Why Certain Home Care Providers Are Seeing Success In Medicare Advantage

The Helper Bees (THB) is smack dab in the middle of home care providers and Medicare Advantage (MA) plans.

As its network of providers and plans grow, its gaining insight into what makes these relationships work, other than its own technology platform.

Andy Friedell – the founder and CEO of healthAlign, and now COO of The Helper Bees – believes that the next policy revolution in home-based care will be due to the supplemental benefit changes made by the Centers for Medicare & Medicaid Services (CMS) within the last five years.

The Austin, Texas-based THB works with payers and providers across the country to take the complexity out of care delivery.

Friedell sat down with Home Health Care News on the latest edition of HHCN+ Talks to discuss what he’s learned about MA-home care provider relationships, and how he thinks the landscape will evolve over time.

The transcription of that conversation is below.

HHCN: Andy, let’s start with a background on you for people who may not be familiar.

Andy Friedell: I’m Andy Friedell, the chief operating officer of The Helper Bees. I’ve got about 25 years in the health care space. I started off in the pharmacy benefit manager space many years ago, moved to home care a little over a decade ago and started a company called healthAlign that was really focused on helping plans better manage a pretty diverse range of services into the home.

It grew out of experience that myself and some of my teammates had around the challenges that plans have in this space — many times challenges that they don’t necessarily see out of the gate. There’s such an incredible administrative complexity of organizing services in the home, the data visibility when you’ve got lots of different providers that all use their own systems, and then really the challenge of fulfillment is probably one of the biggest ones that impacts members.

What we’ve done is we’ve built a large network of non-medical providers all over the country. We brought them together on a common tech platform, and that company I started, healthAlign, was acquired about two years ago by The Helper Bees. It’s just been a great combination for the two of us. I met Char Hu, the CEO of The Helper Bees, probably a little over two years ago now. We were just both surprised at how we were separately trying to solve some of the same challenges for large payers organizing services into the home but coming at it from different angles.

He had focused on the long-term care insurance space. Our team had focused on Medicare Advantage. His team had done an enormous, incredible job around member engagement, member satisfaction and care concierge programs. Whereas the healthAlign team had built this infrastructure to drive fulfillment, and so together, it’s been really a best-of-both-worlds combination where we’ve been able to bring really important tools for members and case managers to organize services.

Then you get the certainty and reliability of knowing that fulfillment is going to happen by this technology that watches fulfillment in the background and helps you close that gap. It’s been great and, for me, a lot of fun getting started in this space.

When you’re working with a non-medical home care provider, are they coming to you or are you going to them?

It’s a little bit of both, but it really grew out of plans. I used to work in a big home care organization and health plans would sort of come to us for their home community-based programs. I think part of their interest was there was a hope that you could maybe solve the fulfillment challenge with a single relationship.

You have one big nationwide partner and that solves it for you. That always sounded great, but in the back of our mind, we knew that was unrealistic. That was where the origins of our approach started. We said, “Give us your programs. Make us your single point of accountability. What we can’t fulfill, we’ll organize with our networks of providers.”

We knew that no home care company, no in-home service provider, is really well-positioned to fulfill all of the needs of a big health plan and so we knew that you have to have the power of many to make it work.

You were also solving some of those logistical challenges and technological challenges for those providers. When they wanted to get in with Medicare Advantage payers — which a lot of them aren’t engaged with — you were able to solve those final steps as opposed to them having to do an overhaul to their operations.

Yes, exactly. And it really fits on both sides.

For the provider, we make it easier, but certainly for the plan as well. I think everybody intuitively knows that services in the home are valuable and important. The problem is, a member doesn’t just need rides or just need meals or home care. They need all these services to interact with each other and that’s when it becomes exponentially complicated for a health plan to think about, “I need a ride vendor, I need multiple ride vendors, I need food, I need home care. I probably need multiple home care vendors.”

Then the thinking of credentialing them all and contracting them all, recruiting them all, watching fulfillment across them all, getting them all paid, getting documentation back from all their different systems in one language that you can make sense of. That’s what we’re trying to solve.

It is really on both sides. We’re trying to make that a central platform for the plan so you can centralize a lot of those elements.

Also for the provider — we’re trying to bring health plan business to providers that maybe either chose not to work with health plans or it never even occurred to them to work with health plans in the past. The only way you do that is to just make it simple. We have very simple mechanisms for credentialing, for onboarding, for documentation and then we’re paying providers every 14 days. So as long as they’re providing our services, documenting and following the rules of our agreement, then they’re getting paid every 14 days.

