Patrick Young, president of population health for Hackensack Meridian Health and Jeff Smith, chief commercial officer at value-based managed services operator Lumeris, share the success story of payer-provider partnership Braven Health.
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Erika Grotto: Payers and providers coming together in the name of value, today on HFMA’s Voices in Healthcare Finance podcast.
Hello, and welcome to the podcast. I’m your host, Erika Grotto. In today’s episode, we’re talking about a groundbreaking payer-provider partnership in New Jersey. That conversation is coming up in a moment, but first, let’s hear what’s happening in healthcare finance news. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.
Nick Hut: Hello, everybody. Our topic for this segment is prior authorization, which, it’s no secret, is something of a boondoggle for healthcare providers. We talked about this topic in the first half of last year after the Office of Inspector General at HHS issued a report basically saying that in Medicare Advantage, health plans often would overreach and delay or deny coverage that should have been approved based on Medicare guidelines. Now, Shawn, CMS has responded in a couple of different proposed rules, both of which were released in December, and one of them has implications across government health insurance programs. Can you tell everybody what the upshot of that rule is?
Shawn Stack: Pretty excited about this rule. CMS has stepped in, and they’re kind of taking important steps to remove those barriers to patient care by kind of streamlining that authorization process for certain health insurance plans. So those impacted are the Medicare Advantage, state Medicaid fee for service, Medicaid managed care plans, state CHIP plans, fee for service and managed care, and qualified health plan insurers on the exchange. So this is kind of exciting. We’ll see where this goes. But for the most part, it really adds a layer of transparency on what health insurers and what coverage plans require prior authorization on for the patients and for the providers. It really promotes a more timely response from the payer on denials…so care is not delayed and the hospital can respond to assign appropriate care if the avenue they took is not allowed. But it really is a huge win for the patient in not delaying their care. And then it also has a ton of, you know, public reporting, prior authorization metrics attached to the rule, things like what some plans list for services that require prior authorization, standard prior authorization requests that they approved, that they denied, that were approved after the patient or the payer appealed them. So a lot of transparency on payer health plans, prior authorization kind of policies and procedures, if you will.
Hut: Yeah, great summary. Thank you for that. I just wanted to note, it’s not until 2026—am I right—that the “requirements” kick in?
Stack: That’s correct, yes. So there’s a lot of build in this rule. Payers are going to have to stand up and use their fast healthcare interoperability resources—the fire approach. So there is quite a bit of a build here to achieve these very timely prior authorization standards and transparency in those standards.
Hut: Yes. So certainly an exciting development in the context of prior authorization. Another rule that was released around the same time was the proposed terms of participation for Medicare Advantage health plans for 2024. Kind of hard to believe that already 2024 regulations are being published. I mean, proposed regulations, but here we are. And this rule really gets to the heart of the OIG report that I mentioned at the top. It basically prohibits health plans in Medicare Advantage from implementing coverage and benefit guidelines that contradict what you’ll find in so-called traditional Medicare, aka Medicare fee for service. So all of the national and local coverage determinations would need to hold sway in Medicare Advantage, unless plans want to go beyond those guidelines and be more expansive in the coverage they provide. And there are other relevant terms and conditions. For example, in scenarios when a beneficiary, for whatever reason, moves from one plan to another during a course of treatment, the approval of that treatment would carry over to their new plan for at least 90 days. So that can help avoid interruptions of coverage for a specific treatment or service. So Shawn, in the last episode, when we talked about the No Surprises Act independent dispute resolution process, we were justifiably, I think, critical of CMS. But here’s arguably an instance where they may be on the ball and at least trying to be mindful of reducing the administrative burden on providers. And obviously, as you noted, that’s all in the name of enhancing care access for beneficiaries.
Stack: I would agree, Nick. I mean, both of these rules do significantly, you know, the more transparency with the prior auths and the new Medicare Advantage rule, they definitely help reduce administrative burden on the hospital staff and really ramp up and help support continuity of care, which is what you were hitting on there. So this is great, great news for providers and patients in following that healthcare plan for the patient.
