Kaiser, Bayada, Senior Solutions Chart The Future Of Value-Based Care At Home

Now more than ever, home-based care providers are exploring and engaging in value-based care opportunities.

This means that providers are going beyond just “chasing contracts,” but instead, aligning on shared goals around outcomes and savings with payer partners.

For the latest episode of HHCN+ TALKS, Home Health Care News connected with Sue Chapman Moss, managing director of payer and provider contracting and strategy at Bayada, Kunu Kaushal, CEO of Senior Solutions and Bill Gammie, senior director of post-acute utilization at Kaiser Permanente.

All three leaders weighed in on what value-based care arrangements look like at their respective organizations, some of the biggest challenges and what the future holds for risk-sharing models.

A replay of that TALKS episode for HHCN+ members is below. A transcript from HHCN’s conversation is also below. The transcript is lightly edited for style and clarity.

HHCN: Can each of you start by giving just a brief overview of your organization?

Gammie: As noted, I’m with Kaiser Permanente, which is one of the country’s oldest HMO organizations, or the oldest, and certainly our focus is truly ensuring that we are supporting members throughout the care continuum. Kaiser Permanente operates in eight states across the country. We serve over 12 million members through our integrated delivery system.

Moss: Bayada was founded 50 years ago on the foundations of compassion, excellence and reliability. Today, we’re now the largest independent non-profit home health care provider in the United States with services in 22 states and 370 offices. We also have a global footprint with offices in six other countries. We’re serving about 170,000 patients annually with an employee base of about 33,000. Our care continuum ranges from personal care to skilled nursing services, home health, hospice, habilitation and autism services.

Kaushal: I’m Kunu with Senior Solutions Home Care. I founded the company 15 years ago. We are a humble home care agency that started with a laptop and cell phone, and a couple of caregivers, with a focus on non-clinical in-home care. Private pay was certainly where we started and focused. Today, we cover the entire state of Tennessee and also the metro area of Atlanta. We are the largest independently owned non-medical agency in Tennessee itself and a preferred provider for Medicaid and VA services within our state. The lens I think that we represent is that of a smaller organization that is interested in working with managed care and other payers to speak on value-based and other topics.

Thank you all for telling us a little bit about your organizations. I think because all of these different organizations represent different parts of the health care system, we will have a very rich discussion today. Can each of you go into detail about the concrete ways your companies are engaging with value-based care opportunities right now?

Kaushal: From our side, we don’t have a firm or set value-based model. I know we’ll talk about that a little bit later. We’re almost future-proofing ourselves for where value-based might go. Specifically, we’re seeing some hints around managed care organizations. For example, WellPoint or Amerigroup in our area, who do want to incentivize us, for example, topics like caregiver training, caregiver matching. These are what I would call low-hanging fruit, with the lack of a definition of what is value-based.

What we are firming up in our organization are things like data. We know that that will be very important. We’ve been tracking hospital readmission, obviously, as a major focus area. We are trying to live within our non-clinical scope and yet function as if our partners are going to look at us as eyes and ears and responders for data and other information in the home, and assist them with some of their mission-oriented things that they’ll be doing.

A prime example of that is that instead of just offering a PERS or Personal Emergency Response System in the home, we’re also bringing in ambient listening and digital care management type of solutions in order to be a provider of some of that data and information as it exists.

You introduced some threads that I’m sure I’ll pull on throughout the rest of this discussion. Sue, what are some of the ways that Bayada is engaging in value-based care opportunities right now?

Moss: Part of our vision here at Bayada is to serve millions worldwide through one home, one caregiver at a time. Our approach to value-based care is very much aligned with this growth mindset. Since joining BAYADA in 2021, we have used our payer relationships as a building block for growth. We’ve expanded in new offices, new service offerings and new states. I like to think of it that value-based care is an opportunity to demonstrate that compassion, excellence, and reliability aren’t just ideals. They’re investment opportunities for our payer partners.

We have a range of preferred relationships with payers that are willing to make that investment, ranging from Medicare Advantage plans, both nationally and regional plans, and local plans, as well as a number of arrangements on the managed Medicaid side. I would say that across the board, we’re offering up the types of outcomes that payers and patients are seeking. More time at home, staying safe at home, and avoiding unnecessary days in the hospital, unnecessary trips to the ER.

