Business Model for Umbrella Hub Arrangements

UHOs may take the following actions to improve health equity:

• Negotiate reimbursement rates with payers which promote and sustain efforts to both deliver the National DPP lifestyle change program and incorporate HRSN screening and referral into enrollment processes.
• Ensure accuracy of participant data, including demographic data which can be used to inform health equity strategies.
• Consolidate and evaluate enrollment data across the UHA to determine effective referral pathways and retention strategies.
• Verify UHA legal documents contain components that support health equity.
• Engage CBOs that provide services to address HRSN.
• Support subsidiary organizations to adapt and tailor the National DPP lifestyle change program curriculum for priority populations (e.g., language translations and/or curriculum updates for older adults).
  • The Association of Asian Pacific Community Health Organizations (AAPCHO) Pacific Islander Center of Primary Care Excellence assembled community collaborators and trusted subject matter experts to adapt the National DPP PreventT2 curriculum to incorporate health beliefs and cultural approaches specific to the Native Hawaiian and Pacific Islander communities they serve. They also worked with Lifestyle Coaches to translate curricula into five Pacific languages spoken by populations served in the Continental U.S., Hawaii, and the U.S. Affiliated Pacific Islands. All available translations of the National DPP Lifestyle change program can be accessed on the Curriculum page of the Coverage Toolkit.
• Provide training and support to subsidiary organizations to understand and incorporate processes centered on working with priority populations and improving health equity.
  • The Hawai’i Primary Care Association (HPCA) UHO holds regular meetings with their subsidiary organizations which include presentations and trainings on topics relevant to their participant population. These presentations are provided by subject matter experts at HPCA or partner organizations like the University of Hawai’i School of Medicine and include topics like screening for social determinants of health (SDOH) and caring for older adults. As part of their organizational operations, the HPCA UHO ensures that subsidiary organizations regularly conduct SDOH screening of National DPP lifestyle change program participants to connect participants to appropriate resources. These meetings provide opportunities for subsidiary organizations to present challenges faced by their populations of focus and ideas for recruiting traditionally hard to reach populations.
• Confirm UHA evaluation metrics contain measures intended to monitor and ensure progress in UHA efforts to address HRSN.

Subsidiary organizations may take the following actions to improve health equity:

• Hire and train staff who are representative of and from the community they are serving, including individuals able to speak commonly spoken languages and understand cultural practices with a high-level of competency.
• Screen participants for HRSN and provide resources to meet participant needs.
  • Within their internal platform, Trellis/Juniper has incorporated the Accountable Health Communities SDOH Screening Tool developed by the Centers for Medicare & Medicaid Services (CMS) Center for Medicare/Medicaid Innovation. Through their platform, subsidiary organizations can either screen participants for HRSN or refer them to a Trellis/Juniper community health worker who will complete the screening on their behalf. Once completed, participants can be connected with resources available to address HRSN.
• Provide perspectives unique to populations of focus.
  • Understanding that food security can be negatively impacted when households have limited access to working appliances, the National Kidney Foundation of Michigan (NKFM) UHO is providing Instant Pots with culturally appropriate recipes as program supports to National DPP lifestyle change program participants who meet certain program milestones. Tailored to unique participant needs, NKFM subsidiaries also offer gift cards to local business which supply groceries, gas, clothing, or household goods.

State health departments and conveners may take the following actions to improve health equity:

• Communicate regional health equity goals to implement with partners.
• Connect UHAs to funding streams and/or concurrent initiatives or interventions for addressing HRSN.
• Facilitate data sharing to help the UHO understand population needs.

UHA costs include (but are not limited to): (1) costs associated with operationalizing a UHA and (2) costs associated with maintaining the UHA. To help understand costs needed to operationalize a UHA, a Cost Study was completed at the beginning of the Umbrella Hub Demonstration. The three Demonstration UHOs tracked time for each staff member and costs for project activities from August 2020 through July 2021. Some of these tasks included initial UHA planning, recruiting, and contracting with subsidiaries, executing the Medicare Diabetes Prevention Program (MDPP) supplier application, and engaging with a billing partner.

The 12 months of data captured in the Umbrella Hub Demonstration Cost Study only represent part of the time and activities needed to establish a UHA. The three Demonstration organizations began activities at staggered intervals. HPC and HPCA began in March 2020, followed by Marshall University in August 2020. As a result, the Demonstration organizations’ statuses and milestones achieved during the cost study period vary. An estimate of the aggregate activities of the three Demonstration UHOs during this period is provided in the graphic below.

Each UHA is unique. The tasks, activities undertaken, and staffing described in the Umbrella Hub Demonstration Cost Study reflect start-up processes for each Demonstration UHO. The Umbrella Hub Demonstration Cost Study may or may not be representative of what other UHAs are able to achieve in a one-year period. More learnings related to costs of operationalizing a UHA will be added as they become available. Additional costs for UHAs to consider are indicated below. However, there may be other costs UHAs incur that are not captured.

