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Let’s start at the very beginning. What is value-based care and why does it matter?
So, what is value-based care. I tend to think about population health and value-based care side by side. And, in some ways, it’s value-based care is population health plus a payment structure that you find in value-based care models to create sustainability for those pop health efforts. So, when you think about population health, you’re thinking about groups of patients, whether that’s groups of patients by demographics, by disease state, by recent hospitalization. They’re all ways you can slice populations. And you’re thinking about caring for that group of patients. Now at the end of the day, population health is delivered one patient at a time, generally speaking, in my mind anyway. But, when you add value-based care to it, you’re creating an incentive structure that creates sustainability so that you can deliver the services you need to care for those populations of patients as they move through the continuum of care. So, from the outpatient setting, to inpatient, to home, to skill nursing facility, back home.
That’s a very broad definition, but when you dive a little bit deeper into value-based care as a clinician, I’m thinking about value-based care as a way to support resources that will assist me in caring for those patients. So, it’s not all falling on the physician or the advanced practice provider at the point of care in the office.
What is the triple aim and how does practicing value-based care help to achieve that?
So, the triple aim was coined back in 2008 and it really aims to do, as you might guess, three things. One, is to improve the patient experience of care. The second is to lower the cost of care. And then the third would be to improve quality or improve the health of populations. Value-based care, and as we discussed already, is perfectly suited to solve these.
So, if I start with improve the patient experience, or patient satisfaction. The fact that a patient is able to access a care team larger than just the provider and the nurse, I think, moves us in that direction. The other aspects of care when you think about, I think about my parents, so, and their encounters with the health care system. And how it’s been traditionally very disjointed. Still is. They live in a part of the state where value-based care is not really penetrated very well. And it’s very disjointed. My Mom gets information from her providers and her payors, and she’s confused. She doesn’t know what’s real, what she should respond to, you know, is this a scam, just all kinds of questions. So being able to reach into a care team on a consistent basis is very important. And especially for that generation. They don’t want to bother their physicians. We could have a discussion about whether that’s the right thing to do or not. But, that’s just the way she thinks. I don’t want to bother anyone. So having a care team whose proactively reaching out to a patient, especially following an important transition, goes a long ways towards bringing comfort and to that patient. And when I hear the stories from our Care Coordination team, including our social worker, the impact their having on patient’s lives is profound. They are addressing things that I as a clinician would never get into in an office visit. In part sometimes because I was afraid to ask the question because I didn’t have any resources to deal with what I figured the answer would be.
To improve the quality or improve the health of populations, so we’re focused on quality, closing care gaps. We’re focused on an Annual Wellness Visit, which is designed to allow a provider to look at a patient’s whole picture. So, where are they receiving care, do they know who their providers are, do they know who their durable and medical equipment providers are. Are they up to date on screening procedures and are they up to date on any...
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Today we’re talking to CHESS Health Solutions own Tammy Yount who shares her experience as a former practice manager and AHEC practice support coordinator to provide insight on why independent primary care providers, their practices, and especially their patients, will benefit from partnering with the right clinically integrated network.
Tammy Yount, welcome to the Move to Value podcast.
Glad to be here, Thomas.
Tammy, what are some of the primary reasons independent providers choose not to participate in Medicaid or why they might hesitate to increase their Medicaid patient population? Are there particular challenges they face in serving this group?
I think one of the biggest barriers is that we still are in this productivity mindset where that time is money paradigm and the goal was to maximize the amount of patients you could see within an 8 to 10 hour day in 15 minute slots. And so, when you think about the reimbursement rates of Medicaid, they tend to be the lowest reimbursement rates coupled with the administrative burden and the regulatory requirements with that. And then oftentimes you have unreliable payment schedules and meaning there may be delays and payments, or whenever there's budgeting shortfalls, or if there's a delay in payment because the state doesn't settle on a budget. Then you also have patients who are high resource demand, and then you have limited resources. So, when you're dealing with patients who have complex health needs or they have social needs or you're dealing with patients who you might need a broader provider network in terms of specialist and those specialists don't accept Medicaid. So you really are looking at a lot of complex issues that when you're thinking about in terms of the overarching population, it is just sometimes maybe the, for lack of a better analogy, the juice isn't worth the squeeze and we don't want we don't want to think of it like that because our patients, it should be patients first, but oftentimes it's a lot of resource intensive and time intensive work.
North Carolina's managed Medicaid program is a significant shift for many providers. Can you tell us why this new model represents an opportunity for independent providers, particularly when it comes to improving care quality and practice sustainability?
So really, as we move away from this productivity model of healthcare into this paying for value, the Medicaid managed care model has incentivized providers to provide quality care. And they reward them for meeting performance metrics and improving patient outcomes. And the model also allows for per member per month care management fees. So advanced medical homes who meet certain requirements are able to receive these care management fees. And they're able to address the medical, behavioral and social needs that align with the holistic care delivery model. And then also they have included some enhanced reimbursement models and shared savings models where they're allowing for value based payments and risk based contracts that can provide for more, like, predictable revenue streams and then the backbone of all of this is the infrastructure and access to resources that we didn't have prior to Medicaid managed care launched and the plans now offer support for population health management in the form of like data sharing. We have claims data, we have risk data, we have pharmacy lock in data, all of these data sharing has allowed us to be able to risk stratify the patients, align our efforts to those patients who need more intensive care management. We've also have some innovative models like the healthy opportunity pilots that allow the plans to pay for social determinant interventions, things that we weren't able to pay for before. So really it is moving to a more holistic and accountable and value-based care models.
That’s interesting. Well, from your perspective,...
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Today on the podcast, we talk with Rebecca Grandy, Directory of Pharmacy at CHESS Health Solutions, about the connection between diabetes and chronic kidney disease, the populations who are at risk, how to address any concerns, and what tests and interventions are available to the provider.
OK, so, Rebecca Grandy, welcome to the move to Value podcast. Could you start by explaining the connection between diabetes and chronic kidney disease and why it's so important to screen for these in diabetic and or for chronic kidney disease in diabetic patients?
Sure. You know, diabetes is one of the leading causes of chronic kidney disease. I think there's lots of reasons for that. A lack of early screening, a lack of just knowing what to do, having accessible medicines. But all of those things now we have relatively good screenings, we have medications and so kidney disease and diabetes is present preventable. And then just from a, you know disease, state perspective, diabetes itself, the high glucoses, the inflammation on the high blood pressure, obesity, all of those things also increase your risk for chronic kidney disease and so you'll see a strong correlation between those two.
And you know, it's also proven that minorities are disproportionately affected by chronic kidney disease and what steps do you think can be taken to address that as we start looking into our social determinants and our HealthEquity components of the quintuple aim?
