Payer-provider partnerships are essential to creating hospital-at-home programs

Healthcare organizations, from payers to providers, have been sounding a common refrain in recent years: Provide the right care at the right place at the right time. Various hospital-at-home programs have popped up in response to this ethos, and some of the most successful entail payer-provider partnerships.

Tina Burbine, vice president of care innovation at Healthlink Advisors, and Tanya Zucconi, chief operating officer of ZGM, which is affiliated with Humana, know the power of a payer-provider partnership firsthand. Their organizations have teamed on a hospital-at-home program that has uncovered 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 join forces on the increasingly popular notion of care inside the home.

Hospital-at-home care – not to be confused with the Hospital at Home trademark by Johns Hopkins – is a combination of pre-hospitalization, acute, post-acute and ambulatory services focused on a patient’s individualized care needs in their own home and replaces hospital admission through a direct admit to home from the community or emergency department.

The idea is to cost effectively treat acutely ill adults, while improving patient safety, quality and satisfaction. Funding through the Centers for Medicare and Medicaid Services and many payers has made establishing and providing this type of patient care a strategic focus for health organizations.

In a way, said Zucconi, Humana’s transition into the space represents coming full circle, as it essentially started as a nursing home in the 1960s.

“Humana is on a strategic journey from being an insurer that offers healthcare to a care organization that offers insurance,” she said.

ZGM is a managed services organization that enables care delivery, and its link to Humana arose out of a dual transformation initiative the insurer started in 2018. One aspect of this transformation was looking at core systems and processes and revamping its legacy systems to get a better handle on 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 its in-home care as palliative and community-based.

“We’re a multi-modal, multi-specialty clinic,” she said. “What we do is supplemental in nature. [We’re] here to supplement the care of the primary care physician. It’s wrap-around.”

Burbine noted that many payers in the market are kick-starting their own hospital-at-home programs, with the focus largely defined by geographic areas. The provider side, by contrast, tends to focus on what condition types can be treated. During 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 going beyond the CMS criteria for home care.

“Because, in order to build a long-term, sustainable approach, we have to think about the side of this that’s beyond CMS requirements,” said Burbine.

From both the provider and payer perspective, the goal is the same: cut down on utilization, lower the cost of care and help patients stay healthier inside their own homes.

Burbine has seen that such programs do, in fact, lower the total cost of care and cut down on observations.

To fund these programs, Burbine recommended turning to payers. Providers have data based on the work their teams have done, and payers are largely willing to invest in these programs if they can see the data and results of that hard work.

“There’s a team approach for this innovation that’s necessary to do this for the long run,” said Burbine. “Take advantage of the skill sets that exist and find a way to strengthen your own programs. It’s not just Humana that’s doing this. All of the insurers have entered this market and are continuing to expand their presence there.”

“Programmatically, we look different, but we’re focused on the same patient,” said Zucconi. “That’s still behind everything that we’re doing.”

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 how they can benefit.

“Any program starts with identifying the population to whom the program will be delivered,” said Zucconi. “In terms of patient identification and stratification, you can always start manually. At Author, there’s a tremendous opportunity for collaboration. … Payers have access to tremendous amounts of data. What they can sometimes lack is access to the clinical expertise. So, by getting together and talking about what a program could look like, Author is able to identify a pool of members who could benefit, 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’re homebound by CMS’ definition, whether they need assistance in daily living, or whether there’s something more nuanced happening in realms like liver disease or heart failure.

On the provider side, “Make sure someone qualifies for an inpatient stay to get that reimbursement,” said Burbine. “Every time there’s a condition type added for that program, identify others who will quality for CMS reimbursement and for new payer reimbursement models. Every time the program grows in scope, more stratification takes place.”

The goal is to scale programs to encompass 60 to 80 patients per day to establish a financially stable model. Resource-sharing in the payer-provider relationship is key to this.

“Resource-sharing is where you need the legal guidance,” said Zucconi. “You don’t want any untoward referral patterns to occur. In some ways, you become more restrictive with your process. But without resource-sharing, you’re never going to achieve those shared outcomes.”

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