financial stability under VBP.

Reasons for Failure:

  1. High Complexity and Cost: The complexity and high initial costs associated with forming provider networks were significant barriers.

  2. Inconsistent Provider Engagement: Not all providers were equally engaged or capable of transitioning to the new models, leading to uneven implementation.

  3. Integration Challenges: Difficulties in integrating physical and behavioral health services further complicated the transition.

Recommendations:

  1. Simplify Network Formation: Streamlining the process of forming provider networks can reduce complexity and lower initial costs.

  2. Provide Ongoing Support: Continuous support and technical assistance are essential to help providers navigate the transition.

  3. Enhance Integration Strategies: Developing more effective strategies for integrating physical and behavioral health services can improve the overall success of the initiative​.

Tennessee Health Link’s Episodes of Care Program

Tennessee's Health Link aimed to improve care for specific behavioral health conditions through bundled payments. The program faced challenges such as inadequate initial design, provider resistance due to perceived financial risk and increased administrative tasks, and difficulty achieving meaningful improvements in care quality and patient outcomes. Despite efforts to engage providers and support the transition, the program saw limited improvements, with many providers finding the model too restrictive and difficult to implement effectively.

Reasons for Failure:

  1. Inadequate Initial Design: The program's design did not adequately account for the complexities of behavioral health conditions.

  2. Provider Resistance: Providers were concerned about the financial risks and increased administrative workload.

  3. Limited Care Quality Improvements: The program did not achieve significant improvements in care quality or patient outcomes.

Recommendations:

  1. Redesign Payment Models: Revising the payment models to better accommodate the complexities of behavioral health conditions can improve acceptance and effectiveness.

  2. Increase Provider Incentives: Offering greater financial incentives can help mitigate perceived risks and encourage participation.

  3. Provide Better Support: Enhanced support and training can help providers manage the administrative tasks and understand the benefits of the new models.

Oregon’s Coordinated Care Organizations (CCOs)

Oregon’s CCOs aimed to integrate behavioral health into a coordinated care model with value-based payment structures. Challenges included complex care coordination requirements, inconsistent provider engagement, and financial instability. Implementation difficulties, such as inadequate data systems and provider resistance, led to limited success. Many providers struggled with financial and administrative burdens, resulting in partial adoption and minimal improvements in care coordination and cost savings.

Reasons for Failure:

  1. Complex Care Coordination: The requirements for coordinating care were too complex and burdensome for many providers.

  2. Inconsistent Provider Engagement: Engagement from providers was uneven, affecting the overall implementation.

  3. Financial Instability: Providers faced financial instability, which hindered their ability to participate fully.

Recommendations:

  1. Simplify Care Coordination: Reducing the complexity of care coordination requirements can make it easier for providers to participate.

  2. Increase Financial Incentives: Providing more substantial financial incentives can help address financial instability and encourage participation.

  3. Provide Better Support: Ongoing support and training can help providers manage administrative tasks and improve engagement​.

The Advanced Health CCO

The Advanced Health CCO in Coos and Curry County southern Oregon, shifted from capitation to a pay-for-performance model to improve outpatient behavioral health services. The initiative faced challenges like provider financial risk and administrative burden. Although outpatient visits increased by 51% initially and 7% subsequently, the high-acuity patient load and administrative complexities led to provider burnout and service disruptions.

Values

  • Quality of Care: Ensuring high standards in behavioral health services.

  • Patient Access: Improving access to outpatient behavioral health services.

  • Provider Sustainability: Maintaining financial and operational stability for providers.

  • Efficiency: Reducing unnecessary utilization and promoting efficient use of resources.

Objectives

  • Increase Outpatient Visits:

    • Implemented: Shifted from capitation to pay-for-performance to incentivize more outpatient visits, resulting in a 51% increase initially and 7% subsequently.

  • Enhance Service Quality:

    • Implemented: Integrated quality measures, such as reducing emergency department visits for behavioral health.

