Doug Nemecek, MD, MBA
Chief Medical Officer – Behavioral HealthJanuary 30, 2017
PAYMENT MODELS AND
INTEGRATED CARE
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna
Agenda
The Case for Change
Pay for Performance and Value Based Reimbursement
Centers of Excellence and Network Tiering
Medical Integration
Telehealth
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
A rapidly changing, dynamic environment
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
Demographic
shifts
Increasing
chronic
conditions
Rising health
care costs
Increased
demand for
transparency
Growth of
technology
and hyper
connectivity
Increased
regulation and
evolving social
safety net
Stakeholders:
• Individuals
• Employers
• Government
• Health care
providers
• Distribution
channels
Health care providers
Consolidating and moving
to a value-based system
Distribution channels
Traditional distribution
channels are consolidating,
while at the same time new
channels are emerging
Employers
Looking for greater
affordability, increased
predictability, improved
productivity
Individuals
Increased role and
seeking greater affordability
and personalization
Rapidly evolving market forces create
changing roles and responsibilities for all stakeholders
EVOLVING MARKET FORCES:
BEHAVIORAL HEALTH
Cost Trends
4Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
• Costs for SUD treatment have outpaced other medical cost trends,
driven largely by OON unit cost.
2013: $4,900 INN vs. $26,500 OON 16% of Opioid Customers OON
2015: $5,700 INN vs. $36,500 OON 24% of Opioid Customers OON
• Higher medical spend for customers with chronic conditions and co-
morbid behavioral health conditions
• $429 PMPM difference – with severe mental health disorder
• $358 PMPM difference – with substance use/opioid disorder
• $190 PMPM difference – with general mental health disorder
P4P, Value Based Reimbursement, COE
NETWORK AND REIMBURSEMENT DEVELOPMENT
5Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
Cigna Collaborative Care behavioral health programs with hospitals
6Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
Reasons for changeCollaboration to achieve the Triple Aim:
Facilities
Metrics: Clinical, cost and satisfaction
Hospital compare
Traditional Model Collaborative Model
Contracting
Facilities:
Clinical metrics
Cost metrics
Quality metrics
Reimbursement for positive outcomes
More case rates; less fee for service
Rewards N/A Rate increases
Enhanced service level from Cigna
Fee-for-service
Better
quality
1
AffordabilityPatient
satisfaction
2 3
+ +
Cigna’s Response to the Opioid Epidemic
7Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
Reducing opioid
prescriptions by 25%
through advocating for
CDC guideline adoption
• Expand Narcotic Therapy Management Program
• Share with physicians their opioid prescribing profiles
• Provide just-in-time education to patients receiving opioid prescriptions
• Partner with Provider Partners in “Pledge” to follow CDC Guidelines
Pharmacy policy • Re-evaluate opioid dispensing quantity limits
• Provide feedback to physicians about their prescribing patterns in
comparison to CDC guidelines
• Update formulary and prior authorization guidelines
High risk customer
engagement
• Direct outreach to customers receiving hazardous levels
of opioid prescriptions
• Train Cigna staff interacting with customers at emerging or high risk
of Substance Use Disorder (SUD) in mental health first aid to improve
their SUD literacy
Community
comprehensive
Opioid Use Disorder
• Expand national designation program around high quality,
affordable intensive outpatient treatment programs including
medication assisted therapy
Comprehensive pain
management treatment
center network
• Identify and contract programs that provide a full range of
chronic pain management
Medication Assisted Treatment Network
8Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
Network Growth
Identify Providers
• Buprenorphine/naloxone preparations
• Vivitrol
• Methadone
1
2
3
Information Available to Physicians and Referral Sources
• Online search
• ACO and Primary Care
• Cigna Case Management Programs
Establish Reimbursement
• Fee for Service – Induction and Follow Up
• Outcomes and Value Based Contracts
Collaboration with the American Society
of Addiction Medicine (ASAM)
9Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
Rewarding health
care professionals
for using proven
therapies
Used to “test and validate” what’s
worked (and not) in substance
abuse prescribing
Provide ASAM with two years of
claims data
Used to develop guidelines for
treatment and prevention
Guidelines to Cigna Collaborative Care
doctors – incentives will shift from volume
to value, rewarding for using proven
therapies to improve patient outcomes
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna 10
A facility in Cigna’s behavioral network that has earned a top ranking for patient
outcomes and cost-efficiency based on Cigna measures. Must be accredited by The
Joint Commission or Commission on Accreditation of Rehabilitation Facilities.
