1. Case Rate Toolkit Measuring Value Payment Models Health Home Rates
Treat
to Target
Bundled Payment

2. Case Rate Toolkit Defining what a “case rate” is and what it is not
Based on “Creeping and Leaping from Payment for Volume to Payment for Value” paper developed by The National Council for Behavioral Health
Defining what a “case rate” is and what it is not
Steps in developing case rates
Using Ohio Medicaid Reimbursement Rates
Outcomes based case rates
Using Ohio Health Home outcomes

3. Case Rate
Definition: A single payment to cover the cost of a case based on the outcome decided upon by a payer.  
Example: An orthodontist charges $5000 for Phase 1 care
Goal: Aligned teeth
Treatment: Spacers
Braces
Retainers
Length: 1 to 3 years (primarily depends on patient’s compliance with treatment)
Cost: Based on the average length of care and type of treatment
Example: patients will require 1 year of care
100 patients will require 2 years of care
100 patients will require 3 years of care

4. Expanded Definition
A case rate (or bundled payment) represents a pre-determined amount of money paid to a provider organization to cover the average costs of all services needed to achieve a successful outcome for a pre-defined episode of care.
Example: A substance abuse agency is paid $3500 per person for six months to provide recovery services for people stepping down from an inpatient treatment center.
Expected short term outcomes: Sustained sobriety, improved coping skills
Expected long term outcomes: Zero recidivism

5. Why are payers looking at case rates as a strategy?
Fee for service billing is difficult to manage and to financially sustain.
For payers like Medicaid, there is a set amount of money to spend, and a set number of people to cover.
Equation:
Total amount of spending
Total # of covered lives = Average cost per case
If everyone gets the same care – the cost will be more than the amount available to spend.

6. Case Rates vs Fee for Service

7. Examples of Health Home Case Rates
Case rates by expected outcome:
Example: Employment pilot
Case rates by Engagement Level
Example:
Case rates by Level of care determination
Example: CMS bundled rate pilot for post hospitalization services
Case rates by population
Example: Michigan Medicaid Capitated Payment
PMPM for SMI
PMPM for SED
PMPM for I/DD

8. What Case Rates Are Not
Case rates are not a fixed budget for a single case
Some cases will require less care than others to achieve an outcome
Some cases will require more care than others to achieve an outcome
Some cases will require a single expensive service
Some cases will require less expensive care than others

9. Data Requirements for Setting Case Rates
Start with questions, not answers………
What is the defined population you are serving?
How much of the population do you plan to serve?
How much are reimbursement are you receiving by client?
What outcomes are you measuring?
What service array is leading to good outcomes?

10. Creating Case Rates for Ohio Health Homes
Purpose: Using data from state and agency reporting, this exercise will compare the average cost of providing care under the fee for service payment model vs. using the Ohio Health Home rate

11. Ohio Reimbursement Data
State Benefit Limits
CPT Codes
Benefit Limit
Health Home Services
Reimbursement
Unit per hr.
Unit per month
BH Services
Individual Therapy
H0004
52 hrs. per year
$90 per hr.
$90.00
Group Therapy
H0004 HQ
$21.33 per 15 min
$85.32
CPST
H0036
104 hrs. per year
S0281
$83.32 per hr.
$83.32
Health Home
$188 per month
$188.00
MH Assessment
H0031
4 hrs. per year
$ per hr.
$129.99
Pharm Mgt
90863
24 hrs. per year
$ per hr.
$210.87
Psychiatric Eval
90792
2 hrs. per year
AOD Services
AOD Assessment
H0001
30 hrs. per week
$96.24 per hr.
$96.24
AOD Ind Therapy
87.27 per hr.
$87.27
AOD Group Therapy
H0005
$9.52 per 15 min
$38.08
AOD CSM
H0007
$78.17 per hr.
$78.17
AOD Med Som
H0016

12. Range of Reimbursement Rate
Example: If a consumer received the maximum amount of services allowable under the Ohio Medicaid Benefit package, what would the cost of care be?
Therapy: $4680
CPST: $4332*
MH Assessment: $ 519
Pharm Mgt: $5060
AOD Services: $2600
Minimum : $ per year cost
Maximum: $17,191 per year cost*
*Additional units of CPST can be provided if approved by Health Plan

13. Questions Are the service provided leading to good outcomes?
How do you know this?
How much service is being provided to people?
How do clinicians know how much service to provide?
How are services being provided?
Example: Groups are more cost-effective than individual services.
Example: Therapy provided by master’s level clinicians cost less than therapy provided by a doctor

