Value Based Care Advisory (VBCA) Podcast

This episode is also available as a blog post: https://healthcare-wiki.com/2022/03/12/changing-demographics-value-based-care/

No two states are alike in how telehealth is defined and regulated. While there are some similarities in language, perhaps indicating states may have utilized existing verbiage from other states, noticeable differences exist.

These differences are to be expected, given that each state defines its Medicaid policy parameters, but it also creates a confusing environment for telehealth participants to navigate, particularly when a health system or practitioner provides health care services in multiple states. In most cases, states have moved away from duplicating Medicare’s restrictive telehealth policy, with some reimbursing a wide range of practitioners and services, with little to no restrictions.

One of the most common trends with live video reimbursement was the addition of eligible services to the list of telehealth eligible services, with applied behavioral analysis being the most common service addition mentioned in Medicaid manuals.

Additionally, in the wake of the COVID-19 pandemic, some states do seem to be adopting the Center for Medicare and Medicaid Services (CMS) communication technology-based services (CTBS) codes, including the virtual check-in and remote evaluation of prerecorded information, audio-only service codes and remote physiologic monitoring.

All fifty states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine, or both. Additionally, because of the allowance in most states to utilize telephone as a form of telehealth during COVID-19, some states are taking steps to broaden its permanent definitions of telehealth or telemedicine by removing the explicit exclusion of telephone or including audio-only services within the definition itself.

One of the states with the most significant changes to their telehealth policy was Massachusetts which passed a comprehensive telehealth law to require reimbursement for both Medicaid and private payers if the services are covered in-person and it is appropriately delivered through telehealth. The law contained some unique elements including specifying that the rate of payment for telehealth services provided via interactive audio-video technology and audio-only telephone may be greater than the rate of payment for the same services delivered by other telehealth modalities. It also provided payment parity for in-network providers of behavioral health services delivered via interactive audio-video technology or audio-only telephone only.

Read: https://healthcare-wiki.com/2021/08/01/telehealth-landscape-overview-50-states-dc/

This podcast episode dives deep into the complexities of mental health parity and the implications of the Mental Health Parity Act. The conversation emphasizes the necessity for behavioral health services to be treated with the same level of care and coverage as physical health services, addressing the ongoing disparities in treatment and reimbursement practices.

Alex Yarijanian and Dr. Chris Esguerra discuss the challenges providers face when navigating insurance plans and the barriers to accessing equitable care for patients.

Dr. Esguerra is board certified in both Psychiatry and Health Care and Quality Management and is a Fellow of the American Psychiatric Association and the American Board of Quality Assurance and Utilization Review Physicians.

Dr. Esguerra’s extensive payer-side executive experience includes:

• Senior Medical Director, Blue Shield of California
• Senior Medical Director, Magellan Health
• Deputy Chief Medical Officer, Health Plan Of San Mateo

They highlight the critical role employers play in advocating for better mental health coverage and how they can leverage their purchasing power to ensure compliance with parity laws. Ultimately, the episode aims to empower providers with the knowledge and tools necessary to advocate effectively for their patients and promote a more integrated and equitable healthcare system.

A significant focus of the episode is on the role of providers in identifying and addressing parity violations. The speakers guide listeners through the necessary steps for raising concerns regarding unequal treatment, emphasizing the importance of gathering evidence and understanding insurance policies.

This segment is particularly valuable for behavioral health providers who may face obstacles in securing appropriate coverage for their patients. The discussion also touches upon the regulatory landscape, explaining how self-insured plans differ from traditional insurance plans and the implications this has for parity enforcement.

Additionally, the episode discusses the importance of employers in advocating for better mental health coverage, encouraging providers to leverage their relationships with these entities to push for systemic changes that prioritize mental health equity.

Takeaways:

• The Mental Health Parity Act requires equal coverage for both physical and behavioral health services, ensuring that patients receive the same level of care.
• Providers should gather evidence of parity violations and present it to state regulators to advocate for fair treatment.
• Behavioral health is lagging behind primary care in integration and reimbursement models, highlighting the need for systemic reform.
• Employers play a crucial role in advocating for mental health parity by demanding better coverage from their insurance plans.
• Effective communication and partnerships between providers and health plans can lead to better patient outcomes and innovative care models.
• Tracking outcomes and demonstrating quality of care is essential for providers to negotiate better contracts with health plans.