  • Support High-Complexity Patients:

    • Partially Implemented: The program struggled to manage high-complexity patients, leading to provider burnout and service disruptions.

Controls

  • Performance-Based Payments:

    • Implemented: Introduced pay-for-performance to incentivize outpatient visits.

  • Quality Metrics:

    • Implemented: Used metrics like reduced emergency department visits for behavioral health as quality indicators.

  • Regular Meetings:

    • Implemented: Held regular meetings with providers to discuss challenges and update agreements.

  • Financial and Data Audits:

    • Implemented: Conducted audits to ensure compliance with payment models and assess financial health.

  • Provider Feedback:

    • Implemented: Gathered feedback from providers to identify and address issues.

Reasons for Failure

1. Provider Financial Risk and Administrative Burden:

  • The shift from capitation to a pay-for-performance model increased financial risk and administrative tasks for providers.

  • High-acuity patients and complex administrative requirements made it challenging to generate sufficient revenue.

2. Complex Patient Load:

  • Community mental health programs (CMHPs) serve high-acuity patients who often miss appointments and require unbillable services like travel.

  • The system's focus on visit duration rather than patient complexity exacerbated the issue.

3. Provider Burnout and Service Disruptions:

  • Increased pressure for productivity led to provider burnout and turnover, particularly among psychiatric providers.

  • CMHPs had to rely more on telehealth and temporary providers, which was not sustainable for managing high-complexity patients.

4. Insufficient Support for High-Complexity Patients:

  • CMHPs struggled to manage high-complexity patients, leading to service gaps as other providers were reluctant to take on these patients.

Recommendations

  • Balance Performance Incentives with Provider Sustainability:

    • Ensure performance incentives are balanced with measures to maintain provider sustainability and prevent burnout.

  • Enhanced Support for High-Complexity Patients:

    • Provide additional resources and support specifically tailored for managing high-complexity patients effectively.

  • Address Financial and Administrative Burdens:

    • Develop strategies to mitigate financial risks and reduce administrative burdens on providers to maintain high levels of care.

  • Improve Coordination and Integration:

    • Enhance coordination between different levels of care and integrate services to provide comprehensive support for high-acuity patients.

  • Regular Review and Adjustment of Payment Models:

    • Continuously review and adjust payment models to ensure they align with the realities of patient care and provider capabilities.

  • Provider Training and Engagement:

    • Invest in ongoing training and engagement initiatives to help providers adapt to new models and maintain high standards of care.

  • Use Statewide Benchmarking Data:

    • Utilize statewide benchmarking data to identify service gaps and set appropriate service levels and payment rates.

  • Incorporate Feedback Mechanisms:

    • Implement feedback mechanisms to gather input from providers and patients to identify and address emerging issues promptly.

Preliminary Conclusions

These analyses of failed case studies highlight the importance of robust infrastructure, adequate financial incentives, and strong provider engagement. Common pitfalls such as inadequate planning, lack of support, and provider resistance can significantly hinder the success of value-based payment models. Addressing these issues through strategic investments in data systems, financial incentives, and provider support can improve the chances of successful implementation and better outcomes.

Essential Requirements for Successful Measurement and Value-Based Payment Contracts

Mentor Research Institute conducted conducted an analysis of a value-based payment contract offered by X Health. The contract offered was not aligned with Federal and State guidelines nor industry objectives, nor with State of Oregon values established under the Oregon Health Authority’s Value-based Sustainable Healthcare Growth COMPACT.

1. Transparency in Contract Terms

  • Clear Definitions: Contracts must clearly define all terms, including performance metrics, reimbursement rates, and responsibilities of all parties.

  • Open Data Sharing: Health plans and providers should share comprehensive data to ensure all parties have a full understanding of performance and outcomes.

2. Fair and Achievable Performance Metrics

  • Realistic Benchmarks: Performance metrics should be based on achievable benchmarks that reflect the realities of clinical practice.

  • Clinical Relevance: Metrics must be relevant to patient care and outcomes, rather than solely focusing on cost containment.

