Latest / The Mental Health Evolution / Ep 16: Why Value-Based Care Can Feel So Hard with Josephine Wilton, Pt. 2

Transcript

Ep 16: Why Value-Based Care Can Feel So Hard with Josephine Wilton, Pt. 2 · The Mental Health Evolution

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  (Transcribed by TurboScribe. Go Unlimited to remove this message.) Two, and now I'm looking at maybe it's measures like the PHQ
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  or something like that.
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  Maybe it's survey data from the patient, you know, things like that
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  that are suddenly tied to that.
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  That is so brand new and additional layers of systems and work
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  to collect that data.
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  Correct.
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  And when you mentioned patient surveys, that's a touchy one for providers
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  typically, even in my experience working with skilled nursing facilities and
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  home health care providers who are rated on the STAR-based system
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  with CMS and at least in the state where I predominantly work,
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  New York State, there's a patient survey aspect, right?
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  So even for hospitals and there's a lot of debate around, well,
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  should we penalize for a few surveys where it was a patient
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  perspective, but on the whole we, you know, perform in, you know,
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  based off of, you know, this patient is an outlier, per se.
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  So there's always these, to your point, right?
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  What is the best metric and best measures?
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  I really think, and I was listening, participated in a webinar where
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  I was just listening just yesterday with three psychiatrists and it was
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  very interesting.
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  So behavioral health was the focus and topic.
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  And one of the psychiatrists said, you know, we know my colleagues
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  and I on this call and out in the field, we know
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  what schizophrenia looks like from a diagnosis and how we would approach
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  it.
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  But a patient suffering from schizophrenia, person suffering from it in
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  whatever geography doesn't apply to another social setting or geography
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  automatically.
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  And so you're not just, you're not just treating the disease and
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  the illness.
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  It's everything that, right?
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  It's everything that encompasses that individual and impacts their life.
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  If they're in a rural setting versus in an urban setting, what
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  does their access look like?
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  Urban setting does not mean you have excellent access to care.
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  Access to care is not just based off of geography, but certainly
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  that's a big part of it.
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  And then what's acceptable, right?
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  You know, given the practice area, is it acceptable to provide predominantly
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  virtual care?
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  And I'm just saying this hypothetically, I don't even know, for someone
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  with schizophrenia, depending on where they are in their illness versus in
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  person, you know, a lot of times the health plans are setting
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  these measures based off of a lot of data.
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  And it doesn't take a lot of these variables into account, right?
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  So they're, they're massive.
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  And some of these pairs as you're, I'm sure you're watching are
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  getting bigger and bigger.
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  There's a lot of consolidation happening.
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  And with them, right, with that, they're amassing more and more data.
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  And that data is aggregated, sliced and diced.
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  And that's how a lot of the metrics and measures are set.
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  That's why it's so important for the providers to understand their data
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  and push back and say, that's fine and dandy, but here's what's
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  happening within our organization.
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  Because you don't drive the service, right?
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  You don't get to dictate what your patients receive per se.
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  They come to you with what they need.
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  So it's a really neat space, right?
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  That's why we started, there was a time we transitioned not too
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  long ago to referring the patients, we called it to consumer, right?
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  Now, we can certainly, if you look at other industries, retail, Walmart
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  doesn't tell me when I walk in where I should go and
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  what I should buy, but they strategically try to place things at
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  the front of the stores, right?
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  Exactly.
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  And quite honestly, I don't know if there was any deliberate attempt,
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  but that's what value-based care has tried to do, right?
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  You hear about scaring patients, educating the patients, but really we need
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  to lean more into a consumer mindset.
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  It's what they need, right?
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  So ultimately, if I walk into Walmart, I'm going to see things
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  front and center that I may not need and I may not
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  engage, but how quickly am I able to get to what I
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  need?
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  And that depends on how they structure it and organize a store.
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  And how easy is it for me to get in and get
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  out?
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  But I should be able to, without over-restrictive processes and workflows,
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  work through the process of what do I need?
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  And some things I didn't know I needed, right?
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  That happens in retail and it's for the benefit of the retailer.
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  Right?
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  We end up spending more money than we needed.
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  We're like, oh, I didn't know this was there.
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  And it happens in health care.
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  The patients don't know this and they're coming for the needs that
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  they have.
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  And they shouldn't know the billing structure.