Our approach to value-based care really is built on that framework, along with the alternative payment model, APM-LAN network model that some of you may be familiar with, is a big part of our journey. We have pay-for-performance relationships and shared savings. We’ll talk a little bit more as we get into the conversation about moving into up-and-down side savings and the approach to delegated risk.

Sue, I’d like to stay with you for this next question. Can you share some of the outcomes you’ve been able to achieve in these value-based care arrangements?

Moss: One of the outcomes that I’m most excited about these days is our clinical innovation in pediatric critical care services at home. We have a very human-centered model that we developed in partnership with a children’s hospital on the East Coast. We’re able to bring home medically fragile children who are medically ready for discharge and yet continue to spend days, weeks and months in the hospital post their medical discharge opportunity. That is due to a lack of advanced critical care nursing services in the home.

Through the model that we started with one health system, we’ve now scaled that to a number of different hospitals in a number of different states. In this model, we are able to reduce readmissions for these medically fragile children by 25%. The average savings that we’re seeing is about $250,000 per patient, per year, and probably my favorite statistic is 5,000 hospital days avoided for these children and their families.

Kunu, I wanted you to weigh in here as well, too. How is your company thinking about value-based arrangements and outcomes?

Kaushal: The biggest thing for us, simply put, if an individual is healthy and at home, we can actually provide them services. As an in-home provider, it’s not just about, let’s say, chasing margins or revenue, etc. Ultimately, our mission is to keep our client healthy and happy. When they’re healthy and happy in the home, we’re actually driving revenue, our caregivers are actually working, and we feel like it’s a win all around. The other element that we’ve seen is just a primary outcome. We just know more. I think when you get into the mindset of a value-based type arrangement or get prepared for that as the future is coming with it, it’s interesting for ourselves to even track some of these numbers.

I know one of the things that’s reported on pretty often is that when hospital readmission was being talked about, you almost had to start a conversation with personal care agencies to say, ‘How many of you are even tracking it?’ The baseline of even people knowing their own numbers is step one. The things that we have found and determined are that not everyone needs all of your tools and resources at once. You have to really identify how to qualify them and individuals that are going to need it. It’s made us a better provider of who all needs those extra touches along the way.

Bill, I’d love to hear your perspective, too. Kaiser Permanente is one of the largest health care organizations in the US, as you mentioned, and your organization has various payer arrangements with home-based care providers. How does value-based care fit into this?

Gammie: I think it’s important to note, Kaiser Permanente really exists to provide high-quality, affordable health care services, really to improve the members’ health and the communities that we serve. The care for our members really focuses on their total health. For us, it’s critical that we do that and we see that across entities that are part of our network that we own and operate, and that those experiences are as similar as possible for those that we partner with.

For me, and the oversight I have, it’s critical to make sure that when we say quality, when we say outcomes, that we’re really founding that into clear measurement, that we can assess that reality and that we can pivot to where we need to make changes to ensure that we are, in fact, achieving those outcomes. For me and for much of the work in this region, the value-based care is really core to creating these objective measurements and to ensure we’re just not looking at volume and utilization, but what value are we actually providing members, their families, and the communities we’re serving?

Our ability to drive these expectations through these arrangements is absolutely critical for us. I think we’re still, in many ways, evolving the direct pay concepts. Right now, in many ways, we’re very much investing into improving data sharing. I think we’ve been very fortunate, both with our internal agency and certainly external, and great folks like Sue and Kunu want to do the right thing and want to see the best outcomes for the members they’re serving. Really, we’ve been able to open up dialogues along the lines of outcomes and achieving that in partnership.

For us, it’s just not on the home health agency. How our home health agencies are accessing our physicians, how they’re accessing our care managers, how we’re managing orders and processing those orders to really deliver timely care. We own that as well. We have to really ensure, through a value-based lens, that these outcomes are measurable, that our processes are in alignment, to really best serve those members in the most timely and effective way possible.

Bill, in value-based arrangements with home-based care providers, are there specific health conditions that Kaiser is focused on? What are some of the outcomes you’ve been able to achieve?

