1. Padron & Associates | Atlanta
cps innovation and trending business models Preconference Peerpocalypse 18 Mental Health association Oregon | peer link padron & associates | atlanta [location]
Padron & Associates | Atlanta
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11/12/2018

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11/12/2018

3. Trending peer deliverables 2018
Certified Peer Specialist
Forensic Peer Specialist
Recovery Coach
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11/12/2018

4. Previous reviews of p2p and cps intervention
Chinman et al. (2014)
“The effectiveness varied by service type. Across the range of methodological rigor, a majority of studies of two service types—peers added and peers delivering curricula—showed some improvement favoring peers.”
“Peer support services have demonstrated many notable outcomes. However, studies that better differentiate the contributions of the peer role and are conducted with greater specificity, consistency, and rigor would strengthen the evidence.”
Davidson et al. (2012)
“Thus far, there is evidence that peer staff providing conventional mental health services can be effective in engaging people into care, reducing the use of emergency rooms and hospitals, and reducing substance use among persons with co-occurring substance use disorders. When providing peer support that involves positive self-disclosure, role modeling, and conditional regard, peer staff have also been found to increase participants’ sense of hope, control, and ability to effect changes in their lives; increase their self-care, sense of community belonging, and satisfaction with various life domains; and decrease participants’ level of depression and psychosis.”
Pfeiffer et al. (2011)
“Based on the available evidence, peer support interventions help reduce symptoms of depression.”
Primarily self-help groups added to traditional services.
* “Research on the Effectiveness of Peer Specialist Interventions,” (Salzer, M. 2015) Professor and Chair Department of Rehabilitation Sciences Temple University, Director, TU Collaborative on Community Inclusion (
Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E. (2014). Peer Support Services for Individuals With Serious Mental Illnesses: Assessing the Evidence. Psychiatric Services, 65(4),
Davidson, L., Bellamy, C., Guy, K., & Miller, R. (2012). Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry, 11(2),
Pfeiffer, P. N., Heisler, M., Piette, J. D., Rogers, M. A., & Valenstein, M. (2011). Efficacy of peer support interventions for depression: a meta-analysis. Gen Hosp Psychiatry, 33(1), doi: /j.genhosppsych
11/12/2018

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6. Fee-for-Service Quality P4P Shared Savings & Shared Risk Narrow & Tiered Networks Procedure Based Episode Payments for Population-Based Patient Centered Payment System for P2P Integration
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7. What is needed is a patient-centered payment system that corrects the problems of Fee-for-Service payment while preserving its strengths.
Enable patients to have their specific healthcare need addressed by a team of providers that have agreed to work together to efficiently deliver high quality care and achieve specific, feasible outcomes for that need;
Enable patients to select which provider team to use based on the quality standards and outcomes that each provider team commits to achieve for that patient and based on the total amount that the patient and their insurer will pay for all of the services the patient will receive with respect to the need that is being addressed;
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8. Give the team of providers adequate resources and sufficient flexibility to deliver the most appropriate combination of high-quality services to achieve the best outcomes possible given the nature and severity of the patient’s need;
Hold the team of providers accountable for meeting quality standards and achieving the expected results for each patient in return for the adequate, flexible payment.
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11/12/2018

9. The delivery and payment for health care services are rapidly evolving:
Health services are increasingly being delivered in integrated systems of care (ACOs) and team-based provider systems (PCMH, FQHC, other).
Treatment for behavioral health conditions are increasingly being coordinated or integrated with primary care.
Medicaid and Medicare are expanding the use of managed care vehicles to improve quality and control costs.
Over time – Commercial insurance, State Exchanges, and Medicaid and Medicare plans will have greater similarity in form and operations.
Models of reimbursement are shifting to population-based outcomes and risk supporting QoL and PHQoL outcome increases.
Peer Support Services (intentional and professionally delivered) are fundamentally health services, and there is a distinct and emerging role for self-care/self-management advocates in the engagement, activation, and ongoing care for those with chronic illnesses.
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11/12/2018

10. Federal Policy Support for Peer Support (1)
1978 President Carter’s Commission on Mental Health offered early federal recognition that “groups composed of individuals with mental or emotional problems” were being formed around the country 2
1987 Surgeon General’s Report recommended strategies for promoting self-help groups 3
1999 Surgeon General’s Report promotes self-help groups and consumer-run services 4
> 2001 Peer support services funded by states and counties
* “Effectiveness of Peer Support Interventions,” (Salzer, M. 2015).
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11/12/2018

11. Federal Policy Support for Peer Support (2)
2001
CMS Funding of Peer Support in GA and AZ
2003
The President's New Freedom Commission on Mental Health promotes consumer-operated services
2004
VA strategic plan recommendation “Hire veterans as Peer Para Professionals.” (Commission Rec &19, Appendix)
2007
CMS guidance letter to states on peer support services
2008
Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics states that “all veterans with SPMI must have access to Peer Support (2, pg. 28)”.
* “Effectiveness of Peer Support Interventions,” (Salzer, M. 2015).
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11/12/2018

12. Do payment rates match the cost of delivering quality care?
Are providers accountable for appropriateness, high-quality, and outcomes of services for each patient?
Do payment rates match the cost of delivering quality care?
Do providers have flexibility to deliver the highest-value services?
Are patients and purchasers able to determine the total amount they will pay?
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13. Are providers only paid when service recipients receive supports?
Are service recipients with greater needs able to receive more services?
Are providers only held accountable for things they can control?
Do providers know how much they will be paid before services are delivered?
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11/12/2018