Wow, that's sort of a can of worms type of question, right? Because you know, when I think about minority populations or even just disparities in healthcare, I think there are lots of reasons for those. One is access and so primary care I think is the solution for that. And so being able to solve access issues to primary care, there are also issues like social determinants of health issues and so thinking through a lot of the work that ACOs are doing, like the REACH model, care coordination, social work, really being able to not only screen for social determinants of health, but to actually have solutions for those. And so I think that's happening slowly. You know, those screenings are starting to be incorporated into primary care, but if we can address some of those issues, I think we can solve access issues. The harder one in my mind to solve is sort of the historical like trauma and distrust that comes with minorities in the healthcare system. That one's harder, but I think. I think you know having minorities go into positions where they are providers, right? So I can see someone who culturally is like me, who looks like me, who I know has my best interest at heart. I think a lot of those pipelines for minorities to be healthcare providers, are really helpful as well.
Yeah, I think that's definitely true. So some of our data at CHESS shows that you know up to 40% of people with diabetes do develop chronic kidney disease. Can you explain why early screening is so critical and how it impacts the progression of that disease?
And I feel like I have to tell a story first. So, you know, when I was working in primary care, one of the most, I don't know, frustrating's the right word, but definitely discouraging things is when you see someone sitting in front of you that has a chronic condition that could have been prevented, right? And I feel like chronic kidney disease is one of those preventable conditions because when you have chronic kidney disease and you progressed in stage renal disease and you're on dialysis that kind of takes over your entire existence, right? Like those people are going to dialysis three times a week, you have to be really careful about the nutrition, about your protein intake. You have to be careful about all your medicines. You can't just go to your cabinet and reach for your ibuprofen. And so the fact that something that you know can be so significant or impact your lifestyle that...
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In this episode we hear more from NCAHEC’s Chris Weathington about the inevitable integration of behavioral health and primary care and the need to realign incentives and alleviate some regulatory burdens so practices can find service enhancement opportunities to remain viable and more accessible to the patients they serve.
I promised you we would get back to the behavioral health. And so I want to dig in a little bit there. As you know, the North Carolina was chosen as one of the states to participate in Making Care Primary. I know your team has done a lot of work in helping practices get information and making that determination whether that is right for them. Medical health integration is a critical part of that program. And you mentioned the collaborative care model that you all do and to support. Can you talk a little bit more not only about your collaborative care model, but also if you are seeing or envisioning that there'll be more integration behavioral health either because of making care primary or do you feel maybe it's that that may confuse it and maybe it slows down? What are you seeing?
Well, great question. Just one more thing. You asked an earlier question, what practice managers potentially could be proud of. I, I think this day and age is everything to be successful is not an individual that is accountable for success. It's true. It's truly a Team. So practice managers who are able to not only recruit but retain a family of high performing team members. I always appreciate practices that have kept their staff for many, many years. And I know that's very difficult this day and age, but those that are able to do it seem to be the ones that are most successful in keeping the doors open and delivering high quality care. But as you talk about behavioral health, that that is something I'm very passionate about. I do myself, do not have a behavioral health background, but I am drinking the Kool-aid if you will. And it's because a few years ago, the North Carolina Department of Health and Human Services Medicaid came to AHEC and said, hey, we would like to see what we can do to encourage or foster primary care to adopt behavioral health. Because as we all know, when a primary care provider sees someone with a behavioral health need or condition, they often have to refer out. And referring out is very, very hard these days with the limited workforce to take care of folks with depression or anxiety or some other behavioral health need. So what we did is we developed a training curriculum of courses and also offer learning collaboratives for practices that are interested in implementing the collaborative care model and also implementing best practices. So we have a course catered towards individual components of the work and the collaborative care model is pretty simple. It is basically a PCP, your primary care provider working in conjunction with a behavioral healthcare manager and a psychiatric consultant to screen and intervene for patients with mild to moderate depression, anxiety, and also pediatric ADHD. And there's some other behavioral health conditions that you can add to that mix, but that that's pretty much the foundation of the model are those diagnosis. But one cannot truly close the quality-of-care gaps that are present with transitions of care or diabetes or hypertension or some other chronic disease when you're not, when you're not really treating the patient holistically, both mind and body. And we tend to do to detach what is going on in the mind with what's going on below the neck. And, and so the collaborative care model really helps address that. So we've seen a lot of pediatric practices to raise this model and COVID really pushed it where this need has been more recognized. Maybe it's partly because of the social isolation we've had during COVID. Part of it is probably, I...
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In this episode we hear from Chris Weathington, Director of Practice Support for North Carolina Area Health Education Centers, about how his organization provides training and resources to enable practices to focus on value rather than spending time on administrative burdens, thereby freeing up providers to better focus on patient care.
Chris Weathington, welcome to the Move to Value podcast.
Well, thank you for having me.
Great. So Chris, for our listeners that may not be familiar with you, can you give us a little bit, tell us a little bit about yourself and your background?
Sure. Well, I, I'm the director of practice support at North Carolina Area Health Education Centers, otherwise known as NCAHEC. I'm originally from Eastern North Carolina in small town called Winterville in Pitt County. My background is I've been working in Health Administration for a very long time, mostly working in a large health system but working largely with primary care and in the field of practice management and business development over the years. I've worked extensively in rural health helping providers figure out how best to survive and thrive with value-based care. So my educational background is about a master's in Health Administration and Bachelor of Science in public health from UNC Gillings School of Public Health. So, I'm a true Tar Heel, but I've been in North Carolina my entire life.
Great. That's great background, Chris. Thank you. And go Heels. So, you mentioned currently you're the director of NCAHEC practice support. Tell us about NCAHEC. Give us a little bit more and specifically what your role is and what your team that you ever see does.
Sure. Well, North Carolina, AHEC was established in the early 1970s. It's been around for about 50 years. It's a state agency. Our program office is based out of the UNC School of Medicine and we have 9 regional AHEC centers located throughout the state, many of them part of large health systems and some that are independent 501c3 not-for-profits. So they're geographically dispersed in Asheville, Charlotte, Winston Salem, Greensboro, Raleigh, Wilmington, Greenville, Rocky Mountain, Fayetteville, and Greensboro. And the mission of AHEC is to recruit, train and retain the state's health workforce. As you know, we have significant health workforce challenges if we didn't have them already prior to COVID. So practice support is one of several offerings or service lines, if you will, to fulfill that mission. So in practice support, we are committed to helping train and retain the state's health workforce. So working largely with practices in rural and underserved areas, primary care safety net providers such as FQHCs and rural health clinics and health departments, specialist and behavioral health providers, helping them to stand on their own two feet and working in doing that in partnership with accountable care organizations and CINs such as yourself over at CHESS. So that's really what we're all about. And in the value-based world, while practices are working in the Fee-for-service model, which still is around maybe a little bit less, but it's still largely there, helping practices not only function in that environment, but also survive and thrive with value based care. And that's hard and it's hard work, but that's what we're committed to do.
That's a great mission and, and you guys do great work. I love meeting with you and hearing about how things are going throughout the, the state and healthcare. You guys have a great pulse on that always. And as you mentioned, one of the things that you guys or one of the areas you really focus on really is in the rural communities. And as you know, much of the care in North Carolina is...
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In this episode we hear the second half of the conversation with Franklin County Public Health Director, Scott LaVigne, in which he shares his views on the role of properly addressing behavioral health, providing a positive patient experience, and the importance of partnerships, and how these elements, and others, work together in order for his team to provide holistic care for patients.