Hut: For sure. So I think that’ll do it for this segment. As with all the topics we discuss on Beyond the News, we’ll definitely be keeping tabs on this one and keeping everybody apprised on further developments. Thanks, and talk to you next time.
Stack: Great. Thanks, Nick.
Grotto: If you search the term “value-based payment” on hfma.org, you’ll get nearly 5,000 results back including news, how to’s, education and more. Despite all that guidance from HFMA and other sources, fee-for-service contracts are dominant in the industry. But for Braven Health, a payer-provider partnership in New Jersey, value arrangements are crucial to the future of healthcare. My guests today are Patrick Young, president of population health for Hackensack Meridian Health, an integrated delivery system covering 8 counties in New Jersey, and Jeff Smith, chief commercial officer at Lumeris, a value-based care managed services operator. You’ll hear Patrick speak first.
Patrick Young: Braven Health came to fruition probably about five years ago. We thought there was a better way at Hackensack Meridian Health to take care of our patients, and we thought that if we could combine what we do as a provider and what an insurance company does and combine those organizations and align the goals formally that we could improve the quality of care that individuals receive as Medicare recipients. We chose Horizon Blue Cross Blue Shield as our strategic partner to really combine what we call now a “payvider,” where a provider and an insurance plan work together to improve the quality care of members that we serve. Braven started out in the eight counties, but we really expanded this year into the entire state of New Jersey, which really transcends just where we operate our business. A part of the process is, we brought in Robert Wood Johnson, who, in the eight counties that we operate in, is our biggest competitor. But we really thought that if we’re really going to have great access and really make a difference, we need to expand our partnership not just with Horizon but to bring Robert Wood Johnson is as a competitor but also as a partner to optimize the scope of members that could be impacted and really to align our goals, their goals, and Horizon’s goals to improve the life of our Medicare members.
Grotto: Let’s talk a little bit about patient and physician needs when it comes to an arrangement like this and the role the physicians particularly play in an effort like this.
Young: So we wanted to make sure that we had the broadest network available, and so we access Horizon Blue Cross Blue Shield’s network of participating physicians. And you know, primary care physicians play a critical role in relation to the care that patients receive. To really think of them as kind of like the quarterback of care for patients. They do coordination, education, ensuring they get access, work on preventive services. So primary care physicians and physicians in general are critical for our success. We also have set up a physician advisory council for Braven. So we want to make sure that the communication between Braven and its participating doctors is a pretty open and fluid process, the physicians provide feedback and express their concerns about the products that we have or concerns about anything they have to do from an operational standpoint, feedback they’re getting from the patients. So physicians really are a critical partner and I believe are driving the success of Braven in the marketplace.
Jeff Smith: Yeah, and Erika, if I could jump in, I just want to state that I think that focus on physicians has been the differentiator for Hackensack in their local market and is something we’ve seen indicative across the country. Having physicians engaging members at the point of care is a point of differentiation that leads to much higher physician and patient satisfaction. And truthfully, when you have a collaborative payer like Braven working with the physician network in the way that they are, magic happens. And I think we’re seeing that emerge in New Jersey with Hackensack’s leadership and their efforts with Braven.
Grotto: What we’re talking about here is a partnership between two entities that typically are not friends, right? The relationships between providers and payers are famously contentious. So what is the secret to Braven’s success here?
Young: The secret, I believe, is that a traditional relationship between an insurance plan and a provider—providers want to receive more revenue for the services they provide, and insurance companies want to pay less revenue so they can have lower premiums for the members who choose their program. In this structure with Braven, we fundamentally have aligned everyone’s goals about making Braven the most successful plan it can be. So we shared data, we have meetings regularly. The chief medical officer for my division interfaces with the medical director at Braven. So it’s an ongoing collaborative goals to improve the Braven experience for our members and for the patients that we serve, and I think that by doing that, you align the goals, so there’s not that inherent friction that there might be between a provider and a payer because we are partners in this endeavor, and it’s important that we remember that the member is the most important aspect of what’s taking place with the patient that we provide care for, or member of Braven. And that’s why I think it works.
