Though it has become more common for larger home-based care providers to enter and find success in value-based care arrangements, so many small- to mid-sized companies still struggle in this area.
Helping these kinds of home-based care companies see success in these arrangements has become Integrated Home Care Services’ sweet spot as a driver of value-based care.
Paul Pino, co-founder and chief growth and analytics officer at Integrated Home Care Services, recently joined Home Health Care News’ Disrupt podcast to talk about the roadblocks smaller providers face when trying to enter value-based care arrangements, and how his company helps navigate these challenges.
During the conversation, Pino also explained why working with each individual managed care plan is a unique experience, and touched on what the future could look like for home-based, value-based care.
Below is that conversation, edited for length and clarity.
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HHCN: For those who don’t know, can you share a little bit about your journey in home-based care and your role with Integrated?
Pino: I came to home-based care about 20 years ago. I had been a corporate investment banker. I had started doing deals, or transactions, within the home care space, and I was introduced to someone within the home care sector. We decided to go into business together.
I joined that first business in the early 2000s. We grew it. It was a fully capitated home health, home infusion and DME company that contracted with Medicare Advantage and managed Medicaid payers. I believe we sold that company around 2012. In 2015, my partners and I came back into the market and we founded Integrated Home Care Services.
Today we’re really focused on value-based care. How does Integrated Home Care Services fit into the value-based care picture? How are you trying to advance this area forward, so to speak?
When we speak about the topic of value-based care, it appears that everyone has a different opinion on what value-based care is.
I would say that back about 20 years ago, value-based care was limited to capitated risk-based agreements, where in which the value was derived from an alignment in payment methodology from payers. Now, IHCS is a traditionally – or a largely – capitated vendor, although we have different payment types and different payment arrangements that include other types of value-based oriented revenue streams.
If you think about touch caps, if you think about capitation with reconciliations and other threshold-based payment arrangements, we handle all of those. But what we really find is of significant value is not just a payment arrangement. From our perspective, every one of our contracts has significant SLA associated with them. That includes specifications around quality, specifications around turnaround times, and compliance and other metrics, that our plan partners, our providers – and more importantly – our patients all appreciate and derive some sort of value from.
I totally agree when you say that everybody has their own perception of what it means to deliver value-based care. Some people really fixate on the quality component, some people really fixate on the cost component. At the end of the day, value-based care is really all of it together.
I agree 100%, it has to be all of it. You need high quality, you need speed and you need some sort of financial arrangement that makes sense for all people, right?
You really want to incentivize the right type of care, not just an abundance of care. There’s additional fee-for-service models, right? There’s people that are coming in and just performing services. They’re performing those services so that they can be compensated, but traditionally, there is no tie in to outcomes and to other performance metrics. When you think about the way that a managed care plan that has experience in value-based care, they’re also tying folks that manage the home care benefit to many more value-based oriented criteria.
Similar to ‘everybody has their own definition of value-based care.’ I think a lot of people care about different outcomes and different metrics. I think that rehospitalization rate is obviously a really big one. I think the rate of missed visits into the home is one I’ve heard talked about more. What are some of the most important outcomes metrics?
There’s an old saying that if you’ve worked with one managed care plan, you’ve only worked with one managed care plan. I think they all have their specific views around utilization and other parameters that they feel are most important.
One of the things that’s often missed, as we talk about this post-acute care space … we think a lot about diversion, right? Think about pre-acute, think about the fact that there are patients out there that are suffering from chronic condition sets that require very basic types of medical equipment or other items, or some sort of intervention. When you have the availability of services — we view DME, home health, home infusion, LTSS, and PDN as all part of our service offering — you’re really able to pivot and do what’s right for the patient at any point in time. With a simple phone call to IHCS, either a care coordinator at a health plan, or a physician or other folks can just reach out to us and make sure that a patient that doesn’t need to present it in the emergency room is seen.
You’ve seen a lot of activity recently in terms of mandates coming down from CMS. You’ve seen the recent view around the managed care rules, everyone has an opinion. The states have been doing all of this care coordination in lieu of service type business for many years.
Right now, what we find is that the services that we’ve been performing on the front end to make sure that a patient is seen and seen quickly, we’re already working around what we believe is to be the appropriate and most expeditious way of serving a member before they present. As you indicated, though, when you think about readmissions, there’s this misconception around them. In many instances, especially if you’re looking at Medicare Advantage plans or other traditional fee-for-service payer, what you’ll find is that many of the plans are not necessarily on the hook for the readmission. You’ll find that, in many cases, the hospital and the methodology of payment under some sort of traditional DRG-like structure, they’re on the hook.
What we find is that it’s not just about readmissions, in terms of cost savings, but it really is about the patient journey around whether or not a readmission is avoidable. A lot of people just focus on the cost structure. Having a patient re-present, having a patient potentially have a hospital-acquired condition that comes into their life, and also what you see in terms of the dislocation from that patient’s home and their family, all those things are high-quality oriented issues that don’t necessarily, in every instance, cost the plan additional money.
What would you say some of the biggest challenges are today for home-based care providers when trying to seek out these value-based care opportunities, and then do well in them if they enter into one of these arrangements?