I want to go back a little bit to something you mentioned earlier. So we talked, you talked about the needs-based care, what I call the contextualized care and Medicaid is very focused on serving the whole patient, right, which includes some of those social determinants of health. And, and we've talked about access and access to behavioral health is really important. How's Franklin County Health Partner Department partnering or attempting to partner with other agencies to address these needs?
Well, one of the things that when I first came down here that that I just said we really needed to do was get our medical staff. And by that I mean everyone from the person that greets somebody when they walk in the door and checks them in to the person that works through everything with their, their claims and submitting and all the financial pieces of all that interaction from start to finish and everything in between that we had a trauma informed and, and with a focus on integrating behavioral health and, and behavioral health is a broad term. I should probably break that down because it's used a lot in different contexts. I don't look at it as a way of, of sanitizing mental health. So I look at it as a collection of mental health and substance use disorder and, and really what we wanted to focus on here and it and it goes to the social or social determinants of health. We wanted to focus on the whole patient, not just one aspect of that patient. I know I don't think I've ever heard of patients say that they felt their life was better because they met all their HEDIS metrics.
Me either, by the way.
But what, what we did and what I, I did do almost immediately was we purchased an outcome measurement tool because I knew that one of the things that we want to do is we didn't want somebody to have all their screenings done, you know, meet all those metrics like that on the healthcare side, but have housing insecurity and be living in domestic violence and to have substance abuse and mental health problems. Because I know as a mental health provider and a substance abuse provider in my background history that most of the people that show up in emergency rooms with preventable emergency room presentations are people that have mental health and substance use disorders and other things on board or have experience childhood trauma. So we knew that if we didn't look at that whole picture and integrate that in, we were going to have a hard time doing that. So we pulled an outcome measurement tool from behavioral health. It's called the DLA 20 and it, it focuses on 20 areas of a human's existence. And we wanted to make sure that if somebody experienced a good positive health outcomes, that translated into all these other areas as well. And that became our outcome measurement tool. So that was a big piece of what we focused on. Let's see. The other thing I mentioned already was we wanted to do more screening. We, you know, we do screenings routinely as a health department. We have to spend more time with patients because of our funding than providers in the community do. That is a blessing because we have budgeted time to take into account all of what we need to do, and that fits very nicely with a more holistic approach. So it really wasn't causing us to suffer a lot in the volume department. And we focused all our efforts. And I told everybody here, you know, one of the things we want to focus on is the equation of value. And yeah, you got to have a certain amount of volume to make that equation...
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Today we hear an important conversation about the role of local government in population health and wellness. Scott LaVigne, Public Health Director of the Franklin County Health Department in North Carolina, talks with CHESS vice president, Josh Vire, about the broad scope of work his team is responsible for and how they are successfully tackling numerous initiatives, including managed Medicaid, to be a safety net provider for community health needs.
Scott LaVigne, welcome to the Move to Value podcast.
Oh, it's great to be here.
We're we're really excited and looking forward to the conversation. Scott, as a public health director, you're responsible for all aspects of the Franklin County Health department from the clinical to environmental services and you balance state mandated services. So for the audience that things like vaccines, basic health screenings, environmental services, and with the expectations of Franklin County government, all while dealing with the critical workforce shortages. Health departments are considered safety net providers in most of North Carolina's counties. Can you share how your team is addressing the specific healthcare needs of the Medicaid population in the county?
Sure. Well, after hearing all that, I'm, I'm getting tired. Yeah. That that is a we have a lot on our plate here at the health department and a lot of they're, they're not very often competing interests. But you know, I think what we look at when we talk about healthcare services in general and the overall health of the county, we don't break it up into per SE Medicaid population, although we do focus on that as part of the work that we do. But we, we have 2 broad missions and one is obviously population health and that it cuts across all payers and everyone in the community. And then the other role, which you correctly identified as we're a safety net provider. So in addition to putting out a lot of population health initiatives, we're also a provider and we're involved in a lot of the initiatives that all the providers in the community are involved in. So, you know, that gives us a unique position and we get to tailor some of our initiatives as a healthcare provider based on what we know the community health needs are. So it's, it's, I'm going to be honest, it's not very easy to do all of that. I would say we, as I said, we don't just focus on the Medicaid population, but we do have a lot of initiatives that cut across all of that.
Great. What are the specific issues that that I think you have a lot of experience in close to 30 years of behavioral health experience with much of that coming in New York. Can you describe the changes in public health that you see in your career and maybe also for the audience contrast the differences between the public health in New York and North Carolina. What are the differences you've seen?
Sure. Well, when I was in New York, I was a a mental hygiene director for a county and, and when I came to North Carolina, I became a public health director. But we were actually in the same building in New York with our public health programs and we had a very close relationship with that program. But there are some significant differences, but a lot of similarities. You know, the some of the big differences though relate to some of what we're talking about. Medicaid managed care being a big one in New York. Medicaid managed care started first with medical care and then they brought behavioral health and IDD into the picture. In North Carolina, they did it the exact opposite. And so that that was a, a big difference. When I came down here, we had a mental hygiene system that had already made the conversion and was and, and medical care, which is what I was now in, we had to make that shift. So, I would say that was a, a big difference. But in New York, most of the public health agencies had gotten out of providing...
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In this episode, we hear the second half of the conversation between Kris Shepard, Senior Vice President at Advocate Health, and CHESS President Dr. Yates Lennon, as they discuss how physician networks and primary care services are the backbone of the value movement in healthcare.
So Chris, welcome back to the Chess Move to Value podcast. Look, look forward to continuing our earlier conversation.
Awesome. Well, had a good time so far and I'm expecting nothing less for the second, second-half.
OK, great. Well, let's start out the second-half here. Just let's talk a little bit about some of some business development goals, both from the lens of the MSOVSO and from Advocate perhaps as well as if I'm an independent physician in the market, whether that's the Carolinas, Georgia, Wisconsin, Illinois, what should I be thinking about? So come at it from both sides.
It's a great, great question. The, the starting point for me is really an acknowledgement that the healthcare industry is changing. And you know, we've, we've talked about change and transformation in healthcare for a long time. So this is I think part of that broad continuum in the future, I expect that there will be increasing, it would be increasingly important for the ambulatory enterprise to take on more of the care delivery then perhaps we have historically it's more and more expensive to build hospitals. I think you, you know, you see a lot of commentators talking about hospitals becoming more focused on kind of higher acuity, higher complexity things. And so you know, they're always going to be here. And we're, you know, we are building broadly in facilities across the advocate enterprise and investing in, in improvements in the facilities. And at the same time, it's going to be increasingly important for the ambulatory enterprise to take to take on more and more. Some of that is is is has a regulatory dimension to it. So for example, CON laws being loosened or removed in in South Carolina, North Carolina, perhaps other places. I think those those kinds of regulatory changes, reimbursement changes that that encourage certain certain types of procedures and certain care to move out of facilities into the ambulatory setting. All those I think point us toward a future where to for a health system we are going to need to be successful in that ambulatory space as well as as as with our facilities. So what does that mean from a physician you know, or a clinical enterprise development lens, a physician partnership lens? I think those relationships become even more important and and in some ways more challenging because there there are a lot of organizations, whether they're payer backed organizations or private equity backed organizations or public companies like an Amazon who are moving into that ambulatory space. There's almost nobody going into the facility areas, you know, not a lot of new money or new entrants, if you will, into in building hospitals, but they're definitely a lot of new entrants rolling up ambulatory practices. So, you know, from a strategic lens advocate can either, you know, choose to focus on, on the facilities or, you know, alternatively, what we've done is, is really geared toward building a significant ambulatory presence. And you know, we, we already have thousands of physicians employed, you know, hundreds and hundreds of clinic sites. We, we have a significant ambulatory presence already. But it's going to it's going to be increasingly important going forward to do that. And I think, you know, some of the some of the discussion we've already had about what's the right relationship within it with a given group and a given specialty is those, those questions become more significant when you think about how the industry is, is trending.