14. Agency Specific Data
Using the requested data elements, provide total reimbursement for services: #
Level 1 Low Utilization: # low cost consumers that will be eligible for Health Homes (may be low cost in terms of MH TX, but may have high medical care costs)
Level 2 Medium Utilization: # medium range utilization consumers that will probably be in the health home
Level 3 High Utilization: # highest utilization consumers that will be eligible for Health Homes
Directions: Take a look at your reimbursement data and sort clients into 3 categories:
Consumers with low utilization of CPST
Consumers with medium utilization of CPST
Consumers with high utilization of CPST
Data can be sorted into even-numbered categories, or in predefined categories like “Meds Only”, “Designated CSM” and “Specialized CSM”

15. Agency Specific Data Example: Agency A
Agency A – took the Health Home eligible population, and sorted the total # by CPST usage (Low, Medium, High)
298
Level 1 Low Utilization: # low cost consumers that will be eligible for Health Homes (may be low cost in terms of MH TX, but may have high medical care costs)
299
Level 2 Medium Utilization: # medium range utilization consumers that will probably be in the health home
Level 3 High Utilization: # highest utilization consumers that will be eligible for Health Homes

16. Agency A – Reimbursement by CPT code and Level
Reimbursement Data
Agency A – Reimbursement by CPT code and Level
Unit per hr.
Unit per month
Total Reimbursement Level 1
Average Reimbursement Level 1
Total Reimbursement Level 2
Average Reimbursement Level 2
Total Reimbursement Level 3
Average Reimbursement Level 3
State Benefit Limits
CPT Codes
Benefit Limit
Health Home Services
Reimbursement
BH Services
Individual Therapy
H0004
52 hrs. per year
$90 per hr.
$90.00
22,845.00
76.66
62,188.00
207.99
122,886.00
412.37
Group Therapy
H0004 HQ
$9.87 per 15 min
$39.48 -
CPST
H0036
104 hrs. per year
S0281
83.32 per hr.
$83.32
40,980.00
137.52
377,862.00
1,263.75
1,439,712.00
4,831.25
Health Home
$188 per month
$188.00
MH Assessment
H0031
4 hrs. per year
per hr.
$129.99
65,552.00
219.97
19,920.00
66.62
19,676.00
66.03
Pharm Mgt
90863
24 hrs. per year
per hr.
$210.87
450,161.00
1,510.61
719,132.00
2,405.12
788,451.00
2,645.81
Psychiatric Eval
90792
2 hrs. per year $
AOD Services
AOD Assessment
H0001
30 hrs. per week
$96.24 per hr.
$96.24
1,731.00
5.81
2,237.00
7.48
1,743.00
5.85
AOD Ind Therapy
87.27 per hr.
$87.27
15,407.00
51.70
19,625.00
65.64
20,150.00
67.62
AOD Group Therapy
H0005
$9.52 per 15 min
$38.08
AOD CSM
H0007
$78.17 per hr.
$78.17
AOD Med Som
H0016
5,353.00
17.96

17. Observations for Agency A
Average usage of CPST by level: Level 1 (Low): $76.66 per year Level 2 (Medium): $1263 per year Level 3 (High): $4831 per year Average: $2076 per year 104 hrs of CPST: $4332 per year On average, Agency A provides less than half the allotted CPST hrs per case. On average, Agency A provides an array of services to consumers, and does not limit itself to providing only CPST

18. Defining the Population
Using state data, identify the number of people within your defined catchment area who will be eligible for population you are proposing to serve. In the case of Agency A, we are looking at Health Home eligibility.
Purpose: This worksheet will help identify the total future population of Health Homes
1) How many people are enrolled in Medicaid in your catchment area? #
a) Total # of Medicaid enrollees currently in services
2) What is the total # of people identified in the catchment area / population who are eligible for HH?
a) Total # of HH eligible currently enrolled in services
b) Total # of eligible who are enrolled in HH

19. Defining the Population
Agency A data:
Purpose: This worksheet will help identify the total future population of Health Homes
1) How many people are enrolled in Medicaid in your catchment area?
1800
a) Total # of Medicaid enrollees currently in services
895
2) What is the total # of people identified in the catchment area / population who are eligible for HH?
a) Total # of HH eligible currently enrolled in services
b) Total # of eligible who are enrolled in HH
300
Total Medicaid in Catchment Area
Total Medicaid currently in services
% of Medicaid in services for catchment area
Total # of HH eligible in catchment area
Total # of HH Eligible Currently enrolled in services
% of HH Eligible at agency
Total # of eligible currently enrolled in HH
Total % of enrolled HH participants at agency
Total % of enrolled HH eligible for catchment area
50%
34%
17%

20. Estimating the Penetration Rate
Purpose: Agencies may be identifying specific targets for enrollment of Health Home participants, which will created an expected penetration rate. This worksheet will provide the expectation of reimbursement based on enrollment. Enter in your expected enrollment percentage
1) # of people who are in catchment area who are eligible for health homes #
a) # of people if target % of eligible are enrolled
% Target #%
i) Monthly revenue = a) X rate
Total # Eligible for HH
Percentage target
Enrollment # target
Monthly Case Rate
Monthly Revenue with enrollment target
Annual Case Rate
Annual Revenue
$ 188 $
$ 2,256