Gammie: Yes, I think there’s some standard areas that we’ve seen that have been around for some time. I think when we look at some of our joint programs, I think when we look at heart failure programming, I think those are pretty standard, and we certainly work within those spaces. Although I think what we’re seeing in our aging populations, and certainly what we’re seeing is that there are limits to specific unilateral health conditions. Unfortunately, what we’re observing is that you have a mix of conditions.

I would say our evolution in that space is looking at a more dynamic risk-type scenario where members have multiple comorbidities. We see unfortunate scenarios where members have both diabetes and heart failure. Having parallel programming just really doesn’t make sense for us. I think we’re really evolving into more global high-risk identification in that members, based on where they’re at in their disease process and the other information that we can garner from their experience with us, helps us to realign resources in a different way to support them and their families on where they’re at and making sure that we’re supporting them in a different way.

In many cases, it means more proactive communication through care management lenses. It means that as we’re communicating with home health agencies and we’re looking at outcomes, we’re specifically focused on how they’re achieving results in those higher-risk populations. That we can work in conjunction with them to align on different care delivery modeling and integration back into our continuum of services. In particular, there’s actually 14 domains overall that we look at and that we measure. Again, I would say it’s more focused on risk versus individual care pathways globally.

Sue, Kunu, I want to direct this next question to both of you. What impact has value-based arrangements had on your margins?

Moss: The margin that we’ve generated as a result of the value-based arrangements that we have in place are reinvested directly back into our workforce, technology and clinical innovation. The example that I gave earlier with regards to pediatric critical care is a great example of this, where the shared savings model that we have in place with some of our health plan partners it’s plowed right back into building the next care team to deploy to the next market.

At Bayada, because we are a nonprofit, our margins are not just numbers. They fuel our mission. It really is a flywheel. On the Medicare Advantage side, I would say the same is certainly true as well. The payment model with Medicare Advantage allows us to be able to distribute upside performance dollars back through our organization to continue to invest in the data pipelines, the talent, the people to be able to deliver the results that we’re really proud of. That’s the impact it’s had on margins. I think what’s really interesting about my tenure here at Bayada is that I can’t imagine what sort of margin pressure we would be facing without having done this body of work.

I think there’s a balance of offensive and defensive strategy. I call that out, given the headwinds that we’re all facing in the industry on Medicare and Medicaid funding. It’s certainly going to be very constrained going forward. We appreciate the successes and the lessons learned we’ve had on value-based, the impact on margins over the past several years is definitely becoming a big part of our playbook as we look towards the future.

Kaushal: I would just say, keep in mind, we have a very small pilot with one managed care organization, which is recognizing some data points of identifying. I’m just going to talk about the Medicaid managed care space for a moment. There’s also not a clear definition of what is quality. If you ask the payer, they will tell you that quality feels like utilization of hours, etc. Missed visits, maybe, is a metric that they’re looking at.

If you ask us as an organization, we’re thinking through the lens like Sue and Bill are likely looking through, and we’re thinking about far more impactful levels. I talk about it more as impact on our mission, which is we’re trying to be a health care organization and not a staffing company, which I think is a mindset shift that has to occur. For us in our small pilot, for example, how we’ve recognized it has offset some training costs. What we’re noticing is that as our caregivers are better trained, they’re providing better services, which allows us to get better data, which now, for the incentive payment that we’re receiving, really just offsets some of that training cost for them.

What I assume will happen over time is that value-based and quality-driven payments, etc., may feel much more aligned in some way. I think at that point, the reality in the market today is that you have a provider that’s doing the bare minimum to meet their contract goals. Forget value-based for a moment. It’s just being compliant, essentially. Then you have other providers, and I hope that we can count into that camp. We are investing far more, and we’ve been doing that before value-based, before anything else, because we think that’s what driving better quality and product or brand really feels like.

We’ve been investing into training additional FTEs in the business, quality assurance managers, so on. That does take that extra effort. Ironically, I think what will end up happening is we’ve been making these investments for quite some time. I think value-based will validate it and offset some of those additional investments we’ve been making for some time. It’ll almost be a reverse impact, where because we have been taking extra steps, now someone’s recognizing it, it is making a difference in a better way, and then we will see the margin improvement down the line.

