Latest / The Mental Health Evolution / Ep 15: Making Value-Based Care Work with Josephine Wilton Pt. 1

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Ep 15: Making Value-Based Care Work with Josephine Wilton Pt. 1 · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) Welcome back everyone to the Mental Health Evolution podcast where we are
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talking about how the landscape is quickly evolving in the mental health
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industry.
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Today we are joined by Josephine Wilton, Principal Consultant at Hulanta
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Consulting.
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Josephine is a healthcare consultant who helps organizations translate value
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-based care principles into real-world implementation.
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Her work includes guiding provider groups, payers, and employers through the
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operational steps required to make value-based care models work, from the
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data infrastructure and billing alignment to care coordination and performance
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measurement.
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We've talked before about value-based care as a concept on this
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podcast, an idea that focuses on outcomes and quality instead of service
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volume.
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But what does it take to actually put that idea into practice?
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That's what we're going to be talking about today.
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And Josephine specializes in turning theory into action, and we're going to
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dive into how systems coordinate care, track data, and make the financial
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side sustainable.
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But first, as always, we have some articles that we would like
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to highlight for you related to the topics today.
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The first one is called Implementing Value-Based Care, a Scoping Review.
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And this recent review synthesizes implementation strategies for value-based
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healthcare across international settings.
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It explores how organizations operationalize key enablers like data systems,
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payment models, and performance metrics, and where common barriers arise when
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we are translating this into actual practice.
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A hint there, the data systems, payment models, and performance metrics are
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all the pieces that make value-based care work, and those can
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be pieces that are sometimes a struggle for different organizations to
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implement, especially in mental health or as it's also called behavioral
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healthcare.
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The second article is called Value-Based State-Directed Payments in Medicaid,
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from February 2023 to May 2024.
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This is a JAMA Health Forum study, and it reviews the design
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of Medicaid programs incorporating value-based payment mechanisms.
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It highlights how states are moving from conceptual frameworks to concrete
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payment models, trying to reimburse performance care continuum and outcomes
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tracking.
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And the third article, Why Primary Care Practitioners Aren't Joining Value
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-Based Care Payment Models.
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In this Commonwealth Fund issue brief, researchers look at the practical
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barriers facing primary care practices when they try to adopt value-based
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contracts.
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They point at things like staffing shortages, limited capital for
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infrastructure, and lack of access to data as hurdles to implementation, all
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pieces that our guest today specializes in.
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So with each of these, they talk about a piece of a
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value-based care puzzle, strategies that make it work, payment structures that
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incentivize success, and then the real world barriers that providers face.
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And Josephine, our guest today, works directly with provider groups and
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organizations navigating these challenges.
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So I'm excited to dive in a little bit more to her
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expertise.
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So welcome, Josephine.
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It's so great to have you on the pod today.
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Thank you, Rachel.
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I appreciate this opportunity to speak with you, your viewers, and your
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listeners.
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This is fantastic.
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Thank you for having me.
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You bet.
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Okay.
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So we know a little bit about what value-based care or
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the why behind value-based care, but I'm curious if you can
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kind of give us a picture of what it looks like when
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an organization decides to actually make that shift.
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Yeah.
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So I will speak to what it has looked like in practice,
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and I can certainly touch on it from my experience and perspective,
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maybe where the deficiencies and pitfalls come into play.
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So what it looks like quite often is that both parties engage
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in some sort of contracting process, right?
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And depending on who you're speaking to, a provider organization or health
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plan, the providers tend to feel that it's a little bit more
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one-sided, and it's what the health plan may dictate and offer,
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and they feel compelled and obliged to accept.
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But there usually is some sort of dialogue that ensues before there's
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an agreement.
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Once there's an agreement, then the parties tend to, depending on the
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organizations on both sides, all parties, depending on their practice and
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cadence, they may very well start on a lot of the preparation
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before, during the contracting phase, or post-execution.
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Quite often it's post.
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And depending on when the contract is signed, you may have weeks,
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months, could be a year, which is great to prepare, but a
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lot of times it's a short turnaround, and that performance year is
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starting.
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And so it's very imperative that the communication between the parties is
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tight and it's consistent.
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Usually during the contracting phase, there's a lot of frequent discussion, and
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it can kind of taper off once this contract's signed.
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There's a tendency to believe that things will just kind of fall
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into place.