Billing rates are going up so much, especially with the private-pay clientele. There’s a smaller amount of people in the country that can afford that private-pay home care for all the hours that they need. I think this is something that providers almost have to look at.

I think so as well. It’s a great place, I think, for a provider to think about diversifying their business mix. You can still be a largely private-pay provider or focus on a certain segment of the market that you’ve had success in, but it’s probably a good idea to put some chips on this space because it’s growing very rapidly. That’s what we’re trying to do: make it easy for providers to make that decision.

On the Medicare Advantage side, there are threats to those payments. CMS is calling it a slight increase, but it depends on who you talk to. Then there are overpayment clawbacks.
Basically, there are worries from Medicare Advantage plans that they’re going to be paid less moving forward in the next couple of years. Because of that, how do you think that will affect home care benefits and these plans working with providers?

I think the impact on some of these new benefits is going to be relatively small, and that’s largely because members have become aware of them. They’ve learned to expect or really want these benefits, and so plans need to have that as part of their overall benefit profile. I think when you look at these rate changes, again, I’m not an expert in all the formulas and whatnot, but I think it depends on who and what markets you’re talking to from a plan standpoint. Because it’s a combination of a lot of factors that are driving this rate conversation.

There is the rate of increase in the amount CMS is paying, but then at the same time, there is this change they’re making to some of the risk scoring methodologies in the background.

Then there is the geography variability of rates. There are a lot of factors that plans are looking at, but I don’t think they’re likely to come at this by ratcheting back some of these benefits that are really popular and that have value to the plan. I think what’s more likely is that it sort of increases the need for the plan to become really efficient or in the way it approaches these benefits. Whereas in the past, it was sort of, “We just have to add these into the mix. We have to add rides. We have to add meals. We have to add home care.”

Now I think plans are thinking about, “Alright, how do we make this work well and efficiently so that we can keep and preserve these benefits and demonstrate the value that they bring, both from a financial standpoint, and to the member as well?”

These plans, even if they need to tighten their belts a little bit financially, their main thing is they want to keep on to these members If they’re losing members, it doesn’t matter where the rates are. That’s what they can’t have happen.

Yes, for sure. I think it’s a combination of retention and a mix of services. In addition to the attractiveness of these benefits that you mentioned from a retention standpoint, I think there is the underlying value of the benefits themselves.

When you think about the value of keeping somebody in home, the value of organizing errands to pick up somebody’s medicines, the value of getting somebody a ride to their doctor’s appointment, these are relatively low costs. Relatively, from a licensure standpoint, easy interventions to engage.

They have a huge impact when you can think about if somebody is or isn’t going to take their medicine or if they are or not going to make it to their doctor appointment. I think that’s what plans were seeing.

You’re right. From a retention standpoint, there’s significant popularity around them, but part of that is just the value as well that they provide, the underlying value of some of these services.

I want to take you back now to your early days at healthAlign. Obviously, you’re still dealing with this, but what was the problem when home care providers and health plans were trying to work together? What were the barriers? What was causing things to fall through?

It’s a great question, and there are probably different barriers on each side which I can speak to.

On the health plan side, there was this idea that out of the gate, you just need to find a provider and make a provider available. A single provider available in all your markets and then you can check the box and call it done.

The reality though is, particularly in the last several years, caregiver availability for many of these services is a very real factor. There’s this idea that if you build, they will come. It’s just not the reality in home care for many services.

The reality is that, what we saw, many health plans would initiate a benefit. They would find that single provider, make the list of providers available to their case managers, members would call in and want the service, a case manager makes a connection to the one provider and basically moves on and assumes that everything is going to flow nicely from there and then the job with that benefit is done.

The reality, though, was that caregivers weren’t coming to the home or there were staffing shortages or delays. The plan didn’t know about that until maybe a month later when the member called back really annoyed and said, “Hey, you told me I was getting home care a month ago, nobody’s called me.”

That was creating a huge amount of abrasion out of the gate with members and plans around these benefits. It just underscores the reliability, the importance of fulfillment reliability, when you’re going to offer these benefits. It’s almost worse to offer a benefit like this that you can’t have than just not offer it at all because you create an expectation. If you can’t deliver on it, it’s a huge hit to your relationship with the member.

That’s what we saw early on: that importance of that fulfillment reliability. We started recruiting multiple providers in every market. Then COVID came. We had to actually look at it almost week by week, and certainly market by market, to see how many providers we felt we needed at any given market at any given time. We would see that places like upstate New York, you would need several more home care agencies to manage your referral volume than maybe you needed in Central Florida. Northern Kentucky was similar.