I wanted to ask all of you, what are some of the common mistakes home-based care providers make when trying to form value-based care arrangements for the first time?

Moss: There are two that definitely come to mind in my conversations with our payer partners. The first is underestimating the need for data availability. A big mistake is to sign a contract based on a set of information that doesn’t exist, or the data pipe breaks on one side or the other has a system upgrade and change in the data that you were getting in the first quarter, you’re not getting in the second quarter. I definitely think we have a long list of examples of what not to do with the data piece.

That’s definitely been a lesson learned for us in terms of the absolute criticality of data use agreements, clear definitions, attribution methodology, and everything that goes along with the data side. It’s just really hard to measure performance and agree without that underlying piece of information. The second mistake I would say we have turned into an opportunity. The mistake is really viewing payers as a transactional relationship. Our approach is definitely a partnership mindset.

We want to ensure alignment, transparency, real-time course correction. We’re in conversation with our payer colleagues, if not daily, weekly, definitely monthly, and an absolute minimum quarterly. We will sit down and review results across the table, talk about lessons learned and adapt together. I think really having the partnership mindset is absolutely critical. At the end of the day, I think the underlying theme here is underestimating, viewing it as the historical, antagonistic relationship is a real barrier to success. Value-based care isn’t about a one-and-done contract. It’s a journey, and on that journey, definitely having the mindset of continuous improvement is really important.

Kaushal: I would echo what Sue said.

Said slightly differently, is also understanding what the payer or the individual that you’re trying to partner with, what are their main interests? I think some of us here have really interesting programs. We just made the assumption, for example, that every payer is going to care about hospital readmission. Although they do, there are deeper aspects or maybe a subpopulation that they’re really focused on. I think having that relationship is enough to talk to them. I call it chasing contracts, but if you’re chasing a contract because you know it exists, they’re not going to spell out the true intent behind it. You have to take that time to talk to them to understand.

Another mistake I would say is assuming that it’s far more complicated than it is. There are some relationships that we have found — it truly is that they want data. They’re looking for data. They would like for us to provide them that next layer of data, which will inform them on their next initiatives as a partner that they might want to do. I think that is an area that’s from a contracting side.

Now, on the flip side, internally, the challenge is also understanding that not everyone on your team is going to understand why we’re doing these things. Really getting to the point, I’m talking now [about] wearing the hat of the small personal care provider. If for years and years or for their entire career an individual’s just “been staffing”, now all of a sudden taking time to fill out the forms, making sure that the care plans are completely done, doing the extra survey, doing the in-home assessments with the extra form.

Those aren’t necessarily optional if you’re truly trying to go down this path. Bringing everyone along for that is probably the other common mistake is that although the leader or the executive team may really want this, the rest of the team doesn’t understand why we are doing “extra work.”

Gammie: You got the right panel because I think Sue and Kunu hit it out of the park on those two answers. I’ll only add that I think in sometimes what I’ve seen is being presented with an opportunity. When you look at some of the publicly available outcomes, let’s say, star ratings, and let’s say patient satisfaction, you’re seeing gaps. You’re coming and presenting information about how this opportunity is going to be amazing and all the wonderful things that are happening, but you haven’t cleaned your own house first.

If you’re going to come to the table, you really need to make sure that you’ve already been able to prove through publicly accessible means the ability to achieve outcomes that are publicly available. Certainly, if there’s gaps there, there should be some very upfront clarification as to how you’re addressing those and why those gaps exist. I shouldn’t be bringing them up, which certainly has been a misstep by some conversations here in the past.

Bill, from the payer perspective, what things should home-based care providers have in place at their organization when they’re trying to land these value-based contracts?

Gammie: I think it’s a mix of a lot of things that have been said. I think Sue’s comment around information, and Kunu’s as well, is very much aligned. Making sure that you do understand your own information and understand your ability to be fluid in that data sharing. Not only generally speaking for the agency, but how have you cared for our members? That’s really critical. It takes some homework to make sure that you’re just not telling us about what you do for everybody, but how are you impacting your Kaiser Permanente membership today?