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So with that being said, there certainly are instances where the ideal
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happens and communication follows appropriate process, and both parties have a
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level of confidence before the performance year starts.
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Once the performance year starts, typically you see a lot more individuals
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on the provider side that may not have been involved on the
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contracting side, and setting those metrics and measures, they're now brought
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into the fold.
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Ideally, we can get into that, they should be brought in sooner,
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but quite often it's post-execution at the start of a performance
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year, and now they, so that's your clinical team, your operations team,
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schedulers, call centers, if you are bringing them into the fold, they're
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usually late coming to the party.
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So now there's that catch up, and it's a matter of what
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does this mean for me in my focused area in this organization?
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And the parties start to try at least to work through that,
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while in real time, you know, that's the performance period, things are
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happening, you're seeing patients, how closely are they aligning to the value
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-based payment care, excuse me, value-based care and payment model that
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you agreed to?
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Because you can't stop that.
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Let me pause you there for a minute.
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I want to go back to something you said early on, which
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is this idea that a lot of times providers feel like they
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don't have much say in this process of value-based care, and
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you said, but there is some discussion back and forth.
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I want to just open that up a little bit, because that's
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a distinction that I don't think I've heard a lot of talk
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about.
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So what do you feel like provider groups have the ability to
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ask for, to talk about in those scenarios?
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Sure.
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So in my experience, working with, speaking with CEOs, CFOs, CMOs, so
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Chief Executives, Chief Financial Officers, Chief Medical Officers and the
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like, the common theme is this is what we were presented with,
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and we thought this is what we had to agree to.
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And that's not necessarily the case.
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That's not necessarily how it's even presented.
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However, I think it's usually based off of past practice.
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So when talking about value-based payment models, it can be direct
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with the health plan.
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You can certainly have a middle party, like an accountable care organization
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or ACO, or an IPA, an independent practice association.
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When you're dealing with an ACO or an IPA, most times they've
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already negotiated something with the health plan.
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So what they're presenting to the provider doesn't mean it's fixed entirely,
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but there are some pre-negotiated terms between the IPA and the
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ACO and the health plan.
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And certainly when it's directly, yeah, the health plan has predetermined, but
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it's all database.
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And we can, maybe when we talk about data, we can talk
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about how the provider understanding its data from a trended perspective, not
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just snapshots, historical, aligning that with their financial objectives and
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goals, understanding the data pre-contracting, during contracting, and post
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-execution and setting some model framework to track in real time is
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going to enable them, especially when they're at the table pre-execution
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of an agreement to negotiate.
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We don't know and understand the utilization of services in your organization
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and how you're paid, what you're paid for, what you're not paid
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for in your revenue cycle, then it's going to be very difficult
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to negotiate terms that align with your business model and care delivery
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model for your organization.
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So that's where I noticed the challenge and the barriers.
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And that makes a lot of sense.
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And then you were saying that some of the implementers, the clinical
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team, the chief medical officer, potentially the operations people often get
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involved more in this implementation stage and not in the earlier stage.
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So would you have an argument that they should be in on
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the earlier stages of talk and negotiation?
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Absolutely.
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Absolutely.
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And I've seen it, you know, happen.
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But again, when you don't have the data and you have the
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right parties, then you still have a major fundamental gap, right?
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So I've seen that happen as well, where you have your COO,
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maybe other operations leaders.
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You may have a strategic business advisor, your CFO, but then there's
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missing data, poor data, data gaps.
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And so they're listening, they're at the table, they're offering up their
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input and feedback, but it's somewhat theoretical, right?
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It's conceptual, it's based off of our subjective view of what's been
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happening and what may happen once we join this partnership for this
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particular VVP.
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So the data is very critical, but yes, those implementers have to
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be involved very early on.
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If they're not at the table, run the contractual terms, the measures,
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the metrics by your operations team before you agree to it.
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Say, hey, when you look at this, what does it mean for
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you?
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What are the implications?
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And you may have to do some translation of sorts.
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Not everyone's used to looking at contractual terms, but I have found
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consistently that is a major gap.
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It's a major, major gap, not understanding the contractual terms.
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And you're typically layering on a VVP to a baseline fee-for
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-service.
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So first understand the baseline and then what you're layering on, and
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then augment your operations and delivery pathways appropriately.
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So yes, folks need to be involved, but it needs to be
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deliberate.
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Let me ask you about size of organization because I know that
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some of our listeners may be a smaller group practice or even
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a solo practitioner.
