Planning for Success in One Clinically Integrated Network's Move to Full Risk

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At the 14 Annual World Health Care Congress, held April 30-May 3 in Washington, DC, Ann E. Oasan, MBA, president of UniNet Healthcare Network, discussed the network’s transition towards assuming full risk and building the infrastructure for success.

Oasan explained that UniNet is a physician-led, clinically integrated network based in Nebraska and Iowa that incorporates hospitals, clinics, and 3000 in-network providers. It is moving toward more value-based contracting but still has some fee-for-service (FFS) contracts with payers like Blue Cross Blue Shield Nebraska. UniNet provides a number of services, from claims issue resolution to care management resources to provider education.

Before moving to the Medicare Shared Savings Program, Oasan said, UniNet first had to build the infrastructure for success by strengthening the coordination of care between physicians, social workers, pharmacists, and patients. To illustrate these robust care coordination efforts, she showed a video featuring patient Mike Halac, aka Mantaur, a professional wrestler who was also unsuccessfully wrestling his diabetes until one of UniNet’s population health coaches helped him get his blood sugar under control.

Coaching from the social workers is free to patients as part of UniNet’s value-based care, and once these coaches started facilitating discharge transitions and following up with patients, satisfaction among the patients and providers went up. “There’s never enough social workers,” Oasan said, emphasizing the importance of the population health coaches in UniNet’s model, especially in driving behavior change while some members are still in a FFS model.

A major goal for UniNet is to improve quality measures in the clinics, but this is where “still living in both worlds” of value-based and FFS care can create misaligned incentives. For instance, hospital executives would be happy to hear that admissions have increased, while it would be a negative sign for UniNet, Oasan said.

From a value-based perspective, the major change has been the shift to shared savings with some of the contracts. In a full-risk model, UniNet, hospitals, and providers share in savings and losses based on clinical and financial targets. Oasan noted that providers are liable for up to $5000 if the goals are not met, as “it’s important that they have skin in the game.”

When making the decision to move to a downside risk model in 2016, Oasan and her colleagues realized that their skilled nursing facility (SNF) spending had been $8 million over the average the previous year. Oasan called this a “huge opportunity” and selected SNF spending as “The One Thing” UniNet would focus on, in reference to the book The ONE Thing, which encourages concentrating efforts on a single task instead of becoming distracted by multitasking.

To impact SNF spending, UniNet had to reframe the conversations around SNF among physicians, physical therapists, and patients. They trained physicians to set the expectation of going home upon discharge instead of transferring to an SNF, and started calling the SNF a nursing home to change the connotations for patients. Acute care managers and physical and occupational therapists were also trained to frame returning home as the optimal outcome, and were required to clinically justify their decision if they did refer a patient to an SNF upon discharge.

A pilot study still in progress involves having patients or family members photograph their living environment so care managers could address any safety hazards and feel more comfortable releasing patients to their home instead of another facility. UniNet has also embedded its population health coaches and advanced practice nurses in SNFs in an effort to lower readmissions and increase patient satisfaction. They are now studying whether the system of discharge planning, follow-ups, and medication reconciliation can reduce the length of stay in SNFs.

Overall, the strategy for addressing “The One Thing” is to focus on appropriate SNF utilization by turning to alternatives like home healthcare or a slightly longer hospital stay and by building partnerships with SNFs that successfully implement the triple aim. Oasan predicted that skilled reimbursement policies would be changing significantly in the future, but she was optimistic that UniNet could weather these adjustments.

“We don’t have it all figured out, but hopefully we won’t lose $8 million this year,” Oasan said, referring to the above average SNF spending last year, then added, “We’ll see.”