Al Alter ernate e Paymen ent Model els for Be Behavi vior oral Health th Servi vices s – Pa Past, Present, and Future Po Policy Ro Roundtable June 2, 2019 Academy Health Annual Research Meeting Washington D.C.
Presenters • Andrew D. Carlo, MD • Senior Research Fellow, University of Washington • Nicole M. Benson, MD • Clinical Fellow in Child and Adolescent Psychiatry, Massachusetts General Hospital and McLean Hospital • Zirui Song, MD, PhD • Assistant Professor of Health Care Policy and Medicine at Harvard Medical School • Internal Medicine Physician at Massachusetts General Hospital • Katherine Hobbs Knutson, MD, MPH • Chief of Behavioral Health, Blue Cross North Carolina • Adjunct Assistant Professor in the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine • Benjamin F. Miller, PsyD • Chief Strategy Officer for Well Being Trust • Adjunct Faculty, Stanford University School of Medicine • Senior Advisor, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine
Disclosures • Andrew D. Carlo, MD • None • Nicole M. Benson, MD • None • Zirui Song, MD PhD • None • Katherine Hobbs Knutson, MD MPH • BCBS Employee • Benjamin F. Miller, PsyD • None
Outline • Define alternative payment models (APMs) • Review existing behavioral health APM literature • Results from commercial payer accountable care organization (ACO) • Discussion of alternate payment for behavioral health integration • Description of APM within an ACO • Discussion of Future Directions
Alternative Payment Models (APMs) • Payment models with incentive payments tied to quality and value • Apply to a specific clinical condition, care episode, or population • Heterogeneous, divided into groups by payment (fee-for- service or population-level) and category of risk (none, penalties, bonuses, or both) • APMs ideally align system-, practice-, and provider-level incentives to facilitate higher quality, integrated, and more cost-effective health care
State of the Field • Paucity of literature empirically evaluating the impacts of APMs on MH/SUD outcomes • Long history of studying other payment models not tied to quality/value • Existing literature with mixed findings • Most commonly evaluated APMs included P4P, condition-specific population payments and shared savings with one- or two-sided risk • Strongest findings in processes-of-care, fidelity, utilization and spending outcomes • Clinical outcome data are lacking
APM Mental Health Examples • P4P for Washington State’s Mental Health Integration Program (MHIP) • P4P patients had a significantly higher likelihood of having (Bao et al, 2017): • At least one follow-up contact • At least one psychiatric case review • At least one PHQ-9 • P4P patients also (Unützer et al, 2012): • Were more likely to receive timely follow-up • Had more rapid depression symptom improvement • Had a higher likelihood of achieving treatment response.
APM Mental Health Examples • Maine Addiction Treatment System (MATS) – condition-specific population payment • APM WAS associated with higher odds of successful matching with a treater, higher odds of referral, and a higher likelihood of receiving effective and efficient care (Lu et al, 2003; Commons et al, 1997) • APM NOT associated with significant changes in time to outpatient assessment or time to treatment (Brucker et al, 2011) • APM WAS associated with possible adverse selection and gaming (Shen et al, 2003; Lu et al, 2002; Lu et al, 2006)
APM Mental Health Examples • Medicare Shared Savings Program: • Initially, one-sided risk only • NO significant differences in process-of-care outcomes, health care spending, service utilization, or adverse selection (Busch et al, 2015) • Slight changes in amount of antidepressants prescribed (Busch et al, 2016) • Medicare Pioneer ACO: • Two-sided risk • Slight reduction in total mental health spending in the first year ONLY (Busch et al, 2015) • Slight changes in amount of antidepressants prescribed (Busch et al, 2016) • Some evidence for adverse selection (Busch et al, 2015)
AcademyHealth Annual Research Meeting June 2019 Zirui Song, MD, PhD Harvard Medical School Massachusetts General Hospital
Payment Reform in Massachusetts Figure. Health care reform in Massachusetts Health care reform: Special state State Cost Control Legislation: individual mandate & Commission: (1) Global payment insurance exchanges global payment (2) Accountable Care Organizations within 5 years (3) Regulation of insurance premiums (4) Medical malpractice reform Insurance coverage Attorney General State Senate bill & expands to over 97% reports: variations in State House bill: of the state population provider payments Global payment 2007 2008 2009 2010 2012 2011 Tufts Health Plan and Harvard Pilgrim Health Care announce plans to expand global payment. Blue Cross Blue Shield of Massachusetts Medicare � Pioneer � ACOs: Alternative Quality Contract: 7 organizations 5 provider organizations with join in 2009, 4 more organizations join in 2010. 150,000 beneficiaries. By 2012, 613,000 enrollees are in the AQC.
Governor Patrick Signs Health Care Cost Containment Bill August 6, 2012 “Massachusetts has been a model for access to health care. Now, we become the first to crack the code on costs.”
Alternative Quality Contract (AQC) • ACO model (5 years) – MDs and hospitals – Continuum of care • Spending growth controls – Global budget (2-sided model) – Budget growth benchmarks – Shared savings & risk tied to quality • Pay-for-Performance – 64 quality metrics (process, outcome, experience) – Large financial incentives: up to 10% of budget
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Quality Ambulatory Measures Measure Gate 1 Gate 5 Weight Depression 1 Acute Phase Prescription 65.3 80.0 1.0 2006-2016 Claims 2 Continuation Phase Prescription 49.6 70.0 1.0 Diabetes 2007-2016 Quality 3 Hemoglobin A1c Testing 69.9 83.2 1.0 4 Eye Exam 58.0 72.1 1.0 5 Nephropathy Screening 79.7 91.4 1.0 Cholesterol Management 6 Diabetes LDL-C Screening 85.3 93.8 1.0 Process 7 Cardiovascular LDL-C Screening 85.3 93.8 1.0 Preventive Screening/Treatment 8 Breast Cancer Screening 77.1 90.0 1.0 Measures 9 Cervical Cancer Screening 83.5 92.4 1.0 10 Colorectal Cancer Screening 65.2 83.3 1.0 Chlamydia Screening 11 Ages 16-20 45.9 63.7 0.5 12 Ages 21-24 50.1 67.3 0.5 Adult Respiratory Testing/Treatment 13 Acute Bronchitis Reporting Only 2009, 2010 1.0 Medication Management 14 Digoxin Monitoring 83.9 91.6 1.0 Pedi: Testing/Treatment 15 Upper Respiratory Infection (URI) 90.6 97.7 1.0 16 Pharyngitis 83.1 99.6 1.0 Pedi: Well Care Visits 17 First 15 Months of Life 91.8 99.3 1.0 18 3-6 Years of Age 85.5 99.2 1.0 19 Adolescent Well Care Visits 60.0 87.7 1.0 Diabetes Outcome 20 HbA1c in Poor Control 45.0 4.7 3.0 21 LDL-C Control (<100mg) 33.4 75.6 3.0 22 Blood Pressure Control (130/80) 30.9 47.3 3.0 Measures Hypertension 23 Controlling High Blood Pressure 71.6 82.5 3.0 Cardiovascular Disease 24 LDL-C Control (<100mg) 33.4 75.6 3.0
Changes in Health Care Spending and Quality 4 Years into Global Payment Zirui Song, M.D., Ph.D., Sherri Rose, Ph.D., Dana G. Safran, Sc.D., Bruce E. Landon, M.D., M.B.A., Matthew P. Day, F.S.A., M.A.A.A., and Michael E. Chernew, Ph.D. n engl j med 371;18 nejm.org october 30 , 2014
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