I think what’s also critical is the ability and the flexibility in being able to do some different things and to use different systems that we may be bringing to you. We really need to make sure that we’re singing off the same sheet of music. An agency’s scope and ability to modify their systems, align in their process, and, in many ways, depending on volume, certainly recognize that. What type of dedicated resources may be required before you’re entering into these conversations is really a gut check that an agency needs to have before diving deeply into wanting this relationship. We want the new thing. We want to land that agreement, but we’ve really got to look in the mirror and say, “Okay, are we ready for this? Where are the gaps that we have today that need to be addressed before we walk into this room?” Because otherwise, things can take a turn very quickly, and other providers that are more prepared and more aligned can take someone’s opportunity very quickly if someone’s coming to the table without being prepared.

Then the next thing I want to touch on is something that has already come up during this conversation. We often hear about the importance of home-based care providers having the right data when trying to go after value-based care arrangements. Bill, what kind of data do payers want to see?

Gammiel: I think each payer has their own dynamics. I think the beautiful thing about Kaiser Permanente and who we are, have been operating since 1945 as a nonprofit agency, an integrated delivery model of care. We’re not short on data here. There’s been significant investment in actually creating centralized repositories of information across our entire network that really allows us to do some very innovative things and really pinpoint, what are the true needs of a member or a member population, and how are we making sure we’re aligning our resources to them?

I think when it comes to home health, there are some things that we don’t have the ability to access. Kunu mentioned that. I think the best piece of information and a lot of the data that we’re actually pulling from providers that are in agreements with sharing that data with us are heavily founded in OASIS. I think that is a standard data set that does provide consistency in our views. We’re certainly aware of the nuances of OASIS and what can happen in that data, but I think that is some of the strong contributing factors.

Also, it may not be the most popular comment, but the advent of [PDGM] has also provided us with some unique insights. If you think about it, Medicare did this in a similar way to be able to create more granularity in regards to the type of members that are being engaged, the type of interventions that are needed. With the evolution of [PDGM], the continued established OASIS data set, we’ve been able to do some pretty neat things to actually come to the agencies and say, “Hey, this is what we’re seeing. What are your thoughts about this? How can we better align in this particular area to achieve outcomes we’re both desiring, which is that overall value for membership?”

When you look at the data, I think making sure that as you’re coding through [PDGM] and you’re aligning on OASIS data, that accuracy is absolutely critical. We’re able to garner a lot of information from that data set.

Sue and Kunu, what have been some of the biggest challenges related to value-based care opportunities? How is your organization navigating these challenges?

Kaushal: I think the largest thing, actually, Bill hinted to it, is that under the home health and more of a clinical setting type model, there are data sets and data points and far more structure. The greatest challenge for us has been that our industry has been in a fee-per-hour type of service. You either did the visit or you didn’t. Complexity, meaning any level of complexity after that is, was there a change in condition? Does everyone track that? Do we even know? What’s happening during the hours we’re not in the home? There’s a lot of gray area.

To me, the model we’re headed towards is: today, we own the time we’re in the home. Let’s say we have an individual. We’re servicing them for 30 hours a week. Our services are really focused on, what is our caregiver doing for those 30 hours while we’re there? To be a true value-based partner, I believe we are going to have to evolve into saying, “We need to worry about all 168 hours that this individual’s in the home,” through our partnerships and other people that we’re involved in a care circle with, the family, the individual, home health, and other partners that may be there. We have to take ownership for all of the time.

Really understanding the how and what tools are available to us, how well will the client actually participate in that process, as well, has been pretty tough. I can’t tell you that we found all the answers. What we have identified, though, is our teams are surprisingly willing to come along for the journey. It takes a moment to make sure that our systems are in place for that, for example, having our EHR system have robust opportunities. We use WellSky. Within it, we have the ability to track hospitalization, to track change in condition, a bit more around disease process management. We now have care insights type of solutions.

I say all that to say, as we have resources and tools to deploy, not every agency may do that, but it has to really be interoperable into our workflows and make that easy. I don’t think we could have done this five years ago because at that time, even our tools and resources were very much focused on clocking in and clocking out and billing for the hours that we service. It’s certainly coming a long way.