3. Balanced Risk Sharing

  • Equitable Distribution: Financial and clinical risks should be distributed fairly between health plans and providers.

  • Support Mechanisms: Contracts should include support mechanisms, such as risk corridors or stop-loss provisions, to protect providers from excessive losses.

4. Adequate Administrative Support

  • Resource Allocation: Health plans should allocate resources to support providers in meeting the administrative requirements of value-based contracts.

  • Efficiency Improvements: Streamlined processes and technological support can reduce the administrative burden on providers.

5. Ethical Contracting Practices

  • Good Faith Negotiations: Contracts should be negotiated in good faith, with all parties working towards mutually beneficial outcomes.

  • Avoiding Ambiguity: Contracts must avoid ambiguous terms that could lead to disputes or unethical practices.

6. Comprehensive Provider Education and Training

  • Ongoing Training: Providers should receive ongoing education and training to understand and effectively implement value-based care principles.

  • Clinical and Administrative Guidance: Health plans should offer guidance on both clinical and administrative aspects of value-based contracts.

7. Robust Data and Analytics

  • Accurate Data Collection: Reliable data collection methods are essential for monitoring performance and outcomes.

  • Actionable Insights: Analytics should provide actionable insights that can be used to improve patient care and contract performance.

8. Patient-Centered Care Focus

  • Quality Over Cost: Contracts should prioritize quality of care and patient outcomes over cost savings alone.

  • Engaging Patients: Patient engagement and satisfaction should be integral components of performance metrics.

9. Regular Review and Adjustment

  • Continuous Improvement: Contracts should include provisions for regular review and adjustment based on performance data and evolving best practices.

  • Flexibility: The ability to adapt contracts in response to new information or changing circumstances is crucial for long-term success.

10. Legal and Regulatory Compliance

  • Adherence to Laws: All contracts must comply with relevant federal and state laws and regulations, including those governing Medicare and Medicaid.

  • Ethical Standards: Contracts should uphold high ethical standards to protect the interests of all stakeholders, including patients, providers, and payers.

11. Independent Certified Internal Auditors (CIA)

  • Professional Expertise: An Independent Certified Internal Auditor (CIA) is a highly trained professional with certifications such as CPA (Certified Public Accountant) or CIA (Certified Internal Auditor), responsible for objectively examining and evaluating financial statements and the operational processes of organizations to ensure accuracy, compliance, and integrity.

  • Impartiality and Independence: CIAs must operate without any direct ties to the organization being audited, ensuring unbiased and impartial assessment, crucial factors for maintaining trust and credibility in financial reporting and operational audits.

12. Ethics Point Portal Overseen by a Independent Certified Internal Auditors (CIA)

  • Centralized Reporting System: An ethics point portal is a centralized digital platform where employees and stakeholders can confidentially report unethical behavior, misconduct, or compliance violations. It provides a structured and secure method for submitting concerns or complaints.

  • Oversight and Investigation: Overseen by a Certified Internal Auditor (CIA), an ethics point portal ensures that all reports are thoroughly reviewed and investigated. The CIA's expertise in auditing and internal controls guarantees that investigations are conducted impartially and in accordance with professional standards.

  • Transparency and Accountability: An ethics point portal enhances organizational transparency by documenting all reported issues and their resolutions. The CIA ensures accountability by tracking the status of each report, implementing corrective actions, and providing regular updates to senior management and the board on ethical compliance and risk management.

These requirements highlight the importance of transparency, fairness, support, and a focus on patient-centered care in achieving successful value-based payment contracts. By addressing these critical areas, health plans and providers can work together to create contracts that improve healthcare quality and outcomes while ensuring financial sustainability.

References

DISCLAIMER and PURPOSE: This discussion document is intended for training, education, and or research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.

For more information see: https://www.mentorresearch.org/disclaimer-and-purpos

Key words: Supervisor education, Ethics, COVID Office Air Treatment, Mental Health, Psychotherapy, Counseling, Patient Reported Outcome Measures,