This document discusses the transition from fee-for-service to value-based payment models in healthcare. It explains that fee-for-service results in poor outcomes and high costs. Value-based payment ties provider reimbursement to outcomes like quality and cost. The document outlines key components of value-based payment implementation including delivery system reform, payment reform, performance measurement, and population health management. It notes that social services organizations will need to demonstrate their value and be accountable for outcomes as the healthcare system shifts its focus to addressing social determinants of health.

1. Value-Based Payment and
Delivery System Reform:
What Does it All Mean?
André Thompson, MPA

2. Abstract
Managed care, Medicaid redesign, DSRIP, value-based payment…what
does it all mean?
Movement away from fee-for-service to alternative payment models
that incentivize value i.e. reduced costs and better outcomes. Fee-for-
service results in poor outcomes and does nothing to reduce costs.
Therefore, change is inevitable for not only hospitals or health centers,
but also health-related social service organizations whose part it is to
address the social determinants of health (SODH). These include
organizations in behavioral health, disabilities, housing, nutrition and
other fields. Social determinants have the largest impact on healthcare
costs and outcomes. Therefore, in a future not very far away, health-
related, social services organizations will also have to get onboard with
the new way in which services are coordinated, delivered, measured,
and paid for.
How are the services and supports you provide related to health, how
valuable are your services and interventions for maintaining health,
how would your services change if you were getting paid based on
value rather than fee-for-service?

3. VBP Implementation
Four essential components required for
implementation of value-based payment:
1. Delivery system reform
2. Payment reform
3. Performance measurement
4. Population health management
We have to change the structure, realign the process
and measure the outcomes

4. Value Based Payment
• New York State is moving up the risk ladder to value-
based payment (VBP) incentives in its payment
methodologies to providers.
• DOH goal to have 80-90% of MCO payments to providers
to be value-based by 2020.
• The goal is to incentivize providers to produce value-
based services, rather than volume-based services that
exist in FFS alone.

5. Risk Continuum & Payment
Combination of financial incentive options and risk levels
generally make up the menu of payment arrangements between
payers, MCOs and providers in VBP, ranging from no financial
risk to more financial risk,

6. Research and Development
Imagine you are engaging in research and development and
contracting with payers who are interested in paying for value.
1. If you had to design an ideal set of programs or a services in your
field what would you envision?
2. What evidence-base would you draw upon to ensure the best
outcomes, such as lower cost, better quality, and enhanced
consumer satisfaction?
3. What services or interventions would you mandate or require in your
model?
4. How would you evaluate or measure whether the programs are
meeting the set outcomes?
5. How would you structure payment to providers to illicit those
outcomes?

7. Health is Your Business

8. Are we #1 in Health?

9. What are the outcomes from your coordination activities,
are they?
ü Evidence based
ü Cost-effective
ü Person centered
ü Measurable
ü Keeping people safe
ü Reducing ED visits
ü Avoiding need for institutionalized care
Population Health Management
& Care Coordination

10. How Do You Prioritize Services and Interventions?
What is important is seldom urgent and what is urgent is
seldom important.
-Eisenhower

11. 1. Lack of timely information sharing even in the same
agency, amongst providers and across other systems.
1. Difficult to ensure services and treatment when all of
the information isn’t available and without IT systems
to manage and share it.
2. Difficult to access appropriate resources and services
to meet the person’s need, especially in an emergency
or crisis.
3. Individuals and their families often act on their own
behalf, without involvement or knowledge of service
providers.
Coordination in Your System Currently?

12. Care Coordination
We can’t achieve the valuable outcomes we seek
without an effective care coordination and a
population health management model.
üEvidence-based
üPerson-centered
üMultidisciplinary
üIntegrated

13. Triple Aim
Cost
Quality Satisfaction
Lower Cost
Consumer Satisfaction
Quality
Best outcomes are achieved from effective care coordination
In the broadest terms when we talk about outcomes in health
services, we are talking about 3 major areas: Cost, Quality and
Consumer Satisfaction.

14. What is Quality?
IOM Committee on the Quality of Health Care in America report Crossing the Quality Chasm (2001).
o Safe: Avoid injuries to patients from the care that is intended to help
them (Medication Errors, wrong surgery etc).
o Effective: provide services/treatment that is beneficial based on scientific
knowledge and avoid providing services that will not have any benefit.
o Patient-centered: Providing care that is respectful of and responsive to
patient preferences, needs and values.
o Timely: reducing wait times and sometimes harmful delays for both
those who receive and give care.
o Efficient: avoiding waste, including wasters of equipments, supplies,
ideas and energy.
o Equitable: providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic location,
and socioeconomic status.

15. Person-Centered Care
ü Engagement & Satisfaction
ü Given Options for Care and Services
ü Asked What Matters to Them
ü Participate in Setting Goals
ü Culturally and Linguistically Appropriate
ü Easily Accessible Services

16. Cost-Effectiveness
Cost-effectiveness is about getting the biggest bang for the
buck, best return on investment or gaining the best output or
outcome given your input.
In which of these scenarios is implementing services
or interventions most worth it?