Moss: I’ll build on a couple of Bill and Kunu’s comments. I’d say externally, one of the biggest challenges that we face is finding the person inside the payer organization who’s ready to have the conversation. We’re talking about doing something different. That takes a lot of change-mindset approaches. For example, if we’re talking about dramatically changing the way that care is delivered in the home, getting a chief medical officer involved is going to be really important to ensure that you have an ally inside the payer organization who’s championing the ideas.

The additional piece on the external side, I would say is, it’s an investment. We’re asking for people to open up the checkbook. You need to show up with a hard ROI. The payers are facing a whole set of margin pressures on their side of the table. Whether it’s a 5X, a 10X investment return, you need to have the data ready and be able to tell the story, and have that ready before you meet with the payers, rather than getting turned down and having to come back around.

Some of the margin dollars that we use are invested in piloting and incubating ideas so that we have the data before we initiate the payer conversations. Internally, I would say, as I mentioned in my interview, there are 370 service offices. I think the internal challenge is doing all of this at scale in an incredibly complicated, fragmented health care delivery system that we face in the United States.

Asking my colleagues in our service offices to do more is a really hard conversation. They’re delivering care. They’re staffing cases. They’re recruiting. They’re training. They’re credentialing. They’re doing so many things, sending the bills out the door, and then I show up and ask them to do one more small little favor. That’s not a good solution. We definitely look at it through the lens of sitting down with our service offices and asking them, “How do you see it? What does care look like on the front lines? What value are you creating? How are you differentiated?” Then reverse-engineering the execution playbook to succeed at scale.

Kunu, we had the pleasure of having you at our conference, FUTURE, in September. During one of the panel discussions, you said, ‘There is no definition of value-based in personal care today. If we, as an industry, can help define what value-based can be in personal care and show them a path of what that will be – and there will be multiple models and we all have to test those out – that is how we truly get to the point where someone says, ‘Here is your incentive payment for doing a great job with this certain population within our state.’ Otherwise, we will all continue to fight this war of, ‘Can we get another 50 cents per hour?’”

I’d like to dig into this a little bit more, this idea of there being less of a framework for value-based care in non-clinical home care compared to your counterparts in home health.

Kaushal: Here’s my lens of looking at all of this. One of our major payers for personal care in general is Medicaid. The other major payer is private-pay. If you say that Medicaid is a grouping, let’s just say. Medicaid, it’s not that they don’t care unless it hits their budget in some capacity, or it will allow them to save money so that they can extend benefits to more people, or something to that lens. It depends state by state, program by program, whatever.

If you ask them, “Well, what do you find from a cost-savings perspective? Is there something there?” In my interaction with Medicaid directors n so far, their ideal scenario is that they find an at-risk partner to do a value-based model with. Most personal care agencies are not large enough, sophisticated enough, or ready to pilot a program that would be at-risk.

To me, there’s a lot of work to be done. One is that the healthy way to do it, obviously, I’m biased, is to say, “We should pilot.” I think Sue nailed that one, is that we should be piloting programs, “Where can we make an impact? What’s important to them?” to find a shared savings, opportunities first. Once that’s been established and there’s enough history and data, predictability, or at least game plans around that, I think the at-risk models may come.

A comment that I made earlier is that if you ask Medicaid or managed care today, “How do you define, just even in quality, a better provider than another?” If you’re starting to look at utilization, authorization, maybe staff consistency or caregiver consistency, you’ve got some elements there, potentially caregiver training or some metrics to that, and credentialing of a workforce, you’re getting into some of that.

I’m not hearing them say things like, “You did a really good job with our chronic disease X, with our diabetic patients or COPD clients.” I’m not hearing them say that they care about our hospital readmission rate. It is speed to service, continuity of service, and then, “Have you been compliant along the way?”

Now, a natural question might be, how would you help build the framework of value-based? In my opinion, even if it doesn’t impact the payer’s financial concerns, I still think client satisfaction is clearly an area of this. An individual’s health or member’s health, overall health maintenance is another. Also, just applying many things that have been learned through population health management along the way. There’s also other data with a dual eligible population, the D-SNP crowd.

Now, through critical incident reporting that a lot of programs have to do, we know this population is doing two to three ER visits a year, and that is a number we can improve. If for nothing else, it was for a total population health improvement, quality of care, et cetera.

