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Moving Toward Value-Based Payment for Medicaid Behavioral Health Services

Learn about the alternative payment models (APMs) framework for Medicaid behavioral health services, including fee-for-service payments linked to quality, bundled payments, and population-based payments. Explore examples from states like Arizona, Maine, New York, and Tennessee that are already implementing value-based payment strategies.

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Moving Toward Value-Based Payment for Medicaid Behavioral Health Services

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  1. Moving Toward Value-Based Payment for Medicaid Behavioral Health Services Neal Bowen, Ph.D – Hidalgo Medical Services David Ley PhD.

  2. Health Care Payment Learning and Action Newtwork (LAN) Alternative Payment Model (APM) Framework

  3. Category 1 • Fee-for-Service payments not linked to quality • Based on number and units of service provided • Not linked to quality data • Not based on performance • Not focused on patient outcomes

  4. Category 2 • Fee-for-Service payments linked to quality and value • Based on number and units of service provided AND ALSO quality metrics • Paid for reporting quality data • Paid for performance on cost savings • Includes penalty disincentives • Not meeting quality indicator levels • Not reporting events or procedures that are harmful or avoidable (Like what CMS is doing with Medicare)

  5. Category 3 • Alternative payment models based on Fee-for-Service • Based on number and units of service provided, effectively managing services AND quality metrics • Shared Savings/Shared Risk • Providers must meet “total-cost-of-care target for some or all services for attributed set of patients • Upside – providers may be able to keep some of the savings • Downside – providers may have higher-than expected costs • Bundled or Episode-Based Payments • Single payment to providers or ALL SERVICES needed to treat a given condition • Providers receive an inclusive payment from start to end for an episode of care

  6. Category 4 • Population-based payments • Structure of payment is dependent on coordination and quality of care within a defined budget • Payments cover wide range of preventive, medical, and health improvement services • Global or capitated per-member-per-month payment • Includes both physical and behavioral health • Plans or providers bear the financial risk for cost of treatment

  7. Moving Forward

  8. What is already underway in NM? • Presbyterian value-added and BQIP • Western Sky developing a menu of VBP contract options • CLNM Health Homes • PMS Primary Care project • MCO delegation

  9. Utilizing the Categories of VBP Systems • Some states use a single category (Maine and Tennessee) • Other states use combinations (Arizona and New York) For example: Arizona uses strategies from Categories 2, 3, and 4 • Measures reductions of inpatient and ER admissions • Follow-up within 7 days post-discharge • Percentage of those with stable housing • Percentage of those competitively employed • Reduction in alcohol or drug use

  10. Utilizing the Categories of VBP Systems Maine uses strategies from Category 3 • Follow-up after hospitalization for mental illness (tied to payment) • Initiation and engagement of alcohol and drug treatment (tied to payment) • Out-of-home placement for children and adults (reporting only) • Cardiovascular health screening for schizophrenia and bipolar disorder who are on antipsychotic medications (reporting only)

  11. Utilizing the Categories of VBP Systems New York uses strategies from Categories 3 and 4 • Pay for reporting on 32 core measures • Track outcomes related to social determinants of health (SDOH) • Percentage who maintained/obtained employment or higher education status • Percentage with stable or improved housing status • Percentage with reduced criminal justice involvement

  12. Utilizing the Categories of VBP Systems Tennessee uses strategies from Category 2 • Whole-person coordinated behavioral and physical health care for some individuals • Outcome payments depend on providers surpassing expectations • Providers are evaluated on 15 measures that assess efficiency • Hospital readmission rates • ER visits • Inpatient utilization • Anti-depressant medication management • Initiation and engagement of alcohol and drug treatment • BMI for comprehensive diabetes care

  13. Utilizing the Categories of VBP Systems Pennsylvania uses a strategy based on Pay-for Performance determined by Medicaid MCO • Members are stratified in categories and re-stratified every 6 months: • High physical health/high behavioral health needs • High physical health/low behavioral health needs • Low physical health/high behavioral health needs • Low physical health/low behavioral health needs • Payments based on 5 performance measures • Physical/behavioral health inpatient admissions for those with SMI • ER visits for those with SMI • Combined physical and behavioral health 30-day inpatient rates for those with SMI • Adherence to antipsychotic medication for schizophrenia • Initiation and engagement of alcohol and drug treatment

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