How to Add, Pay Community-Based Organizations in Value-based Care Contracts

Value-based care is now firmly entrenched in our healthcare system. Payers credit value-based care with lowering costs, improved outcomes, enhanced payer/provider relationships, and improved patient engagement.

With the growth of value-based care models, a trend gaining traction is the transition from treatment at a provider’s site to a patient’s home. This shift to home and community-based care, accelerated by the COVID-19 pandemic, shows no signs of abating.

Value-based care is well-suited to handle this change. This model by its nature is focused on wellness; members don’t always need facility-based care. Moreover, value-based care factors in both medical and non-medical aspects of an individual. The question then is how best to keep members healthy at home.

The Importance of Incorporating Social Determinants of Health

One integral way for payers to leverage this shift is to ensure that they capture the member’s social and behavioral information as well as medical information for use in affecting the plan of care. A fundamental yet still nascent component of value-based care is seeing members more holistically and integrating social determinants of health (SDOH) data with clinical data. SDOH data – such as access to healthcare and safe housing, and economic stability – affects a wide range of health risks and outcomes.

There is a growing consensus that SDOH need to be taken into account in order to succeed in providing value-based care. Payers that align medical and nonmedical data, and address SDOH for those members that need such assistance have seen lower costs, improved health equity, and more effective care coordination.

Bringing Community-Based Organizations into the Fold

To fully leverage SDOH information and provide more complete services throughout the care continuum in support of value-based care, payers should include community-based organizations (CBOs) in their value-based care network contracting strategies. Doing so creates a broadened, higher performing set of resources to keep people healthy and at home.

Taking the leap and making CBOs a compensated part of the care continuum provide several advantages:

• First, broadening the perspective on the member: CBOs and social services agencies (SSAs) help determine at a “street level” the personalized services payers should provide as well as assist in identifying risk factors to suggest targeted care.
• Second, a more complete picture of care plan success: increased closed-loop referrals, whereby the clinician who refers a patient to a CBO receives notification once the referral is acted upon, or perhaps more importantly, knowing for certain when it is not.
• Third, a cost advantage, and financially stronger community assets that are attune to the shifting needs of the community: CBO services are typically cheaper than medical services, an added plus and benefit greatly from a non-philanthropic revenue stream.

Incorporating CBOs into the Network

If we are being honest with ourselves, aligning traditional medical networks to incorporate CBOs is not without its challenges. For instance, not all CBOs are subject to the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws, which, if not appropriately architected, can raise privacy and security concerns.

A further barrier is revealed as each value-based care network partner approaches adding CBO information into the technology used to run their business (e.g., hospital information systems and practice management systems) as about 80% of the data required to do so is unstructured. On top of both these hurdles is the enormous sunk cost in the existing IT investments made by the stakeholders – a solution that requires abandonment of those investments is economically unfeasible.

That all said, it can be done, and done today. Payers that are incorporating SDOH into their value-based care programs typically layer SDOH technology platforms onto the medical network’s existing infrastructure to add these capabilities. There is no need to “rip and replace.” Unstructured CBO information can be digitized and included in a medical provider’s electronic health record (EHR) to create longitudinal health records (LHRs) covering the care continuum.

Compensating non-medical partners such as CBOs differs somewhat from payment to a medical provider. Payers need a mechanism for a CBO to submit an invoice, which often will not be digital, and confirmation of verification of the service, such as electronic visit verification (EVV), to trigger payment.

For instance, a social worker contracted with a value-based care network would look in on members regarding their needs and inform them of services available. The payer would confirm the visit by obtaining the clinical, social, and/or behavioral service completion documentation (e.g., via a member form, or via an agreed upon detailed invoice from the CSO digitized to extract the required information to confirm the visit), accept the invoice from the CSO, and then initiate payment.

Best Practices to Integrate, Compensate CBOs and SDOH Data

As the time is now to incorporate CBOs and SDOH into a payer’s value-based care program, payers should embark upon a thoughtful and proactive planning process taking these steps:

• Integrate CBOs and SDOH into your current business model. Fold it into the network’s current workflows and align with the network’s medical services. Fit it into what you’re already doing. That is easier and less expensive than operating medical and non-medical data separately.
• Layer SDOH technology platforms into your existing infrastructure. Use complementary solutions to plug gaps, support EVV and invoicing, and create fully digital and actionable medical records.
• Put procedures in place to emphasize security, since there will be data sharing outside the purview of HIPAA. This entails not only strong language in the CBO contract to address privacy and security safeguards, but also capturing patient consent and incorporating role-based, permissioned data sharing.
• Enhance interoperability. Ensure that different data systems can communicate with each other to securely exchange SDOH information among stakeholders – this means prioritizing the ability to digitize unstructured data.
• Be flexible about technology and payment methods. Not all CBOs are tech-savvy. For example, some of them cannot accept automated clearing house (ACH) payments.

The shift to home- and community-based care requires alignment between traditional medical service delivery and non-medical home and community services. Payers should include CBOs in their value-based care networks to prospectively address risk-management, capture SDOH data and enhance the network’s performance. Since CBOs are not traditionally part of payer networks, payers need to deploy mechanisms to support the logistics of CBO service delivery, invoicing, and compensation. Value-based care is poised to grow significantly; payers that can master CBO payments now will be the best positioned for success.

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.