16. Samhsa/hrsa cihs cms CMS BEHAVIORAL HEALTH CODING
Medical Billing and Codification (MBAC)
SAMHSA US Integration, Financing, Billing-Tool Worksheets
Samhsa/hrsa cihs cms
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11/12/2018

17. 2019-2021 projections (three tiered trial)
padron + associates

18. Revenue Forecast H0038 Peer Support H0038 Peer Group Services
FY2019
FY2020
FY2021
Revenue
H0038 Peer Support
$600,000
$2,313,000
$2,868,000
H0038 Peer Group Services
$27,000
$54,000
90863 Group Therapy Mental Health
$30,000
$60,000
H2011 Crisis Intervention
$87,750
$175,500
T1017 Case Management
$62,400
$124,800
96150 Assessment New Patient Health and Behavior (HABI)
$66,000
$132,000
96153 Group Treatment Health and Behavior (HABI)
$36,000
$72,000
G0108, G0109 Individual | Group Diabetes Education Health, Obesity and Tobacco Counseling F2F and Telemedicine
G , Smoking Cessation Health, Obesity and Tobacco Counseling F2F and Telemedicine
$9,000
$18,000
G0446 Behavioral Counseling for CDV (WHAM, WRAP)
$22,500
$45,000
Therapy Services, Mental Health (FQHC Billable)
$93,750
$187,500
H0031 Mental Health Assessment, Mental Health, FQHC Billable
$108,000
90863 Group Therapy, Mental Health FQHC Billable
$90,000
Established Patient, Add on 90833, 90836, for OMHC (Outpatient Mental Health Clincic)
Total Revenue
$1,205,400
$3,523,800
$4,078,800
Direct Cost
H0030 Intervention [Hotline Services]
$50,000
$192,750
$239,000
H0036 Individual Community Support/$21.97]
$2,250
$4,500
H0038 Individual 1:1 Peer Services [Self-Help / Peer Services/00:15/$21.97]
$3,000
$6,000
H0038HQ Group Peer Services [Self-Help / Peer Services/00:15/$6.65]
$4,050
$8,100
H2016 Peer Support / Recovery Services [Comprehensive Community Support Services / Per Diem]
$4,800
$9,600
H2015 Peer Support / Recovery Services [Comprehensive Community Support Services/00:15]
$1,200
$2,400
Direct Labor
Total direct costs
$65,300
$223,350
$269,600
Gross margin
$1,140,100
$3,300,450
$3,809,200
Gross margin %
95%
94%
93%
FY2019
FY2020
FY2021
Revenue Forecast (3 Year Tiered)
H0038 Peer Support
$600,000
$2,313,000
$2,868,000
H0038 Peer Group Services
$27,000
$54,000
90863 Group Therapy Mental Health
$30,000
$60,000
H2011 Crisis Intervention
$87,750
$175,500
T1017 Case Management
$62,400
$124,800
96150 Assessment New Patient Health and Behavior (HABI)
$66,000
$132,000
96153 Group Treatment Health and Behavior (HABI)
$36,000
$72,000
G0108, G0109 Individual | Group Diabetes Education Health, Obesity and Tobacco Counseling F2F and Telemedicine
G , Smoking Cessation Health, Obesity and Tobacco Counseling F2F and Telemedicine
$9,000
$18,000
G0446 Behavioral Counseling for CDV (WHAM, WRAP)
$22,500
$45,000
Therapy Services, Mental Health (FQHC Billable)
$93,750
$187,500
H0031 Mental Health Assessment, Mental Health, FQHC Billable
$108,000
90863 Group Therapy, Mental Health FQHC Billable
$90,000
Established Patient, Add on 90833, 90836, for OMHC (Outpatient Mental Health Clincic)
Revenue Forecast
All Rights Reserved. Padron and Associates (c) 2018.
11/12/2018

19. Total Revenue (Three Year Tier)
$1,205,400
$3,523,800
$4,078,800
Direct Cost
H0030 Intervention [Hotline Services]
$50,000
$192,750
$239,000
H0036 Individual Community Support/$21.97]
$2,250
$4,500
H0038 Individual 1:1 Peer Services [Self-Help / Peer Services/00:15/$21.97]
$3,000
$6,000
H0038HQ Group Peer Services [Self-Help / Peer Services/00:15/$6.65]
$4,050
$8,100
H2016 Peer Support / Recovery Services [Comprehensive Community Support Services / Per Diem]
$4,800
$9,600
H2015 Peer Support / Recovery Services [Comprehensive Community Support Services/00:15]
$1,200
$2,400
Direct Labor
Total direct costs
$65,300
$223,350
$269,600
Gross margin
$1,140,100
$3,300,450
$3,809,200
Gross margin %
95%
94%
93%
All Rights Reserved. Padron and Associates (c) 2018.
11/12/2018

20. Total Operating Expenses
 Three Year Tiered
FY2019
FY2020
FY2021
Revenue
$1,205,400
$3,523,800
$4,078,800
Direct Costs
$65,300
$223,350
$269,600
Gross Margin
$1,140,100
$3,300,450
$3,809,200
Gross Margin %
95%
94%
93%
Operating Expenses
Total Operating Expenses
Operating Income
Interest Incurred
Depreciation and Amortization
Income Taxes
$307,827
$891,122
$1,028,484
Total Expenses
$373,127
$1,114,472
$1,298,084
Net Profit
$832,273
$2,409,328
$2,780,716
Net Profit / Sales
69%
68%
All Rights Reserved. Padron and Associates (c) 2018.
11/12/2018

21. Jennifer m. padron P | A ATLANTA (706) 391-3864 jennifermpadron@gmail
Jennifer m. padron P | A ATLANTA (706)
All Rights Reserved. Padron and Associates (c) 2018.
11/12/2018