Making Value-Based Care Work with Josephine Wilton Pt. 1

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next.

Welcome back everyone to the Mental Health Evolution Podcast where we are talking about how the landscape is quickly evolving in the mental health industry. Today we are joined by Josephine Wilton, Principal Consultant at Hulanta Consulting. Josephine is a healthcare consultant who helps organizations translate value based care principles into real world implementation. Her work includes guiding provider groups, payers and employers through the operational steps required to make value based care models work, from the data infrastructure and billing alignment to care coordination and performance measurement. We've talked before about value based care as a concept on this podcast, an idea that focuses on outcomes and quality instead of service volume. But what does it take to actually put that idea into practice? That's what we're going to be talking about today, and Josephine specializes in turning theory into action and we're going to dive into how systems coordinate care, track data and make the financial side sustainable. But first, as always, we have some articles that we would like to highlight for you related to the topics today. The first one is called Implementing Value Based Care A Scoping Review and this recent review synthesizes implementation strategies for value based healthcare across international settings. It explores how organizations operationalize key enablers like data systems, payment models and performance metrics and where common barriers arise when we are translating this into actual practice. A hint there. The data systems, payment models and performance metrics are all the pieces that make value based care work and those can be pieces that are sometimes a struggle for different organizations to implement, especially in mental health or as it's also called, behavioral health care. The second article is called Value Based State Directed Payments in Medicaid from February 2023 to May 2024. This is a JAMA Health Forum study and it reviews the design of Medicaid programs incorporating value based payment mechanisms. It highlights how states are moving from conceptual frameworks to concrete payment models trying to reimburse performance care continuum and outcomes. And the third article, why Primary Care Practitioners Aren't Joining Value Based Care Payment Models in this Commonwealth Fund issue brief, researchers look at the practical barriers facing primary care practices when they try to adopt value based contracts. They point at things like staffing shortages Limited capital for infrastructure and lack of access to data as hurdles to implementation, all pieces that our guest today specializes in. So with each of these they talk about a piece of the value based care puzzle. Strategies that make it work, payment structures that incentivize success, and then the real world barriers that providers face. And Josephine, our guest today, works directly with provider groups and organizations navigating these challenges. So I'm excited to dive in a little bit more to her expertise. So welcome Josephine. It's so great to have you on the POD today.

Thank you, Rachel. I appreciate this opportunity to speak with you, your viewers and your listeners. This is fantastic. Thank you for having me.

You bet. Okay, so we know a little bit about what value based care or the why behind value based care. But I'm curious if you can kind of give us a picture of what it looks like when an organization decides to actually make that shift.

Yeah. So I will speak to what it has looked like in practice and I can certainly touch on it from my experience and perspective, maybe where the deficiencies and pitfalls come into play. So what it looks like quite often is that both parties engage in some sort of contracting process. Right. Depending on who you're speaking to, a provider organization or health plan, the providers tend to feel that it's a little bit more one sided and it's what the health plan may dictate an offer and they feel compelled and obliged to accept. But there usually is some sort of dialogue that as soon as before there's an agreement, once there's an agreement, then the parties tend to. Depending on the organizations on both sides, all parties, depending on their practice and cadence, they may very well start on a lot of the preparation before, during the contracting phase or post execution. Quite often it's post. And depending on when the contract is signed, you may have weeks, months, it could be a year, which is great to prepare, but a lot of times it's a short term and that performance year is starting. And so it's very imperative that the communication between the parties is tight and it's consistent. You know, usually during the contracting phase, there's a lot of frequent discussion and then it can kind of taper off. Once this contract signed, there's a tendency to believe that things will just kind of fall into place. So with that being said, there certainly are instances where the ideal happens and communication follows appropriate process and both parties have a level of confidence before the performance hear starts. Once the performance hear starts, typically you see a lot more individuals on the provider side that may not have been involved on the contracting side and setting those metrics and measures, they're now brought into the fold. Ideally we can get into that. They should be brought in sooner, but quite often it's post execution at the start of a performance year. And now they. So that's your clinical team, your operations team, schedulers, call centers. If you are bringing them into the fold, they're usually late coming to the part. So now there's that catch up and it's a matter of what does this mean for me and my focused area in this organization. The parties start to try at least to work through that. While in real time, you know, that's the performance period. Things are happening. You're seeing patients. How closely are they aligning to the value based payment care, Value based care and payment model that you agreed to? You can't stop that.

Let me pause you there for a minute. I want to go back to something you said early on, which is this idea that a lot of times providers feel like they don't have much say in this process of value based care. And you said. But there is some discussion back and forth. I want to just open that up a little bit because that's a distinction that I don't think I've heard a lot of talk about. So what do you feel like provider groups have the ability to ask for, to talk about in those scenarios?

