Alternative Payment Models The Arkansas Medicaid Approach Laurence - - PowerPoint PPT Presentation
Alternative Payment Models The Arkansas Medicaid Approach Laurence Miller, M.D. Senior Psychiatrist, Division of Medical Services Arkansas Department of Human Services Clinical Professor, Psychiatry University of Arkansas for Medical Science
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Arkansas Department of Human Services
University of Arkansas for Medical Science
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Episodes of Care (EOC) Medical Behavioral Health Patient Centered Medical Home (PCMH)
(Under discussion)
Behavioral Health (BH) Long-term Services & Support (LTSS) Developmental Disabilities (DD)
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Arkansas Medicaid (EOC/PCMH) Commercial Carriers
Self-Insured Organizations
State Employees and Teachers (PCMH) Qualified Health Plans for “Private Option” / “Arkansas Works” - Medicaid Expansion (PCMH) Various Dual Special Needs Populations (PCMH)
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2011 AR Medicaid BH Spend by Provider Type 2011 AR Medicaid BH Spend by Care Category Behavioral Health Provider $76 Million Medication $29 Million Primary Care Physicians $14 Million Non-medication $49 Million Other $2 Million Office Visits $13 Million Other $1 Total $92 Million $92 Million
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Approximately 25,000 Beneficiaries
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Medical Home and Health Home Episode-based Care Delivery
Providers proactively work as a team to manage a patient’s
Patient Experience: all healthcare and support services by a patient over time. Patient Experience: all services related to a specific condition, procedure or disability.
One provider is designated as a Principal Accountable Provider (PAP) for all patient needs for a period of time. The PAP is the provider in the best position to influence prevention and management chronic disease. The PAP is in the best position to influence cost and quality of services for the episode.
Providers are rewarded for providing high-quality care at an appropriate cost. The outcomes measured includes the overall health of the provider’s patient population (across all conditions and episodes). The outcome measured is the average cost and quality
particular episode.
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PAP Role Core provider of services This could be a physician, psychiatrist, psychologist, or other behavioral health organizations. Episode “Quarterback”
coordination, early intervention and patient education. Performance Management
decision making.
Patients seek care. Providers provide services. Providers submit claims for services and provide quality data via Provider portal. Arkansas Medicaid reimburses provides based on standard fee-for-service rates. EOC algorithms are executed quarterly (based on paid claims) and reports are made available to providers via a provider portal. At the end of a performance period (12-months), incentive payments/recoveries are calculated and transmitted.
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Trigger An episode is triggered from multiple professional claims with a relevant diagnosis. Pharmacy claims are also considered if the therapy is consistent with the episode. Scope of Services
frames are established and all paid claims for a beneficiary are brought into consideration. PAP Attribution
beneficiaries see multiple
are set to determine who the Principal Accountable Provider (PAP). Global and Episode Exclusions
algorithm, based
flags each relevant claim for inclusion
episode.
episodes are excluded for business or clinical reasons. Adjustments
episode, medication costs are adjusted (leveled) to compensate for wide variance in medication costs. Thresholds
Commendable Cost Thresholds are determined.
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Episodes of Care are based on paid claims. All costs are derived from paid claims. Some Quality Measures are derived by the provider’s response to questions through a provider portal for information not attainable from claims.
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Episode recurrence New patients PAP to submit on Provider Portal
Client diagnosed as ADHD Level I episode Partial or full 365 days Patients included
▪ ADHD-only; no BH
comorbid conditions
▪ Positive response to
Rx treatment Treatment
▪ 4-6 physician visits/
year
▪ Rx stimulants and
medication
▪ Parent/Teacher
Behavior support Level II episode 365 days Patients included
▪ ADHD-only; no
comorbid conditions
▪ Inadequate response
to Rx treatment; other complications Treatment
▪ 6 physician visits/year ▪ Rx stimulants and
non-stimulants
▪ Parent/Teacher
Behavior support
▪ Psychosocial therapy
‘Quality assessment ’ certification ‘Severity’ certification ‘Continuing care’ certification ‘Continuing care’ certification Price for Level 1 Price for Level 2
Participating providers submit on Provider Portal
14 Treatment recommended in AAP/AACAP guidelines2
▪
4 - 6 physician visits / year
▪
Rx medication
▪
Parent / Teacher administered behavioral support3 ADHD with no BH comorbid conditions, positive response to medication
▪
6 physician visits / year
▪
Rx medication
▪
Parent / Teacher administered behavioral support3
▪
Psychosocial therapy if needed ADHD with no BH comorbid conditions, sub-
to medication Not indicated by evidence- based guidelines
▪
Psychosocial therapy
–
In-office psychotherapy
–
Group psychotherapy
I II
Note: All services currently billable are still billable Recommended treatment is only used to set benchmark prices
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Individual providers, in order from highest to lowest average cost Acceptable Commendable Gain sharing limit Average cost per episode for each provider Low High
Average Cost per Provider Costs and Quality Care are primarily derived by: The bundling of claims related to a diagnosis by beneficiary to determine an Episode average cost. A provider’s average cost is compared to his or her peers to determine commendable, acceptable or non- acceptable total cost.
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17 Episode of Care Performance Report ADHD Level I As of April 2016
Financial Summary Baseline Year Payment Year 1 Payment Year 2 Payment Year 3 Total Number of Valid Episodes 14,044 3,046 3,768 4,392 Total Cost Unadjusted $61,863,917.47 $5,507,472.07 $5,737,171.89 $6,427,343.33 Total Cost Adjusted $61,863,917.47 $5,507,472.07 $5,737,171.89 $6,427,343.33 Average Adjusted Episode Cost $4,405.01 $1,808.10 $1,522.60 $1,463.42 Quality Measures % with completed certification N/A 46.42% 43.50% 47.45% % of episodes with medication 92.09% 97.14% 98.94% 99.45% Average number of physician visits per episode 1.78 3.54 3.33 3.47 Average number of behavioral visits per episode 24.02 3.25 1.15 0.54 Average medication fill rate per episode NA 0.90 0.86 0.90
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Raised the discussion in the health care community related to incongruities between actual treatments and standard of care. Improved provider’s coding
Revealed deficiencies in many provider’s billing software and claims submission. Raised awareness of the some of the complexities of treating behavioral health beneficiaries – care coordination, patient comorbidities etc. Brought renewed Statewide attention to behavioral health. ADHD is best suited for care management through a Health Home or a PCMH for medication-only treatment. Provided program analytics here-to-fore non-existent. Still searching for an acceptable outcome measurement.
www.paymentinitiative.org
ARKPII@hpe.com
Arkansas Department of Human Services
Division of Medical Services
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