Smith: And to amplify just two or three points there if I could, the access to the data, as Patrick talked about, bringing the physicians to the table around the benefit design and how they’re designing the engagement. And you think about claims denials or what can really be a point of abrasion between a health system and a payer. Having the system and the payer together helps to set a much better collaborative engagement. And think about also alignment of these programs and initiatives. You don’t have payers outreaching to members that are then separately being outreached by the patients. There’s just a greater coordination of care and leads to a higher level of patient satisfaction with the care they’re receiving through a Braven program.
Grotto: So this definitely sounds like a win all around. Are there any lessons learned that you’d like to share?
Young: One of the reasons why Braven has been successful is that we structured it to be successful. This is not about us bringing business to HMH. It’s about providing a viable insurance product that provides great access. So it’s not about driving volume to HMH facilities. It’s about great access with patients. It’s about a collaborative effort. Braven has its own license. It has its own CEO. It has its own CEO. It is a separate organization from both HMH, Robert Wood Johnson and Horizon. So we really had that dedicated focus in order for it to be successful, and I think that if you have some underlying structure in place and governance that really ensures that the focus is about making Braven the best it can be, that goes a long way to having better outcomes. I would say that one of the things that anyone thinking about doing this is, if you’re on the provider side of the house, you’re now moving into the insurance business, and it’s a pretty significant endeavor to do. So you need to make sure that the management team, the board of directors understands that you’re getting into a business that’s somewhat close to what you do but taking on risk, providing risk-based capital, the investment that is needed is significant and it’s a different creature than providing care to patients. So that would be my insights or watch-outs.
Smith: If I could, Erika, also taking a national view on this, one of the themes we’re hearing consistently now is coming out of COVID, the direction that Hackensack has gone towards value-based care post-pandemic—and Patrick even used the term being a “payvider”—is the trend that we’re seeing emerge. And it very specifically is doing two things if you start to move toward value-based care. First is, in this example, it’s perfect. Patrick is establishing a relationship between a payer and a health system that’s turning likely unprofitable or lower-profit business into something that’s more profitable on the Medicare Advantage side. And two, because of all the collaboration they’re doing around the data and the insights around the patients, they actually are providing better care continuity for these patients. So you’re starting to, as you move toward value-based care, do this incredible job of driving collaboration between PCPs and specialists, care coordination is occurring in a better way and likely is also helping in other populations such as commercial business, where it’s more profitable for this system. So value-based care opens up a whole new business profitable line on the Medicare side and starts to drive care continuity towards the more profitable commercial lines of business and better care overall for the patient. So it’s really exciting to see what’s emerging.
Grotto: We’ve been talking about value-based care for a very long time at HFMA, and a lot of our member organizations, our provider members—some have embraced it. Others are still, even now, nervous about it, scared of it. What do you say to them?
Young: The idea of making sure that you socialize the approach and the structure of what you’re doing internally within the organization with the board is critically important. You know, I talk to a lot of other organizations where the CFO wants to have more heads in beds, and the value-based structure is to get people out of the hospital. So you have two factions within the same organization that have different goals and objectives. So you need to make sure that as a provider, as you move into value-based care, you really have a vision that this is the direction that we’re heading, this it the right thing to do for the patients. It will improve the quality of care, but also means that you’re underlying value-based contracts, your data analytics, all the thing that you need to manage that, you have that structure in place in order for you to do those things. I think a lot of organizations don’t have the data, don’t have the infrastructure, don’t have the culture to do these kinds of things and that’s why a lot of them fail.