Realistically speaking, what we find when we’re thinking about smaller providers that want to work with us under a value-based arrangement, is a lack of capacity to serve an entire population.
When you’re thinking about your traditional value-based arrangement, you have someone that says, “Hey, I’m going to take this book, or this geography, or this group of patients, and I’m going to perform X, Y, or Z. The results that I yield will provide X, Y, and Z as well.” What we find is that a lack of capacity to serve large swaths of a population can really slow down someone’s ability to have some sort of true value-based arrangement. Now, if the value-based arrangement with a plan is focused on a quality-only component then, quite frankly, the issue that they have is getting a network management person to sign a contract that’s unique, and to come up with an appropriate reimbursement structure for that provider, when they have so many other provider network agreements that they have to configure. It’s really understanding whether or not you can make a significant enough dent to garner some sort of unique contract.
If I’m that person with the managed care plan, setting up a value-based care arrangement, do I just copy and paste the language from one home-based care provider to another, or am I really trying to cater it to what that provider does well?
Nine times out of ten, there’s a standard network agreement, and the only thing that changes within the network agreement is specifically around reimbursement. What you’ll find is, “Hey, here’s our agreement. Here’s a provider fee schedule associated with the agreement.”
Now at IHCS, we have the ability to customize down to the provider level. We have the ability to set up rules in place and other conditions, where a value-based arrangement with a downstream provider is something that we’re more than willing to do, given the appropriate parameters. For us, one of the most important components of our service offering and the manner in which we contract with payers, is the time to staff.
If you think about the speed in which one is required to staff in order to be able to adequately discharge a patient in a coordinated fashion, so that that patient doesn’t re-present within the emergency room, or any any facet of the hospital, or inpatient setting, we need to coordinate all lines of business. If you think of a home health agency that needs to show up after the infusion medication gets there, that infusion medication needs to get there after the patients in the hospital bed. All these functions are things that require coordination.
When you have an entity like ours that’s working with multiple providers to make sure that we’re getting the most appropriate provider out there, as quickly as possible, these things can change. We’re not looking for the easiest provider to call, we’re looking for the best provider to call. In almost all of our arrangements, when we go live, and in almost all of our utilization, small to regional providers have the bulk of our business. Our competitors have a significant amount of exposure, and services being provided by large national home care entities, and by large national DME companies.
When you think about the way that our network participants are assembled, it really is different, we really do focus on the smaller entities. From our standpoint, customizing around those smaller entities and making sure that those entities understand the potential volume that they’re going to be receiving really makes a significant impact for them, in terms of planning. It also allows us to really plan around the ability to meet our SLAs on discharges.
Can you walk me through a real world example of a value-based care arrangement in home-based care?
We recently went into the market of South Carolina in a very large way. What we recognized before going into that market was that there were significant concentrations of utilization, specifically around home health, that were being directed to entities that may not have necessarily had certain utilization patterns that we wanted to continue.
We set up parameters, working relationships and guarantees around quality and staffing, and speed to staffing and communication with a core group of network participants that you would consider to be regional to small entities. With those arrangements in place, and with their clinical reporting, we have found that we have right size utilization to the point where these entities are always busy now. They’re not busy with turning around the same patient over and over. They’re meeting their goals, and then they’re receiving additional referrals. What we’ve seen with certain entities is the ability not only to come up with a methodology in which they want it to contract, but also deliver on the promises of “If you need us to staff, we will make someone available to staff. As long as we agree that if we continue to perform this way, we will continue to receive the amount of volume that we’re receiving.”
Those types of arrangements with these providers — there’s some that we’ve looked at now that have grown tenfold, in terms of volume that they’re receiving from this specific planned cohort. We’re really excited for them, and they’re really excited about working with us.
How do you see the future of value-based care in home-based care contexts evolving, as we look ahead at 2025, 2026, five years from now?
Let me start with a little bit about our team. Our team has a significant amount of managed care experience, we have provider expertise. Our home care leads … have over 30 years in certain instances, and certainly over 20 years in provider-oriented experience. Our senior team has a significant amount of managed care experience, coming from a diverse background. I’ve personally had the opportunity to establish and build out a large primary care risk-based MSO..
When you think about value-based care, what you need to start with is who is responsible for the dollar value of what’s being provided, and then ultimately, who is accountable to make sure that those dollars are adequately allocated? When you think through that component, then you start making assessments around, what is it that you’re going to be able to do to positively impact those stakeholders, by positively impacting all other components of care? In our specific case, we’ve started working very closely with risk-based entities. When we start speaking to them about how they want us to grow alongside them, what we have found is that the value-based arrangement and environment that we see evolving is going to be one that goes outside of your traditional skilled home-based care.
What we find is that we are being pushed more and more to make sure that we’re looking at whole-person care, that we’re looking at what specific things a member needs, in order to be able to be home. This includes components of contracting around identifying certain aspects of what’s happening within the home, whether it be food insufficiency, whether it be loneliness, whether it be, believe it or not, electricity. All those components, I believe, are going to become more and more salient as we see true value unlocked within the home setting.
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