value based payments clinical, operational, and revenue ... · value-based healthcare is a...
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Value Based Payments –
Clinical, Operational, and
Revenue Cycle Success Strategies
Andrea Brown, RN
AB Coaching and Consulting, Inc.
Phil Feldman, CPA
Revenue Management Solutions
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Today’s Agenda
Value Based Payments
• What are they and how are they derived and
administered?
Role of Financial Departments
• Data compilation, analysis, publication
• Financial partnership with Clinical, operational,
• Revenue management cycle
Preparation for VBP – Internal and External Strategies2
Value Based Payments (VBP)
Per NYS DOH VBP Program Outline:
NYS DOH Goal: Improve population health through enhancing the quality
of care for specific subpopulations that often require highly specific,
intensive care.
Value-based healthcare is a healthcare delivery model in which providers,
including hospitals and physicians, are paid based on patient health
outcomes. ... Value-based care differs from a fee-for-service or capitated
approach, in which providers are paid based on the amount of healthcare
services they deliver.
Value-based programs reward health care providers with
incentive payments for the quality of care they give to people. These
programs are part of the larger quality strategy to reform how health care is
delivered and paid for.3
Value Based Payments (VBP)
DOH required inclusion in MLTC/Provider contracts starting 12/31/17
Method of Payment to MLTC’s:• Quality of all contracted care is rewarded through up-and downward
adjustments of premiums received by managed care plans from the State
Method of Payment to providers:• Performance bonus (Level 1 contracts)
• Required measure - potentially avoidable hospitalizations (PAH)
• Other measures at plans’ discretion
• E.g. - percentage of enrollees vaccinated for flu
• Payments made based on provider exceeding statewide averages
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VBP Arrangements With MLTC’s
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Risk Assumption LevelNo Risk
Assumption
Low Risk
Assumption
Medium Risk
Assumption
High Risk
Assumption
VBP Level (per NYS VBP
Roadmap)FFS VBP Level 0 VBP Level 1 VBP Level 2
"In Other Words" VBP Nope VBP - Ish VBP For Real VBP Supreme
Provider Service Requirements Provide the Service
Beyond FFS but not yet
Level 1 (eg - PAH not
included)
Meet performance targets
for specific quality
measures including PAH
Meet performance targets
for specific quality
measures including PAH
If not met - withhold
minimum 1% of annual
expenditures
Upside Opportunity
Revenue Modeling –
It Ain’t So Easy
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DOH Guidance to MLTC’s?
Per Template Amendment to the Participating Provider Agreement Between MLTC Plans and LHCSAs (and Comments/Responses) – October 2017
• These templates were drafted at the request of the MLTC plan trade associations and are solely to be usedas an optional tool to assist plans who are getting started with VBP contracting.
• Use of the templates in any form is not mandatory.
• If the templates are used, they may be modified.
• The templates are not to be considered guidance.
• The templates are not intended to be inclusive of every possible VBP contracting arrangement between the parties.
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What Can We Reasonably Assume? Base Period = July – December 2016
Providers will be measured on improvement (or maintenance) of MY over BP
Computation varies for providers with 30+ or <30 “Attributed Enrollees”
• 30+ - Provider performance specifically computed
• <30 – Provider participates in Pool OR can attach to “Lead Provider” (maybe)
DOH will calculate PAH and other measurement performance for Provider-MCO combinations from MCO-submitted data
DOH will provide PAH computations per above semi-annually to MCO’s only
PAH is the only required measure required for Level 1 contracts and PAH + one other Category 1 measure are required for Level 2 contracts*
Bottom Line – READ YOUR CONTRACT
* - Source – NYS DOH - Managed Long Term Care Premium Rate Update
Division of Finance and Rate Setting September 6, 2018 8
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Source – NYS DOH MLTC VBP Quality Measure Data Reporting Timeline published January 2019
MLTC/DOH Data Analysis Process/Timeline
Rates and Payment – NYS will use VBP quality results to provide incentives for Plans and VBP Contractors
Baseline year = 2016
Quality results for MY 2017 will affect ???