Smith: To amplify and add, Patrick started this journey a few years ago. It isn’t something like he said, hey, tomorrow let’s start taking downside risk, let’s move in this direction. So one of the things that I don’t think any of us can underestimate is the time to build the muscles, shape the network, get the competencies in place and then secondly, this value-based care allows you to actually change some of the profitability of government programs. It literally opens up a whole new direction for health systems as they think about their pathway forward, and you know, the government has stated that they’re going to have 100% of their population in a value-based care arrangement by 2030. It’s coming. So how do you think about your government business, your commercial business, and we’re on the right strategies and tactics and start early enough so that you can make the moves you need as a system to be successful and you’re not forced into it too early.
Grotto: Let’s talk about results. You said you’re in the 25th month of this, although I know that there’s some expansion in that time as well. Can you share any results at this point?
Young: Sure. So, we are not profitable. We didn’t expect to be profitable. It takes some time to get this kind of endeavor moving in the right direction. I would say that we had a significant amount of headwinds with Covid. It’s really hard to improve the quality of care that individuals receive when nobody can go to see their primary care physician, and you can’t really optimize the outreach and the preventive services and everything that you want to do to improve the quality of life for those patients if, you know, for two years of your existence, a lot of people are apprehensive about going in to see their primary care physicians. So I think that that’s led to some of our risk scores in relation to the population to be somewhat outdated. So I think we’re kind of coming out of that. Those headwinds are kind of diminishing. And I do believe we’re moving in the right direction.
Grotto: Yeah. I think this is going to be a good interview for many of our members to hear a success story like this, even if it’s not a profitable success story yet. I definitely look forward to hearing the results down the road, and I invite you to come back and talk about that at a later date when it’s time. Jeff Smith, Patrick Young, thank you so much for joining me today.
Smith: Thank you, Erika
Young: Thank you.
Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is the director of content. Our president and CEO is Joe Fifer. Registration is open for our upcoming Revenue Cycle Conference in Phoenix. We’ve got some great speakers lined up, and it’s a great opportunity to connect MAP Award winners and other organizations with insights into solving the most challenging revenue cycle issues. Sign up today at hfma.org.
A story about payers and providers getting along — no, really
On a recent episode of HFMA’s “Voices in Healthcare Finance” podcast, Patrick Young, president of population health for Hackensack Meridian Health (HMH) and Jeff Smith, chief commercial officer, population health, at value-based managed services operator Lumeris, shared the success story of payer-provider partnership Braven Health.
The long road to partnership
Although Braven Health is just entering its third year of operations, the wheels started turning about five years ago when HMH, an integrated delivery system serving eight New Jersey counties, decided to partner with Horizon Blue Cross Blue Shield to create a so-called “payvider.” Braven recently brought in RWJBarnabas Health — one of HMH’s competitors — as an additional partner.
“We thought that if we’re really going to have great access and make a difference, we need to expand our partnership … to bring [RWJBarnabas Health] in as a partner to optimize the scope of members that could be impacted and really to align our goals, their goals and Horizon’s goals to improve the life of our Medicare members,” Young said.
Smith added that the journey to value is — and should be — a long and thoughtful one.
“One of the things that I don’t think any of us can underestimate is the time to build the muscles, shape the network and get the competencies in place,” he said.
Braven is not yet profitable but did not expect to be, Young said. The lack of patients seeking care during the early days of the pandemic provided an obstacle that is only now dissipating, he said.
A “payvider” partnership is a different type of business for providers, and the learning curve could be steep, Young cautioned.
“If you’re on the provider side of the house, you’re now moving into the insurance business, and it’s a pretty significant endeavor to do,” he said. “You need to make sure the management team, the board of directors, understands that you’re getting into a business that’s somewhat close to what you do, but … it’s a different creature than providing care to patients.”
He encourages other provider organizations considering such arrangements to spend time on ensuring the focus and governance are what they should be.
“This is not about us bringing business to HMH. It’s about us providing a viable insurance product that provides great access,” Young said. “I think that if you have some underlying structure in place and governance that really ensures that the focus is about making Braven the best it can be, that goes a long way [to achieving the access goal].”