Companies mentioned in this episode:

• Blue Shield of California
• Magellan
• Kaiser Permanente
• Google
• Apple
• Anthem
• Centene
• United
• Cigna
• Aetna
• Humana
• CalPERS
• Pacific Business Group on Health
• National Business Group on Health

Chris Esguerra MD MBA

This episode explores the rising tide of healthcare startups pursuing value-based care (VBC) with ambitious visions to improve patient outcomes and lower costs. However, without a robust patient acquisition strategy, many founders find themselves struggling to meet volume requirements, maintain contracts, and deliver quality care. Through candid dialogue and practical insights, host Alex Yarijanian addresses these pain points and offers actionable advice for navigating the competitive healthcare market.

Segment Highlights

Startup Realities in Value-Based Care

• Analogy to Streaming Service Overload: Alex compares the influx of VBC startups to the crowded streaming industry, highlighting how many of these startups lack a practical strategy, assuming that contracts with big payers alone will drive patient volume.
• Importance of Patient Acquisition: Building meaningful connections and community engagement is critical for driving patient volume—something often overlooked by startup founders. Alex discusses tactics like forming referral networks and partnering with local organizations to build a sustainable patient base.

Key Strategies for Healthcare Startups

• Understanding Payer Volume Thresholds: Alex underscores the need for startups to grasp the minimum patient volumes required by payers to maintain contracts.
• Patient Engagement & Marketing: Effective marketing and visibility are as essential as clinical quality. Engaging patients through tailored messaging and demonstrating value within local communities can solidify a startup's presence and relevance in the healthcare landscape.

New Segment: 'Tough Calls in Healthcare'

• This episode introduces a new segment, where Alex addresses real-world negotiation dilemmas faced by healthcare professionals. In this installment, he discusses:
• Negotiating Reimbursement Rates: Tips on understanding local market rates and using data to strengthen negotiation positions with payers.
• Handling Contract Amendments: Strategies for managing unilateral changes imposed by payers and knowing when to push back or walk away.

Key Takeaways

• Beyond Business Models: For startups, having a robust business model isn’t enough—securing patient volume is essential.
• Value-Based Contracts: These can be highly advantageous, but they require a substantial patient base to fulfill the value equation.
• Community Connection: Building credibility and visibility within the local healthcare ecosystem is crucial.
• Balancing Act: Startups must balance patient volume and care quality to sustain payer relationships.
• Negotiation Essentials: Effective contract negotiation includes knowing market benchmarks and maintaining flexibility.

Companies Discussed:

• UnitedHealthcare
• Cigna

Listeners can expect a blend of in-depth analysis, actionable advice, and fresh perspectives on how to navigate the complexities of launching and sustaining a healthcare startup focused on value-based care.

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During the 2019 legislative session, Florida passed Chapter 2019-137, Laws of Florida, which establishes standards of practice for telehealth services, including patient evaluations, record-keeping, and controlled substances prescribing. The law also authorizes out-of-state health care practitioners to perform telehealth services for patients in Florida. Signed by the Governor on June 25, 2019, this law became effective on July 1, 2019.

Out-of-state health care practitioners must be registered with the Florida Department of Health to perform telehealth services for patients in Florida.

Health care providers must be licensed within their scope of practice by the appropriate licensing body to practice telehealth in Florida.

Providers must also use two-way, interactive communication tools, such as live video, instead of email or audio-only communication. If you use Medicaid, your telehealth provider must be registered with the Florida Medicaid program to receive reimbursement for telehealth services. Florida doesn’t require private insurers to cover telehealth, so check with your insurance company to determine if you’re eligible for the service. Some of these regulations may be altered during the COVID-19 pandemic.

In Florida, telehealth providers are permitted to prescribe medications if the medications aren’t listed as controlled substances.

However, there is one important exception to this rule: If you need a controlled substance to manage a mental health condition, your telehealth provider is allowed to prescribe it.

Before prescribing medication, your telehealth provider must conduct an evaluation and explain the risks and benefits of the medication to you.

Filling out a questionnaire before your telehealth appointment isn’t enough to satisfy the evaluation requirement, so you should expect the provider to ask multiple questions about your symptoms and health history.

This episode is also available as a blog post: https://healthcare-wiki.com/2021/06/22/florida-market-telehealth-rule/

A Carenodes Production.