Sure. So in my experience working with, speaking with CEOs, CFOs, CMOs, so chief executives, chief financial officers, chief medical officers and the like, the common theme is this is what we were presented with and we thought this is what we had to agree to. And that's not necessarily the case, that's not necessarily how it's even presented. However, I think it's usually based off of past practice. So when you're talking about value based payment models, it can be direct. With the health plan, you can certainly have a middle party like an accountable care organization or ACO or an ipa, an independent practice association. When you're dealing with an ACO or an ipa, most times they've already negotiated something with the health plan. So what they're presenting to the provider doesn't mean it's fixed entirely. But there are some pre negotiated terms between the IP and the ACO and the health plan. I see. And certainly directly. Yeah. And when it's directly between the health plan and the provider, some things the health plan has predetermined, but it's all data based. And we can maybe when you talk about data, we can talk about how the provider understanding its data from a trended perspective, not just snapshots, historical aligning that with their financial objectives and goals, understanding the data pre contracting, during contracting and post execution, it's setting. So a model framework to track in real time is going to enable them, especially when they're at the table, pre execution of an agreement, to negotiate. You don't know and understand the utilization of services in your organization and how you're paid, how you, what you're paid for, what you're not paid for in your revenue cycle, then it's going to be very difficult to negotiate terms that align with your business model and care delivery model for your organization. So that's where I notice the challenge and the barriers are.

That makes a lot of sense. And then you were saying that some of the implementers, the clinical team, the chief medical officer, potentially the operations people, often get involved more in this implementation stage and not in the earlier stage. So would you have an argument that they should be in on the earlier stages of talk and negotiation?

Absolutely. And I've seen it happen. But again, when you don't have the data and you have the right parties, then you still have a major fundamental gap. Right? So I've seen that happen as well, where you have your coo, maybe other operations leaders, you may have a strategic business advisor, your cfo, but then there's missing data, poor data, data gaps. And so they're listening, they're at the table, they're offering up their input and feedback. But it's somewhat theoretical, right? It's conceptual. It's based off of our subjective view of what's been happening and what may happen once we join this partnership for this particular vbp. So the data is very critical. But yes, those implementers have to be involved very early on. If they're not at the table, run the contractual terms, the measures, the metrics by your operations team before you go to it, say, hey, when you look at this, what does it mean for you? What are the implications? And you may have to do some translation of sorts. Not everyone's used to looking at contractual terms, but I have found consistently that is a major gap. It's a major, major gap not understanding the contractual terms. And you're typically layering on a VBP to a baseline fee for service model. So you got to first understand the baseline and then what you're layering on and then augment your operations and delivery pathways appropriately. So, yes, books need to be involved, but they need, it needs to be deliberate.

Let me ask you about Size of organization because I know that some of our listeners may be a smaller group practice or even a solo practitioner. Do these same pieces apply there as well? Is there something where I have heard in other states, not so much my state, where value based care is rolled out by an insurance provider and even those smaller level folks are expected to comply with that.

That's true. And let me say this. Working with your solo practitioners or smaller physician group practices, the CEOs first and foremost are. They're physicians. You know, typically that's the case. But they're also their business people. Right. They're running a business and they're running either a small business or a medium sized business in those scenarios. And that's often overlooked. What I do find I'll, you know, highlight the positives is that your solo practitioners actually understand their business pretty well, you know, because they typically. Right. They're able to wrap their arms around more of the financials, even if there's additional support that's needed in terms of modeling out contractual terms, understanding the revenue cycle process. But they typically understand it a little bit more because it's just a smaller organization and by nature they have to. But you're absolutely correct that I've heard that consistently. I've witnessed it. And one of the things we can discuss is that I've worked on the other side for eight and a half years. I worked for a plan and did contracting. So I know exactly what that looks like and how it can feel, at least from both sides. So the solo practitioners, there's more, you definitely have more engagement. They understand the financials typically better than the larger organization CEOs, this is my experience. And I mean beyond just the balance sheet. Right. Because the CEOs and CFO, the CEOs understand that. But when you really start to dig in, do you understand how the percentage, basic percentages, what's your revenue on the dollar? How many pennies do you get per dollar billed out? Right. What is your break even for your services on a cost basis? For services, usually it's a very high level aggregated balance sheet that you need. But oftentimes the larger organizations and CEOs kind of, that gets a little bit, there's ambiguous of sorts and they start to drill down, prepare and vbp, that's where they get lost. So the smaller organizations, what they need, they still need support with data that's time consuming. Again, brilliant, very sharp, savvy businessmen and women leading these organizations who also are positions, but they don't have the time or resources to comb through data to do the modeling that's needed in your preparation before you enter into these VPPs. Again. The common theme, no matter what provider size, is that they enter into these relationships and arrangements without enough due diligence before doing so. And then they feel like they've been bamboozled. Right. They'll tell me, we thought we were going to get X and we didn't, we didn't get anything. Or we got far less. And we feel like they just tried to pull the wool over us. And it's not. I haven't witnessed that with a health plan. The issue is a lot of times they're speaking two different, somewhat two different languages.