You have these different markets where caregiver availability was a really huge issue and you needed to bring together that kind of “power of many.”

On the provider side, I think it was more about claims. Providers just didn’t want to submit claims, they didn’t want to deal with all that. We offloaded that responsibility from those providers and said, “Here, here’s a link. Here’s a simple page, upload your documents, your license, your insurance, your policies.”

Then we told them to manage through this agreement with us. We told them, “When we give you a referral, you reach out to the member in 48 hours or less. You start services in a certain number of days. As long as you do that, you’re going to get paid from us every 14 days.”

How has that evolved over time compared to what you were doing, let’s say three or four years ago, now that you’re with The Helper Bees? How have things evolved? What have you seen in terms of improvements? Are providers and the plans improving in terms of what they know about each other and how they’re working together?

Yes. One thing that I stumbled across in our data recently, which blew my mind, I’ll share it with you.

There’s been a change in the last few years in some of these benefits evolving from what I would call case manager-directed to more member-directed. Case manager-directed means a case manager would say, “I want to approve a member for 48 hours of home care or 60 hours of home care or a certain number of visits.”

That was what the member got. That was the benefit. Member-directed is, many times, the member is getting a wallet and they’re making decisions. “Do I want to spend this on home care rides, handyman meals, etc.?”

What we saw is really incredibly interesting. When you look at the same exact service, just look at home care, when it’s a member-directed versus a case manager-directed benefit, the fulfillment rate is completely different.

Case manager-directed home care benefits, we see fulfillment probably in the 45% range. Member-directed, 75% to 80% of those benefits are getting fulfilled to the member. It just really speaks to the member being more invested in the process. The member is saying, “I know I want this service, in this amount, at this time, and I’m going to order it now. I’m going to see that through to completion.” Versus a case manager just bestowing on you some number of hours that you may or may not feel you want.

That’s really interesting and I appreciate you sharing that data. The fulfillment with the case managers, can you explain further why there may not be a great fulfillment rate? Is it just because the members may not have prescribed it for themselves so they’re not necessarily engaged?

Yes. It’s a great question. Just to be clear — this is not at all in any way a knock on the case manager. This is just a byproduct of how we are allocating the services to the member. Some of these are the case manager playing a gatekeeper role and they’re saying, “OK, Andrew, you’re approved for 60 hours of home care.”

You might feel like that’s what you need or you might not. You may have just taken it in your conversation with a case manager, but you’re not terribly invested in it the same way you are if I say, “Andrew, here’s $300. Here’s a website, or here’s a care concierge number, you call and you make decisions on which of these services from this menu you want and when you want them.”

It’s that simple change of putting you in the driver’s seat. That has a huge impact and almost doubles the fulfillment rate of the services. A lot of times, the challenge of getting home care into the home is just making the connection between the agency and the member, securing the date and making it all scheduled to happen. When you’ve placed the order, you’re like, “I want it now.” That whole barrier is taken off the table and it’s just enabling a much simpler transition into getting services started.

Since you joined Helper Bees, is there anything that’s changed in terms of your processes, or is it the same but just embedded in a larger company?

Changes have definitely come about. There’s the combination of our products, but then there’s the combination of two teams that, when they work together, has been like one plus one equals three or four. Combining services, as I said earlier, Helper Bees had just done a really great job building out member experience, member engagement tools and care concierge benefits.

Right away, we were able to build that into one of our engagements with an MA plan. We turned that on at the start of 2022 and it had a huge impact on that plan, their population and our ability to engage the members. That honestly was a big factor in driving that fulfillment rate I talked about. Getting a team of people who get on the phone with a member, talk to them and really handhold these services to start made a huge difference. That’s been great.

I had a lot of respect for the investment in data analytics. It’s Char’s background, and he had invested a great deal there. That has allowed us more resources to be able to capture the information, make sense of and analyze the information that’s coming out of the home. That has been great.

Have you noticed that plans are more engaged in the idea of wanting to get home care for the members? That home care providers are more engaged in working with MA plans and members are more engaged in trying to get their own home care?

Yes, we see it at two different levels. There’s that publicly available information that’s out there. You see some of the reports. ATI Advisory does a great job. There are others that put out really great information on the progression of these benefits.

You look at in-home supports benefit. I think it started in 2019. It started with like 50 plans, then went to 200 plans, 400 plans, 700 plans, 1,000 plans. You see that growth in that publicly available information.

What we see behind the scenes is another level of growth that is, in addition to the plans that are adding the benefits, we’re seeing what we think of as an internal adoption rate of these benefits as well. I think, in some ways, it’s exceeding that ramp-up I just mentioned because what percent of the population are being referred into these programs? It was nominal out of the gate, then it was a half a percent, coming up to a percent.