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  They shouldn't really need to be concerned about total costs of care.
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  But the way these measures and metrics are set up, it puts
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  a lot of responsibility on one provider versus another.
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  And I'll share my insights on that.
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  And then it's completely contingent upon, which always blows my mind, of
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  the patient compliance, right?
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  You hear about patient compliance, but why should I?
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  Why should I even know about this and care about your value
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  -based payment?
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  I just have a need and I need to service.
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  So it's really about, I get it about, you do want to
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  provide the care that's needed.
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  This is about outcomes.
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  And there's a way to do that.
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  And I haven't, it's subtle and it has to be deliberate.
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  And that's where understanding your utilization data is so important.
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  So not to belabor it, but when the providers are engaging in
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  those discussions, pre-contract execution for VEP.
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  Health plan says these are the metrics measures based off of national
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  best practice benchmark standards for our network itself, wherever they're
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  getting their data from.
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  You can push back and say, like I said earlier, that's fine.
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  Here's what our utilization looks like.
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  And don't rely on their claims data, right?
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  They're just another organization like you are.
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  And there may be a lot of services and supports your organization's
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  providing that they wouldn't necessarily identify in the claims or their data
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  analysts are not looking for.
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  I've worked with a lot of data analysts, very brilliant, very sharp
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  actuaries, epidemiologists, data scientists, you name it.
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  And they're looking at it from one perspective, but it's not going
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  to be from your perspective as a provider.
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  Just keep that in mind for your listeners and viewers.
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  So it's very incumbent upon you to tell your story in your
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  way.
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  Don't let someone else tell your story.
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  Wow.
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  I love that.
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  And for organizations that are not tracking their utilization data, that then
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  becomes a piece of information that's really important to pay attention to.
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  It is.
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  And I've worked with some, it can seem very daunting and overwhelming.
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  And obviously, I have a passion for contracts.
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  For decades, I've been working with contracts, and everything lies there.
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  But quite often, I keep an attorney's, I've had two attorneys tell
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  me it takes a special kind of person, and they said it
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  would have smiled when you were reading contracts when I said I
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  do.
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  I think that's true, Josephine.
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  Two separate occasions, unsolicited, random, and I said, I think the universe
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  is telling me something.
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  I didn't, and coming from an attorney, right?
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  But I'll give you a use case where, you know, working with
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  an organization, pretty sizable, multi-location, or sites of service across
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  spanning multiple counties.
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  And there were some operational issues, administrative issues with claims
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  denials.
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  And I said, I'd like to look at your contract.
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  It seemed very random for them.
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  I said, listen, everything's in there.
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  Everything's in there.
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  Not just the numerical parts of it either.
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  It's all in there.
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  Every word impacts your organization in some way, right?
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  And when I did that, I discovered some other problematic things without
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  even verifying or confirming.
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  There's just some things that just were glaring.
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  Reimbursement, the Jerry, I shouldn't probably, it's not fair to say Jerry
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  Riggins, but just the, I call it hip hopscotch, or gymnastics that
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  the provider unfortunately agreed to and determined reimbursement for any given
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  visit.
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  And it was a combination of the plan, the product, the patient's
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  age, gender, service.
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  It was everything you name it.
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  So it was like, it's this, then that, then this, then that.
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  And then you get this little chunk change.
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  So there were a lot of things going on.
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  And I started to work with leadership to explain how the contract
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  on the whole impacted the entire organization.
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  And folks throughout that hadn't ever reviewed it.
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  They were just used to looking at the output, right?
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  What are we getting paid?
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  And so over time, and I would say the revenue is pretty
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  consistent.
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  I would say for your listeners and viewers out there who are
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  provider organizations and you look at your financials or revenue cycles,
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  probably consistent, but that doesn't mean it's right.
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  That doesn't mean you're optimizing the terms that you agreed to, right?
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  And until you've fully optimized it, then you're kind of, your starting
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  point is not really ideal to layer on a VBP.
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  It doesn't mean you don't do it, but you first want to
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  understand your baseline and where you're at, right?
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  I love that perspective.
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  And I think how many providers have not really looked too deeply
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  at their contracts.
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  I mean, I think that's a pretty common experience.
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  It is.
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  Find someone in your organization, doesn't have to be a lawyer, someone
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  who enjoys reading, who has good reading comprehension skillset, and ask them
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  to read it.
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  When I trained contracting specialists, that reported to me when I did
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  this work in a leadership role on health plan side.
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  First week, there was no test that would say, read this contract.
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  And it was like the biggest contract that we had with all
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  the employees.
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  That was my style because if you're uncomfortable, you're not even intrigued
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  or want to read a contract and I'm not so sure I
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  can trust you to negotiate one.
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  And it's very easy for things to get in, certainly very difficult
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  to get out, but it's very, very important.
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  And you don't need to have an attorney on staff.
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  I mean, ideally if you can, but you're going to run up
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  a big tab to have them review it.
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  And not all attorneys are familiar and adept with provider contracts, where
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  they may be in that space, but they work for a health
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  plan.
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  And so it may be somewhat of a conflict.
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  So just start with someone who has the basic skill set and
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  is not averse to it in your organization.
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  There's someone, there's absolutely someone.
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  And it does not excuse your leadership, your CEO, et cetera, from
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  doing it because contracts and amendments are being signed continuously.
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  And so that's why it's very imperative that there's review and scrutiny.
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  But it can be done.
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  It can be done.
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  It's just acknowledging that it needs to happen.
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  I'll add this note.
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  At a conference, and I was very impressed with the CEO of
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  the federally qualified health center had gotten fairly new to the
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  organization, but noted that in his time there, and certainly I'm sure
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  over a culmination of his experience, he realized data was so important
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  to their success as an organization and to be able to innovate
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  and move forward, that they moved to hiring an actuary.
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  That's impressive.
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  And I've worked with actuaries.
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  A lot of providers and folks in the industry don't understand the
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  difference between an actuary, a data analyst, an accountant, a CEO.
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  You need everyone.
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  You need everyone.
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  And so I was just so impressed by that.
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  And I think it speaks to where the industry is going in
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  terms of understanding more about where the deficiencies are.
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  And I was pleased to hear that that CEO and I'm hearing
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  from other leaders that they're understanding.
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  I need to start looking at my data and I need to
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  start looking at my contracts and taking ownership in that regard and
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  not just accepting where things are.
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  Wow.
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  You have given so much to think about with these implementation steps,
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  even just sort of preparing people for awareness of their own organizations
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  and kind of taking into account where we are right now before
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  even thinking about next steps.
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  Looking ahead, what else do you think might come into play or
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  might be helpful in the industry?
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  What trends are you seeing?
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  What innovations, policy or data or partnership models do you think are
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  going to start happening that will be related to value-based care
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  models?
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  Well, one of the things that Rachel might be right up your
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  alley is that I know this early on and I was the
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  one raising my hand and asking questions when I was on the
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  health plan side.
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  Why aren't we including more of our specialists and ancillary providers into
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  these VBPs?
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  They're just baffled, right?
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  When you look at total cost of care, for example, highest cost,
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  right, hospitals.
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  That's why everybody talks about let's bring down hospital costs for avoidable.
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  Certainly there's a time and place, but if it's avoidable and not
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  medically necessary, we don't want the patient going there.
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  The reasons why those patients have heard it from hospitals and seen
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  it in the data, they're in the providers that are servicing them.
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  A lot of times, depending on geography, their social circumstances, this is
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  where social determinants of health come into play, but you have people
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  trying to shelter from the cold, from the elements, going to the
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  hospital.
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  They don't have utilities.
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  Certainly behavioral health, mental health issues, and it's not linear.
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  It's not one or the other and it's fluid.
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  Today, I'm showing up in the EV because of this.
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  Tomorrow, it's these set of things and unfortunately, the way even now
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  through 1115 waiver, right, through the Social Security Act that is available
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  throughout the country and each state is kind of modeling it how
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  they choose to address social determinants of health.
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  The payment for social determinants of health screening is tied to essentially
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  one screening a year.
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  Well, my situation is changing daily, minute by minute, so how do
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  we address that?
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  How do we ensure?
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  Now, certainly care coordination, there's a little bit more frequency and
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  payment, but it's very low.
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  Social determinants of health screening payment is low, at least when you
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  look at in the aggregate and when I looked at New York
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  State, so then that's where the provider has to use the data
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  to try to make the argument of what they're doing that they're
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  not getting paid for and how it ties to total cost of
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  care.