21. Estimating the Penetration Rate using Agency A data
Purpose: Agencies may be identifying specific targets for enrollment of Health Home participants, which will created an expected penetration rate. This worksheet will provide the expectation of reimbursement based on enrollment. Enter in your expected enrollment percentage
1) # of people who are in catchment area who are eligible for health homes
1800
a) # of people if target % of eligible are enrolled
% Target
30%
i) Monthly revenue = a) X rate
Total # Eligible for HH
Percentage target
Enrollment # target
Monthly Case Rate
Monthly Revenue with enrollment target
Annual Case Rate
Annual Revenue
540
$ 188
$ 101,520
$ 2,256
$ 1,218,240

22. Determining Actual Utilization
The purpose of this step is to look at what actual services are being provided to consumers by intensity level.
Health Home consumers receive other services that contribute to positive health outcomes beyond CPST & MH Assessment
What is the total cost of care for a consumer?
Health Home eligible service + other BH services
What is the range of Health Home eligible service provided by level of intensity

23. Agency A Utilization Data
Low intensity Services
Medium Level Intensity Services
High Intensity Services
Total Reimbursement
CPST
$ ,980.00
$ ,862.00
$ ,439,712.00
$ ,858,554.00
BH Assessment
$ ,552.00
$ ,920.00
$ ,676.00
$ ,148.00
Other MH services
$ ,006.00
$ ,320.00
$ ,337.00
$ ,165,663.00
AOD Services
$ ,491.00
$ ,862.00
$ ,893.00
$ ,246.00
$ ,029.00
$ ,200,964.00
$ ,392,618.00
$ ,195,611.00
Eligible HH Services (CPST+MHA)
$ ,532.00
$ ,782.00
$ ,459,388.00
$ ,963,702.00

24. Utilization Data Low intensity Services
Low intensity Services
Medium Level Intensity Services
High Intensity Services
Total Reimbursement
CPST
$ #
$ #
$ # $
BH Assessment
$ #
Other MH services
AOD Services
Eligible HH Services (CPST+MHA)

25. Range of CPST Provided
With comparing HH potential revenue with actual fee for service reimbursement, we need to look at actual range of use, rather than anticipating that all cases will need and are currently receiving the maximum amount of CPST ($4332)
Low intensity Services
Medium Level Intensity Services
High Intensity Services
Total Reimbursement
Eligible HH Services (CPST+MHA) $
CPST Cost Range $# #

26. Agency A Range of CPST Provided
For Agency A, CPST usage was low for both low intensity and medium intensity consumers. The range for high intensity users was wide.
Low intensity Services
Medium Level Intensity Services
High Intensity Services
Total Reimbursement
Eligible HH Services (CPST+MHA)
$ ,532.00
$ ,782.00
$ ,459,388.00
$ ,963,702.00
CPST Cost Range
$ $341.28
$ $
$ $
$0 - $11,517.70

27. Replacing Fee for Service Reimbursement with Case Rates
Using data from Agency A, this worksheet replaces the reimbursement from CPST and MH Assessment with the monthly case rate:
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Reimbursement
Health Home
$ ,288.00
$ ,544.00
$ ,019,120.00
Other MH services
$ ,006.00
$ ,320.00
$ ,337.00
$ ,165,663.00
AOD Services
$ ,491.00
$ ,862.00
$ ,893.00
$ ,246.00
Total Annual Reimbursement
$ ,167,785.00
$ ,477,726.00
$ ,605,518.00
$ ,251,029.00

28. Digging Deeper into the Data
For Agency A, looking at the range of case specific data, 36% of the Health Home eligible consumers received services reimbursed at more than the Health Home Rate. The primary difference in reimbursement is with the high intensity utilizers of CPST.
Low Intensity Services
Medium Intensity Services
High Intensity Services
All Services 28
298
326 0% 9%
99%
36%

29. Comparing Fee for Service Reimbursement to Health Home Reimbursement
Using Agency A’s data, we will compare reimbursement for Health Home eligible services:
Health Home Only Services
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Reimbursement
Health Home
$ ,288.00
$ ,544.00
$ ,019,120.00
CPST+MHA
$ ,532.00
$ ,782.00
$ ,459,388.00
$ ,963,702.00
Difference
$ ,756.00
$ ,762.00
$ (787,100.00)
$ ,418.00
For Agency A, moving to Health Home case rates for 100% of consumers will result in a $55,418 surplus.
Other conclusions:
Enrolling an even mix of Low / Medium / High intensity services will yield possible savings.
Enrolling only High intensity services consumers will result in a loss of revenue