Potential Start-up Costs:

• Staff time to identify and recruit subsidiary organizations
• Staff time to complete the CDC National DPP UHA Application for CDC-Recognized Organizations
• Staff time to identify and contract with a billing vendor (or confirm in-house billing capabilities will meet the needs of the UHA)
• Staff time to access payer reimbursement. For example:
  • Complete the MDPP enrollment application;
  • Enroll in Medicaid, if coverage is available; and/or
  • Contract with private health care payers
• Legal counsel associated with developing and executing contracts (see the Contracts section of this page for more information)

Potential Ongoing Costs:

• Staff time to engage with a billing vendor, support claims submission, and maintain Diabetes Prevention Recognition Program (DPRP) recognition
• Staff time to maintain accuracy and upkeep of relevant databases needed by contracted payers
• Staff time for ongoing engagement with subsidiary organizations, including support for technical assistance
• Costs associated with increasing the sustainability of the UHA (for more information see the Sustaining Umbrella Hub Arrangements page)

Revenue from Payers and Other Funders

Unless the UHO has enough capital to set up the UHA, the UHO may need to secure start-up funds from external organizations. Potential funders, public or private, can help launch a UHA by supplementing costs before payer reimbursement reaches sustainable levels.

UHAs may use a multi-year approach to achieve sustainability. For example, the UHA could use grant funding or other funding sources to operationalize the UHA and a combination of grant funding and payer reimbursement in subsequent years, eventually reaching the goal of the UHA operating primarily on payer reimbursement from a diverse payer mix.

Payment from Subsidiary Organizations

Accepting payments from subsidiary organizations may be critical to helping the UHO offset the costs of operationalizing and sustaining a UHA. UHOs will likely charge the subsidiary organizations a fee for the administrative services provided. UHOs are encouraged to discuss the following both internally and with subsidiary organizations.

• UHO payment collected from subsidiary organizations: UHAs have flexibility in how the fee is structured and how much subsidiary organizations will contribute to offset costs of the UHO’s administrative functions.
• Costs associated with the billing vendor: The UHO can determine whether to build these costs into the payment subsidiaries make to the UHO, or to pass the costs through to subsidiaries per the vendor’s fee schedule.
• Timing of payments from subsidiary organizations: The UHO has flexibility in setting up the payment process. The UHO could carve out its required payment before distributing the health care payer claims reimbursements to subsidiary organizations or receive a payment from the subsidiaries after passing on full reimbursements to subsidiary organizations.

UHOs are encouraged to be in transparent dialogue with subsidiary organizations when making decisions about payments.

Contracts

Contracts detail the expectations, roles, and responsibilities for each entity in the UHA. The figure below illustrates the contracting arrangement used in the Umbrella Hub Demonstration, though each UHA may be unique in its contracting arrangement.

For an additional example of how the different contracts and agreements can join a UHA together, please see the Diagram of Contracting in the Umbrella Hub Demonstration.

The following sections describe example content in the various UHA contracts.

Contracts Between UHOs and Billing Vendors:

• Expectations for both parties on claims submission and other types of data submission, including timelines and responsibility for data accuracy and completeness
• Expectations for the payment amount and timing of payment the UHO will make to the billing vendor
• Expectations for how the subsidiary organizations’ data can be used

Contracts Between UHO and Subsidiary Organizations:

• Expectations for subsidiary organization payment to the UHO for administrative services and/or vendor fees
• Expectations on subsidiary performance related to CDC- recognition parameters

Business Associate Agreement Between Subsidiary Organizations and Billing Vendor:

• Expectations for use of private health information and compliance to Health Insurance Portability and Accountability Act (HIPAA) standards
• Expectations for payment amount and timing of payment the UHO and/or the subsidiary organizations will make to the vendor

For examples of business associate agreements (BAAs) between all UHA participants, please see the two sample BAAs below.

• Provide enough time and resources for contracting efforts: Demonstration UHOs found that the contracting process took more time than originally anticipated. In general, it took around a year to operationalize a UHA including contracting between entities.
• Hire a lawyer or use in-house legal counsel to assist in contract development and review: Demonstration UHOs noted legal teams were a valuable resource for resolving language concerns and other concerns in their contracts.
• Develop HIPAA-compliant processes: At least one Demonstration UHO provided HIPAA training to their subsidiary organizations and found secure ways to store and share data.

Charters

Although a charter is not required, having a shared agreement on the structure and operating principles of the UHA can establish a shared vision for the UHA. Additionally, the charter can state the UHA’s goals and outline the roles and responsibilities of the UHO, the subsidiary organizations, and the billing vendor.

For examples of charters between a UHO and subsidiaries, please see the two sample charters below.

• Collaborate with subsidiary organizations to develop a charter: Demonstration UHOs worked closely with their subsidiary organizations to develop a charter. Collaborating on the charter builds trust between the UHO and subsidiary organizations and helps establish agreement on the mission of the UHA.