Based on the many discussions I’ve had with treatment center leaders over the years, I suspect that negotiating with health insurance payers for a fair reimbursement rate is one of (if not the most) challenging aspects of running a treatment center. And it seems to be getting even harder.
To help our clients prepare for these make-or-break negotiations, Vista is now offering to produce up to three Payer Summary reports each year at no additional charge for full members of the Vista Research Network. These reports focus on three types of data:
Financial Metrics
Providers and payers look at patients through a different lens. Since payers are heavily focused on minimizing cost, asking the payer to calculate how their members’ post-treatment medical spend compared to their medical expenses prior to treatment can be helpful. But before you make such a request, you want to feel comfortable that the analysis will show a substantial reduction.
Vista’s research shows that patients completing 12 month post-treatment outcomes surveys average only about half as many emergency department visits, unplanned hospitalization stays and detox treatments in the year after they leave treatment compared to their pre-treatment year:
Making the conservative assumption that the patients who didn’t submit a 12 month survey showed no improvement, there still should be about a 25% reduction in medical spend among this group of patients. If the patients who are insured by the payer you're negotiating with report a similar reduction in medical spend, it could be helpful to ask the payer to analyze their before- and after-treatment spending data for your center.
Other financial metrics of key concern to payers are 30- and 90-day readmission rates and the number of days patients spent in treatment. In this latter area, unfortunately, payers want to see short treatment stays instead of the longer lengths of stay that lead to better recovery rates according to Vista’s data.
Treatment Effectiveness Data
Vista will attempt to include the most compelling patient-reported treatment effectiveness data in your Payer Summary Report. If possible, for example, we’ll show that substantially more of your patients are meeting their drug and alcohol usage goals one year after discharge compared to Vista’s norm:
Payers should also be impressed to see that the severity of your patients’ co-occurring symptoms drop dramatically during treatment and remain low throughout the post-treatment year:
We’ll also include other indicators that you’re providing effective treatment such as graphs showing that a high percentage of your patients complete all recommended treatment, strong patient satisfaction scores, and improvement in key quality of life measures.
HEDIS Measures
The National Committee for Quality Assurance (NCQA) has defined multiple metrics to measure the performance of different health plans. While typically process-oriented, not outcomes-based, these HEDIS measures are of great concern to many payers. Vista’s Payer Summary Report analyzes member data for relevant HEDIS measures such as how quickly patients could access care and whether patients with depression improved during treatment.
There are four separate HEDIS measures related to how quickly members received follow-up care after visiting the emergency department, being hospitalized or receiving high-intensity SUD care. Vista analyzes how quickly after making the decision to attend patients who were hospitalized and/or attended another SUD treatment immediately prior to treatment were able to start treatment at your center:
Another crucial HEDIS measure for payers is Depression Remission or Response. Vista reports the percentage of patients who entered treatment with moderate to severe depression who achieved remission (i.e., ended treatment with a PHQ-9 score of less than 5) or experienced a 50% reduction in their PHQ-9 score:
How Helpful Is a Payer Summary Report?
One of our long-term Vista clients had this to say:
“Thank you for our Payer Summary Report. It is pretty hard to dispute our treatment effectiveness when presented as well as Vista Research Group details the components critical for client success. Our clinical team utilizes the data provided by Vista in tailoring the delivery of our treatment and you can see how well it works! It is a shame that so many in our industry do not take advantage of the better outcomes they could achieve if they invested in the data required to properly see what they are doing and the changes required to increase their effectiveness.”
Jim Brady, CEO
AToN Center
Request Your Own Payer Summary Report
If you’re not already a member of the Vista Research Network, please schedule a Discovery Call now. I look forward to showing you how effortlessly you can collect payer-specific data you'll be happy to have during next year’s payer negotiations!
