Payment and quality reform for mental health and substance abuse care: The time is now (part 2)

April 21, 2021 / By Dawn Weimar, RN

In my last blog, I discussed mental health and substance abuse (MHSA) payment and quality in the midst of parity initiatives, team-based care and value-based payment. Certainly, adherence to fee-for-service (FFS) payment alone has not ensured the provision of appropriate, quality MHSA care. I reviewed the history and success of prospective bundled payment briefly and how state Medicaid programs have implemented IPPS and OPPS bundled payment for medical services and MHSA. Let’s dive more deeply into EAPGs and APR DRGs as they relate to MHSA and how rate-based quality initiatives are linked.

There are 18 base APR DRGs with a severity of illness score ranging from 1-4 for a total of 72 groups for payment and analysis related to MHSA inpatient stays. EAPGs have 34 patient cohorts to explain the amount and type of MHSA services provided to patients. Keep in mind that more than one EAPG can be assigned to an outpatient encounter. Clearly, a glance at the lists of APR DRGs and EAPGs for MHSA demonstrates the spectrum of MHSA care available. 

Seven EAPG types exist and are assigned for each CPT® or HCPCS code captured during the visit. EAPGs include:

1. Per diem – MHSA day care is treated as a significant procedure but is a distinct type.
2. Significant Procedure EAPGs– Includes a significant procedure and may include medical or ancillary services. Significant procedures include physical therapy and rehab, behavioral health and counseling, dental, radiologic and diagnostic or therapeutic procedures.
3. Medical visit EAPGs– When a medical visit is reported, the diagnosis code is used to assign the EAPG to provide more insight for analysis and reporting. No significant procedure exists.

4-7. Ancillary visit, Incidental, Drug and DME EAPGs– Routine services, drugs or DME when no significant procedure or medical care is provided.

The concept is to bundle services which are similar both clinically and in typical cost to the provider through sophisticated bundling functions that 3M has built into the algorithm. These bundling functions are configurable to accommodate your policy with relative ease. Examples of these sophisticated bundling functions include:

• Significant procedure consolidation– Significant procedures are consolidated if they are related.
• Significant procedure discounting– Significant procedures are discounted if bilateral.
• Ancillary packaging– many ancillary services within a Significant Procedure or Medical Visit EAPG are assigned a payment relative weight of zero. Incidental EAPGs always package.

“[EAPGs] …bring organization to the jumbled world of ambulatory care utilization and payment where traditionally, it had been very difficult to understand and compare what services were provided at what cost for what purpose.” This is also true of APR DRGs which are commonly used as an aggregator and for casemix adjustment. 

In conjunction with the value-based quality goals of the Triple Aim, modernization of both payment and system-level metrics for MHSA quality care is paramount. Any strategy must include a foundation linking payment to quality even if in a phased implementation; several examples exist which build upon the APR DRG and EAPG payment foundation.

As part of their Quality Incentive Payment Program (QIPP), Mississippi Medicaid and Conduent published a readmission analysis using 3M^TM Potentially Preventable Readmissions (PPRs) and return emergency department visits (PPEDs).  Analysis was completed by APR DRG; the readmission or return ED visit (EAPG) must be clinically related to the inpatient admission per the algorithm design. Medical and MHSA admissions were similarly analyzed (See Table 4.1). Other states such as New York, Texas and Florida use Potentially Preventable Events (PPEs) as the backbone of their value-based payment or quality improvement initiatives.  

In March, the 3M Clinical and Economic Research team published research titled “Geographic Variation in Hospital Emergency Department Visits in the Medicare Population.” APR DRGs and EAPGs were used to identify the clinical cohorts, then the Potentially Preventable Visit (PPV) algorithm was applied for quality analysis across medical and behavioral health care. Study design for this rate-based analysis can be done using any population’s claims.

The 3M Clinical and Economic Research team also conducted a robust geographic variation study published last year that includes eight PPE measures of quality across the U.S. based on Medicare FFS claims. Then, in July 2020, 3M further demonstrated the flexibility of the potentially preventable measures through the creation of a composite inpatient episode quality outcome performance value (QPV) in which PPEs were correlated with five population utilization metrics to assess the overall functioning and effectiveness of the systems of care.  

The goal of all these studies is to identify variation in the potentially preventable rates of health care encounters, whether inpatient or outpatient, to propel movement toward averages. As mentioned previously, 3M estimates that Medicare would save $8 billion by reducing variation in eight inpatient and emergency department outcomes measures for the FFS population. State Medicaid programs using PPEs have reported similar success.  

3M’s rate-based approach is unique as a gauge for overall function of the health care system and as a driver for systemic improvements in quality. APR DRGs and EAPGs are foundational in defining patient bundled cohorts in conjunction with the 3M PPE algorithms applied similarly to medical and MHSA care. This is critical especially in light of team-based care and parity as we pursue whole person care in a value-based world.

Dawn Weimar, RN, is director, state regulatory affairs for 3M Health Information Systems.