This article is sponsored by Curana. This article is based on a discussion with Tony Gamboa, Chief Growth and Innovation Officer at Curana. This discussion took place on September 13, 2023, during the SNN RETHINK Conference. The article below has been edited for length and clarity.
Skilled Nursing News: Tony, tell us about Curana Health and how the company was formed.
Tony Gamboa: Curana Health was formed by an investment led by a large venture capital group that wanted to investigate the thesis of bringing great national best-in-class medical organizations and medical groups. Effectively bold on different opportunities to participate in value-based payment models including ACOs and Medicare Advantage which I know it’s a bad word around here but it’s I-SNP models in particular. The thesis is to evolve the way that we can provide care for residents and senior living in general, skilled and beyond.
We have to also evolve the way that we get paid so that we can afford to invest in different resources and different care models that add additional resources, technologies, and personnel and improve their chances of partnering with facilities to improve care outcomes.
What innovations do you feel set Curana Health apart?
I think what we do as a medical practice, I’ve often been quoted as saying that healthcare is very micro-local. You have to be in a community to make an impact on a patient-by-patient level. When it comes to providing care, stay away from making outlandish claims or inaccurate claims that our clinicians are better. I think as an organization we like to believe we’re creating a culture of a medical practice that is very much centric, medically led. As well as empowering them with different technologies that we’ve invested heavily in and evolved clinical models of care.
Education is specifically aimed at training our clinicians to move from an episodic day-by-day model of care to a longitudinal one. We think of our residents as lifelong patients, which I know can be a difficult thing to do in a skilled nursing environment where there’s rapid turnover and there are challenges in care daily. We hope that we continue to evolve the way that we practice medicine and move our clinicians.
Using technological advances to support their transition from a fee-for-service mentality to an outcomes-based mentality and ultimately passing on that success to our facility partners both simply on good outcomes and good patient satisfaction as well as financially through are value-based payment models with which we partner with communities.
How do you feel Curana Health is living their mission of improving the health, happiness, and dignity of senior living residents?
On the health front, we have over 750 clinicians that are onsite daily Monday through Friday in some cases seven days on, seven days off depending on the need. It starts with clinical care. It starts with local engagement. It starts by training clinicians and giving them the resources with which to provide excellent care and be very patient-centric. On the happiness side, I would say it’s a matter of culture. When we first created Curana, we really focused on creating a culture whereby the health, happiness, and dignity statement wasn’t just something that we put on a billboard or something that we put on our website.
It was something we wanted to live up to. When you think about the things that we do on a day-to-day basis, it’s not about the big things that you have to build, you have to document, you have to help with PDPM. All those things I consider a right to play as a medical practice, especially in the rapidly evolving healthcare landscape. As an example, we had one of our care allies who found that one of our residents who was in a value-based model had very bad eyesight and she could no longer read. She enjoyed reading.
For months and months, she wasn’t able to get a book with a font large enough to enjoy any book. One of her care allies on her own account decided to go to the local library and check out audible books. Brought them back to the resident and the resident was just moved and touched by that. I think there’s a daily example of something similar happening either by one of our clinicians, by one of our care allies, or by one of the members of the care team that brings that fulfillment to life. We try to highlight that every month.
We have great monthly staff meetings which we call town halls, where we highlight a member of the Curana Health team. It can be anybody from the front lines all the way to an executive person who went out of their way to live the Curana values and that’s what makes us very different.
What is the future of Curana Health and how are they changing the value-based care landscape?
To talk about the future, I think we have to start with where we are. We have had tremendous success in our population health for our patients on a pound-for-pound basis on a per-member basis. We’ve had the second-best first-year ACO that’s ever been created. That’s on a per-member basis. We’re not incredibly large but when you compare us on individual patient outcomes, we have the second-best ever first-year ACO performance.
As it pertains to over the last 10 years, there’s not been a better performing ACO. Starting there, I think it’s an incredibly important tangible element. We can talk about care models, and we can talk about value-based performances, but you have to back it up with the actual outcomes and fortunately, as of today, we can do that. We can say we have had the best-performing ACO in the last 10 years. Moving into the future, we only hope to continue to expand on that and frankly engage our facility operator partners to help them become a member of value-based care payment opportunities and meet them at whatever stage they’re ready to come into.
It could be that they want to dip their toes into the water and maybe that they want to go all in and dive headfirst. The reality is that because we have the flexibility of multiple care models from two types of ACOs too, and also the ability to partner with or create institutional special needs plans for operators, we’re bringing the control. We’re bringing the ability for them to decide where they want to be and put them in the driver’s seat. This is what I call the progressive path toward being a provider themselves.
You can be a participant in a value-based economy with no risk or you can be somebody who’s taking partial risk and getting some quality bonuses associated with that or you can be an owner of one of your own plans and ultimately take control of where you want to be in the future. We hope that we can continue to move the needle forward and work to mitigate a lot of longstanding concerns about what it means to be a Medicare Advantage operator. More importantly, just provide the opportunity for providers themselves to participate in this as opposed to having it be enforced upon them.
I understand even for us as clinicians before we had this opportunity, we felt the same way.