Quality results for MY 2018 will affect 2020-21 rates
Quality results for MY 2019 will affect 2021-22 rates
Quality results for MY 2020 will affect 2022-23 rates
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Source – NYS DOH MLTC VBP Quality Measure Data Reporting Timeline published January 2019
Value Based Payment Computation to Providers – MLTC 1 Plan 1
Providers With 30 or more Attributed Members AND > 5,400 member Days* Across All MLTC Plans in MY:
NYSDOH computes PAH rate in BP and MY for Provider/Plan
Plan computes Quality Modifier for Provider based on PAH reduction of MY vs BP
< 0% = 0
0%– 24% = 1
25% - 49% = 1.5
50% + = 2
Quality Modifier X Member Days = Modified Member Days
Modified Member Days for Provider / Modifier Member Days All Providers in Region =
Percent of Regional Pool Earned by Provider X Regional Pool Paid to Plan by DOH =
Bonus Payment to Provider
*Member Days = # members served X # days served
Providers with < 5,400 member days across all MLTC Plans are excluded from computation
o NO BONUS FOR YOU!11
Value Based Payment Computation to Providers – MLTC Plan 1
Providers With Less Than 30 Attributed Members:
Provider is placed into the Regional Provider Pool
Weighted average based MY membership days is computed for the Pool
Quality Modifier for the Pool is computed using the MY vs BP PAH experience
Pool Membership Days X Pool Quality Modifier = Pool Modified Member Days
Pool Modified Member Days / Total Region Modified Member Days
X Total Regional VBP Payment = VBP Allocated to Pool
Plan Allocates VBP to Pool Provider based on Member Days of Provider
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Value Based Payment Computation to Providers – MLTC Plan 2
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Value Based Payment Computation to Providers – MLTC Plan 2
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Value Based Payment Computation to Providers – MLTC Plan 3
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Financial Department
Where Do We Fit?
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Financial Opportunity
17Source: NYS Roadmap for Medicaid Payment Reform
NYSDOH Medicaid Redesign Team
Financial Department
Skillsets:
• Data analysis – relate cause and effect
• Agency management system – data compilation – queries and
reports
• Comprehensive analytics and reporting tools – Excel, Access,
Business Intelligence Platforms (Domo, Sisense, etc.)
• Forecasting, Budgeting, Performance/Cost Analysis
• Understanding of clinical, operational and revenue cycle
processes
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Financial Department Role as Partner to
Maximize Organizational Effectiveness
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Financial Department
Clinical Department
Operations Department
Financial Department Contribution
ROI
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“In G-d We Trust –
All Others Must Bring Data”
W. Edwards Deming
Metrics – Goals vs Projections vs Actual
Earned Bonus
Revenue Model
Bonus KPI’s
Clinical KPI’s
Operational KPI’s
RCM
KPI’s
Cost
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Revenue Modeling and Bonus KPI’s
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VBP 2019 MLTC Measures – Category 1
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Percentage of members who did not have falls resulting in major or minor injury in the last 90
days
Percentage of members who received an influenza vaccination in the last year
Potentially Avoidable Hospitalizations (PAH) for a primary diagnosis of heart failure, respiratory
infection, electrolyte imbalance, sepsis, anemia, or urinary tract infection
Percentage of members who remained stable or demonstrated improvement in pain intensity
Percentage of members who remained stable or demonstrated improvement in Nursing Facility
Level of Care (NFLOC) score
Percentage of members who remained stable or demonstrated improvement in urinary continence
Percentage of members who remained stable or demonstrated improvement in shortness of breath
Percentage of members who did not experience uncontrolled pain
Percentage of members who were not lonely and not distressed
VBP 2019 MLTC Measures – Category 2
Percentage of members who rated the quality of home health aide or personal care aide
services within the last 6 months as good or excellent
Percentage of members who responded that they were usually or always involved in making
decisions about their plan of care
Percentage of members who reported that within the last 6 months the home health aide
or personal care aide services were always or usually on time
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Clinical KPI’s
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What Is Your Value Proposition?
Organizational Assessment
• IT Infrastructure
• Regulatory Compliance
• Staff Resources and Readiness
• Operational fitness
• Clinical Programming (patient care)
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Preparation for VBP
Clinical Quality Measurement• Falls, hospitalizations, other adverse episodes
Quality Improvement Programs• Prevention of adverse events
• Enhance patient satisfaction
Build relationships
Exchange Data • MCO’s
• Other VBP Contractors (ACO’s, IPA’s)
• Contracting group leaders and participants
• Regional Health Information Organizations (RHIO’s)
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Data Collection
What data should providers collect?
What VBP projects have you chosen? Align with State
requirements.
Prioritize data collection according to the project
goals.
Understand your resources for data collection.
• Data collection must be consistent and become a part
in the LHCSA operation and its workflows.
