This article is sponsored by Netsmart. This article is based on a discussion with Anthony Spano, Director of Client Development at Netsmart and Nikki Davis, Vice President of Palliative Care Programs at Contessa Health. The conversation took place on April 20, 2023, during the Hospice News Palliative Care Conference. The article below has been edited for length and clarity.
Anthony Spano: We are very lucky to have Nikki Davis on stage, so I wanted to just open up and give her the chance to tell us a little bit about herself.
Nikki Davis: I’m a nurse practitioner and have been working in geriatrics and palliative care for about 21 years now. I have spent about 11 years total with Optum and then worked with Aspire, but now I’m currently working with Contessa and Amedisys to help support palliative care at home programs. I made my way through the ranks as a CNA, then a registered nurse, and then a nurse practitioner and now, I’m in a leadership position. I’m excited to be here and talk to you about some of the technology components that we’re using to help drive our palliative care at home programs at Amedisys.
Spano: I’m a health informaticist by background and spent the opening of my career as a data scientist helping IDNs stand up value-based arrangements. Now I work at Netsmart in a client development role where I work with folks like yourself developing strategies on palliative care and operating it. We know that Part B can be tough with that. I’ve had the chance to help groups stand up those operations from a strategic standpoint. To open, I want to say Amedisys has a very large Part B program. Nikki, why invest a quarter of a billion dollars and purchase Contessa? Talk to us about that.
Davis: That’s a great question. All strategic decisions have a purpose and I think the biggest purpose behind this decision was really to help us be a differentiator in the market space that has a growing demand for high-acuity care in home settings. That’s what Contessa was founded on and we’ve been able to expand on that for palliative care at home services. We’re able to provide these services with a tech-enabled home-based care platform that’s coupled with the analytics and clinical services, and to provide some risk-bearing type contracts that we’re able to now work with to provide the home-based care delivery.
Last February, Contessa launched a partnership with Mount Sinai Health System in New York City to provide palliative care at home. Now, here we are, just a year later, and we are getting ready to launch with at least three new joint venture health system partners by the end of the year which is pretty exciting. There’s also a new contract that we have, a direct-to-payer contract for value-based care with BlueCross BlueShield of Tennessee. This contract is a mutually beneficial risk-based model that’s going to allow our members to receive palliative care in person or even by telehealth at no additional cost.
Anthony, for some folks, thinking about a joint venture may be a new term. Having to think about how it’s different as we’re providing a joint venture with a health system to provide palliative care at home versus how we are working with a payer to provide value-based care and a contract that’s a risk-bearing entity.
In the joint venture models, we contract per engaged member per month. You may also hear that it is sometimes referred to as the PEPM rate. This is guaranteeing savings to the health plan that’s at least equal to the PEPM reimbursement, and then we also share in the health plan savings in that model. In the value-based contracts that are direct to payer, we receive a care management payment advance for each attributed member. This is a per member per month model which is different and that’s key, that it’s per member per month instead of per engaged member per month, because we’re taking full risk for all attributed lives that are assigned to us.
In that model, we have shared risk on the medical expenses that we reconcile annually. The differentiator is that the savings and losses for the performance period for this type of contract are determined by just calculating the difference between the expenses and the expense target. A little bit more background about the two different models for palliative care at home that we are growing at Amedisys and Contessa.
Spano: I was thinking about our conversations and where the palliative care industry is and where it’s going and the idea that you have to have your eye on these programs. It’s happening today. In the future, there will be multiple groups that we’re working with that are doing these models of care and that are operating palliative care programs in that manner. Nikki, when you think about operationalizing that clinically and articulating and showing value to the payers as you get into these arrangements and then deliver on them, can you elaborate on how Contessa is achieving that?
Davis: Yes, absolutely. We think that managed care is the key to palliative care. Managed care, meaning it could be many different types of arrangements as we all know. We can talk a little bit more about some of the components with ACO REACH or some of the other opportunities that are available through supplemental benefits, through the MA plans but essentially, we think that the Medicare Advantage plans realize the value of paying for palliative care and the value add of hospice. We know that when we are delivering the right type of care for the right patients at the right time, it’s something that we’ve all heard, we all say, I think we all in this room believe in, that the plans are starting to see that. This is also showing tremendous cost benefits to the plan as well.
