Home-based care providers are increasingly earning a seat at the table for care-pathway transitions, including whether an inpatient hospital stay is truly necessary before a patient moves to a skilled nursing facility (SNF).
Some payers require a two-day hospital stay before authorizing a transition from home to a SNF. But SCAN Health Plan is cutting the hospital out of that pathway entirely, said Quingan Zhou, vice president of growth strategy and ops at SCAN Health Plan, at Home Health Care News’ PAYER Summit in June.
“We do direct SNF authorization. SNF admissions from the home require a two-day stay in the hospital,” Zhou said. “We don’t do that; we go direct from the home to the SNF and skip the hospital altogether, because that [requirement] doesn’t make any sense.”
Long Beach, California-based SCAN Health Plan is a non-profit organization providing Medicare Advantage plans to more than 425,000 members across Arizona, California, Nevada, New Mexico, Texas and Washington. The company operates its Embrace institutional special needs plan (I-SNP) in California and Arizona. The plan and serves more than 4,000 members across the two states. The Embrace plan focuses on care delivery for people bound to their homes, a nursing home or assisted living facility.
Eliminating hospitals from the home-to-SNF pipeline allows SCAN’s utilization management turnaround time to stay within the same business day or one business day, Zhou explained.
“Our clinical team, our medical directors have decided that being able to give timely care to patients is just the right and reasonable thing to do,” Zhou said.
The shift to eliminate the hospital stay was difficult for clinical operations, Zhou said, but made the most sense for patients.
Embracing the abnormal
Zhou recognizes that SCAN is operating outside of the industry standard, but she said this model aligns with SCAN’s philosophy to reject inefficiencies even if they are common. Therefore, it is crucial to talk with payer partners to clarify which processes may not make sense.
“We all collectively have a responsibility of holding each other accountable for not normalizing the abnormal,” Zhou said.
She emphasizes ensuring that both the payer and the provider leave conversations in a better state than they were before.
One discussion SCAN has with providers involves benefit design. These can impact providers directly or indirectly, Zhou said, but providers may not realize the full implications because of the complicated nature of the healthcare payment structure. Having these conversations can help rule out inefficiencies and help all parties succeed. Zhou said the best contracts and partnerships are fair and right for both parties.
SCAN is able to enact its unique operating model because it is a nonprofit, Zhou explained. Rather than reporting out its earnings on a quarterly basis, the company can reinvest in its own technology and infrastructure to ensure it has the best workflow for providers.
These provider partnerships are integral to the organization’s growth.
“Provider partnership is truly at the core of our growth story, both on a special [needs] product as well as just general products across the board,” Zhou said.
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