It’s now several percentage points of members across the whole are getting these benefits. How much of the benefits are they using? Again, it’s ramping up. I think that’s being driven by internal adoption, which is due to case managers who are now familiar with these benefits. They know how to use them. They know how to bring them into the conversation with their members.

Members, I think, are starting to understand these benefits and appreciate the role that they play and really wanting to look for health plans that have good combinations of in-home support services.

I also assume that utilization begets utilization. The more this is delivered on, the more in-home care is happening, the more people want it and also the better at delivering it these providers and plans are.

That is for sure. We see that all the time. The members who are familiar with the benefit are the members who are going to now engage it more regularly.

A few years ago, you told me that as these Medicare Advantage regulatory changes were akin to when Medicaid began paying for home- and community-based services. Could you explain that further?

It’s a really interesting comparison. I think people should be paying more attention to it because it is the driver and why Medicare is looking at what it’s looking at now. Think about Medicaid. Medicaid, you go back to several decades back, early ’80s, the amount of spend that Medicaid was spending in the home was zero.

There were no dollars being spent on services in the home, but you had these seemingly small policy changes that took place in 1981, ’82, that allowed for the first states to introduce these waiver programs for home- and community-based services. Again, if you and I could go back to that point in time and have this conversation then around that, we’d probably be answering the same thing about, “Oh, is this really going to catch on? Are these really going to take root?”

Again, it was a seemingly small change. If you just looked at one waiver program in one state in one really small population dollar amount, you would not have seen this huge groundswell that follows that. In the several decades that have passed since then, what happened was the total share that Medicaid was spending on long-term care went from 0% to more than 50%. The institutional and home care spend just flipped. You just saw that ramp up.

The really, really, really interesting piece about it is — during that exact same period — the share of all Medicaid spend that it was spending on long-term care went from like half down to a third. That’s the really interesting outcome of all this. It means that, not only was it great for members getting services in the home, it was a great deal for the federal government and for the states. By making these policy changes, they effectively rearranged the program dollars and made room for the program to spend dollars elsewhere.

They got value out of that home- and community-based spend that I think people don’t look and see and understand how important that is. Fast forward today, these seemingly small policy changes are opening the door to some of these in-home support services in 2019. Then SSBCI in 2020 was allowed. You have the VBID models that were introduced and now expanded. You’ve got some of the changes like the GAO report came out recently looking at the importance of encounter documentation of these services into the home.

There are lot of things that are going on that, in my mind, are really the moving pieces coming together for Medicare. How do you carve these services into the revenue model so that they become a component of the member’s profile the same way it is with Medicaid? Medicaid looks at the member, and they value these services because they’re trying to care for the whole member. They recognize the social components as an important part of the member’s health.

They want us to understand that, invest in that, and better manage that, but then they also know there’s just value of care in the home. I think Medicare is starting to see that as well. But really, it’ll be important for the documentation to be correct and available and for CMS to be able to start to capture that information so they can demonstrate the value.

That’s where we’ll become the real catalyst on bringing these into the program once CMS has created the environment to measure the value of them. The changes you’re seeing right now are CMS setting the stage for being able to better measure the value of these investments.

The reason I ask this is because I think it’s so interesting and also important to keep that positive, long-term view because they’re still relatively new, these benefits. So obviously there’s going to be pain points, things are going to have to be worked through. I think if that is the case, providers will probably want to get involved now, if they aren’t already, then when this is more ubiquitous in two to three years.

Yes. I think it’s definitely where this is going. I think the VBID model is particularly interesting. Plans increasingly adopting it and CMS extending it out further are really indicators of that because it’s really giving plans the incentive not just to think about ways to introduce these services for certain populations, but also to require that they be tied to value.

That’s going to drive better encounter documentation. That’s going to drive better efficiency and organization of these benefits. Honestly, that’s where we see our opportunity at Helper Bees because that’s the solution we are trying to bring to this space. We’re all about helping plans. I think 2.0 of these services is all about efficiency and better documentation and more reliable fulfillment. That’s completely what our model’s geared towards.

You work with a lot of plans. What are the ones that you know are really easy to work with for both you and home care providers? What’s their approach? What’s their attitude like?

We just went live this year with a really large nationwide MA plan. Char and I, we would speculate on our side what caused them to pick a small company in Austin to do this rather than doing it themselves. What we heard from them was that they saw the challenges that some of their competitors were having in trying to organize several single endpoint solution providers, challenges from an administrative standpoint, challenges from data, challenges from fulfillment.

