Photo: Jeff Lagasse/Health Financing News
ORLANDO — Health care organizations, from payers to providers, have repeated a common refrain in recent years: providing the right care in the right place at the right time. Various hospital-at-home programs have sprung up in response to this philosophy, and some of the most successful involve payer-provider partnerships.
Tina Burbine, Vice President of Care Innovation at Healthlink Advisors, and Tanya Zucconi, COO of ZGM, which is affiliated with Humana, know firsthand the power of a payer-provider partnership. Their organizations partnered with a hospital-at-home program that discovered best practices for getting the most out of their relationship.
During their session “Hospital at Home: Why Now?” at the HIMSS22 conference in Orlando, they said market pressures are driving payers and health systems to converge and team up on the increasingly popular notion of home care.
Hospital home care – not to be confused with Johns Hopkins’ Hospital at Home brand – is a combination of pre-hospital, acute, post-acute and outpatient services focused on the individualized care needs of a patient in their own home, and replaces hospital admission with direct home admission from the community or emergency department.
The idea is to cost-effectively treat critically ill adults, while improving patient safety, quality and satisfaction. Funding through Medicare and Medicaid Service Centers and numerous payers has made establishing and delivering this type of patient care a strategic priority for healthcare organizations.
In a way, Zucconi said, Humana’s transition into space represents a full circle, as it essentially started out as a retirement home in the 1960s.
“Humana is on a strategic journey from an insurer that provides healthcare to a care organization that provides insurance,” she said.
ZGM is a managed services organization that enables the delivery of care, and its connection to Humana grew out of a dual transformation initiative that the insurer launched in 2018. One aspect of this transformation was to review the systems and core processes and revamp its legacy systems to better manage the growing Medicare Advantage space.
The second aspect was an innovation strategy, anchored by a business segment called Author by Humana, which aimed to provide a more personalized healthcare experience for members. Zucconi described his home care as palliative and community-based.
“We are a multi-modal, multi-specialty clinic,” she said. “What we’re doing is complementary in nature. (We’re) here to complement the care of the primary care physician. It’s wraparound.”
Burbine noted that many market payers are launching their own hospital-at-home programs, with emphasis largely defined by geographic areas. The provider side, on the other hand, tends to focus on the types of conditions that can be addressed. At the height of the pandemic, the focus was on treating COVID-19, but with the pandemic receding somewhat, the focus has broadened to include more conditions and go beyond the criteria of CMS for home care.
“Because to build a long-term sustainable approach, we have to think about the side of it that goes beyond the CMS requirements,” Burbine said.
From a provider and payer perspective, the goal is the same: to reduce utilization, lower the cost of care, and help patients stay healthier at home.
Financially, Burbine has found that such programs actually reduce the total cost of care and reduce observations.
To fund these programs, Burbine recommended turning to payers. Providers have data based on the work done by their teams, and payers are widely willing to invest in these programs if they can see the data and the results of that hard work.
“There’s a team approach to this innovation that’s needed to make it happen long term,” Burbine said. “Take advantage of the skill sets that exist and find a way to strengthen your own programs. It’s not just Humana that does this. All insurers have entered this market and continue to expand their presence there.”
“Programmatically, we look different, but we’re focused on the same patient,” Zucconi said. “It’s always behind everything we do.”
Everyone involved in creating hospital-at-home programs spends so much time operationalizing the programs that it’s important not to lose sight of the patient experience and the benefits they can derive from it.
“Any program starts with identifying the population to whom the program will be delivered,” Zucconi said. “In terms of identifying and stratifying patients, you can always start manually. At Author, there is a tremendous opportunity for collaboration. …Payers have access to huge amounts of data. is access to clinical expertise together and by discussing what a program might look like, Author is able to identify a group of members who could benefit from it, and then we can have those conversations.”
If a patient is interested in the program, they typically go through an intake process that looks for the presence or absence of certain criteria: whether they are housebound as defined by the CMS, whether they require help in day-to-day life or if there’s something more nuanced going on in areas like liver disease or heart failure.
On the provider side, “Make sure someone qualifies for an inpatient stay to get that reimbursement,” Burbine said. “Each time a condition type is added to this program, identify others that will qualify for CMS reimbursement and new payer reimbursement models. Each time the program grows, more stratification important takes place.”
The goal is to expand the programs to encompass 60-80 patients per day to establish a financially stable model. The sharing of resources in the payer-provider relationship is essential in this respect.
“Resource sharing is where you need legal advice,” Zucconi said. “You don’t want untoward SEO patterns to happen. In some ways, you become more restrictive with your process. But without shared resources, you’ll never get those shared results.”