Can a nursing home have both an I-SNP and ACO REACH programs?
That’s a great question and the immediate answer is yes. I’m not the smartest guy so I try to simplify things for myself. Medicare Advantage is always going to trump ACOs. That said, Medicare Advantage typically requires specific requirements, and a patient has to enroll and agree to be in Medicare enrollment on a month-to-month basis, as opposed to an ACO, which typically is either through retrospective or prospective attribution. In the case of the ACO REACH in particular is prospective.
That said, both can exist and in fact, it’s a key element of a value proposition that we speak to our potential and existing partners and explain to them that with our medical groups present and empowering the communities, we can bring both the ACO model which from an operational standpoint, there’s less of a lift and it’s less disruptive initial entry into a value-based economy. It’s also a fantastic way for us to collect data and evaluate how we perform together.
It is most definitely not something that, as a medical group, we can do without the facility partnership and their buy-in and without the support and participation. Ultimately getting initial data on the ACOs is always a great path to being objective in our evaluation of what the success possibility is in a more engaged model like a Medicare Advantage-type model I-SNP.
How does Curana’s I-SNP differ from other MA plans that are perceived to limit care?
When you think about Medicare Advantage plans that are either third-payer-owned or even that are in partnership with other community resources, hospital systems, etc., at the end of the day, when you’re trying to generate savings, it’s a simple mathematical equation, right? First of all, you should not be sacrificing outcomes. That should be number one. To generate savings, you cannot sacrifice outcomes, otherwise, you’re not performing to the goodwill of the residents.
Number one is you can’t sacrifice some patient outcomes, but the intent is to generate savings, and then share amongst those savings. In order to share savings, you have to do the calculus, right? There are a few ways that you can share savings, you can cut down on all resources across the board. I think in some cases, that’s the approach that some MA plans take. They try to reduce the length of stay; they try to reduce specific resources. I don’t think there are VPs that are dedicated to saying no and doing those kinds of things.
At the end of the day, from an economic standpoint, the equation is such that you have to be conscientious and restrictive in specific costs to generate savings. When you look at our Medicare Advantage plans, it’s in partnership with the community. We are fully aligned with the community’s needs, which means that our priority is to reduce unnecessary spending and incredibly high-cost elements. When you look at the impact on a pound-for-pound basis, it really means reducing unnecessary, which is a critical point.
An average hospitalization and emergency room visit can cost $20,000. Anytime that you can avoid an unnecessary hospitalization, you go a long way towards generating savings, by the way, without compromising care. More so, we think that in our care model, we provide more care because we deliver care through a more expanded care team, and we bring more resources to the community. In fact, it’s completely the opposite. In a care model where there’s an I-SNP and we’re in partnership with the community, we’re bringing more resources to that community and those residents.
We’re partnering with and aligning fully with that community to avoid incredibly high-cost elements of care. Fundamentally, there are a few nuances that we know we have to mitigate, for example, changes from long-term care residents to short-term stay. We have mechanisms that allow us to have waivers in some of our programs, ACO REACH in particular, where we can grant waivers and hospitalizations to avoid what could be perceived as a loss of revenue for those long-term care residents who are not effectively transitioned into a skilled short stay.
On the technology front, do you provide technology solutions? If not, do you partner with such providers?
To be clear, we do provide technological solutions. We don’t own them. We’re not a development shop. Curana is a technology-enabled clinical service, but we do not own the technologies. For example, we partner with Innovaccer, EndNote, and GEHRIMED. These are three of the most well-known and more community-facing technologies. We do provide those technologies to both the facility operators, either directly by providing them with reports through our reporting capabilities, or in essence via integration.
Either from GEHRIMED or from Innovaccer, we will integrate with facility operators’ technologies, most commonly MatrixCare, PointClickCare, etc. We will bring that technology to the table and facility operators so that our partners will enjoy the visibility that we have for those residents who are participating in our care programs, and they will get additional resources and technology.
What’s the biggest fear you hear from operators about taking ownership in a Medicare Advantage plan?
I think there are three big buckets there. One is what is the cost? There’s a real cost if you want to own your own Medicare Advantage plan and there are specific monies that you have to set aside at a state level associated with Department of Insurance qualifications to have something to back your own plan. That’s not an insignificant sum.
That’s bucket number one. Bucket number two is operational. What’s the operational lift? That’s where we feel like we can relieve a lot of the concerns because that’s what we do for a living.
We have a full organization with resources and personnel to make it very turnkey for the operator and all we need from them is their participation on a facility-by-facility local level. The third bucket is the financial bucket. What happens with my revenue if I’m not going to see some of my long-term care patients become skilled patients? I try to address how we mitigate some of those things through both waivers and also, just trying to help facility operators understand that on a pound-for-pound basis when we generate savings, it really outdoes whatever potential decline short term and revenue associated with it.
There’s an upside to the shared savings that I think overcomes that problem.
Curana’s integrated model of care increases patient satisfaction and reduces unnecessary hospitalizations by making real-time medical consultations available to residents and their families. To learn more, visit: https://curanahealth.com/.
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