They saw that and they wanted to take a better approach and, at the same time, they saw and liked the value of our ability to aggregate information up across a lot of providers. Whether it’s a handyman working out of a truck, a pest control exterminator coming or a home care agency with their local branch, all of those need to bring documentation back to the plan in a way that can be aggregated together. That’s what we do.

I think our success with plans has been around plans that want or see this landscape evolving and recognize the value of a platform that brings multiple services together and allows aggregate documentation visibility across lots of different services.

On the other side, what are the providers doing now better than they may have before, or what are the best ones recognizing in terms of these relationships between plans and themselves?

That goes back to where you and I started. Whether or not you’re a provider, how do you want to play in this space? Year 2023 is not going to make or break this business, but it’s worth putting some chips on this space. What’s gone well are providers who maybe dedicated a few caregivers to these MA services because it can be a little bit different. It can be almost like an intermittent home care because the visit length is sometimes dictated by what the member wants at that time.

There can be different variability in that. We’ve had success where we have found care agencies that wanted to dedicate a couple of caregivers to this business specifically.

Interestingly, we found them because our platform scores providers. We rank providers based on how well they do in our environment, how much of what we assign do they accept, how quickly are they getting in the homes starting service. It reinforces future referrals to those that have done well in the past.

That’s actually how we found some of our best providers. The system found those for us. We found a local franchisee down in Southern California. We found a woman and her husband, who run a great agency franchisees in the Central Florida area, really just because our system was scoring and reinforcing. Then suddenly, you look in and you see that providers who have dedicated a small mix of their caregivers to us had a huge share of our volume.

We would scratch our heads and say, “We’ve got to look in and figure out why are these individual providers suddenly appearing in our system with so much share?” It was because they were approaching the business a little bit differently.

They were saying, “I want to invest in this space. I’m going to put a few caregivers on it.” They were putting one caregiver on it initially because our system was reinforcing it. Then they were putting two, three, four. Suddenly, they had a good share of their business coming through this relationship with us.

That’s a positive feedback loop. The more that you put into it, the more you’re going to get out of it down the line. I assume, too, that the technology that you’re working on at Helper Bees is also one of the biggest drivers of this.

Yes, for sure. You’ve got to make it as easy as possible for these two parties to work together in order to enable this to succeed. That is honestly what we’re trying to drive. You and I have had conversations in the past about conveners and I know there’s mixed views on that word. We look at our role entirely as enabling easier access to these services.

We don’t play a role in utilization compression. We are always trying to get the best deal, but our role is not predominantly rate compression. It is really about creating easier access points for plans and these social service providers to be able to work together.

What would keep this trend from continuing, if anything?

I talk to our team about that frequently and it’s hard to see what could keep it from continuing because you look at that Medicaid history, you look at the value of services in the home, value from the standpoint of what the member wants, what’s best from a health care standpoint and what’s best from a cost standpoint.

All signs point towards wanting to have better organization of more services into the home. It’s hard for me to see something that would turn this direction around. I think the key thing is it’s got to become better managed and better organized. I think the initial phase of these benefits being brought in by MA plans was a land grab. It was like, how simply and quickly can we turn on these new benefits to be offering something that’s attractive in the marketplace?

2.0 of that trend is us really now coming and helping plans rationalize these benefits in a better way. Make them easier, more organized, manage fulfillment better, make better connection points with more services through single channels. That’s where we see it. That I think has to happen. Big health plans are doing that now.

They are investing in technology that’s going to watch and redirect fulfillment across a large network of providers, and that’s going to standardize counter documentation from a diverse range of services as well. I think that’s the way to solve for that. That will then accelerate this trend I think further.

What’s one prediction that you have for the space?

I do think these signals you’re getting out of CMS right now, there’s speculation. Is it revisionist thinking on the supplemental benefits? I don’t read it that way. I look at it like CMS is bringing together the components that they’re going to want to see in order to tie value to these services, which is what they’ve done in the past and absolutely what they should be doing here as well.

When they’re looking at that GAO report on encounter documentation, that’s just an indication of recognition that this is really important. You can’t tie value to something if you don’t document it well. The fact that CMS wants to see better encounter documentation, I see as a good sign. I see it as they’re wanting to find the pathway for their ability to invest further in this space.

I think you’ll see change coming down the pike. I think you will see CMS moving in that direction, and it’ll bring Medicare to a spot where it’s looking at bringing that whole person set of factors into the calculation of member risk and member reimbursement and paying plans for, not just somebody who has a complex medical condition, but maybe helping recognize somebody who’s got a complex set of medical and social conditions that interplay with each other.