The value-based piece on payers, my understanding, I’m going to go out of my depth here and just say, from a home health and facility, etc., some of these others, it’s because commercial payers are in there, Medicare dollars are in there. I think the thing that’s lagging with us is the interest and readiness for a managed care or a partner along those lines, and then potentially, a state Medicaid program to really help create that criteria.

I see light at the end of the tunnel. I do know that CMS, in their broader plan, wants to see value-based in personal care. They have a framework of at least what was deployed with home health and other settings where they know there can be an impact. My assumption is that they’re leaving things loose enough for the best ideas to percolate, really come up to the top. What were the real difference makers?

I am excited for it, but at the same time, it’s gray enough that we don’t know exactly what to do from a 5 or 10-year planning perspective. Once there are the leaders that are stepping up, and it sounds like many of us are willing to, just by saying, “Well, these are best practices we think are possible,” then to do exactly as Sue mentioned, we put those pilots together, we make the investment, then we call the managed care or the medical director and say, “Look what we’ve done.” It starts a conversation. It may not be the final model of what they’re after, but it shows capability.

If I could leave with one comment here, it is, in order for value-based and personal care to work, we will have to be more than a staffing agency. If we become a sophisticated health care partner, then we will have the opportunities to do these types of things, including incentive payments and shared savings, etc.

Sue, I had the opportunity to interview you a few years ago for an HHCN story about the payer innovation strategies at various home health companies. You, at the time, mentioned that Bayada usually has conversations with payers that have never entered a value-based arrangement with a home health provider before. How do you often overcome this hurdle when it comes up?

Moss: I would definitely say a lot is evolving rapidly in this sector. We’re starting to see more payers ready, but it’s very market-specific. All health care is local.

To build on what Kunu mentioned, if in a state like Pennsylvania, where the legislature is actually mandated as part of the Medicaid RFP process, the health plans need to demonstrate in order to renew their bids to deliver Medicaid services in the state, they need to demonstrate their commitment to moving dollars into value-based. That’s an easier scenario where we show up to meet with the health plans, and we’re an answer to a regulatory requirement. They’re all ears. That’s an ideal state.

On the other end, I definitely think it goes back to finding your allies, your champions for change inside a health plan if they don’t have the experience and the expertise yet, but they want to pilot and they want to innovate. It could be the chief nursing officer. It could be somebody in the quality department. It could be a chief medical officer. To bring them to the table early, I think, is really important because they will understand the value that you’re creating. We like to think about the fact that we’re the eyes and ears in the home.

For our clients, e often the only person that they may see for the entire week is the Bayada caregiver who’s coming into their home. We have a wealth of data and insights on what’s going on with those individuals. That’s a more compelling way to start a conversation with a payer, “we’re your eyes and ears. Here’s what we’re seeing. How can we unlock this value together?” rather than showing up and asking for a traditional re-increase and whatnot. I think it really depends on meeting the plan partner where they sit in their journey towards value.

Sue, what you said about allies may be a good segue into this next question that I have for Bill. Before joining Kaiser, you had a home health background. Can you talk a little bit about that and how that influenced your perspective?

Gammie: The ability to be part of home health, palliative hospice care and integrated delivery completely framed the reference point in coming to Kaiser and being able to, as Sue mentioned, I like to feel like a champion in my space to really have a unique ability to see both sides of the scenario. That’s helped me navigate communications at various levels in this organization.

It’s helped me navigate the reality of the constraints that the home health agencies had. Sue listed a few of them. I understand those challenges and those opportunities that the agencies are continually managing to really ensure everything that’s required in delivering that level of care. For us, and because of who we are, as I mentioned, that total care of that individual, the examples Sue talked about, we’re the only one in the home, that resonates with us. That’s exactly what we care about. I think that’s why Kaiser Permanente has had longevity.

We’re not interested in some of the other scenarios that exist in managed care. When I have these conversations with leadership, both regionally here and in KP Mid-Atlantic, but even at the national level, my ability to communicate those constraints is welcomed. We really want to figure out how we’re figuring it out together, because to us, it definitely isn’t just about that margin and that ticker price. It’s about what’s happening to this member in their home, what’s their experience. When they have Kaiser Permanente Health Plan, we want them to have something different than what you traditionally see in the space. As I mentioned earlier, those partnerships are critical.

