How We Got to “Yes” on Alternative Payment Models Elizabeth LaMair, JD Director of Healthcare Policy Texas Council of Community Centers

Continuing Legal Education This session qualifies for 1.5 hours of CLE credit. Course Title: 33rd Annual Texas Council Conference Course Number: 174018572 Dates: June 20-22, 2018 Please request credit on the State Bar website.

Our Distinguished Panel Ayanna Castro-Clark, MPH, Director of Contract Management, Western Behavioral Health Network Martin Cook, Director of Revenue Cycle Management, Integral Care Stacey Durr, MEd, Director of Managed Care, MHMR Tarrant Yulanda Haynes-Mims, MBA, Director of Health Plan Reimbursement, Bluebonnet Trails Community Services Elizabeth Reed, LMSW, Director of Managed Care, The Harris Center for Mental Health and IDD

Terminology Alternative Payment Model (APM) Value-based Payment (VBP) Value-based Contracting Quality-based Payment Payment Reform Healthcare Payment Transformation Pay-for-Performance Model Potato or Potato? All of these terms are used to describe the same thing – paying for quality vs. quantity. Outcomes vs. FFS encounters.

At the National Level … Medicaid Waiver Programs CMS Managed Care Rules MACRA’s MIPS and APMs MACRA = Medicare Access and CHIP Reauthorization Act of 2015 (quality payment program for Medicare Part B). MIPS = Merit-based Incentive Payment System APM=Advanced Alternative Payment System

… and Here in the Lone Star State 2015 General Appropriations Act – Rider 79 House Select Committee on Mental Health (85th R.S.) Statewide Behavioral Health Strategic Plan for 2017-2021 1115 Waiver – VBP Roadmap In recent years, Texas lawmakers and human service agencies have identified a need for delivery and payment system reform. Recognizing that coordinated mental health, substance use and physical health care improves health outcomes and reduces costs, the Texas Legislature directed Health and Human Services Commission (HHSC) to pursue the SAMHSA Certified Community Behavioral Health Clinic (CCBHC) planning grant in 2015. The Texas Legislature also convened a House of Representatives Select Committee on Mental Health for the 85th Legislative Session. The committee issued a number of recommendations promoting value-based and integrated care models, triggering significant health care reform legislation in 2017.   Following this lead, the HHSC Statewide Behavioral Health Strategic Plan for 2017-2021 incorporates the CCBHC delivery model and outlines the agency’s strategy to “explore and promote alternative payment structures that reward or incentivize the provision of services that avert more costly care.” Likewise, the HHSC Value-Based Purchasing Roadmap outlines plans for value-based payment (VBP) initiatives, including a shift to outcome-based payments in the Delivery System Reform Incentive Payment (DSRIP) program, and describes efforts to transform managed care provider payments to risk-based models. In addition, beginning in 2018, HHSC health plan contracts include value-based payment (VBP) thresholds for network providers that increase over time. By 2021, at least 50% of health plan payments must be made through VBP models, and 25% must be risk-based. HHSC contracts also require health plans to use VBPs for CCBHC pilot sites beginning September 2018. HB 1, Article II, Rider 79, “Excellence in Mental Health,” (84th R.S., 2015). http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf Texas Statewide Behavioral Health Strategic Plan, Strategy 4.2.1, p. 36. https://hhs.texas.gov/sites/default/files/050216-statewide-behavioral-health-strategic-plan.pdf

HHSC VBP Roadmap The VBP Continuum Category 1: FFS, no link to value Category 2: FFFs with links to quality and value (examples: FFS plus bonus, care coordination fees, pay for reporting, $ for HIT) Category 3 -4, “Population-based Accountability” Category 3: Alternative Payment Models with shared savings, or AMPs with shared savings and downside risk Category 4: Population-based payments (e.g. PMPMs, risk-based)

Taking Our System to the Next Level: The Delta Center Grant

Getting Ready to Negotiate with MCOs: Do Your Homework Build the Relationship Identify Strengths and Weaknesses Know Your Data and Costs Set Realistic Goals What’s Important to the MCO? Prepare to Educate and Pitch

Study Guides Managed Care Steering Committee Resources THLCportal.com Managing and Negotiating MCO Contracts Contracting Questionnaire Quick Reference Guide for Medicaid and CHIP Managed Care THLCportal.com HHSC’s Website Delta Center (More to Come)

Negotiate the “Ms” Measures/Metrics Methodology Money

Panel Discussion

Questions?