Nebraska Health Network Fine-Tunes Approach to 14 Value-Based Care Agreements

One of the 2025 Excellence Award winners announced at the recent National Association of ACOs (NAACOS) fall meeting was Nebraska Health Network (NHN), the ACO co-founded by two health systems in Nebraska: Methodist Health System and Nebraska  Medicine. Following the conference, Healthcare Innovation spoke with the Omaha-based organization’s CEO, Lee Handke, PharmD, M.B.A., and vice president of value-based care, Mallory Callahan, M.P.A.S., PA-C.

Formed in 2010, Nebraska Health Network has more than 3,600 primary care and specialty physicians and advanced practice providers working throughout the Omaha metropolitan area, Fremont and western Iowa.


Before joining NHN, Handke was the senior vice president, health network services for Blue Cross and Blue Shield of Nebraska. 

Healthcare Innovation: Is it fairly unusual to have two health systems coming together to form and oversee an ACO?

Handke: I would say it is unusual. The other one that some people know about is Delaware Valley ACO. I think it makes a lot of sense, because in a town like Omaha, there's so much partnership. There's so much sharing of referral patterns with specialties. A lot of providers were trained at the med center or at Creighton. For us, it's been a nice blend of having the strong support of the health systems, but it also allows us to do some of that peer-to-peer comparison, and no one wants to be second to their peers. So when we share data, it is a nice way for us to really encourage quality. 

Callahan: I think we are unique. Anytime we talk to other ACOs, which is pretty frequently, we get the same question. There are plenty of opportunities in the way that we steer our two large ships trying to get to the same location. There are obviously different paths that we each take to get there, but it definitely leads to unique conversations, and I think a lot of opportunity for us to do things differently. I see that within each of our strategic initiatives we're definitely handling things differently, with one being on the academic side [Nebraska Medicine], and one being more of that community focus [Methodist Health System].

HCI: The NAACOS award presentation noted that Nebraska Health Network participates in 14 value-based care agreements across Medicare, Medicare Advantage, Medicaid, and commercial plans. I was watching a panel session at NAACOS where leaders spoke about the challenges of managing a large portfolio of value-based models across multiple types of payers. What would you say is the most challenging thing about it? What kinds of infrastructure has your organization built up to manage that portfolio?

Handke: There are a lot of challenges there. One involves how we handle the numerous quality measures, across those 14 agreements. We have a centralized, integrated data warehouse where we bring in both claims and clinical data, so no matter what the payer is measuring or telling us in their reporting or displaying in their portals, we can see for ourselves where we have opportunities, and that may be a quality opportunity or may be a cost opportunity. 

We try to make sure the contract terms are fair, reasonable, and they're things that we think we can achieve. One example of that is recently, we saw some very disturbing trends in Medicare Advantage, so we went back to the payers and said we're not going to take on risk in these agreements at this point.

Callahan: Internally, we have a team of population health coordinators who are the experts in different contracts. We have that split out by type of payer, and then all of those lines of business. So, for example, we have a United Healthcare expert, and we have a Nebraska Medicaid expert, so they know the nuances of that contract language extremely well. They also are monitoring how our quality performance looks. Throughout the year, they are tracking if we could redo this for next year. What are the key contracting pieces that we would want to see change? We also do a lot of forecasting and modeling, looking at previous performance and trying to map out trajectories. I do feel like we've gotten a lot of sophistication in that in the last two or three years.
 
From a quality perspective, as Lee said, we do have at least 60 unique quality measures. I always joke that it'd be amazing if Blue Cross commercial and United commercial could agree on quality, but they don’t. 

We've created a chart of all of those just to show the magnitude of the number of quality measures and what each one is truly measuring. From that, we've developed what we call the Nebraska Health Network core quality measure set. It's a subset of measures. We have 11, and we're looking at what is the frequency in our different contracts, what is the clinical relevancy, so that we can see outcomes we want to look for from birth to grave — immunizations, annual wellness visits, so that we're really encompassing all different groups. In the data aggregator system, regardless of contract, for those core quality measures we're able to look at the ACO level, the TIN level, clinic level, down to the NPI, and generate gap lists so that if a group says breast cancer screening isn't something they care about, we can still make sure we're getting those individuals in for breast cancer screenings. 

HCI: I heard  that one of your hospitals groups is on Epic, and the other is on Oracle Cerner, and smaller clinics are on a multitude of other EHRs. How much of a complicating factor is that? Has working with a data aggregator partner solved a lot of those issues?

Callahan: We have an entire team focused right now on our MCQ [managed care quality] reporting and getting all of that information into our data aggregator system. What we started was Epic and Cerner having weekly feeds for those core quality measures, but then we've been able to expand to some other measures that have a large enough denominator that we can get to the payer. 

When I first started, we just had claims coming to us and very minimal EMR data. It's constantly evolving. Right now we're focused on getting more of that data in for our larger community clinics, and then next year, starting to focus on our larger specialty clinics. We have a full-time project manager who is looking at those different data pieces. I would love to say that that is history, but we’re definitely still learning. 

