Healthy Alliance is one of the few companies that has adapted the independent medical practice association model to meet social needs.

As payers and other stakeholders attempt to address social determinants of health (SDH), one question, with many answers, remains: how?

Beyond identifying and prioritizing needs, allocating investments and demonstrating return on investment, there is the challenge of creating a whole new infrastructure for contracting, “complaints” and reimbursement involving community-based organizations (CBOs).

At New York, healthy alliance is leading these innovations. He created one of the first Independent Social Practice Associations (Social API) in the country, taking the traditional API model, i.e. allowing independent providers to share resources and gain power collective agreement with payers, and apply it to community organizations rather than medical providers. .

HealthLeaders interviewed Healthy Alliance leadership to discuss how Social APIs support different stakeholders, how they contract with payers, the steps needed to become a Social API, and why Healthy Alliance thinks that their model is better for payers.

Create a social IPA

“We created the entity, obtained the IPA label at the end of 2018 [from New York state government agencies]and built it from there,” says Erica ColettiCEO of Healthy Alliance.

“We were one of the first,” she notes, adding, “Other APIs that have emerged since are often focused on subpopulations such as people with mental health conditions or intellectual disabilities. We want to work with these APIs and, more broadly, help everyone who has essential needs.”

Coletti says, “The organization’s referral network and IPA come together and work with community partners — from regional hospitals to local pantries — to address social needs before they turn into serious medical issues. and costly”.

The Social IPA is one of three affiliates of the Healthy Alliance, which connects underserved people to a growing network of organizations large and small that provide essential services for healthy living. Healthy Alliance partners with more than 580 organizations in 22 New York counties. The goal is to ensure that every New Yorker has consistent access to the resources they need to enjoy the same chance of good health.

Coletti adds that “the mission/business model is the same everywhere, laying the foundation for the Healthy Alliance to improve health and empower the underserved.”

Contracting with payers

Independently or as a hospital contractor, Healthy Alliance can provide its network of social service providers to New York payers in a streamlined way.

“The IPA was created so that we could enter into contracts with managed care organizations [MCOs] on behalf of our network of social care providers,” Coletti said.

Contracting is only the starting point.

Michele Kellythe organization’s CFO/CAO notes, “We are able to provide basic infrastructure and analysis to work with payers, CBOs and other entities on individual costs and services, to scale a new model that begins to project volume.”

Coletti adds that, for SDOH: “Claims don’t exist in social services today and we need to work with community organizations to figure out how to charge for services, like setting a case rate, a fee schedule and how they can cover their costs.”

“Health plans have plenty to do”

“Health plans are already forming and starting to contract with networks of social care providers,” says Kristen SchollVice President of Strategic Partnerships for Healthy Alliance.

She notes that this is required for Medicaid’s Value-Based Payment (VBP) program in New York and that national players like Permanent Kaiser and Etna, a CVS Health company, are creating their own closed-loop referral networks. Scholl believes, however, that social APIs convened on behalf of payers, community organizations, vendors, and other stakeholders are the best solution.

“Health plans have enough to do,” adds Scholl. “They try to meet so many state and federal regulatory requirements, Medicare Star ratings, Medicaid NCQA/HEDIS quality – so many requirements and standards”

“You want your limbs to be healthy in part to monitor your results,” says Scholl. “It involves reducing unnecessary hospitalizations and managing the total cost of care to improve the health of the people you cover with downstream benefits.”

A better model

Healthy Alliance believes its model enables health plans to move beyond a philanthropic SDOH approach to one that unifies and streamlines.

It is for these reasons that the Healthy Alliance Social API model is intentionally payer and population agnostic. Scholl thinks this is the direction payers should be heading in instead of creating their own social provider networks.

“MCOs are in an exciting position to develop a social care strategy that leverages referrals, data, and resources in meaningful ways,” adds Scholl. “It makes a difference for CBOs, who are often stuck between payers and members.”

Kelly adds, “Health plans also don’t have the resources to provide a CBO infrastructure. They’re not set up for it. Healthy Alliance provides monthly high-level contact support.”

Kelly also says, “Community organizations are being asked to move into a space they have never been involved in. Healthy Alliance is helping build knowledge and infrastructure related to billing, data and analytics. Why did they take the time to build this on their own?”

Government approval

Becoming a social API requires state government approval. In New York, it’s the same process by which medical APIs are licensed: first, by the Department of Health; then, the Department of Financial Services; and finally, the Ministry of Education. For example, the Ministry of Health requires this:

• API provides services in accordance with its contracts and remuneration agreements with MCOs.
• The IPA can be a corporation, a limited liability company (LLC) or a not-for-profit corporation which must identify its officers, members and their affiliations (eg health plans, health care companies).
• The states in which principals (if the API is a corporation or LLC) may be “licensed or approved to operate an HMO, IPA, PPO, or to provide health services or insurance.”

Unique and shared benefits

Healthy Alliance stakeholders include MCOs, clinical providers and health systems, as well as community organizations, the latter ranging from community organizations to schools and government agencies. Scholl notes that the main benefits of Healthy Alliance are common to several stakeholders.

“In a way, the Social API doesn’t need to be framed any differently for hospitals or payers since the goal is to contract with HMOs,” she says, adding, “Hospitals will have VBP agreements with MCOs that have SDOH components so that the IPA can provide social services as a sub-contractor of the VBP hospital contract.”

Advantages common to payers, providers and CBOs include:

• Mutual accountability and better alignment
• A platform to identify needs, track referrals and results
• Better outcomes and better care delivered at a lower cost
• More sustainable VBP SDOH investments with demonstrable ROI
• A streamlined approach that allows each stakeholder to focus on what they do best

Kelly adds, “The goal is to bring the whole network together.”