Yeah, Yeah. Let's let's head toward, I mean MSOs/VSOs are networks in and of themselves. But let's talk a little bit about physician...
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Today hear from Kris Shepard, Senior Vice President of Clinical Enterprise Development and Core Market Growth and Physician Partnerships at Advocate Health. In a conversation with CHESS President, Dr. Yates Lennon, Kris talks of how Management Services Organizations benefit patients and creates opportunities for practice growth and professional development for providers.
OK, Well, good morning, Chris. Glad to have you on the chess Move to Value podcast. Look forward to our conversation today.
Good morning. Yeah, great to be here.
Good. So Chris, I'm looking at your title clinic, SVP, clinical enterprise development and core market growth physician partnerships. Tell us what you do.
I do a few different things. And as that title probably implies, sometimes I'm working on your plain vanilla physician practice acquisitions. Sometimes I'm working on acquisitions that are not so plain vanilla in a more complicated in a larger scenarios, something particularly unique. And then I work on a range of other physician partnership transactions, professional services arrangements, as well as working on management services opportunities that we see with groups. And we really view that clinical enterprise development as, you know, broadly designed to look at our physician networks across the Advocate enterprise and and pursue what we think will work in a given market, a given specialty. And so that's why it's a fun job to have. I get to be creative and yeah, engage with people in a very different settings and try to put together things that that are appropriate in the right context.
Yeah, never a moment of boredom, I would imagine with that much variety. Well, you, you, you touched on managed services. You know, there's a lot going on today with various managed services organizations as well as what you might call value services organizations. Talk to me a little bit about sort of at a high level, what do you think the opportunity is in the MSO slash VSO either or both market today?
Yeah. I think I'll, I'll come at it from the perspective of physician groups that we talked to pretty regularly And you know, different groups have different needs. But one of the realities that seems to be hitting a lot of, you know, physician owned practices is that they don't necessarily have the scale to keep up with whether it's, you know, physician practice infrastructure needs or, or it's and, or the value-based care capabilities that they need to be successful. And so, it's, you know, two different buckets that are that can be addressed through management services and value services arrangements. But that's the reality. I think practices used to be able to kind of, you know may do just fine on their own. I think there are a variety of factors playing in to the challenges on independent practices now, payer relationships and kind of reimbursement challenges that exist, the cost pressures that are hitting every everybody, especially in the healthcare industry, kind of inflationary factors. And then there are things like, you know, EMRs are expensive. It's expensive to fend off cyber-attacks, to have the right cyber security frameworks in place, to make sure that you can you can continue in operations, to have the best revenue cycle, the best supply chain options. All those are things that are I think increasingly challenging even for the larger physician practices out there. So there's a, there's a scale factor there, same kind of themes with respect to value services. I think it, it takes a lot. There's analytics platforms, there's teams of people to support, to support a practice in, in delivering care the right way and then being able to record that and have that be a parent in quality metrics that get reported and cost metrics and, and everything else. So I just think, I think it's this moment. And from a, you know, I work for Advocate health for the health...
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In this episode, we hear the second half of the conversation between CHESS Vice President of Value-based Operations, Josh Vire, and Wilson Gabbard, Advocate Health Vice President of Quality and Condition Management, who discuss the importance of partnerships with payers and implementing value based care practices with all patients, even if they aren’t in a value-based arrangement.
Wilson, thank you so much for being willing to stick around and continue this conversation. I really appreciate it. Wilson, you had just talked about on our last episode, you, you talked about clinician engagement, that relationship management and that activation. And, and this is something that I think you guys have been leaders in for a while in the Midwest. You your team not only supports the Medical Group of Advocate, but also support a large CIN that includes a significant number of aligned independent physicians in the area. Can you talk a little bit about the challenges of supporting aligned physicians versus the Advocate Medical Group?
Well, absolutely. And thanks again, Josh for inviting me to participate in this forum. So, I think, you know, we certainly don't have all of this figured out. I'd be lying if I said we did, but I think many of our listeners will probably appreciate the challenge that it is to operate in both of these worlds. And in our space, especially here in Illinois, it's especially pronounced. I think we have over 830 aligned clinics that participate in our clinically integrated network. And so the challenge that we talked a little bit about last time or about the data exchange and data exchange barriers is incredible, especially at that scale. But I think true clinical integration is really hard to accomplish without strong data and handoffs. And so I think we've leaned into this space of trying to bridge that gap with data exchange efforts. Again, time back to some of the work we're doing in ECQM reporting to kind of bridge the gap between those aligned DMRS and our data warehouses so that our reporting is as accurate and as timely as possible. That we are reaching out to patients for Medicare Wellness visits, annual Wellness visits. But when we can go in and see in an electronic means that they're already scheduled for those Wellness visits that we aren't, that we build off of care plans when we're doing care coordination activities that their PCT and their instances of EMRs have already documented. And so that is very hard work. And again, we're not completely there yet. If anyone listening has figured it all out, please add me on LinkedIn and give me a call because I'd be happy to hear from CIN who has figured it all out from the provider-based space. But anyway, it's certainly a challenge, but I think that it has applications across what we do in quality or condition management or utilization management. And I think that all of the principles about clinician activation that we talked about last time and kind of building out those teams and points of contacts are critically important to translate those messages that we do. I call it internally, I call it we have one strategy with different flavors, right. We have a flavor that is applicable to our internal clinicians on their instance of their EMR. And we have a different flavor that is applicable to the clinicians who maybe are on dozens of different EMRs.
Yeah, that's, that's great. It's I will accept your modesty, but also toot your horn a little bit. That why you guys may not have it figured out. You, you guys just evidence here in this conversation are pretty good at it and are probably more advanced than a lot of the other folks. And, and really impressed every time I talk with you guys about how you approach and work with your line providers. It's not an easy thing to do. We've been at this for a long time as well at CHESS and, and, and I think you highlighted accurately some of those challenges. So I appreciate...
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In this episode, CHESS Vice President of Value-based Operations, Josh Vire, talks with Wilson Gabbard, Vice President of Quality and Condition Management at Advocate Health, about how to gather and present meaningful data to providers in an easy and accessible way which enhances their delivery of better patient care.
Well, Wilson Gabbard, thank you for joining us on the Move to Value podcast.
Thanks, Josh. Thanks for having me. It's good to be here.