Designated Substance Use Treatment Provider
Capabilities
• Inpatient and residential,
detoxification
• Partial hospitalization program or
Intensive Outpatient program as an
optional level of care
Annual admissions
• Minimum of 25 unique treatment
episodes required for consideration
Total cost per episode
• Total dollars paid for services
Readmission rates
• Total admissions within 30, 90
and 180 calendar days of
original admission must be
10% or less
Seven-day ambulatory follow up
• Number of face-to-face
outpatient visits with licensed
behavioral practitioner within
seven days of discharge
Selected based on five health outcomes and cost-efficiency metrics:
INTEGRATION WITH MEDICAL CARE
11Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna
Collaborating with large physician groups
12Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
Dedicated toll-free line
Release of information
GeoAccessreports
Claim and coverage validation
Integrating
behavioral
capabilities
Release behavioral
health information
• Get complete patient
information including
behavioral and
substance use
diagnoses
Dedicated 800 #
• Specially trained teams
of Cigna Behavioral
Health staff
• Patient’s benefit details
• Review patient care with
licensed clinical staff,
including psychiatrists
GeoAccess reports
• Identify in-network
behavioral professionals
• Maps of therapy,
psychiatry, and
behavioral health
services close to
practice
Claim and coverage
policy validation
• Receive current
policies according to
contracted services
and provider types
Integrating behavioral care with primary care means patient
is helped faster and costs are reduced
Making behavioral health integration financially viable
13Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna
• G0502 Initial psych care mgmt, 70 min
• G0503 Subsequent psych care mgmt, 60 min
• G0504 Initial/subsequent psych care mgmt, additional 30 min
• G0507 Care mgmt. services, min 20 min
G codes can be billed by the treating primary care provider (PCP) and are intended to incorporate the services of all members of the collaborative care team as incident-to services of the PCP
Health & Behavior (H&B) codes: 96150-52:
Value Based arrangements:
• Reimburse for biopsychosocial assessment and brief intervention to address issues impairing a patient’s ability to manage a medical illness
• Reimbursable to behavioral providers who are not actively engaged in the diagnosis and treatment of behavioral health condition
• Activities performed by licensed behavioral staff that cannot be billed fee for service including high-acuity screening, psychosocial assessments, treatment plan coordination, family and caregiver support, educational groups, peer to peer consultation and education; medical and behavioral activities should be documented in a shared EMR
• Paid on a pmpm basis and based on performance metrics
Behavioral Telehealth
Reimbursement
14Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2016 Cigna
> Telephonic: 99441, 99442, 99443: telephone services
provided by a physician to an established patient. The
patient must initiate the contact as these codes may not
be used for calls initiated by a provider
> Video: 99444: video services provided by a physician to
an established patient
CPT CODES
> 98966-98968: telephone services performed by qualified non-physician health
care professionals. Not covered by Medicare
> E/M 99201 to 99205: Codes for new patient encounters, require referral,
requires documentation of level of complexity
> E/M 99211 to 99215: Codes for established patients, requires documentation of
level of complexity
> Traditional BH CPT codes: 90832, 90792…
> GT, GQ, 95 modifiers
Virtual Healthcare - Headwinds
15Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna
Barriers to HCP entry into Virtual Healthcare are too high (technology / payment)
HCP reimbursement
•72% of physicians and 45% of ACOs offering telehealth services are not reimbursed by any
commercial payer
Technology
•HIPPA
•No standard platform
•Ability to electronically share telehealth encounter information to HER
telehealth vendor networks - finding the right balance of services to extend
•Do we need to re-contract for minor medical conditions, or reimburse same rates as in person?
telehealth policy - Emerging and inconsistent regulation of telehealth services
•Lack of reciprocity in medical licensing across state lines
•Some states require an in-person encounter after a telemedicine encounter
•Drug prescription as a result of diagnosis via telehealth is regulated or prohibited in some states
Confidentiality and liability concerns of HCP offering services via telehealth
Cost-save or driver?
•Challenging to identify the cost of paying doctors for services they are providing gratis today (e.g.
prescription refill over the phone)
16Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna
A TRANSFORMATIVE APPROACH
COST
QUALITY
SATISFACTION
COLLABORATION IS KEY.
CHANGE THE MODEL. IMPROVE VALUE.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company,
Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo,
and other Cigna marks are owned by Cigna Intellectual Property, Inc.
000000 00/16 © 2017 Cigna. Some content provided under license.