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Survey Readiness
First, you must be compliant
Current deficiency trends
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Clinical Management Metrics
Impactors to Value Based Care Outcomes
Care plan compliance
Care plans not entered
Tasks not entered
Tasks not performed
Caregiver observations
Gait, symptoms changes, safety concerns
Client compliance with meds, diet
Adverse events relative to all of the above30
Clinical Management Metrics
Impactors to Value Based Care Outcomes
Examples
• Care plan tasks relative to Dx – consistent?
• Adverse events relative to Dx
• Adverse events relative to care plan task compliance
• Adverse events relative to caregiver observations
• Adverse events relative to client compliance with meds, etc.
Uses of data for Risk Avoidance
• Identify high risk clients
• Modeling for internal protocols31
Goals of a Value Based Project
To meet NYS requirements
To meet payer requirements
• Level 1 or Level 2 contracting
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Potentially Avoidable Hospitalizations
Look at your patient population – hospitalization rates and
reasons
Develop and implement specific care protocols – standardize
Train staff – nurses, coordinators and aides, and hold
accountable – take advantage of WIO (Workforce Investment
Organization) training
Monitor the data
Adjust programming as needed
Celebrate the success at all levels
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Staff Training Opportunities
Educate staff about VBP
• Clinical – Review assessment and supervisory
responsibilities and care plan development and
oversight – include assessment of impact of SDOH
• Coordinator – Review assignment responsibilities and
information capture from home care aides and
communication responsibilities to agency nurses
• Paraprofessional – Review reporting and recording
responsibilities, provide education on SDOH
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Operational KPI’s
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Operational Management Metrics
Impactors to Value Based Care Outcomes
Client Service Quality
• Unverified Hours
• Under-Served Clients
Authorized But Not Scheduled Cases
Missed and Short-Served Shifts
Late shift starts
• Call-outs, substitutions, schedule changes
• Client complaints36
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Importance of Agency Clinical and Operational Metrics
What Payers Will Be Looking At
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Visual Analytics – Your QI Story
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Visualization of Gender, Primary Dx, and Change in Status
Source – Visual Analytics for Pattern Discovery in Home Care
Clinical Relevance for Quality Improvement
External Opportunities to Improve Value
Collaborative relationships
Other provider organizations, CBOs, etc.
Participation with the RHIOs
Grant opportunities
Mergers and Acquisitions
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Regional Health Information Exchanges (RHIO’s)
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The Skinny on SHIN-NY
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What’s In It for Me?
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Participation is Free
Alerts (Clinical Event Notifications)
Access patient clinical data
Raised profile with MCO’s
Profile with other participants
Revenue Cycle Management Metrics
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Revenue Cycle Management
Matters More Than Ever With Value Based Payments
Agency profitability depends on bonus achievement and penalty avoidance
Revenue must be protected as much as possible
Don’t lose focus on this important area
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Revenue Cycle Management Disciplines
Impactors to Value Based Care Outcomes
Bonus and Penalty Tracking – Warning System
• Cash posting – timeliness and discrepancies
• Bonus and penalty quantification
Value Based Outcomes Maximization
• Denials – authorization compliance and eligibility
Revenue Integrity
• Held Billing
• Denials – timely filing and appeal
• Rates and contracts administration
• EDI transmissions and rejections management
Billing Quality and Efficiency
• EDI, ERA
• Denials minimization – coding, eligibility, data integrity
• Resubmission minimization and compliance
• Payer projects minimization46
Revenue Cycle Management
Payment Monitoring and Posting
Identification and quantification of bonuses and penalties
• Payer compliance
• Prospective agency maximization of bonus opportunity / minimization of penalties
• How well are clinical/ops minding the store?
• Cost-benefit of investment in outcomes maximization – manpower and tech investments
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Tools - Visual Analytics
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Multi-Department Integration
“The most important element is receiving direction
from leadership that gets everyone on the same
page.”
Source – Rev Cycle Intelligence
Q&A
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Check for NYS DOH Updates VBP Information
• The State is constantly updating the VBP University which is an online, educational resource created to raise awareness, knowledge and expertise in the move to Value Based Payment (VBP). https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm
• VBP University combines informational videos and supplemental materials that stakeholders interested in VBP can use to advance their understanding of this massive transformation effort
• The VBP Resource Library has a section for Managed Long Term Care with additional guidance: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/
Source – NYS DOH - Managed Long Term Care Premium Rate Update
Division of Finance and Rate Setting September 6, 2018
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Thank You
Keep in Touch!
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AB Coaching and Consulting, Inc.
Tel: (718) 535-7295
Email: [email protected]
Revenue Management Solutions
Tel: (516) 484-4400 X 1494
Email: [email protected]