Great. Wilson, I know you have a wealth of knowledge, both population health and value based care. Can you just start by giving our audits an overview, a little bit about you, your background, where you've been, what you've been, what you're up to today, and your responsibilities at Advocate Health?
Yeah, absolutely. Well, again, Josh, good to be here. You know, value our friends and colleagues at CHESS and have long followed all the great work that you all have done. And so, it's a privilege to be here. Again, you know, by way of background, I'm a former practice operator, used to lead clinic operations in Eastern North Carolina and had the privilege of kind of pivoting into a population health focused role back in 2013. So, over a decade ago now helping build out some of this work in a prior life. And you know, over the years it's been really interesting to see the evolution of value and how we've gone to taking on more risk and building out more sophisticated programs and blending together Medicare Advantage and MSSP or different value-based programs together to ultimately really just better serve the patients and clinicians that were really just privileged to be able to serve on a daily basis. So, you know, today what I'm up to is here at Advocate Health, I have the pleasure of leading quality and condition management efforts as part of our enterprise population health structure. You know, we think about value-based work and kind of the formulaic equation that is driven based on three main components, which are quality, utilization and premium and lives. And how we do that, how we operationalize that is really around the two functions that I again have the privilege of kind of serving in or related to the quality and condition management work and have the again opportunity to do that along a really amazing physician dyad, who I feel very privileged to work alongside as we implement some of these programs.
That's great, Wilson, thanks for that background and I'm glad to share that with the audience. You mentioned you've been you've been at this for a while, you're very well versed on what drives and improves contracts in value-based care. So really excited about again having you here and could you go a little bit layer deeper in what is condition management and documentation? What does that mean specifically at Advocate and a little bit about what your how your role plays in supporting value-based care efforts.
Yeah, great question. I think that our approach to value and again I think value-based care is you know the corollary or antithesis maybe is the wrong word, but to fee for service, right. As we move from fee for service to value, we think about the premium and lives component that I mentioned earlier about ensuring that we are receiving the appropriate reimbursement for the patients that we're caring for. And the way that CMS, our government programs have implemented that financial model and value is through a risk adjusted payment mechanism. But at the end of the day, the way that we think about risk adjustment here at Advocate is that risk adjustment really at its core is just a population health fundamental that ensures that it's really, it's all about ensuring that patients and their conditions are not lost to care. In value-based care, I love that the focus is not about on widget counting, but rather on caring for conditions, ensuring that those...
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In this episode we finish our conversation with Rebecca Grandy, Director of Pharmacy at CHESS, and learn how pharmacists can overcome barriers to issues in patient care through tools such as prior authorizations. We also talk about how CMS doesn’t consider pharmacists care providers and how resolving that will lead to greater efficiency and better outcomes.
So Rebecca Grandy, welcome back to the Move to Value podcast. Glad you could stick around and continue this conversation about pharmacy services with us.
Thank you.
Rebecca, last time we were talking about all kinds of great things and how a pharmacist is such an integral part of the care team and we talked about collaboration with clinical providers and other healthcare professionals. One of the things I wanted to talk about is prior authorization because that's prior authorization for medication is crucial in value-based care. Can you explain to us a little bit about the process and any, I don't know, administrative burdens that might be there and how do we address these to make sure that our patients are getting timely care?
Sure. You know, I think if you were to ask some of our physician or provider colleagues, they would probably say prior authorization is a four-letter word, right? However, I do believe that as we think about value based care and we think about cost effectiveness, we have to have some sort of process or I'm blanking out here Thomas, we have to have, we have to have some sort of process or way to guarantee that the medicines we're using are going to be cost effective. So, when you think about prior authorization, that's really the intent, right? Usually they're for expensive medicines or they're for medicines that can potentially have lots of side effects or that have very specific clinical niches, if you will. And so I do think they're necessary. However, more and more medicines are needing prior authorizations now, and that's really created an administrative burden for our providers and provider offices That has gotten to the point actually where Congress is sort of intervening at this point. And there's lots of legislation over the next few years, you should see that process get better. So for example, if I'm a physician and I want my patient to have a very specific diabetes medicine, so there's some diabetes medicines that need prior authorizations, I send the prescription. And for most of our providers, they're not even going to know it needs a prior authorization until the pharmacy sends either a fax or an electronic prior authorization back to that office. So I may not even know. So my patient has already left the office. I tried to send in their prescription. Now I get kicked back from the pharmacy saying, OK, this needs a prior authorization. So you can already see in this example, you sort of set yourself up for some dissatisfied patients and some for dissatisfied providers. And so once I get that prior authorization paperwork, someone has to complete it. And in my experience, I've actually had experience doing prior authorizations. If you don't dot every I and cross every T, you're not going to get it approved and you're going to get a denial. You may not know about it, you know, for several days or even several weeks, depending on the insurance and depending on the priority. And so now you have a patient that's sort of left in the dark because they don't know why they can't get their medicine from the pharmacy. The pharmacy's saying why I sent the paperwork to your provider. They need a prior authorization. The physician offices has no idea where it is in the insurance queue. And so you take that and you compound it with the fact that every insurance has a slightly different process, every medicine is a slightly different process. You have to log into external portals which are not part of the day-to-day workflow. And so the administrative burden, again, it's just a...
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Today we continue the discussion between Yates Lennon and community health expert Randy Jordan, about how good health is typically achieved through a good clinical home, which has always been an insurance discussion but now should shift to a discussion about the uninsured who need the knowledge about where to go when sick, to increase savings in the cost of caring for the entire population.
OK, All right, Randy, thank you for sticking around. Our first conversation was fascinating. Looking forward to continuing that. I think you've touched a little bit on the next question I have for you, but we'll maybe expand a little bit more. Tell us about you talked about the health, the safety net and being that term being used pretty widely and you I think listed out free and charitable clinics, FQHCS, rural health clinics as sort of the network. I think I might have left one out. So fill, fill that in for me. But why is it so important? Why? Why is the health safety net so important? And to one of my earlier questions in the first session, why does it not get more attention than it does?
Well, I think added to the list Yates would be public health units and school-based health centers.
There you go.
You know it. It's a fascinating question that you're asking because I think to those who work in the space, it gets all the attention in the world. It's built around mission minded folks who want to see this issue of the uninsured being taken care of. If, if we just pause for a moment and look at all the energy that was brought to North Carolina recently about Medicaid expansion, it brought all kinds of groups together. But it was in that case, it was for the intention of getting a health insurance card in the hand of people in need. That same passion though, exists for those that are in the business of trying to, to provide healthcare services to uninsured patients. And so at one level there's a lot of attention to it, but at another level, there's, a real absence of attention. I don't think it's because people don't care. I think it's because we've not informed them well enough. And it's one of the things I appreciate, appreciate about the chance to be on your podcast today is when the message gets out, people are good hearted, they'll respond in the right way. But we do need to get the the message out. We need to get it out to policy makers. We need to find ways for that voice to be united. And that's, you know, those are some things that I'm also working on in my spare time.
