This article is a part of your HHCN+ Membership
Believe it or not, some home health providers have figured out a way to get what they want from Medicare Advantage (MA) plans. At least to a certain extent.
Frontpoint Health has become a standout in the industry for running towards MA opportunities with gusto, rather than simply being dragged by the penetration..
From Frontpoint Health’s inception, the company wanted to avoid depending on Medicare fee for service for the majority of its revenue. The company’s CEO, Brent Korte, even pointed out what he viewed as a “subservient relationship” between payers and providers.
Korte explained that for Frontpoint Health, the key to walking away from the negotiation table happy is understanding what’s important to MA plans.
“At that first conversation, we essentially try to show up with a cadre of information and start with questions that lead to a better understanding of what they really want out of home health,” he told Home Health Care News. “They have to know what we are able to provide, in order to sort of glean some benefit for their folks, so a lot of it is early education too, and an absolute focus on data.”
Backed by Cimarron Healthcare Capital and Tacoma Holdings, Frontpoint Health is a home health and hospice provider that centers its business on MA patients. The Dallas-based company delivers care across 176 counties in Texas.
Dallas-based Elara Caring is a home-based care provider with about 200 locations across 17 states. The company serves more than 60,000 patients.
Brent Nash, chief development officer at Elara Caring, describes the company’s approach to MA payer negotiations as “holistic and multifaceted.”
“We’re not looking to go in and negotiate simply based on rate,” he told HHCN. “It would be nice if payers were receptive to that, but they aren’t. What you really need to be doing is working to get all of the right players in the room, so that you can have a conversation about outcomes and return on investment.”
This means getting plan executives, medical directors, network executives, and even actuaries in the room, so that Elara Caring can speak in-depth about the value that the company is able to deliver, according to Nash.
Similar to Frontpoint Health, data is a big part of Elara Caring negotiation approach as well.
“We’ve gone out and commissioned studies using the different Medicare and MA databases that exist from CMS,” Nash said. “We believe that we’ve been able to prove that home care services for those who are prescribed home care, when they’re discharged from a hospital and they receive them, drive material value, versus those folks who are prescribed the home care services and don’t receive it. In fact, MA plans often lack on receiving that level of access, so we try to use that data to compel the conversation.”
Rates are, understandably, top of mind for most providers. Korte believes that figuring out what a fair rate means to Frontpoint Health has guided the company forward.
“Our goal is to be at a fair rate with all of our insurance companies,” he said. “Frankly, many other large home health organizations that can solve the network adequacy issue for insurance companies assume a good rate is parity with Medicare, and that’s not a reality.”
Frontpoint Health has come to define a fair rate as one that puts them on track to building a deeper long-term partnership with an MA plan.
“We want to be a provider to your patients,” Korte said. “And a partner to your organization to the point that you can see on your P&L through your medical loss ratio, and your network adequacy calculations, the value of our organization because we keep people home. It’s worth you paying us a fair amount of money to provide that care.”
A good MA player, Nash believes, possesses qualities such as good systems, good contract loads, and the willingness to work with the provider when there’s an error in the contract load.
Still, Elara Caring is looking for something more when they form these MA relationships.
“We want payers who are proactive in thinking about the ways that they can administer contracts, administer value-based care, monitor the outcomes measures that we need them to monitor, in order to be able to put in place a partnership,” Nash said. “In the end, we need to build that trusting relationship with them.”
In the last six months, Elara Caring signed a contract with an MA plan. Nash noted that the plan recognized that the company’s ability to deliver care drove value for the plan and its patients.
“Once that contract was put in place, and we had the trusting relationship, we were really able to increase our admissions for that payer by over 100% per month, which meant for the right patients, they were getting more care, at the right time, in a venue where they want to receive care, which is in their homes,” Nash said.
Despite being able to identify what the right payer relationship looks like for each of their companies, both Korte and Nash also have a clear understanding of when to walk away from opportunities that aren’t benefiting their organizations.
Korte, in particular, has distilled it down to a simple citieria.
“The simple answer is, we walk if we’re losing money,” he said. “There are a handful of insurance companies that are recalcitrant about rates — we are not here to subsidize the bottom line or MLR of these major insurers. That said, we work really hard to bend the cost curve, so that none of our contracts are at a loss. The trick here, in my opinion, is not just getting better rates, but it’s providing real value. That means that you have to run your organization providing excellent care and lower costs.”
Companies featured in this article:
