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How In-Home Care Providers Can Advance Conversations With Payers, ACOs, Managed Care Organizations, and Physician Groups

“As a provider, we want as much information as possible about the patient population we will be working with so we can: identify issues that need to be addressed; determine how we can utilize our in-home aides and other interventions to keep patients at home; lower costs; and deliver results that lead to healthy Value-Based Purchasing (VBP) savings and rewards.”

– Christy Johnston, MPH
VP, Governmental and Managed Care Services
Premier Health Care Services

In a perfect world, there would be a neatly mapped out playbook for home care providers to follow when launching conversations with payers about value-based payment contracts or other strategic relationships.  This playbook would guide the conversation, have all the right questions to ask, and lead you straight down the path to sealing the deal!

What we have found, however, is that the path of these conversations with managed care plans, ACOs, physician groups, or other partners is rarely straight and everyone meanders along various paths as both parties try to figure out how to get from here to there and establish the best possible scenarios for success.

While the process might be longer than anyone would like, there is one common theme embedded in every conversation and it is worth investing resources into – getting the right data.  Regardless of the programs you are proposing, solutions you are offering, scope of services and deliverables you are aligning, or risk arrangements you are negotiating, having meaningful data is essential to developing a strategic relationship in which both parties are in alignment and able to establish measurable, achievable outcomes.

In spite of the challenges that a global pandemic poses in getting everyone to the table and looking beyond the immediate world of coronavirus, we have continued to pursue strategic partnership conversations with a number of different payers, including ACOs, managed care organizations, and physician groups.  As a result, we are excited to be launching a few different transitional care and related in-home aide service programs over the next few months.  Data was a driving factor in finalizing all of these strategic partnerships.

Payer Conversations: Return on Investment

Payers are interested in talking about the data.  In particular, they are interested in understanding how home care providers are able to reduce their penalties and increase their rewards in a value-based payment system.  They want to know how you will be able to impact their re-hospitalization rates, limit emergency department visit exposure, and increase their quality outcomes and patient satisfaction.  They’ll also want to know how to operationalize this smoothly and secure buy-in from their organizations, which means being able to provide the data to show what the return on investment will be in this strategic alliance—and this means demonstrating this ROI to everyone up and down the service delivery chain.

Moving beyond the data conversations and outcome targets, payers are looking for home care provider partners that understand their systems, reimbursement challenges, and can pivot their thinking to figure out how to meet their gaps in care—seamlessly.  They expect providers to be able to operate in the payer’s electronic health record system and may expect you to follow compliance standards that are above and beyond what your licensure requires.  In the end, they want to lower their risk and have you fit neatly into their workflows.

In order to meet payer expectations, home care providers also must be keenly focused on data.  As a provider, we want as much information as possible about the patient population we will be working with so we can: identify issues that need to be addressed; determine how we can utilize our in-home aides and other interventions to keep patients at home; lower costs; and deliver results that lead to healthy Value-Based Purchasing (VBP) savings and rewards.  Most importantly, it is essential to understand in advance, the baseline scores, penalties, or other benchmarks we will be measured against so we know what is needed to be successful.

None of these points are necessarily surprising—everyone wants and needs data.  The big surprise often seems to come from the fact that many of the payers are not able to deliver the data that home care needs.

ACO Conversations: Drilling Down Data To The Patient Level

An ACO or managed care plan clearly has access to significant amounts of data, but it is often challenging to tease out the data we need.  ACOs often have plenty of data, but meaningful data to understand the patient population may be coming from multiple sectors of their system and isn’t easily combined.  At times the payers have aggregate data, but limited ability to drill down to the patient level information that would be most helpful and typically data that would help inform what is happening in the home or with social determinants of health are not even collected.

How In-Home Care Providers Can Advance Conversations Driven By Data

In these instances, providers need to look to themselves for the data, which means making the investment in advance of conversations with payers.  For Premier, over the past few years, we have developed specialized aide training programs—Observe, Ask, Report—that have led to our in-home aides collecting and reporting targeted data.  Through our Real Time Data Program (RTD), our aides are the eyes and ears in the home to provide actionable data that allows our interdisciplinary teams to implement timely interventions and support better patient care and outcomes.

Along the way, as we devoted time to source outside data sets and tried to secure information from our payer partners, we realized that the data being collected on a daily basis through RTD was our own source of analyzable data.  Taking the RTD data points, combining them with nursing assessment information, and details of diagnoses from the patient health records, we are able to develop a better understanding of the patient population.  In turn, this information provided data that has been helpful in refining and developing more effective population health strategies—particularly for the more vulnerable dually eligible population.

This is the kind of patient information that payers do not have in their data warehouses or electronic health records.  Home care providers, when we really look and think about what we have access to through our workers, we have the ability to collect and understand our populations better than ACOs, managed care plans, or other strategic partners.  It is important to take a look at what you already have access to or could begin tracking.

In addition to utilizing our own data to collaborate and bring new information to the table during conversations with payers, Premier’s internal data has helped refine and enhance our own programs.  Newly launched transitional care models will be supported by enhanced training programs for our aides.  Built off of our OAR training platform, our specialty Gap Aide training program has been developed to provide an enhanced training that will help fill gaps in care and focus on additional diagnoses that were consistent indicators of adverse events—such as an increased likelihood of falls tied to hypertension and/or diabetes diagnoses, which was the case in 2019 when we saw that 46% of falls occurred when the patient had either or both of these diagnoses.  The information gathered by Premier’s Gap Aides will be relayed through WebOAR+, an enhanced web-based reporting system, utilizing a Chromebook Tablet and will capture more detailed information on patients, including vital signs, for the interdisciplinary team to identify the need for interventions.

Regardless of how organizations secure the data needed to find the right path with payers, it is now more important than ever that the home care industry collectively figure out how to remain relevant and involved in changing health care system.  Tied to this is the imperative to be able to quantify the added value being brought to an ACO or Health Plan’s existing service delivery model. Ensuring that our most vulnerable populations have the choice of and access to high-quality home care services has always been important, but it has become even more apparent that these services are ever so critical during a pandemic when simply being able to remain at home can save lives.