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Taking Action to Address Global Problems Emerging Payment Reform Models for Health and Behavioral Healthcare. ACMHA Summit Thursday, March 25,2010 Dale Jarvis, CPA MCPP Healthcare Consulting, Inc. [email protected]

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Taking Action to Address Global Problems Emerging Payment Reform Models for Health and Behavioral Healthcare

ACMHA SummitThursday, March 25,2010Dale Jarvis, CPAMCPP Healthcare Consulting, [email protected]


My hypotheses healthcare reform will pass and will usher in unprecedented change
My Hypotheses: Healthcare Reformwill Pass and will usher in Unprecedented Change

  • Federal Healthcare reform will trigger dramatic changes in how health and behavioral health services are organized and funded

  • These changes will create a tipping point in how the healthcare needs of persons with serious mental illness and the behavioral healthcare needs of all Americans are addressed



The two part problem
The Two-Part Problem

“The American healthcare system is a dysfunctional mess.”(Ezekiel Emanuel, MD, Chair of the Department of Bioethics at the Clinical Center of the National Institutes of Health)

$2.3 - $5.2 Trillion

As much as 30% of health care costs (over $700 billion per year) could be eliminated without reducing quality


The two part problem1
The Two-Part Problem

Fixing the problem can be described as:

  • Moving further upstream with prevention & early intervention services to prevent health conditions from becoming chronichealth conditions

    • Dramatically improving the management of chronic health conditions for the 45% of Americans with one or more such conditions whose treatment draws down 75% of total medical costs

  • Reducing errors and waste in the system

  • Reducing incentives for high cost, low value, procedure-based care


  • Emerging delivery system and payment reform models
    Emerging Delivery System and Payment Reform Models

    Where the U.S. Healthcare System is headed (at a glance)


    Delivery system redesign elephant in the room
    Delivery System Redesign Elephant in the Room

    • Need to invert the Resource Allocation Triangle

    • Prevention Activities must be funded and widely deployed

    • Primary Care must become a desirable occupation and

    • Decrease Demand in the Specialty and Acute Care Systems

    • These are dramatic shifts that will not magically take place


    Two types of payment reform are the key
    Two Types of Payment Reform are the Key

    Value-Based Purchasing (VBP)

    Value-Based Insurance Design (VBID)


    Value based purchasing the holy grail
    Value-Based Purchasing – The Holy Grail

    Global Capitation to an Integrated Health System

    But... Integrated Health Systems will be only one of many system models


    Value based purchasing medical homes
    Value-Based Purchasing – Medical Homes

    • Fee for Service is headed towards extinction

    • Health Care Home models will begin with a 3-layer funding design with the goal of the FFS layer shrinking over time

    • Being replaced with case rate or capitation with a pay for performance layer


    Value based purchasing inpatient care
    Value-Based Purchasing – Inpatient Care

    • Payment for inpatient care will bundle hospital and physician services

    • Bundled payments that only pay for part of Potentially Avoidable Complications (PACs) will penalize providers that have higher error rates and reward those with lower PAC rates

    • Bundled payments may include all costs in the 30 days post an inpatient stay, including any return to the hospital


    Value based purchasing other strategies
    Value-Based Purchasing – Other Strategies

    • Pay for Performance funding layer

    • Differential Rates for providers that use published Practice Guidelines (EBPs)

    • Capacity-Based Funding to kick start innovations

    • Funding to community organizations that improve health status and bend the cost curve


    Value based insurance design vbid
    Value-Based Insurance Design (VBID)

    • Developed in response to problems related to increases in co-payments implemented by employers and insurance companies to save money


    Value based insurance design features vbid
    Value-Based Insurance Design Features (VBID)

    • Decreasing cost-sharing for interventions that are known to be effective

    • Increasing cost-sharing for those that are not known to be effective

    • Providing financial incentives based on behavioral economics research

    • Providing a deep education component to explicitly guide patients to use high-value, and avoid low-value, interventions


    So how does the mh su system fit into this new equation
    So How does the MH/SU System Fit into this New Equation?


    So how does the mh su system fit into this new equation1
    So How does the MH/SU System Fit into this New Equation?

    The MH/SU delivery system has two roles to play:

    • Integration of CBHOs into Person Centered Healthcare Homes

    • High Performing, Recovery and Wellness-Oriented MH/SU Providers

      And, in both cases,

      will need to learn to

      play by the payment

      reform rules


    So how does the mh su system fit into this new equation2
    So How does the MH/SU System Fit into this New Equation?

    • We’ve learned from 50 years of effort that if you work in the BH Safety Net...

    • Focusing inward to create a high-performing CBHO does not always prevent you from ending up at the bottom...


    Understanding where the healthcare management models are headed
    Understanding Where the Healthcare Management Models are Headed

    • Status Quo: Fee-For-Service, Non-Integrated Model: All the wrong incentives and disincentives


    Understanding where the healthcare management models are headed1
    Understanding Where the Healthcare Management Models are Headed

    • Integrated Healthcare System


    Understanding where the healthcare management models are headed2
    Understanding Where the Healthcare Management Models are Headed

    • Accountable Care Organization (ACO) Model


    So how does the mh su system fit into this second part of the new equation
    So How does the MH/SU System Fit into this Second Part of the New Equation?

    Integrated Healthcare System

    • If you are operating in a state and community where integration efforts are under way and the IHS model is being pushed, your choices are:

    • Do nothing and hopethey ignore the SMI/SED population

    • Become a PreferredProvider of an IHS

    • Create a consortium of BH Providers and contract with the IHSas a Provider Network

    • Become an Acquisition Target and become part of the IHS’ BH Division


    So how does the mh su system fit into this second part of the new equation1
    So How does the MH/SU System Fit into this Second Part of the New Equation?

    Accountable Care Organization

    • If you are operating in a state and community where integration efforts are under way and the ACO model is being pushed, your choices are:

    • I’m going to skip “do nothing”

    • Become a Preferred Provider to the ACO

    • Become a Memberof the ACO

    • Get in on the groundfloor and become a Founding Member/Owner of the ACO



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