While the Department of Medical Assistance Services (DMAS) continues to adjust With an influx of new beneficiaries throughout the pandemic, the Commonwealth’s Medicaid program leadership is leading conversations about value-based care purchasing models to improve health outcomes and affordability.
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DMA ‘ Value-Driven Procurement Office (OVBP) oversees financial and non-financial policies that promote the delivery of high-quality health care, which translates into better health outcomes for Virginians on Medicaid, according to an OVBP spokesperson.
The role of the OVBP will be important as more and more leaders in the health sector advocate for the move towards value-based care, rather than traditional fee-for-service (FFS) models. The OVBP said the FFS model lacks quality measurement standards.
“While [FFS] does a good job of defining a large number of discrete items and services provided, there is also an underlying financial incentive for higher volume. There is really no assumption in the base charge for a service model of a certain level of performance or quality.
The OVBP currently uses programs that use the quality of care provided as a determining payment factor. For example, the withholding tax program, which applies to managed care organizations (MCOs), withholds 1% of the capitation rate that a health plan pays to its providers. At the end of the year, providers will be reimbursed this rate based on their performance in areas such as chronic disease management and emergency or acute care follow-ups.
The OVBP said this is particularly important when it comes to providing services to a community with specific needs. For example, parents and children of Medicaid Medallion population may have relatively less complex medical needs than the population Commonwealth Coordinated Care (CCC) Plus population, who may need to receive health services in long-term care facilities.
The OVBP has also implemented the Clinical efficacy program, which emphasizes the ability of an MCO to reduce unnecessary visits to emergency departments (ED) or acute care services. Data from the Virginia Health Information Agency found that in 2018, 13% of emergency room visits in the Commonwealth were avoidable, and cost the state $ 91 million.
Clinical Efficiency Program MCOs are encouraged to reduce these visits by leveraging a coordinated care system or investing in preventive care services.
However, programs like the OVBP’s Episodic Payments model – which covers a set of services that address ‘episodes’ such as an asthma exacerbation or an emergency room visit – have lost funding due to the COVID-19 pandemic.
OVBP also temporarily changed its performance restraint program model from a pay for performance to pay for recording Last year. Essentially, providers would have costs covered as long as they provided data on the success of a service, rather than adapting to specific performance metrics.
The OVBP said staying flexible and responsive to available data has helped the office adapt to the changing COVID landscape.
“One thing that we always hold – in any program, really – important is [to] make sure you do no harm. Make sure that the incentives you create in the structure of the program are developed in a way that will achieve the best result for the member.
Going forward, the OVBP aims to expand the value-based model of care, with assistance from the Virginia General Assembly. On August 5, 2020, Governor Ralph Northam created a intervention force on primary care, the objectives of which include the search for alternative models of payment for more affordable care. The task force has worked continuously with DMAS to promote value-based care conversations ahead of the next legislative session.
Specifically, the OVBP is working on the implementation of a budget language that will establish a pilot program for a value-based model of care in nursing facilities. The OVBP said the initial methodology for the pilot program is expected at the end of the calendar year.
“We are very excited about value-based purchasing from nursing homes. This is our first truly provider-focused program, which means it’s designed specifically for the provider, not necessarily the MCO, but the care facility itself. There has been a lot of stakeholder outreach and discussion about this and we are very excited about the program.