Jill Sumner is vice president of population health management at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL). To this role, she brings more than 20 years of experience, including on the payer side. Having built and operated Medicare Advantage Special Needs Plans and one of the first Medicare-Medicaid products in the United States, she offers a valuable perspective to long-term care providers who are adapting to value-based care and reimbursement.
Through the Value-Based Care series, Sumner offers her perspective on how long-term care providers can work together to tie financial incentives to better patient and resident outcomes, and seize opportunities in a system built for hospitals and physicians. She also discusses the tech helping long-term care providers in their efforts, and some promising interest from payers in long-stay nursing home residents.
In one sentence, define what value-based care means to you.
Value-based care is achieved when reimbursement is aligned with quality outcomes — simple as that.
What are some of the keys to success in achieving that definition of value-based care?
One of the greatest challenges to achieving value-based care agreements is payer willingness and payer volume.
A lot of our members are interested in working on value-based contracts and in value-based arrangements. They provide value and they want to be reimbursed for that value that they’re creating. One of the largest challenges is finding payers that are willing to do that. CMS has a value-based payment program focused on the one measure, but that is easier for the government to do because they have a significant volume of beneficiaries.
On the payer side, it is more complicated to administer a value-based program when low numbers of members are coming through a provider’s door. To achieve that payer volume, we’re helping providers to understand that if they work together and form networks, they can pull that volume, which makes it easier for a payer to contract in a way that incentivizes quality outcomes.
Do you see any downsides to value-based care?
One of the pitfalls is the availability of value-based care, both from the payer willingness and volume standpoints. Value-based care is on a spectrum, and sometimes the level of risk varies.
If you’re looking at different models of reimbursement, such as fee-for-service with a value incentive bonus payment, all the way up to capitated arrangement, they only work if a certain number of individuals are covered by that payer in your building.
If you are a small building, and you have a contract with a payer for value, it could be based solely on a couple of residents or short-term patients who come through your building. It can get complex very quickly with the number of payers that facilities have to deal with. We definitely see that increasing as CMS looks to have all Medicare beneficiaries enrolled in some type of accountable care relationship by 2030.
That means the number of people involved in the care of an individual through some type of value-based arrangement is going to increase exponentially. Having metrics tied to the reimbursement is great, but you can see how that could become very complex very quickly as those metrics vary among payers.
Why do you think it has been difficult for SNFs to get a seat at the table when it comes to value-based care?
Our health care system has been built with a focus on acute care. The initial value-based contracts were only offered to physicians and to hospitals and they focused on acute care. As payers start to see the growing need for long-term care services, it makes sense to apply some of the same value-based methodology to providers that are seeing people 24/7 and providing long-term care.
It’s been a slow movement with a lot of the value-based opportunities focused on physicians and hospitals. Providers and payers have both told us that specifically all of their value-based programs will be focused on physicians and hospitals — not anyone else. That simplifies things for the payer, but it doesn’t necessarily guarantee good outcomes when you’re assuming that the physician and the hospital are actually going to have some meaningful interaction with a long-term care facility to manage the outcomes for that patient. That’s certainly been challenging.
The other thing is just the size of facilities. There are two populations of patients in a nursing facility, but we often think of it as one large group. Imagine a hundred-bed building, which may have 20 short-term residents and 80 long-term care residents. Those two groups need different services and are usually covered by different payer sources.
If you’re talking about traditional value-based care in the Medicare Advantage or the Medicare space, those short-term residents are receiving skilled services and then going home. It’s really hard to maintain the level of tracking and payer involvement needed for a small population. We’re starting to see some payers interested in the larger group within the facility which is the long-term care population I-SNP, and a few ACOs out there are focused on long-term care residents.
Those payers seem to have an understanding and interest in some type of value-based arrangement because they get that the facility has influence over the outcomes for those patients. That is relatively new. We are starting to see an uptick in the interest from payers who are focused on that long-term care resident side.
What does it take for operators to get a fair financial reward in value-based care?
Some large payers are unwilling to do anything differently, especially if you are a standalone building or a company that doesn’t have 40 or 50 facilities — that’s going to impact their network adequacy. A lot of this has to do with the payer’s ability to meet network adequacy. You can have great metrics and you need to be able to produce those metrics and show payers that you’re able to manage the care, but there are still hurdles to participation.
One thing that can help is working with other providers in the networks that I mentioned. A number of provider-owned networks are being built in different states so that providers can work together on implementing best practices and evidence-based care tracking to benchmark outcomes against the state or their peers. Looking at the opportunities in provider-owned networks is a good place to start. It makes value-based agreements much more accessible.
You can have great relationships with health plans and the people on the other end can be very well-intentioned, but it’s not an easy thing to manage. Having worked on the payer side, it’s not an easy thing to do a one-off value-based agreement for a different provider type and get it properly configured within a claim system, especially if you’re in a large Medicare Advantage organization.
One of the things we talk to folks about is understanding the smaller payers in the state or who’s interested in coming into the state, especially if it has MLTSS. By trying to develop a relationship with those smaller health plans sooner rather than later, they’re sometimes willing to be more flexible and than a large organization covering the entire country where your business is a very small fraction of their total book of business.
How is technology supporting the shift from fee-for-service to value-based care?
It doesn’t have to be high-intensity technology. Most facilities have some type of EMR at this point and that is really helpful. With AHCA/NCAL, we also offer a product called Trend Tracker that is free of charge to our members. That is a great tool for being able to look at your own quality metrics and how you compare to others in your state.
Using available tools to monitor benchmarks and develop a strong program to determine where you need to be doesn’t need to be technology-intense.
In the future, I also see technology helping with responsiveness in terms of primary care.
One of the larger challenges in skilled nursing facilities is finding physicians who are truly engaged and focused on our population. A lot of facilities, especially those in small communities, may just have the local physician who has a community-based book of business and comes to a nursing facility in addition to their regular practice. That scenario is very common.
It also means the nursing facility and its residents may not be getting the attention they need because the practice isn’t designed for it, such as the forwarding to after-hours call centers. The response to that scenario is typically to send them to the hospital. Then you have an increase in emergency department visits and an increase in inpatient admissions that could have been prevented. I-SNP has an enhanced primary care team that’s available after hours with access to the EMR in the facility, and they understand the patient population.
I think telehealth and the increase in availability of skilled professionals who can connect to the facility and get to know the residents has a lot of promise for helping to prevent some of those unnecessary hospital visits.
Do you see the shift to value-based care taking place fast enough?
In the past six to eight years, there’s been a significant change in the overall focus. We’ve seen from two very different administrations now, the same focus on getting beneficiaries into some accountable care relationship. When we talk about that in itself, what does it mean? Is that accountability focused on care management, or is that accountability also focused on payment?
We don’t necessarily know yet, but all indications of the new physician role and the changes that they’re making to ACOs shows that they want to re-engineer both the payment and the outcomes piece of this. That’s a good thing, and I think our providers are ready to embrace that.
Again, it’s largely focused on the primary care and hospital areas, our acute care system. I don’t see the change happening quickly enough from a government program’s perspective to be able to offer these types of contracts. These contracts drive the clinical care in the building, and it makes a difference when providers have an opportunity to take a leadership role. We had the bundled payment model three, which was around for a very short time and was available to long-term care providers to take a leadership role in, and that ended up going away.
We’ve shown when long-term care providers have an opportunity to take a leadership role in value-based care and population health, we can yield significant outcomes. That is evidenced in the provider-owned I-SNPs that have grown very quickly over the past seven to eight years. It seems to me the private market is driving this more than CMS, and those opportunities seem to still be focused in the acute care space.
