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Innovative Reimbursement Paradigm

Introduction

To revolutionize overdose prevention efforts, the manner in which agencies are reimbursed for overdose prevention engagement must be transformed. This critical strategic element is consistently forgotten in the discussion of combatting the overdose epidemic.

 

Presently, the ways in which managed care organizations support and reimburse OUD prevention, treatment and general recovery services are all too often lacking alignment, coordination or integrated economic structures that incentivize long-term recovery. Even more pointedly, there is often not one entity who assumes ownership of improving an individual’s condition and is properly supported and rewarded for doing so. This leads to a system in which chronic substance disorder patients are engaged by multiple providers without any coordination, volume of services provided is favored over value for the patients, and the hardest to reach, most at-risk individuals are not prioritized.

 

The Hotspotting program sets out to transform this reimbursement stalemate, as it is an irreplaceable element of fulfilling the dual aim of improving overdose related outcomes and bringing down aggregate healthcare costs in a responsible manner. The program’s central thesis is that by piloting a superior reimbursement scheme and proving its impact on this dual aim, the business case for managed care organizations to adopt this model will be clear and impossible to ignore.

“Opioid use disorder is a chronic illness and payment models for the condition must align with whole health outcomes rather than fragmented treatment incidents. ”

Greg Williams

Manager, The Alliance for Addiction Payment Reform

The Hotspotting program implements a highly innovative reimbursement which provides guaranteed staff funding, provides a quarterly incentive reimbursement, and holds treatment partners to a rigorous reporting standard. Participating organizations will receive funding for staffing and for achieving tiers of outreach, engagement, and outcome metrics. Underpinning this model is the notion that treatment partners will be capable of adopting a risk-based reimbursement model if they do not have to shoulder the burden of resourcing direct treatment staff. Finally, a key component of the payment model is incentivizing comprehensive care management focused on reducing opioid harm, promoting a continuum of recovery, addressing critical social determinants of health factors, and ultimately delivering value to the local health system.

The Hotspotting
Reimbursement Model

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Treatment Staff Funding

The Hotspotting program provides bi-annual payments to treatment partners for the full salaries of one CRPA and one clinician, who will lead the patient outreach and engagement process. These dedicated engagement staff must be hired and/ or identified before the start of the program, and they must pass a hotspotting program led class on 42 CFR and patient confidentiality. All program staff must also be assigned a unique user ID for access to all program related systems.

Quarterly Incentive Based Reimbursement

Each treatment partner will be eligible to receive quarterly incentive-based reimbursements. These performance bonuses will be evenly focused on the agency’s efforts to outreach patients identified by the predictive analytics system, engage them with holistic service plans, reduce the rate of overdose incidents amongst their clientele, and reduce the utilization of unnecessary hospital based services. All deliverables and outcomes described herein are recommended per The American Society of Addiction Medicine (ASAM) Guidelines.

Reporting System

A strong outcome and process focused reporting system is a critical prerequisite for executing this alternative reimbursement system. Certain outreach and engagement activities will be documented in the Channels care management platform including contact attempt workflows and tasks, collecting demographic intake information, completing SDOH assessments and making referrals to social service agencies and resources, and completing sets of tasks related to tracking the completion of deliverables. Channels is a customizable care management referral platform with the ability to make closed-loop referrals to different care networks.


Channels is used by treatment partner program staff to track deliverables, activities, and make referrals to social service providers. Full email integration has been executed with each of the treatment partners so as to enable these closed-loop service referrals. SI PPS has also worked with Channels to customize the workflows within the platform and the workflows have been set up in the production environment of the system. The Channels platform has been refined by the Hotspotting leadership team in coordination with Ready Computing to track substance use disorder services. This new pathway can easily be applied to hotspotting programs in other geographic locations.
That said, many engagement activities, including clinical tasks and assessments, will not be documented in the Channels care management platform. The Hotspotting Program will request attestation through a set of tasks in the platform that will document that the activity was completed, the date, provider name and location of each service, assessment, etc. These activities will be tracked in the back end of the system to generate a monthly performance report, which will be used to populate monthly partner performance reports.
© 2022 Hotspotting the Overdose Epidemic