30. Comparing Fee for Service Reimbursement to Health Home Reimbursement
Using Agency A’s data, we will compare reimbursement for all behavioral health services:
All Behavioral Health Services
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Reimbursement
Health Home
$ ,167,785.00
$ ,477,726.00
$ ,605,518.00
$ ,251,029.00
Fee for service
$ ,029.00
$ ,200,964.00
$ ,392,618.00
$ ,195,611.00
Difference
$ ,756.00
$ ,762.00
$ (787,100.00)
$ ,418.00

31. Looking at Outcomes
We know that reimbursement is only one part of case rate. We have to compare the services that are provided to the outcomes that we want to achieve

32. Paying for the Outcome
Going back to the definition of Case Rates: A case rate (or bundled payment) represents a pre-determined amount of money paid to a provider organization to cover the average costs of all services needed to achieve a successful outcome for a pre-defined episode of care. What if payment was based on the outcome of the services?

33. Pre-Health Home Data
Using data from Agency A, we look at three outcomes:
Inpatient admission rates
Emergency Department admission rates
12 or more pharmaceuticals rates

34. Pre-Health Home Data Inpatient Admission Data # Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Population
Total Number #
Average
Range

35. Agency A Pre-Health Home Data
Inpatient Admission Data (9 months -2014)
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Population
Total Number
148
173
177
498
Average
0.50
0.58
0.59
0.56
Range
0-15
0-20
Health Home eligible consumers had a total of 498 admissions, with a .5 admission rate per person.
Range of admissions for medium to high intensity consumers was 0-20

36. Pre-Health Home Data Emergency Department Admission Data #
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Population
Total Number #
Average
Range
20 plus (ave 2X per month)
ED admission rate was HIGHER with the low intensity service population
The range of admissions was 0-49 admissions
A small portion of the low intensity and high intensity consumers had 20 plus admissions in a 9 month period

37. Agency A Pre-Health Home Data
Emergency Department Admission Data (9 months – 2014)
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Population
Total Number
991
755
835
2581
Average
3.33
2.53
2.80
2.88
Range
0-46
0-49
20 plus (ave 2X per month) 8 2
ED admission rate was HIGHER with the low intensity service population
The range of admissions was 0-49 admissions
A small portion of the low intensity and high intensity consumers had 20 plus admissions in a 9 month period

38. Pre-Health Home Data 12 or more pharmaceuticals #
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Population
Total Number #
Average
Consumer with low intensity services were more likely to be prescribed 12 or more pharmaceuticals than consumers high intensity services

39. Agency A Pre-Health Home Data
12 or more pharmaceuticals – 9 month data 2014
Low Intensity Services
Medium Intensity Services
High Intensity Services
Total Population
Total Number
161
157
115
433
Average
54%
53%
39%
48%
Consumer with low intensity services were more likely to be prescribed 12 or more pharmaceuticals than consumers high intensity services

40. Data Collection Needs
Agencies need to have someone who can work w/ spreadsheets
Having raw data makes it easy to sort
The data should not come w/ conclusions
Don’t make it complicated
If there are other factors / sources of income –remove them out of the equation
Be open about looking at the data
Don’t use the data to prove a decision you have already made

41. Data Collection Elements
Agencies need to have access to the following data:
Current Medicaid eligibility & enrollment by catchment area
Current agency reimbursement by client
Works best if the data spans 1 year
IF the only available data is for less than a year, formulas in the worksheet need to be adjusted
By CPT code
Separate out CPST & MH Assessment
Can add BH services together
Therapy codes, group codes, pharmacy mgt, psych eval
Current range of reimbursement
Necessary in order to start drilling down the data

42. Data Analysis Decisions to make: Health Home enrollment target
If you are just starting out – what is your target?
Separate out by program type
Ex: Low intensity = Traditional Outpatient Services
Medium Intensity = Community Case Management
High Intensity = Specialized Case Management
Separate out by CPST usage evenly
Ex: 900 consumers
Sort into 3 groups w/ # of CPST units ranging form high to low

43. Drilling it Down Drill data down by program
Add in other reimbursement data
Health Homes are not stand alone programs
Agencies need to look at outcome data
Are the services provided making a difference?
By Program?
Which services?
Agencies need to look identify their target populations
High intensity consumers
Mix of intensity of consumers
Varying % of intensity of consumers

44. Conclusion The data analysis is just a starting point
Data should lead to more questions
Data should generate a lot of discussion

45. Clinical Services Implications

46. Clinical Services Implications
Disease Pathways/Care Flows must be designed:
Levels of Care & Associated Service Packages
Identification of Treat to Target Parameters
Team Based Care
Bundled Rate Estimates

47. Clinical Services Logic Model

48. Resources
American Hospital Association: Issue Brief Moving Towards Bundled Payment
CMS Bundled Payments for Care Improvement: Learning & Resources Area
Transitioning to Episode Based Care