Awesome. So you, you mentioned in the first session the hospital in Jacksonville that worked with the free and charitable clinic. Can you talk to us a little bit about how the Medicaid, the the health safety net can be strengthened? What, what, what needs to happen? What are some ideas and needs for strengthening that safety net?
Well, we mentioned a number of times Medicaid already today. One of the strong ideas that came out of Medicaid transformation was a recognition that social determinants of health are important for good health. And so we're talking about housing, food insecurity, transportation, and basically protections against family violence and other forms of interpersonal violence. So the Healthy Opportunities pilots that have sprung up across the state, three of them now have identified and brought together sort of the safety net of social services. It's a wonderful thing and we celebrate it. But it because it applies only to Medicaid, that access to that network is not organized in a way to also apply to the uninsured. And I think that that's one challenge that that lays ahead for us is finding a way to leverage what's being built in the Medicaid system and apply it to the uninsured. Now here's an interesting thing. If you look at the demographic of, of most Medicaid patients, it's very, very similar if not identical to uninsured patients. The it's all income
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Today we get to know Rebecca Grandy, Director of Pharmacy at CHESS Health Solutions, and learn how a clinical pharmacist is an integral part of the care team, not only for improving patient outcomes by being the medication expert, but also by developing relationships with patients and using psychology to ensure medication adherence, resulting in better outcomes at a lower cost.
Rebecca Grandy, welcome to the Move to Value podcast.
Thank you for having me, Thomas.
So, Rebecca, why pharmacy? Can you tell us your story of how you came to be in the role that you sit in today?
I ran out of time and ran out of options, but it was one of the best decisions that I think I've made in my career. I think like a lot of folks who go into healthcare, when I was in high school, I really enjoyed science, really enjoyed math, was good at it and wanted to use those skills, you know, to be helpful to get back to the community. And so when I was in high school, I actually thought I wanted to be a pediatrician because I loved kids, worked at summer camps. I just thought that would be, you know, a great career to combine the things I was good at and the things that I enjoyed. And so then when I went to college, I remember being in my intro to biology class and I walk in and it's a class of like 400 to 500 people and they all want to be physicians. And I'm like, well, I don't really know why I chose pediatrician. Like it just felt like the right fit. I grew up in a rural community and so I think my knowledge of careers and job options was pretty limited, right? And healthcare physician, nurse, that's what you do. And so after being in that intro to biology class and seeing everyone, wanted to be a physician and I was like, well, you know, I'm going to keep my options open, not put too much pressure on myself and just sort of see where I end up going. And I decided to get a biology and chemistry in undergrad. And I knew that would really prepare me for anything in healthcare that I wanted to do. And so I just spent the next few years in college shadowing, learning, volunteering. I volunteered with physical therapist, pediatrician physical therapist. I did respiratory therapy, I did high risk dental clinics, I did medicine, spent some time in an inpatient pharmacy and really never found what I felt was a good fit. And so in my junior year, end of my junior year, I was like, OK, I was like, I'm graduating in a year and I need to make some decisions here because with a biology undergrad degree, you're sort of limited. I knew I didn't want to be a teacher and I didn't want to work in a lab. So I was like, OK, I got to do something here. Luckily, at the time, my roommate, her boyfriend, and a good friend of mine, his dad was a consultant pharmacist. I had never heard of that. You know, really when I thought about pharmacy, I thought about the folks who work in retail, CVS, Walgreens, you know, Walmart, grocery store, and really didn't know much more about pharmacy. I had spent some time in the inpatient pharmacy at UNC Hospitals volunteering, but I was literally taking expired drugs off the shelf and getting rid of them. That's what they needed. So I was willing to do it, but it wasn't that exciting. And so she was like, well, have you looked into pharmacy? So being the per type of person I am, I go to the library, I pull all these books about the career of pharmacy and I'm reading about all the different options. And I'm like, OK, I'm like, I like science, I like math. This pharmacy thing seems like it could be a good fit because I'd already ruled out some of the other professions. And so I ended up applying and I got in. So again, it was sort of that I had explored lots of options, really ran out of choices. I felt it was something that I could be good at, and there were lots of options. And that's how I ended up in pharmacy school.
Nice. And after pharmacy school, what?...
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Today we hear a conversation between CHESS President Yates Lennon and community health expert Randy Jordan, who is the current Chief Advisor of Impact for Health at Next Stage Consulting. We listen as they discuss Managed Medicaid, funding the health safety net for the uninsured, and how different types of healthcare organizations can work together in a sustainable way.
Alright, Randy Jordan, welcome to the Chess Move to Value podcast. We're thrilled to have you here today. Look forward to our conversation.
Well, thank you, Yates. It's really good to be with you and with your audience today.
Awesome. So why don't you just start by telling us a little bit about yourself, what you do today, and then your journey through the healthcare maze to get to where we are today.
Be glad to starting with today's probably the easiest part because the rest is kind of a winding path. But today I'm working as a healthcare consultant with consulting practice out of Charlotte by the name of Next Stage. It's an interesting place to work. They have a great vision and mission for helping local communities and underserved populations and that's why I'm there. But prior to this current role, I had started out as a young man as a pharmacist practice pharmacy in the state of Florida come from a long line of pharmacists. So healthcare runs as a deep strain in my family history. After running a pharmacy, community pharmacy for a while, I ended up going to law school and decided to become a healthcare lawyer and that was a really interesting time in my life. I learned a lot from that experience and then moved on to become involved in nonprofit work and spent nearly 20 years working for an international faith-based charity out of Philadelphia by the name Hope Worldwide. And the last seven years I was that organization CEO. And then most recently, having moved to North Carolina eight years ago, I accepted the role as CEO of North Carolina's Free and Charitable Clinics Association. And that gave me a real great sense of the local flavor of North Carolina safety net. So that's how I got here today through that windy path. Always, always focused on healthcare, Always, as I look back, always focused on trying to help others.
OK, that's an interesting story. I know you spent a little bit of time in Cambodia. Can you tell us a little bit about what you did there and then we'll come back to that I think more a little bit later in our conversation, but really curious about what that was about and what you learned there.
Yeah, I, I actually never lived in Cambodia, but had a a strong period of work there. It started at the beginning of my time at the international charity, where I started as the general counsel, and the first assignment there was to put together a joint venture between Japanese Shinto priest, a journalist from Time magazine, and the CEO of our charity. And so that was an eclectic mix right there. But the purpose of that mix was to open up a free care hospital in Phnom Penh. Cambodia was named after the king and its purpose was to help people that didn't have access to healthcare. At the time, Cambodia was one of the poorest nations in Southeast Asia. They were spending about $2.50 per year on those that live there. They had undergone a horrible genocide through Pol Pot, and it was a very unique chance to get involved in that country. We brought up that first hospital in Phnom Penh. In the course of that work, there developed three free clinics in order to help support that hospital because some of the patients were able to pay a small amount and then finally open another hospital in the South of Cambodia in a little in a town by the name of Kempat. But all very formative experiences for our conversation today.
Wow, really interesting. So in your role as the CEO of the North Carolina Association of Free and Charitable...
