Problems Facing Payers Right Now, And How To Combat Them

Bridging the gap between payer/provider groups, and hospices/SIP providers

Prior to COVID-19, payers were already experiencing a number of stressors: meeting quality metrics, maximizing patient and provider satisfaction, minimizing acute care utilization, and more. Now, amidst a global pandemic, that list has only gotten longer.

What’s keeping payers and provider groups awake at night now? For starters, practices are facing a $67,000/provider loss each this year, and staring down a backlog of patients who have delayed their primary care during the pandemic, and are now dealing with the health consequences of delaying that care. Integrating telehealth and remote work into the normal workflow also takes time, and providers must compensate for decreased access to acute care and long-term care in certain markets.

Industry leaders are now wondering if Medicare is sustainable, and whether it will survive the impact and demands of COVID-19.

“Even if only 20% of the U.S. population is infected, there would be 11.2 million hospitalizations, 2.7 million ICU admissions, 1.6 million patients requiring a ventilator, 62.3 million hospital bed days and $163.4 billion in direct medical costs — all on top of an already maxed out system,” said Robin Stawasz, Program Development Executive at Acclivity Health.

So, what are payers and providers to do? A new innovation model introduced in 2019 by the Centers for Medicare and Medicaid Services (CMS) may give hospices a new role to play in meeting these needs.  CMS’ Primary Care First (PCF) program, which will start enrolling patients in 2021, includes the Seriously Ill Population (SIP) model. The SIP program is designed to improve care for high-need, high-risk patients who currently receive fragmented or inadequate care. To do this, CMS will assign SIP patients to participating hospice programs, paying the providers to establish coordinated care plans, stabilize the patient and avoid unnecessary hospitalizations, all with the ultimate goal of transferring these patients to a care provider for their ongoing care.

As Stawasz explained, hospices’ skill sets specifically address many of payers’ pain points, like patient and provider satisfaction, right-sizing care and meeting quality metrics. In states where the SIP program is available, participation could benefit payers, too.

“SIP addresses two of the biggest challenges that payers and providers have — managing the care for patients with serious illness and patients whose care is fragmented. These patients drive the utilization and cost overages for payers and require the greatest demands on resources for providers. SIP’s entire structure is focused on this exact population and applies multidisciplinary, holistic care in the home, provided through a predictable, value-based, capitated payment structure.”

While the SIP program will not be available in all 50 states at first, payers can use the program as a model for their own practices. SIP providers can enter into contracts with individual payers or provider groups to offer care using the same structure being used in SIP.

“So, the payers or providers would be paying the SIP providers directly, instead of CMS, but the gains — lower costs, more appropriate utilization, higher hospice utilization — are also directed toward the payers or providers. Also, since the contracts are individual, those involved are free to innovate and design the program to specifically meet their needs.”

Payers and providers interested in participating in SIP, or creating their own SIP-like practice model, will need data analysis capabilities to effectively address their practices’ needs.

“CMS is going to be using data analysis on their own claims to identify the patients to enroll into the program. Payers need to be able to identify those people within their own patient population, and perform ongoing metric analysis to ensure the clinical and process goals of the program are being met,” said Stawasz. “Perhaps most importantly, there must also be interconnectivity between SIP providers and payers and providers, so they can easily communicate and work collaboratively.”

If you want to learn more about solving the stressors facing payer/providers, please feel free to email us at info@acclivityhealth.com.