Exploring the Critical First Step in Adding and Paying CBOs in Value-based Contracts

The transition from treating patients at a provider’s site to delivering care in the home and community requires two things: an ability to incorporate social determinants of health (SDOH) into the care coordination process and the inclusion of value-based care (VBC) and community-based organizations (CBOs) as compensated care delivery partners in VBC networks.

For health plans, risk-bearing providers and risk bearing entities (i.e., altogether referred to as “payers”) alike, we recommended implementing a Partner Onboarding Model that enables scale today and flexibility in the future. In this article, we explore the current environment and how payers and providers can take the critical first step to add CBOs to their VBC contracts and ensure they are compensated.

Raised expectations

The concept of assembling, managing, contracting and paying for medical provider relationships has evolved over many years, with innovation born of necessity. Payers have had many years to figure out how to:

• Pay healthcare providers
• Organize providers in a way that saves employers money
• Access many (and a variety of) providers
• Provide coverage in many geographies
• Rate providers on quality
• Know which providers are willing to share risk (and which aren’t)

But with the current focus on VBC creating payer advantages by adding CBOs to the network of providers used to execute care plans, they won’t have the luxury of figuring it all out over decades. Contracting, secure information sharing, outcome measurement, and payment to partners across all up/down-stream partners become table stakes for payers on Day 1.Also, as it is likely that resource outlays have already been made for infrastructure to secure a portion of these table stakes, thus, whichever path forward is chosen, it must at least leverage existing tech investments.

Unprecedented Complexity

Supporting CBOs within a VBC contract introduces an unprecedented layer of complexity for payers. On the broadest level, payers familiar with today’s “one to one” relationships with a specific provider or set of providers must also now be able to maintain “many to many” relationships that could include a mix of financial and data-sharing models in each. Without automation to manage execution of these increasingly complex, multiparty contracts, payers will find themselves quickly overwhelmed, being forced to hire additional employees to manually execute invoice-payment, track status and audit for accuracy.

There are differing business processes that may be required simultaneously across a given service provider network, ultimately governing how information is shared securely. As such, a payer preparing to transact value-based care will likely have several questions come to mind:

1. With so many partners, are we sure we have the patient’s consent?
2. Is there a CBO in our network that doesn’t understand HIPAA?
3. If a provider doesn’t have/can’t provide electronic visit verification (EVV) for a home visit, how does that impact our mutual relationship?
4. Can all my providers produce an electronic invoice for their services, or will I have to help them provide it?

Although the above is not an exhaustive list and others will most certainly surface, these business processes must also manage details of multiple financial models and outcomes measurements across the relationships – i.e., is a particular partner reimbursed, subsidized, incentivized or fully/partially capitated – or is it some combination thereof?

The ability (or inability) of the down-stream partner to support the various models becomes a factor in the relationships you can form and how quickly.At least initially, a payer’s partners in a VBC contract – particularly CBOs with smaller budgets – may lack the technology to efficiently participate. To overcome this obstacle, payers may need to consider “providing” their downstream partners with the ability to contract, measure, pay and get paid.

Implement for complexity, plan for flexibility

Payers need a partner onboarding model that handles complexity with the supporting technologies to create a VBC network that integrates, supports, leverages and compensates CBOs – thus, delivering immediate scale and providing an element of future proofing. It is the critical first step in developing a sustainable VBC network.

A payer’s partner onboarding model and related technologies must drive all mission-critical business processes, including:

1. Consent capture
2. Permissioned data sharing
3. Measurement and reporting
4. Electronic visit verification
5. Invoicing and payment
6. System administration

The onboarding model and supporting technologies also must be able to meet the needs of each key stakeholder – payers, risk bearers and delivery partners – and accommodate “many to many” relationship models. This means nimbly managing upstream payment receipt, measuring critical metrics, and executing partner payments in an environment that protects downstream proprietary relationships – all from the same technology used to deliver on the mission-critical business processes listed above and doing so with the security and audibility required in today’s heavily regulated healthcare information exchange environment.

Once partners are onboarded into a structure that facilitates their roles and financial arrangements, ebbing and flowing based upon their involvement, payers will have created a “network of networks,” providing a competitive advantage while simultaneously allowing them to better serve patients and their communities.

Lynn Carroll is the chief operations officer, and John Schwartz, the chief revenue officer, of HSBlox, which enables SDOH risk-stratification, care coordination and permissioned data sharing through its digital health platform.