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Today, we're discussing Care Management in Managed Medicaid with Tammy Yount, CHESS Application System Analyst. We'll explore why it's essential for organizations to tailor their care management programs to fit their own unique needs, so they can holistically focus on the patient while optimizing value in healthcare.
Tammy Yount, welcome to the Move to Value podcast.
Thank you Thomas, for inviting me and I'm happy to be here.
So, Tammy, let's talk about care management in managed Medicaid. How does a care management program save money and healthcare?
I would say that saving money is one goal of a care management program. However, I would offer that the goals of a care management program should align with the triple aim that's born out of the 2001 Institution of Medicine report Crossing the Quality Chasm. So that report underscored 3 aims, if you will, one primary aim and two secondary aims. So the primary aim is to improve the health of populations with the secondary aims of improving the patient experience of care and at the same time reducing the per capita cost. So these are lofty aims given our current healthcare landscape and the payment models that we exist in. Not all organizations are the same. You have some large organizations that have a plethora of resources and smaller organizations with very limited resources. So each organization has its own unique structure and individual challenges and there's no one-size-fits-all care management program. So I would say there are many ways to build a care management program that will allow you to achieve the triple aim and organization needs to find the blueprint that works best for them. So when an organization's doing the right things, measuring the right things and focusing on improving the right things, the cost savings should follow. And I believe it was W Edward Demmings that said it best, you know, manage the cause, not the result. That's not to say that the organization doesn't need to have a clear understanding of the underlying processes, cost drivers, the population characteristics. He also said if you can't describe what you're doing as a process, you don't know what you're doing. And my favorite quote for him is in God we trust, and all other things bring data.
Tammy, tell me, how would a practice create a care management program?
So it's a bit of a chicken and egg conundrum when you're trying to create your care management program, you need many things in the least of which is data. I would say you need to start with the data, but few organizations have the data to inform their program design. Most organizations design their care management program backwards, meaning they design the program around the resources they have versus identifying the resources that they need based on the characteristics of the populations they're managing. So I would say the first thing you need to do is collect data and evaluate the data. So from the data that you've captured, then you would begin to develop your road map for how you're going to operationalize your care management program. And these would be very specific to each organization because each organization serves different patient populations, has different resources and different needs.
What are the keys to a successful care management program?
It's going to depend on who you ask. So I'm a data person, so in my world, all things starting in with data. But if you were to ask the payer, the nurse, the CEO, the CFO, the CIO, and most importantly, the patients, their families or caregivers, you're going to get a different response and varying perspectives. For a care management program to be successful, it's going to need to combine all of these perspectives. And critical to any successful program is having a mission, vision and values. And you'll need to operationalize your plan with those elements. And so...
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It’s patient experience week here in the United States, and we have asked CHESS President Dr. Yates Lennon to share his story about how, as a practicing provider, he took the time to listen to feedback from his patients and implement changes which not only led to better patient experience scores but shed new light on the importance of value-based care.
Doctor Lennon, welcome to the Move to Value Podcast. Would you share your story about being a provider and how you came to realize the importance of the patient experience in health care?
So, my name is Yates Lennon and I am an ObGyn by training, practice, private practice, obstetrics and gynecology from 1993 to 1998 in Hot Springs, Arkansas and then in 1998 moved back to North Carolina, which was home, to practice in a small private practice in Asheboro, North Carolina. From 98 until 2008, we were a small independent group for physicians at at most. And in 2008, our group really saw the early, phases of value-based care coming. We saw, the landscape of regulatory requirements, changing quickly and, and understood that keeping up with that was going to be a significant challenge. We were one of the first ObGyn practices as a small group to go on to, electronic health records. So, we did that, and actually we did that in 2002, I believe. But then in 2008, as we really sort of started seeing the handwriting on the wall, we felt like we needed to join forces with a larger organization that could really help us keep up, stay abreast of what was happening while we continued to focus on delivering care to our patients.
So in 2008, we merged our practice into what was then Cornerstone Health Care, based in High Point, as we merged in and became a part of that organization around 2011, I had expressed an interest to the leadership at that time of becoming more involved in an administrative capacity of some sort, did not have a particular path in mind, but but knew that I had always enjoyed the administrative side of medicine and, and running a small practice. So, I was asked at that time if I would consider taking on an overhaul of the patient experience for the Cornerstone Group. So, we formed a multidisciplinary team, included, physicians, advanced practice providers, CMAs, nurse assistants, nurses, office managers, front desk staff. The throughout the whole organization, through all levels of the organization came together and formed a group, that later was named peak, patient expectations are key. And in the course of that, I really began to see, how important patient experience really was. And, and even though I had practiced for a long time, I never really thought that much about the patient experience of care. Fast forward another year or two. Cornerstone had begun the their first efforts at a patient experience survey, which was done online.
Prior to that, it was a paper survey, and it was handed out at the desk to patients. So not incredibly random. We employ a employed, a large provider that, did these online surveys. And I was actually very excited to see my first survey. I had a large patient panel, had a good reputation in the community, and was excited to see these first results. Unbeknownst to me, when they came in, our office manager took it upon herself to post them at the back door, and I came in and saw my scores and they were by far the worst of anyone in our practice, and I was devastated. I went through all of Kubler-Ross stages of grief in the span of about 15 minutes. But following that, I decided, you know what? There's a message here. So, what is that message? What What are my patients trying to tell me? are kind enough to fill out the surveys, tell me how I'm doing. I need to be wise enough to listen. So, I started assessing what a visit in my office actually looked like. I thought the the highest standard was efficiency, that if I was efficient and always on time, that that would be what made everyone happy....
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Today we listen to a conversation that began at the North Carolina Hospital Association’s winter meeting between Bamboo Health Senior Director of Growth, Ellen Solomon, and CHESS Director of Value-based Operations, Rachel Holder. Ellen and Rachel get together for the podcast to continue the discussion on the topic of Navigating Value-based Care through Real Time Intelligence.
RH: Thanks so much, Ellen, for joining us today. So can you give us a really brief introduction about yourself, your role, and tell us a little bit about Bamboo Health?