17. Population Health Management
• Population health is not only about medical care, but
also a range of services from behavioral health to
LTC, to social services, and nutrition.
• It is what you eat, where and how you live, who are
your relatives and their health history.
• It is your age, your sex, whether or not you smoke
or exercise.
• When you do care coordination, you’re not just
talking about the patient, but the population; at the
systems level and at the individual level; across
settings.

19. Wellness Impairment Disability
Disease Activity Restriction Death
Health Continuum

20. Managing Your Case Mix
5% high risk/high cost/high
touch
15% potentially high risk/high
cost/high touch
80% Medium to low risk, low
cost and low touch

21. Care Coordination Risk Ranking
Care Coordination - Activities Prioritized by Patients’ Risk Level
You need to know and be
able to stratify your low,
high risk, and highly
complex cases and prioritize
accordingly.

22. Levels of Care

23. Basic Evaluation Model

24. VBP and the Services you Provide
• You have to determine the "valuables" in the
services you provide using evidence-based
methods.
• You have determine the broader changes/goals
that you would like to see as a result of moving
to VBP (more collaboration, integration, reduced
cost, efficiency, etc)

25. Measuring performance and quality is difficult to do in medical care,
yet it is even more difficult to measure outcomes for the social
determinants and other health related quality of life (HRQOL) aspects:
• Independence
• Self-Determination
• Community Integration
• Opportunity
• Dignity
How much are we willing to pay, and how do we measure the
outcome from these services?

26. What is value
• .
• Value means different things to different people.
• Value-based payment suggests that there are
outcomes of interest that have been prospectively
determined to be "valuable" and toward which
payment will be directed and structured as
incentives to induce them.

27. Lack of Measures
• Challenging to define value and quality measures.
Quality in medical care is difficult; defining quality in
social services, human services etc is even more
difficult.
• We cannot assess whether we have achieved value
without appropriate, established, and defined measures
of quality performance.
• Are we interested in outcome measures, process
measures or both?
• Measures should be derived from the best evidence
available for the population (generic measures) and
measures that are more specific to individuals and their
conditions (condition-specific measures).

28. Setting Up Measures
• Whose performance is being measured?
• What is the basis of measurement (are they based on
sound clinical and technical merits)?
• Is the performance measurement specific to a
particular program, a sub-population, specific
conditions?
• How often to measure and how often to report?
• Who determines what is being measured, who are the
stakeholders and decision-makers?
• What kind of data is available and how is it collected
and shared (claims, encounter data, surveys)?
• How should we determine the benchmarks?

29. What Makes a good measure?
National Governor Association- Compendium on Medicaid Purchasing 2016

30. • Healthcare reform will continue to drive the payment
and delivery system reforms we are experiencing.
• Value-based payment reform requires not only time and
resources but also a systems and culture change
• There should be organizational infrastructure to support
value-based care
• Data sharing amongst payers, providers, and
purchasers is another core requirement.
• The incentives have to be strong enough to illicit the
desired outcomes
Implications

31. • Fee-for-service alone results in poor outcomes and does
nothing to reduce costs. Yet, health related, social
services providers have no experience in risk-based or
shared savings arrangements.
• A great starting point for providers may be P4P, which is a
start in the direction towards better quality and outcomes.
There are incentives for meeting performance measures,
and can be implemented without large IT, systems and
infrastructure.
Implications

32. The National Quality Forum (NQF) reviews, endorses, and recommends use of
standardized health care performance measures; have major initiatives for
measures in LTSS http://www.qualityforum.org.
The Robert Wood Johnson Foundation- quality-focused initiatives can be found at
http://www.rwjf.org/en/our-topics/topics/health-care-quality.html
Centers for Healthcare Strategies: Its work focuses on alternative models that link
payment with improved quality. More information is available at
http://www.chcs.org.
Network for Regional Healthcare Improvement (NRHI) brings together RHICs to
share best practices in health care redesign http://www.nrhi.org/
The National Business Coalition on Health (NBCH) NBCH and its members are
dedicated to value-based purchasing and the standardizing of performance
measurement http://www.nbch.org/
AHRQ conducts and supports research on a range of healthcare quality topics
including performance measures: http://www.ahrq.gov
National Sources in Healthcare Delivery System
and Payment Reform

33. About the Speaker
André Thompson, MPA
Has ten years of senior management experience at social service
agencies working in the areas of community engagement and
outreach, Medicaid service coordination, residential, day services,
employment, and self-direction. He has worked with disability
organizations on various projects and initiatives. He has also delivered
numerous workshops and presentations at social services agencies
and conferences for professionals and advocates related to managed
care, care coordination, program and staff development to prepare for
the future. He has an MPA degree (Baruch College) in healthcare
policy with a focus on healthcare financing and payment.
athompson643@gmail.com