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  See, that's where you have to make the business case for the
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  health plan because it's not so much that they're trying to be
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  tricky and they don't want to do it.
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  They cannot.
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  If it's not on a claim, they can't get to it and
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  historically, providers of all scopes of practice didn't bill for social
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  determinants of health because there was no payment for it, so it's
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  a resource issue.
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  If I don't get paid for it, I'm not going to burden
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  my administrative team to code and bill for it.
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  Not good practice because now the data can't get over to the
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  health plan and I tested this out personally when I was on
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  the side, but I understand why it happens.
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  What I see that can help is, like I said, bringing in
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  your ancillary providers and specialists who were historically ignored.
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  Everybody agrees behavioral health utilization needs to go up.
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  The need is there.
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  We need to, certainly there's a shortage, but we need to support
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  behavioral health organizations and organizations that provide behavioral
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  health services.
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  They need the financial support, so reimbursement on the fee-for-service
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  level needs to be increased and providers can negotiate.
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  It's a free market.
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  It's America.
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  They can say no.
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  I'm used to no.
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  They will tell you no and you just keep pushing past the
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  no until you get to yes, right?
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  I think there's even a book titled that, Get a PS.
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  I haven't read it, but yeah, it was recommended some time ago.
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  I'm not opposed to reading it, but yeah, I think it's called
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  Getting PS or Getting Past No.
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  I think there's two.
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  I would say to providers, don't be afraid to hear no.
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  Again, look to the person on your team, but the CEOs, maybe
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  it's not your strength.
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  Maybe it's not something you've practiced yet, but you've got a pretty
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  well-informed and eager CMO who's willing to do it.
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  It doesn't matter.
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  There's no rule that says it has to be this person or
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  that person.
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  Just make sure it's data driven and they understand some of the
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  fundamentals of it and just go for it.
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  It's not going to happen on its own.
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  Behavioral health, I'm hearing more and more about services like that being
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  put on direct value-based payment arrangements, which is awesome.
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  We'll give you more money, but we're going to incentivize it.
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  We recognize you need more in terms of revenue.
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  Well, it could be a combination of fee-for-service and a
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  VBP methodology that could be risk-based or non-risk-based, purely
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  incentive, maybe upfront funds.
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  A lot of times you'll see a per member per month payment.
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  That's strictly volume-based where I talked about attribution, how many
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  patients are attributed to this VBP on a monthly basis.
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  They'll give you $10, $5, $2, whatever it is to cover your
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  administrative costs.
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  These are all negotiation points.
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  You're seeing more and more where health plans are offering it to
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  ancillary and specialist providers.
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  Again, primary care cannot do it alone.
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  You need cardiology, endocrinology, podiatry, everyone involved, and they
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  typically haven't so they're contributing to the total cost.
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  They're seeing different needs of the patients than the other providers.
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  Everyone needs to talk.
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  There needs to be data sharing, more data sharing, and in a
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  way that's actionable depending on your provider types and scopes of practice
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  or specialties is very, very key.
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  Dental, oral care has been left out.
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  I'll be honest, I don't see as much happening in VBP space
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  around that, but I hope we get there.
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  I truly do.
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  The data is there.
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  It's incumbent upon those oral care providers and institutions or organizations
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  that provide oral care or other disciplines of care.
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  They have to make the case.
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  They have to make the case, and they're only going to be
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  able to make the case through the data.
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  That's what I feel like I am learning from you in this
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  conversation is understand your own data, your own values, your own numbers,
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  and then be able to make the case for yourself.
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  We are pretty much out of time.
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  Josephine, you are a wealth of knowledge, and I feel like you
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  could keep talking.
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  We've already made kind of a part one and part two episode,
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  which I love because I think this is so crucial, and there
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  are so many things that people do not understand about value-based
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  care systems.
• 21:15
  Thank you for everything that you've shared.
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  We will definitely include Josephine's information if you want to reach out
• 21:23
  and contact her, get more data, get more information.
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  She's clearly an expert in this field.
• 21:29
  Thank you so, so much for being here.
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  I have enjoyed every moment of chatting with you today.
• 21:36
  Thank you, Rachel.
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  This has been a pleasure, and thank you to everyone who's listening
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  and watching and who knew.
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  I really appreciate it.
• 21:43
  This has been a great discussion.