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Do these same pieces apply there as well?
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Is there something where, I have heard in other states, not so
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much my state, where value-based care is rolled out by an
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insurance provider and even those smaller level folks are expected to comply
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with that?
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That's true.
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And let me say this working with your solo practitioners or smaller
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position group practices, the CEOs, first and foremost, are their physicians,
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typically that's the case, but they're also their business people, right?
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They're running a business and they're running either a small business or
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medium-sized business in those scenarios.
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And that's often overlooked.
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What I do find out, highlight the positives, is that your solo
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practitioners actually understand the business pretty well.
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They're able to wrap their arms around more of the financials, even
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if there's additional support that's needed in terms of modeling out
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contractual terms, understanding the revenue cycle process, but they typically
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understand it a little bit more because it's just a smaller organization
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and by nature they have to.
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But you're absolutely correct.
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I've heard that consistently.
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I've witnessed it.
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And one of the things we can discuss is that I've worked
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on the other side, you know, for eight and a half years,
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I worked for a health plan and did contracting.
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So I know exactly what that looks like and how it can
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feel, at least from both sides.
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So the solo practitioners, there's more, you definitely have more engagement.
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They understand the financials typically better than the larger organization
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CEOs.
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This is my experience.
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They, and I mean, beyond just the balance sheet, right?
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Because the CEOs understand that.
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But when you really start to dig in, do you understand how
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the percentage, basic percentages, what's your revenue on the dollar?
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How many pennies do you get per dollar billed out, right?
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What is your breakeven for your services on a cost basis for
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services?
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Usually it's a very high level aggregated balance sheet that you need.
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But oftentimes the larger organizations and CEOs kind of, that gets a
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little bit, there's ambiguous of sorts and they start to drill down
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per payer and that's where they get lost.
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So the smaller organizations, what they need, they still need support with
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data.
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That's time consuming, again, brilliant, very sharp, savvy business men and
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women leading these organizations who also are physicians, but they don't have
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the time or resources to comb through data, to do the modeling
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that's needed in your preparation before you enter into these.
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Again, the common theme, no matter what provider size is that they
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enter into these relationships and arrangements without enough due diligence
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before doing so.
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And then they feel like they've been bamboozled, right?
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They'll tell me, we thought we were going to get X and
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we didn't, we didn't get anything or we got far less and
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feel like they just tried to pull the wool over us.
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And it's not, I haven't witnessed that with a health plan.
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The issue is a lot of times they're speaking two different, somewhat
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two different languages or dialects.
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Oh, I would agree with that.
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Yeah.
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Right.
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And at the table, that sounds right.
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Because typically the conversation is around the outcomes and the metrics, but
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very seldom do you hear any discussion around operationalizing those terms and
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execution.
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Right.
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Very quickly, like I said, performance here starts real time.
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Things are happening and active, the regular meetings you're going to have,
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right?
17:25
The providers will meet with the health plans monthly or whatever frequency
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they're going over what I would call report cards.
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And that's when you start to see a lot of the friction,
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especially those, the smaller provider organizations, the solo practitioners,
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once they feel they've had a bad encounter with BVPs, they tend
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to just say, nope, no more, not doing it.
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Right.
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Or because, right.
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Because they understand their businesses a bit more, they might even shy
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away from ever joining one and say, nope, I don't see that
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happening.
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Looks good.
17:59
Sounds good.
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But I don't see how you can support me because of the
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health plan, not articulating enough, or maybe it's just a lack of
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understanding and how that provider organization works.
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So when the solo practitioner feels like you don't understand my business,
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or I don't have a certain confidence level that you truly do,
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then I'm not sure this is the best partnership.
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I'll stick with the fee-for-service.
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Right.
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Right.
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So what are some of those functional pieces that are needed?
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You mentioned data multiple times.
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What things do practitioners or organizations need to have in order to
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understand how value-based care is going to be paid out, how
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it's going to work?
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Yes.
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So we talk about data.
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I mentioned like the equivalent of a report card, performance score cards,
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and what health plans typically use for an ACO or IP with
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provider organization.
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That's usually once, it's not very close to real time.
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And what the providers need, when I talk about data, what's somewhat
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missing is as close to possible as real time data.
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You're seeing the patient on a given day.
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The provider, the leadership within those organizations should be able to see
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which one of those patients, not only what their insurance demographic is,
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but if they're attributed to a VVP, right?