When you think about this from the financial side of the plans, but really the true impacts, as we all know, are the benefits that this ends up providing to the patients and their families. I think from our perspective, that’s where we believe that Medicare Advantage plans are starting to see that value add. In order to provide that value add and the benefits to patients and their families that are tangible to them, you have to have clinical operations that run smoothly and seamlessly. You have to make sure that you’re thinking about and asking yourself a lot of questions upfront so that there’s the true benefit and impact seen for all of our key stakeholders.
We don’t ever consider a key stakeholder to just be the health plan. That’s going to be our interdisciplinary care teams that are helping to provide the model. It’s their families. It’s our staff. For that to happen, there are a lot of things that are needed but I think key take-home points are strong data science, analytics, product team, reporting and clinical quality teams too. For the end-to-end workflows to work like you want them to and be seamless, you need to have an above-average outreach and engagement system in place, engagement strategies, system integrations and technology platforms, and a technology platform that’s not just any technology platform, one that is truly patient-centric while it can also support the interdisciplinary care team in their day-to-day workflows and help them be as productive and efficient as possible too.
Spano: I wanted to touch on one point there. We’ve talked a lot about the plans and how you’re articulating the value there, talk to us a little bit about how this works in a physician-owned ACO. We see here ACO REACH and some of those different terms.
Davis: Yes, I’m glad to do that. The ACO REACH model of course is provider-based organizations that offer three types of participants. It is something that I have been involved with in a past life, but I was definitely not where I would consider myself a subject matter expert. Just for general awareness, for provider groups that are in the ACO REACH models, there are three different types. Standard, those that have new entrants and then the high-risk population ACOs. Within those three, there are at least two voluntary risk-sharing options under the ACO REACH model and in each option, the participating providers, except Medicare claims reductions, agree to receive some compensation from their ACO. Even though you can hear the differences there between the way that those models are set up and how some of the payment reimbursement models are different, those are still the same things that you need to make sure that you’re providing value-based care as a whole to the patient population you’re serving.
Understanding the things that you need to know for both models are along the same total cost of care. For a patient, a panel is essential. You’re going to need to know that for any of these types of care models along with other similar data and analytics that are essential in Medicare Advantage value-based contracts such as predictive analytics with risk stratification and also the health information exchange integration is critical for some real-time dynamic decisions that can be made by the care team.
Spano: We’re seeing that model as well be deployed by whether it be hospices that form up alliances to create larger palliative practices to create the footprint from a physician ownership standpoint that’s required for an ACO. To the point that Nikki is making the concepts, whether you’re thinking about a value-based arrangement in Medicare Advantage, whether you’re thinking about a JV, an ACO, that you’re going to have some of those same challenges that you have to solve for. To that point, Nikki, maybe you can talk to us from a technology perspective, how do you support these types of models?
Davis: There’s a lot of systems that we use, a lot of different systems, so a CRM, or a Customer Relationship Management system. We also have some workforce management tools and in particular, an ONC-certified EHR that’s designed to provide value-based care that has components for comprehensive care coordination and care navigation components in it.
I would say the data sharing capabilities are also huge for us to have real-time information and dynamic risk stratification for patients to make decisions that normally you may not be able to make in such real-time without that information in front of you and on a dashboard. Anthony, I think this would probably be a good time. I’d love for you to share a little bit about how the components within Netsmart that we are using for our models are helping to support population health management because it’s different than just charting in the EHR, right?
Spano: Yes, and that’s a great point. I think an ONC-certified EHR is simply table stakes. You can Google that. I think the piece that takes it to the next level is when you start talking about managing tens of thousands or more lives in a community. How do you create a control tower or a population health team as many of the IDNs would call it, that oversees that group? What do they log into every day to see if someone on my caseload presented in the emergency room last night or if a new claims feed has a new diagnosis on someone that’s on my caseload management that changes my clinical pathway or the assessments that I’m doing, whether that be virtually, whether that be by phone or maybe it’s time to dispatch human resources, clinicians, whether or not necessarily a nurse practitioner but a social worker. You’re in a value-based model, you have to manage your resources and your workforce in that manner.
The digitization of that population health team and a care management product is also paramount in conjunction with an ONC-certified EHR to truly operationalize these models. That’s exactly the work that we’re excited about doing with Contessa and others that are not thinking about these models but actively executing them.
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