Oh, I would agree with that.

Yeah, right, right. And at the table everybody says, yeah, yeah, that sounds right. Because typically the conversation is around the outcomes and the metrics, but very seldom do you hear any discussion around operationalizing those terms and execution. Right. Very quickly, like I said, performance year starts real time. Things are happening and active. The regular meetings you're going to have, the providers will meet with the health plans monthly or whatever frequency. They're going over what I would call report cards. And that's when you start to see a lot of the friction, especially those, the smaller provider organizations, the solo practitioners, once they feel they've had a bad encounter with VBPs, they tend to just say, nope, no more, not doing it because they understand the businesses a bit more. They might even shy away from ever joining one and say, no, I don't see that happening. Looks good, sounds good, but I don't see how you can support me because of the health plan not articulating enough, or maybe it's just a lack of understanding and how that provider organization works. So when the solo practitioner feels like you don't understand my business or I don't have a certain confidence level that you truly do, then I'm not sure this is the best partnership. I'll stick with the for service.

Right, right, absolutely. So what are some of those functional pieces that are needed? You mentioned data multiple times. What types of things do practitioners or organizations need to have in order to understand how value based care is going to be paid out, how it's going to work.

Yes. So we talk about data I mentioned like the equivalent of a report card. Performance scorecards are what health plans typically use. Or an ACO or ipa. With provider organization, that's usually once it's not very close to real time and what the providers need. When I talk about data, what's somewhat missing is as close to possible as real time data. You're seeing the patient on a given day, the provider, the leadership within those organizations should be able to see which one of those patients, not only what their insurance demographic is, but if they're attributed to a vbp. Right. So that you can understand what's happening in real time, what the gaps are, if they were closed or not. And then you're certainly not just a CEO or CFO needs to look at this, your operational leadership. So there's the planning that that comes into play, but the real time data, why it's so critical, it's also what's been understood in the industry is lag in VBP data. And that's because. Right. So that's because the provider organization sees the patient today on service today at your organization, your billing team, first of all, there's coding and notes and things. And once the rendering provider closes their notes, et cetera, there's a delay there. It's not like it gets build out that day. Right? Right. Maybe. Right. So 30 days, then it goes over to the payer. They're adjudicating it for payment. Hopefully it doesn't get denied. That's a whole other topic for administrative denials. But it goes through that process. Then the claims data has to kick over to their DBP team on the health plan side. Now the ACO and IPA still don't have it. If they're involved, it's still with the health plan. They need to reconcile, do their analysis and then see where that patient lands in terms of outcomes and services according to the tools of the agreement. With that being said, these are known delays and lags in data that leads to the scorecards. However, provider organization is still meeting with the health plan. So what are you talking about? Right. What you need to be looking at is what's happening in real time. What the health plan doesn't have. If it's not on a claim, it didn't happen. So now the onus and the responsibility is on the provider organization to be able to comb through their electronic health record system, utilize what other tools and resources are available to connect the dots. Right. So the primary care provider is not the sole. They're not solely whatever the provider is, whether it's primary care, behavioral health, et cetera. Usually VBPs are tied to primary care, but they're also more so tied to total cost of care. Right. From a health plan perspective, better outcomes means control costs. So you're only responsible for what your organization does in terms provides in terms of services. But now you've got a health plan meeting with you more frequently than the claims data is able to process to show them what happens, what do you talk about? Unfortunately, what I've seen, and solo practitioners and smaller organizations suffer more, but it's across the board. I've seen it with hospital systems is how do we, the provider organization, how do they present. Well, first source the data that they need that aligns with the VBP and then present it to the health plan in a meaningful way. Health plan is not going to necessarily pay you based off of that data because remember, it's not on a claim yet. That's their source of truth. But it certainly helps guide the conversation and allows both parties to make adjustments as needed. If you start to see trends within that lag of 60, 30, 60, 90 days, whatever it is, you should be talking about it. You should be looking at what the data is showing you in that period of time before that the claim is able to be scrubbed and dissected. So yeah, that's a huge known issue. Maybe we'll see more in terms of technology development. A lot of these EHRs, they can support VBPs, but again, it requires the provider to work through a lot of configuration with the vendor, sometimes because it's a vendor. Right, right.