We're working through MCQs now and there are eCQMs [electronic clinical quality measures] in the future.

HCI: What about alternative payment models targeted at specific specialties, like in the kidney care space, oncology or cardiology? Do you participate in any of those?


Handke: We had one of our health systems, Methodist, participate in the optional bundles a few years ago. I think they thought the work they put into it was not worth what they got out of it. They backed out of that. 

Mallory and I are both excited to see the specialty programs come forward, because one of the flaws with value-based agreements to date is they've been so primary care-focused that our specialists really feel like they've been on the sidelines. In fact, we'll have our physician dinner meeting, and the specialists say, ‘Hey, I'm only going to come so many more times where I have to hear about childhood immunizations and wellness visits.’ We're excited that CMS is going in that direction. Even though those programs are going to be mandatory, I think as long as it's a fair playing field and we can work with our specialists to understand what we being measured by, and what opportunities we have, then we really welcome those programs that will engage the specialists.

HCI: But did you and your specialists look at earlier ones such as the Oncology Care Model or Kidney Care Choices?

Handke: We didn't at the time. I think we were just so focused on the basic value-based agreements. Probably, if those were introduced today, we may have had a different perspective on it. We still have opportunity in the primary care space to look at more of our risk-adjusted utilization measures, but we do have specialists who've been reaching out and are interested and asking what is coming out of CMS. 

Once we see some of these new programs come out in 2026, we'll be able to start looking at the data and where we would have our greatest opportunity.

HCI: The NAACOS write-up about your organization noted that you have worked on embedding community health workers into clinical sites. What kinds of things do they focus on, and does it involve screening patients for health-related social needs?

Callahan: That’s been a multi-year project. A colleague and I worked with the University of Nebraska Medical Center on a HRSA grant on recruiting, training and placing community health workers across the state. We were trying to look at how we could effectively screen for social determinants of health, and where might place these individuals so that we're maximizing that opportunity to show not only the ROI, but could we then sustain and scale this up? 

We looked at our data. One thing that we noticed was that there were certain pockets where ED rates were through the roof or inpatient conversion was high, but the risk was really low, so we thought this might be a good place to put in an individual who could do that screening. 

We worked with our health systems. We designed what that job description would look like, came up with funding opportunities from payer partners, and wanted to place them strategically to show that return on investment. 

We have a few community health workers who work in the emergency department, and they do screenings on patients there. We started with the ED, and these community health workers are now going in and out of the inpatient space as well, following those patients on their inpatient journey to try to shorten their length of stay if they're medically stable. They’re also going out into the community space. They're helping them if they need to sign up for Medicaid or they're having food instability or housing issues. 

What we found from our data is that patients who have those social drivers of health cost four times more than those individuals who don't, and they're utilizing the ED six times more. So we feel that the ROI is pretty significant. 

One challenge to navigate is how do we not only screen patients but pull those social determinant of health codes into the claims? Because they are not risk-adjusted in the current state, and some of those claims are truncated before then. So it's getting them to actually pull through onto our claims to show that full story. We've been doing mapping within each of our EMRs to have those questionnaires pull through to a Z code automatically.

HCI: The NAACOS award also said that you have established partnerships across the continuum, including with skilled nursing facilities (SNFs) and hospice and home health. Have you built a post-acute network and worked on them with quality?

Callahan: We have a post-acute care network that is comprised of skilled nursing facilities. Then in 2024 we brought in home health and hospice. We used a data-driven approach to identify who were the ones we had the highest referral basis with from our hospitals and developed criteria for them to be part of a preferred network.

We're really trying to make sure that at the time of discharge and at the time that referral is received that there's better insight into what that care transition looks like. We've developed scorecards that we share with that council on a quarterly basis that show what is their star rating, and how many patients they are accepting, what’s their length of stay, and what's their risk score. 

We're now starting on the same journey with home health to catch up with where our SNFs are, and starting to look at some of those key performance indicators. We shared our first scorecard last week, so I think there's still opportunity for us to identify other key performance indicators, but it has already spurred great conversations.

HCI: Did you have any overall impressions of this year’s fall NAACOS meeting in terms of trends?

Handke: Everyone's talking about reporting MCQMs and eCQMs, and how to navigate that. We're also looking at whether we should consider having more than one MSSP ACO based on membership. Should there be an advanced one and a starter one? We talked to some people at the conference who have done some work around that. I attended a great presentation on approaches to skilled nursing. So even though Mallory talked about how we have these networks in place, we realize we still have a lot of work to do there. 

Also, everyone’s waiting to see what's next from CMS. Unfortunately, with the government shutdown, we didn't hear directly from CMS. But a lot of people are preparing for what these specialty programs — for low back pain and coronary artery disease — will look like when they come out in 2027. The sessions are great, but I like the networking that comes with the conference as well, and just hearing what other people are thinking.