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So that you can understand what's happening in real time, what the
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gaps are, if they were closed or not.
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And then you're certainly not just a CEO or CFO needs to
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look at this, your operational leadership.
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So there's the planning that comes into play.
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But the real time data, why it's so critical, it's also what's
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been understood in the industry is a lag in VVP data.
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And that's because, right?
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So that's because the provider organization sees the patient today, I'm
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serviced today at your organization, your billing team.
20:12
First of all, there's coding and notes and things.
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And once the rendering provider closes their notes, et cetera, there's a
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delay there.
20:18
It's not like it gets billed out that day, right?
20:22
So 30 days, then it goes over to the payer.
20:25
They're adjudicating it for payment.
20:26
Hopefully it doesn't get denied.
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That's a whole other topic for administrative denials, but it goes through
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that process.
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Then the claims data has to kick over to their VVP team
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on the health plan side.
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Now the ACO and IP still don't have it.
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If they're involved, it's still with the health plan.
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They need to reconcile, do their analysis, and then see where that
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patient lands in terms of outcomes and services according to the terms
20:52
of the agreement.
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With that being said, these are known delays and lags in data
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that leads to the scorecards.
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However, provider organization is still meeting with the health plan.
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So what are you talking about, right?
21:09
What you need to be looking at is what's happening in real
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time with the health plan doesn't have.
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If it's not on the claim, it didn't happen.
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So now the onus and the responsibility is on the provider organization
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to be able to comb through their electronic health record system, utilize
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what other tools and resources are available to connect the dots, right?
21:34
So the primary care provider is not the sole.
21:37
They're not solely whatever the provider is, whether it's primary care,
21:41
behavioral health, etc.
21:43
Usually VVPs are tied to primary care, but they're also more so
21:48
tied to total cost of care, right?
21:50
From a health plan perspective, better outcomes means controlled costs.
21:56
So you're only responsible for what your organization does in terms of,
22:01
provides in terms of services.
22:03
But now you've got a health plan meeting with you more frequently
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than the claims data is able to process to show them what
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happened.
22:10
So what do you talk about?
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Unfortunately, what I've seen, and solo practitioners and smaller organizations
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suffer more, but it's across the board, I've seen it with hospital
22:20
systems, is how do we, the provider organization, how do they present,
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well, first source the data that they need, that aligns with the
22:31
VVP, and then present it to the health plan in a meaningful
22:34
way.
22:35
Health plan is not going to necessarily pay you based off of
22:38
that data, because remember, it's not on a claim yet.
22:41
That's their source of truth.
22:43
But it certainly helps guide the conversation and allows both parties to
22:48
make adjustments as needed.
22:49
If you start to see trends within that lag of 60, 30,
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60, 90 days, whatever it is, you should be talking about it.
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You should be looking at what the data is showing you in
23:00
that period of time before the claim is able to be scrubbed
23:04
and dissected.
23:05
So yeah, that's a huge known issue.
23:12
Maybe we'll see more in terms of technology development.
23:15
You know, a lot of these EHRs, they can support VVPs, but
23:20
again, it requires the provider to work through a lot of configuration
23:24
with the vendor, sometimes, you know, right.
23:31
So, right.
23:33
And there's a cost.
23:35
I can definitely hear there, there are pieces of this where there's
23:39
a lot more work, maybe time on the provider side is a
23:46
lot of what I'm hearing with these pieces.
23:49
Yeah, it's, I would say, and I would even use a term,
23:52
a lot of burden, right?
23:53
A lot of burden that I really don't think even the health
23:57
plans are fully aware of.
24:00
I think, so the data is there, the information is there.
24:05
It's a time and resource issue to get to it and then
24:10
certainly analyze it.
24:11
And then when you talk about as close to real time as
24:14
possible, most of the provider organizations do not have that resource
24:18
available or resources.
24:21
Right.
24:23
Yeah.
24:24
And so then that affects pay, ultimately.
24:27
There you go.
24:28
So, and when we talk about if it's not on a claim,
24:32
then it didn't happen for whatever reason.
24:34
If claims are administratively denied, if your billing system is set up
24:38
to run into all these circumstances, say the revenue cycle process has
24:44
certain codes, procedures compared within a provider organization system that
24:51
identifies a code that's not billable.
24:53
Well, I've witnessed where that kind of went on a set it
24:56
and forget it.