So, I mean, I think I can definitely hear there, there are pieces of this where there's a lot more work. Maybe time on the provider side is a lot of what I'm, I'm hearing with these pieces.

Yeah, I would say, and I would even use the term a lot of burden. Right. A lot of burden that I really don't think even the health plans are fully aware of, I think. So the data is there, the information is there. It's a time and resource issue to get to it and then certainly analyze it. And then when you talk about as close to real time as possible, most of the provider organizations do not have that, that resource available or resources.

Right, yeah. And so then that affects pay ultimately.

There you go. So, and when we talk about if it's not on a claim, then it didn't happen for whatever reason. If claims are administratively denied, if your billing system is set up to run into all these circumstances, say the revenue cycle process has certain codes, procedures configured within a provider organization system that identifies a code that's not billable. Well, I've witnessed where that kind of went on a set it and forget it. Those things change. Right. But now that that claim's not going out the door, but you rendered a service that may be tied to a vvp, but the health plan is not going to count it because it wasn't on the claim or you didn't even submit the claim for pima. So that's why financial, the revenue cycle process is so important to understand that for every CEO and CFO for the success of the VBP program, it's not just a conversation with your clinicians or your providers. You got to get revenue cycle involved because your providers are rendering the service and they have no control over the revenue cycle process. And you really need those claims to get out the door with that. If you say a patient, we didn't talk about attribution like who gets counted on the VVPs. So it's based off of a rendering provider. But typically what did the health plans use? A billable provider. So again if that provider is not having the claim listed on the claim and the claim doesn't get out the door, then the service for that patient that may be already attributed to the value based program doesn't get counted. But the patient's still in your denominator. Right. So there's just the total attribution. So all patients who are going to be attributed, it's usually based off of the health plan and product. So I have X insurance and product and there might be other demographics that qualify me, but I'm now in this provider organization. So now denominator, meaning the total pool of patients that need to follow this DDP model claims are now getting out the door. Maybe there's a coding issue. We, you know, risk scoring issues. It's there all sorts of things that could be happening that I'm still in the denominator. But as far as the numerator, what happened to me is not being accounted for. And then there's certainly friction there when providers are at the table speaking with the health plans, the health plan saying you didn't do it, you don't see it, we don't see you moving the needle in the right way. They're saying, well we have been doing it. Or the providers may even acknowledge this patient's in our denominator. But. And we've provided the service that our organization can provide, but this patient is in need of other services. Right. So what happens if your providing the behavioral health services that patient needs, but the VBP may be tied to primary care, certainly avoidable hospital encounters, et cetera, that are outside of your control and now you're penalized? That's how the system works. Because from the health plan perspective A value based payment program where there's risk involved. And sometimes, you know, even if it's just an incentive and there's no risk, meaning there's no punitive element to it, they're still looking at total cost of care. What did Josephine Wilton cost the health plan in the baseline period of a given time period? So say 20, 23. And then what is the potential for those costs to go down? Total costs, some costs you want to go up right now in the industry, there's a consensus behavioral health utilization should increase. Right.

Okay.

People need those services. So those are costs that should go up. That's acceptable. That's what the health plans want to see. That's what the industry wants to see. That's what the government payers want to see because they know that it's good care. Primary care costs should go up. We see an underutilization, but the need is there. Similar to behavioral health. What's often not talked about is dental. Dental care, very low reimbursement in the industry. Historically it's a lot of procedures are not seen as medically necessary or appropriate. But in the industry, providers see it all the time. You know, a person's dental care can severely. Or dental status or oral care status can significantly impact their health and well being.

Definitely. Yeah.

Right. So it's all tied together. I think it's going to require more dialogue. I've witnessed both parties, the payers and providers come to the table with a lot of preconceived notions and assumptions. And it's been for the most part, not in every instances, but a lot of times those preconceived notions and assumptions are quite, quite negative.

Yes.

Yeah. I mean, I think sometimes there's some naivete involved where it's not negative, but it's still not based in fact. So.

Well, and I think anytime you go from a system like you're saying a fee, fee for service model where I see a client for a set amount of time for a mental health session, individual therapy session, and then I'm paid for that. It's not tied to anything other than the amount of time that I spent in session with that patient. So to switch this to. And now I'm looking at maybe it's measures like the PHQ or something like that, maybe it's survey data from the patient, you know, things like that that are suddenly tied to that that is so brand new and additional layers of systems and work to collect that data. I'm going to cut in here because this conversation with Josephine Wilton has been so rich that we have decided to pause here for today and kind of highlight the pieces that we have so far, which I hope you've taken some good information from. And we will be back next week to discuss discuss more of Part 2 on Implementation of value based care and how it applies to specifically behavioral healthcare practices. So tune in next time and we'll see you then. Bye for now.