Value-Based Contract Negotiation: A case Study
The Independent Mental Health Practices Alliance (IMHPA) has been deeply involved in developing measurement-based care and value-based payment services since 2015. As the healthcare landscape shifts from fee-for-service to value-based payment contracts, IMHPA recognizes the necessity of these changes for economic survival. Despite their readiness, Healthplans have shown reluctance, primarily due to risk aversion and concerns over downside risk.
Framing Problems as Opportunities
IMHPA identified 281 problems with Moda Health's proposed contracts, 42 of which are critical. Their attorney recommended reframing these problems as opportunities, a perspective shift that aligns with IMHPA’s goal of creating a successful contract with Moda Health. To facilitate this, IMHPA has published 70 articles on their website for discussion and training and education purposes, highlighting opportunities for collaboration and successful contract creation.
The Importance of Measurement-Based Care
Measurement-based care is crucial for setting baselines and performance targets, known as benchmarks. Accurate data must be gathered from various populations to account for different resource needs. IMHPA has invested significant resources in technology, integrated analytics, training, and contracting requirements to ensure successful value-based contracts. Despite these efforts, Moda Health’s contract offered in 2023 did not address 281concerns of which 42 critical opportunities, leading IMHPA to conclude that they cannot sign the contract for ethical and moral reasons. However, IMHPA remains committed to negotiating in good faith with fair dealings.
Case Example: Moda Health’s Deviations
Moda Health’s contracts deviate from state, federal, and industry guidelines and best practices. This deviation poses a probable to almost certain moderate or catastrophic impact on public employees under the Oregon Education Benefits Board (OEBB) and Public Employee Benefit Board (PEBB). The Moda contract is an uncontrolled experiment at best, and the fraud perpetrated thus far justifies independent oversight of experimental measurement and value-based contracts. Independent oversight is a standard practice in healthcare systems but not yet in Healthplans, which control these systems, especially where Healthplans are paid with taxpayer dollars.
Independent Certified Internal Auditors
Engaging independent certified internal auditors is crucial for ethical and effective oversight. These auditors should report to the CEO, and the Board of Directors a Board duly appointed Audit Ethics Committee. The independent certified auditor should not report to Healthplan management. Additionally, they must provide quarterly reports to stakeholders to maintain transparency and accountability.
Ethics Point Portal
An ethics point portal allows stakeholders to anonymously report illegal, unethical, or immoral practices without fear of retaliation. This mechanism ensures prompt identification and resolution of issues, maintaining the integrity of value-based contracts. All reports will go directly to the appointed independent certified internal auditor.
Plain and Understandable Contracts
Contracts and policies must be written in clear, understandable language to ensure that all parties comprehend the terms. This clarity is essential for avoiding misunderstandings and ensuring good faith and fair dealing.
Ensuring Legal, Ethical, and Moral Compliance
For value-based payment contracts to be successful, they must meet legal, ethical, and moral requirements. Gaining the trust and full engagement of mental health professionals necessitates that Moda Health incorporates these requirements into their contracts. These industry-standard requirements are perfectly aligned with the mutual success of all stakeholders, including Moda Health.
Conclusion
IMHPA's commitment to ethical practice and collaboration highlights the importance of addressing critical opportunities in value-based contracts. By focusing on transparent measurement and fair dealings, IMHPA aims to create sustainable and successful partnerships in the evolving healthcare landscape.
Essential Requirements for Healthy Contracts Legislation
Independent Certified Internal Auditors: Ensuring unbiased oversight.
Ethics Point Portal: Facilitating anonymous reporting of illegal, unethical, or immoral practices.
Plain Understandable Contracts: Ensuring all parties clearly understand contract terms and policies such that requirements, audits, and calculation are clear.
Ethical and Legal Review
An ethical and legal review of IMHPA opportunities to create a successful contract requires review by Moda Health's General Counsel and CEO. This review will ensure that the contract and policies aligns with stakeholder interests, including Moda Health.
Legislation Implementation
Legislation is an alternative of last resort. Legislation will require Healthplans to:
Appoint Independent Certified Internal Auditors: These auditors will monitor Healthplan practices, ensuring they adhere to legal, ethical, and industry standards. They shall not report to Healthplan management to maintain independence.
Establish an Ethics Point Portal: This portal will allow stakeholders to anonymously report illegal, unethical, or immoral practices without fear of retaliation.
Draft Contracts in Plain Language: Contracts and policies must be written in clear, understandable language, ensuring all stakeholders can comprehend and adhere to the contract terms and policies.