24:57
Those things change, right?
24:59
But now that that claim's not going out the door, but you
25:02
rendered a service that may be tied to a VVP, but the
25:05
health plan is not going to count it because it wasn't on
25:08
the claim or you didn't even submit the claim for payment.
25:11
So that's why financial, the revenue cycle process is so important to
25:17
understand that for every CEO and CFO for the success of their
25:21
VVP program.
25:22
It's not just a conversation with your clinicians or your providers.
25:27
You got to get revenue cycle involved because your providers are rendering
25:31
the service and they have no control over the revenue cycle process.
25:35
And you really need those claims to get out the door.
25:39
With that, that if you say a patient, we didn't talk about
25:45
attribution, like who gets counted in the VVPs.
25:48
So it's based off of a rendering provider, but typically what the
25:53
health plans use, a billable provider.
25:56
So again, if that provider is not on the claim, listed on
25:59
the claim, and the claim doesn't get out the door, then the
26:02
service for that patient that may be already attributed to the value
26:06
-based program doesn't get counted, but the patient's still in your denominator,
26:11
right?
26:11
So there's just a total attribution.
26:13
So all patients who are going to be attributed, it's usually based
26:16
off of that health plan and product.
26:18
So I have X insurance and product, and there might be other
26:22
demographics that qualify me, but I'm now in this provider organization
26:27
denominator, meaning the total pool of patients that need to follow this
26:33
VVP model.
26:35
Claims are not getting out the door.
26:37
Maybe there's a coding issue.
26:39
We, you know, risk scoring issues, et cetera, all sorts of things
26:42
that could be happening that I'm still in the denominator, but as
26:46
far as the numerator, what happened to me is not being accounted
26:51
for.
26:51
And then there's certainly friction there when providers are at the table
26:56
speaking with the health plans, the health plan saying, you didn't do
26:59
it.
26:59
You don't see it.
27:00
We don't see you moving the needle in the right way.
27:03
They're saying, well, we have been doing it, or the providers may
27:06
even acknowledge this patient's in our denominator, but, and we've provided the
27:11
service that our organization can provide, but this patient is in need
27:15
of other services, right?
27:18
So what happens if you're providing the behavioral health services that patient
27:24
needs, but the VVP may be tied to primary care, certainly avoidable
27:31
hospital encounters, et cetera, that are outside of your control.
27:36
And now you're penalized.
27:38
That's how the, that's how the system works because from the health
27:41
plan perspective, the value-based payment program where there's risk involved,
27:47
and sometimes, you know, even if it's just an incentive and there's
27:50
no risk, meaning there's no punitive element to it, they're still looking
27:54
at total cost of care.
27:56
What did Josephine Wilton cost the health plan in the baseline period
28:00
of a given time period, so say 2023, and then what is
28:06
the potential for those costs to go down, total costs?
28:12
Some costs you want to go up, right?
28:14
Right now in the industry, there's a consensus, behavioral health utilization
28:19
should increase, right?
28:20
People need those services.
28:22
So those are costs that should go up.
28:24
That's acceptable.
28:26
That's what the health plans want to see.
28:27
That's what the industry wants to see.
28:29
That's what the government payers want to see because they know that
28:32
it's good care.
28:33
Primary care costs should go up.
28:35
We see an underutilization, but the need is there, similar to behavioral.
28:39
What's often not talked about is dental, dental care.
28:44
Very low reimbursement in the industry.
28:47
Historically, it's a lot of procedures are not seen as medically necessary
28:52
or appropriate, but in the industry, providers see it all the time.
28:58
You know, a person's dental care can severely, or dental status or
29:03
oral care status can significantly impact their health and well-being, right?
29:09
Definitely.
29:09
Yeah.
29:10
Right?
29:10
So it's all tied together.
29:14
I think it's going to require more dialogue.
29:18
I've witnessed both parties, the payers and providers come to the table
29:23
with a lot of preconceived notions and assumptions, and it's been for
29:28
the most part, not in every instances, but a lot of times
29:31
those preconceived notions and assumptions are quite negative.
29:36
Yes.
29:37
Yeah.
29:39
And sometimes there's some naivete involved where it's not negative, but it's
29:43
still not based in fact.
29:46
Well, and I think anytime you go from a like you're saying,
29:51
a fee for service model, where I see a client for a
29:56
set amount of time for a