As the skilled nursing industry shifts towards managed care plans like Medicare Advantage and Medicaid managed care, “conveners” have become essential in managing care for specific patient populations, especially for long-term care residents and dual-eligible individuals.
And while conveners have helped nursing homes and health care providers adapt to the changing landscape and achieve better clinical and financial outcomes for their patients, navigating relationships with conveners comes with pros and cons.
“I think it’s important to understand the risk associated with a payer choosing to bring in a third party to manage this population, which ultimately reduces control for the provider,” Jonalyn Brown, VP of operations at Consonus, told Skilled Nursing News, as part of the Payment Perspectives series. She added that conveners can take control out of the providers’ hands, which can be really challenging.
“Having said that, I also think it’s important for providers to develop strategies and/or solutions, which may involve either developing the infrastructure and technology to support value-based payment, or working with a partner who already has developed this, ultimately, to stay in front of that payer,” she said.
The inception of conveners
American Health Plans Chief Development Officer Hank Watson told SNN that NaviHealth was the first health care convener he really saw gain prominence in the market. NaviHealth now is part of UnitedHealth Group’s Optum arm.
NaviHealth specializes in post-acute care management and care transitions. It was founded in 2012 and is headquartered in Brentwood, Tennessee. NaviHealth’s primary focus is on improving the coordination and management of care for patients as they transition from acute care settings (like hospitals) to post-acute care facilities (such as skilled nursing facilities, home health care, or rehabilitation centers).
The company works with health plans, hospitals, physicians, and post-acute care providers to develop and implement value-based care models NaviHealth’s services often involve care management for high-risk and high-cost patients, to coordinate the transition from one care setting to another.
Watson said that with the initial development of conveners like NaviHealth, oftentimes length of stay got cut and utilization got reduced, or individuals were sent home directly rather than to a nursing home.
“Nursing homes hurt and learned a hard lesson,” he said. “Value-based care has a lot of opportunity potential, but you can be on two sides of that. You can be the convener or the owner of the premium dollar and the clinical model of care, or you could be the downstream entity that is the rate taker and gets managed.”
Operators have options
Watson said that what the industry collectively has realized is that the most clinically sophisticated and financially elevated role that nursing homes can play is with the long-term care dual eligible population. And, nursing homes are uniquely positioned to be “on point” for that population.
“As we look across the landscape, [nursing homes are] an asset, and are managing those long-term care residents and owning that premium dollar and managing that model of care and taking true accountability for the outcomes clinically and financially for those residents,” he said. “We’re in the position of the managed care organization; we’re in the position of the clinical convener, or at least certainly avoiding the need for one.”
Still, Brown said that for each unique market, payer and provider should be treated differently. It is essential to assess their individual tolerance for financial investment and risk, considering the specific circumstances and dynamics at play.
“For instance, if a payer is examining a subset population of individuals aged 65 and older with exceptionally high medical expenses and the payer lacks the means to effectively manage costs and care, they may find value in contracting with a third-party convener to oversee the management,” she said.
Susie Mix, CEO of California-based Mix Solutions, Managed Care & Contract Consulting, said that to be successful in the managed care environment, it is imperative to have a workflow in place that accounts for the nuances of each convener and the health plan.
“It’s important to get it right in the beginning,” she said. “For some states, it starts with finding the group that is ‘at risk’ for the stay. Verifying benefits leads you down the path of ensuring the patient has coverage and … who to send the claim to and where to send it. It has to be rolling right from the beginning.”
In working with conveners, nursing home operators also could look to other parts of the continuum, where providers also have been contending with — and often complaining about — conveners. Home health providers, for instance, have been vocal about the challenges presented by conveners.
“These intermediaries, these companies that tell managed care how to save money by denying care, and then take a layer of the revenue for that service – are they not worse for us than the Medicare Advantage plans themselves?” asked a panelist at last year’s National Association for Home Care & Hospice’s (NAHC) Financial Management Conference.
While many different organizations play some sort of convener role, there’s no doubt that many of these entities have become crucial pieces in how some of the nation’s largest managed care plans operate. Not only does Optum own NaviHealth, but Walgreens Boots Alliance, Elevance Health (formerly Anthem) and CVS Health all have acquired or invested in convener-type organizations, as reported by SNN’s sister publication, Home Health Care News.
The convener can create friction in the communication between health care providers and Medicare Advantage insurers, and the convener’s incentives and goals can further complicate an already complex situation in which various entities are vying for dollars. But as concern around conveners mounts, there is some pressure on them to change their practices and ensure that the patient experience is prioritized, while the incentives for insurers and health care providers are aligned.
And Chris Bradbury, CEO of Integrated Home Care Services, is seeking to approach the convener role in this manner, HHCN reported.
“It needs to create value, not for us, but for the patient and their family who we try to serve, and create more value for the entities that are at risk,” Bradbury said.
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