ES: Yeah, sure. Thank you so much for having me, Rachel. It was great getting to chat with you at the North Carolina Healthcare Association winter meeting. But for folks that don't know me, my name is Ellen Solomon. I'm senior director of National Health System growth at Bamboo Health. I've been here for six years and I currently live in Charlotte, but I always love calling out to my North Carolina customers. I was born and raised in a small town of Reidsville, NC And so in terms of what we do, folks in North Carolina may remember us as patient ping or Appriss Health. We've since come together and rebranded as Bamboo Health back in 2021. And I'll first start again with sort of who we are at a very high level and then I'll go into North Carolina as well as obviously how we work with you guys, Rachel. But in one sentence, Bamboo Health is an intelligent care collaboration network across all 50 states. The problem we work to solve is that as you know better than me, healthcare was built on silos. Those silos could be the EMR that you use, your geographic location, state lines or the setting of care, whether that's acute post, acute, ambulatory. And those silos make engaging patients and coordinating care in real time very difficult. And even more difficult when you're actually trying to bend the cost curve and improve patient outcomes like readmissions, Ed utilization, post acute length of stay and many others. And so in short, I compare Bamboo Health to expedia.com. You have all these hotel chains, you have all these airline companies that are competing for your business. They operate their own platforms, their own tools and they don't really want to share with each other. But Expedia brings them together in a really simple way and that's where Bamboo Health sits. And so today in North Carolina, we support our customers really in three use cases. The first one which we'll drill into more I believe in, in this discussion and how chess uses Bamboo is we enable value based care use cases through our engaged admission discharge and transfer or ADT network. And in North Carolina specifically over 80% of the hospitals in the state participate. We have over 800 post acutes, over 50 provider organizations. And this actually started back in 2017 when we partnered with NCHA who's really been instrumental in helping us build out this ENGAGE network. That network does extend to all 50 states. Secondly, we partner with the state of North Carolina as well as 45 other states to support prescription drug monitoring or PDMP program to help continue to curb the opioid epidemic. And then lastly, we're rolling out a behavioral health referral network also known as BH scan in the state. So I think the, So what their common thread between all those use cases is it's real time actionable and through an engaged network. And so Rachel, I know when we spoke at NCHA, Chess has been such a long standing bamboo partner. You all have really been with us from the beginning. I'd love if you could share more about some of the challenges you're hearing from your value partners as they're transitioning into more risk and value based care.
RH: Yeah. Thanks so much Ellen. So I think gone are the days that just a high AWV rate and some...
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In this episode, we listen in on a conversation between Mountain Valley Hospice Senior Vice President of Strategy and Innovation, Maria Hayes, and CHESS Health Solutions Senior Director of Clinical Operations, Dr. Kim Vass Eudy, about End of Life Care, the difference between palliative care and hospice care, and how Providers can utilize these services.
KVE: Well, thank you and welcome to the Move to Value podcast. I am really excited to bring a guest with me today. Her name is Maria Hayes. She is the Senior Vice President of Strategy and Innovation at Mountain Valley. I am excited to speak with her because in my clinical team, we are working towards bringing advanced care planning to our value partners and their patients. And Maria and I have been working kind of behind the scenes talking about this. So I really want to bring that conversation out forward Maria and I'm really glad to have you here today.
MH: Thank you. I'm super excited to be here. Thank you for the invitation.
KVE: I was hoping you could kind of kick this off by telling us a little bit about palliative care and Hospice care. I know as a clinician, when I make a referral, sometimes I just do a bucket referral, I say just give them palliative or give them Hospice, whichever one this patient qualifies for. So maybe you could help me understand and our listeners understand the difference between the two.
MH: Absolutely. And I can actually start off by kind of giving you a little bit of an overview about Mountain Valley, if that will be helpful. And then I'll kind of go into Hospice versus palliative care. So, Mountain Valley is a Hospice and palliative care organization serving 18 counties across North Carolina and southwestern Virginia. We were established in 1983, so we just celebrated our 40th anniversary. Headquartered in Dobson, NC, we provide care in a large service area with six Hospice offices, 4 serious illness specialist locations and two inpatient Hospice care centers. We also have two Hospice thrift stores. We call them the Humble Hare and those stores actually benefit our charity care programs.
Palliative care is a little bit different than Hospice care. So palliative care is a specialized medical care for people living with a serious illness. This can be cancer, heart failure, lung disease, dementia, Parkinson's disease or ALS. Patients in palliative care may receive medical care aimed at easing their symptoms along with treatment intended to be aggressive or curative. Palliative care is meant to enhance a person's current care by focusing on quality of life for them and their family. In addition to offering support to ease symptoms, the palliative care provider also specializes in leading and navigating the goals of care discussion, which we kind of referenced earlier. We help patients consider or even complete their advanced directives as well. Our palliative care providers are serious illness specialists who add another layer of support and work as a part of the patient's medical team. So that's kind of how palliative operates in, in that form or fashion.
KVE: I was going to ask you a lot of times, I know that a patient may start in palliative care and then transition to Hospice is and I know you're going to explain a little bit more about Hospice. Is that a pretty natural transition for a lot of patients?
MH: It is sometimes for patients. We see a lot of patients that truly can be Hospice, but they actually choose palliative because they feel more comfortable still kind of seeking their curative approaches, still seeing their medical doctors still treating their heart failure with the heart failure medications and they really kind of they're just not ready for that Hospice conversation. And but typically I would say palliative and Hospice, we really like to focus on the six months or less for their life span kind of looking at all those factors and then...
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In today’s episode, we visit with Josh Vire, Vice President of Value-based Operations at CHESS Health Solutions, who shares his insights on managed Medicaid and how CHESS leveraged years of experience to enter into Medicaid to create an all patient solution.
Josh Vire, welcome to the Move to Value podcast.
Thank you, Thomas. Thanks for having me. Pleasure to be here.
So, Josh, let's talk about managed Medicaid. First, can you tell me what is managed Medicaid?
Sure. It may be easiest to start by sort of describing how traditional Medicaid works. In traditional Medicaid, typically this operates under what's called a fee for service payment model. This model is going to reimburse providers directly for every service that they provide to Medicaid beneficiaries. And generally the upside to this model is that it's going to allow for the flexibility and provider choice for the beneficiaries. But what we often see is that this leads to fragmented care and ultimately the incentives in this fee for service type model really incentivizes the volume of services over outcomes. So, in contrast to that, Managed Medicaid utilizes alternative payment models including capitation and what are called value-based payments. And the way that the capitation works is that a managed care organization or a MCO as they're referred to will receive a fixed monthly payment per Medicare beneficiary that's going to cover all their health care needs. And then that fixed payments are paid regardless the amount of services that are provided. And then those MCOs are going to use those funds to incentivize providers to be more cost effective in their care as well as incentivize sort of tighter coordination of the care. And then what they can layer on to those, as I mentioned, is the value-based care payments which are intended to reward providers based on the quality and outcomes of care rather than just the quantity of services provided. And so in theory, right, this would encourage more efficient, high-quality delivery of care. In addition, managed Medicaid may employ other payment models that are along that continuum of value based care payments, which could be like pay for performance or bundle payments. But really the goal there is to align the incentives to focus on driving down total cost of care as well as improving health outcomes for beneficiaries.
Well last December North Carolina made the transition to managed Medicaid and Chess spent the year prior to that establish establishing the infrastructure and beginning to make preparations to offer this service. Can you tell me why this decision was made and a little bit of the story about how Chess built this service line.
Absolutely. CHESS has a decades plus long history of working with providers to transform care delivery to value based care. And historically our focus has been on traditional Medicare, Medicare Advantage and commercial contracts. But as we went through our engagements with our value partners and then as we began to have discussions with providers across the state, we heard consistently that one of their pain points was the need to work with of having to work with multiple enablement companies to serve all their patients. So some enablement companies only work with MA or maybe the traditional Medicare options or commercial. But no one was really acting as sort of a one stop shop in in serving the entire patient population for these providers. So our decision to expand our services to include Medicaid was really driven by our desire to be what we call an all-patient solution, which essentially just means we want to be able to align incentives across the provider's entire patient population. And really that's because we believe this is how true transformation can and will occur, not in certain segments, but by treating all patients with an eye towards that cost containment and...
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