Having that background and experience has helped me navigate those waters with more fluidity, with more focus, and really taking both the things that we need as an integrated delivery provider and the constraints and the opportunities that exist as delivering home health. Kunu, we are expanding a lot of discussions in private-duty as well. That’s only helped me navigate and really help having some deeper conversations at all aspects, how information is moving to and from the agency. How are authorizations working or not working? How is data being fed? How are we connecting all of the resources we have? What’s reality for these providers?

For example, we’re like, “Oh, well, we just need their team to integrate into this portal.” It’s like, we can’t do that. Not everybody can log in. Their devices themselves, with one of the most popular systems out there, most of it’s tablet-based. We’re talking about a PC-based technology. That’s not going to work.

I’ve been able to navigate conversations more quickly and get to what’s most important for all of us here, which is improving that member experience, managing through, in many cases, chronic conditions for a lot of this focus here, for us here, and specific to Medicare populations and really make sure that we’re driving measurable outcomes and experience. We, at the end of the day, then can celebrate those wins with our network providers, knowing that we did something special for the communities we serve.

We are nearing the end of our conversation. I’d like to throw out one last question to all of today’s speakers. Where do you all see value-based care and home-based care in the next five years?

Gammie: I think full steam ahead would be my comment. If I speak to one particular area of focus, obviously, we have more flexibility in some of our commercial products. If we look at us as a Part C Medicare Advantage provider, we want to see and work certainly with our legislative bodies, and the ability to be more dynamic in that work. How we pay, in many cases, is already aligned for us through those expected arrangements. Data is becoming more relevant and more accessible. Through various, certainly AI platforms, we are seeing much more relevance to that information. I think that will only grow very quickly.

At the end of the day, there are a lot of things that we know as home health providers are basic blocking and tackling, making sure we’re doing what we need to be doing, and that will yield outcomes. I think we should all be ready for more dynamic-based identification of needs and us being able to manage through the current constraints and really see how our partners can achieve more specificity in regards to particular areas as information becomes more readily available.

Kaushal: I think the biggest thing will be around infrastructure. What I mean by infrastructure is some standardization of data. I look back and think about social determinants of health when that was a popular topic. There were still three or four different styles of an SDOH form that you could get to. I think what we’ll see is, in value-based, part of the opt-in or part of the contracting will be standardization of data in some way to define certain KPIs, whatever that might be for organizations, which will benefit and help the payers really understand from each other on an equilibrium of, “What is apples-to-apples comparison for organizations?”

That’s probably on the front end. On the back end, as you have the value-based relationships happening, if infrastructure gets established, then I think clinical and non-clinical will start to blur and instead will look like a care team. I think you’ll see the need for this non-clinical caregiver and or family in the home is also producing some data that overlays with what home health and other partners are also doing, as well as a primary care physician and others in the health space.

How we work together is going to be a very powerful element. Over the next five years, it will be the next pain point. As a payer builds their value base, they will have silos of information and silos of partners, and their burden will still exist, which is, “How do we pull it all together? How do we get them functioning together?” Brands aside, I think the concept of what makes true outcomes happen is, it takes a village. It takes everyone’s involvement, the family, the caregiver, the member themselves, and then clinical and non-clinical support folks around.

Moss: I think in the next five years, we will move up the framework that I referenced at the beginning, the alternate payment models. I think we’ll be moving away from the entry-level models of pay-for-performance and upside only as payers become more ready. As Kunu and Bill have described, it’s payer readiness, data readiness, and provider readiness.

I think one of the forcing functions may be the funding constraints that we’re all facing, the One Big Beautiful Act. We’re certainly starting to see that impact on Medicaid budgets in some of the states in which we operate. I certainly think the outlook on Medicare Advantage has changed. It is not the opportunity for tremendous growth that it had been. I think we’re at an inflection point on both sides.

I think that disruption is going to lead us up the value curve. I don’t think we want to spend more on health care overall as a society. We have a lot of value that exists in the health care delivery system. I’m looking forward to, maybe the industry headwinds will unstick some of the conversations and really bring value-based care to scale in the home.