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HCC V24 to V28 Transition Explained: Risk Adjustment, Coding, and Value-Based Care - TaSonya Hughes

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Content provided by CHESS Health Solutions. All podcast content including episodes, graphics, and podcast descriptions are uploaded and provided directly by CHESS Health Solutions or their podcast platform partner. If you believe someone is using your copyrighted work without your permission, you can follow the process outlined here https://ppacc.player.fm/legal.

In this episode of the Move to Value Podcast, we take a deep dive into one of the most impactful updates in healthcare risk adjustment: the transition from CMS-HCC Version 24 to Version 28. Our guest, TaSonya Hughes, CHESS Health Solutions’ Manager of Coding and Documentation Education, explains what the shift means for providers, coding teams, and care managers—and why now is the critical time to prepare.

CMS-HCC Version 28 introduces new disease classification categories, retires thousands of existing diagnosis codes, and emphasizes greater specificity in clinical documentation. TaSonya walks us through how these changes affect Medicare risk adjustment, the financial sustainability of value-based care, and ultimately, the ability to deliver accurate, coordinated care for patients with complex chronic conditions.

  continue reading

82 episodes

Artwork
iconShare
 
Manage episode 489630454 series 3335700
Content provided by CHESS Health Solutions. All podcast content including episodes, graphics, and podcast descriptions are uploaded and provided directly by CHESS Health Solutions or their podcast platform partner. If you believe someone is using your copyrighted work without your permission, you can follow the process outlined here https://ppacc.player.fm/legal.

In this episode of the Move to Value Podcast, we take a deep dive into one of the most impactful updates in healthcare risk adjustment: the transition from CMS-HCC Version 24 to Version 28. Our guest, TaSonya Hughes, CHESS Health Solutions’ Manager of Coding and Documentation Education, explains what the shift means for providers, coding teams, and care managers—and why now is the critical time to prepare.

CMS-HCC Version 28 introduces new disease classification categories, retires thousands of existing diagnosis codes, and emphasizes greater specificity in clinical documentation. TaSonya walks us through how these changes affect Medicare risk adjustment, the financial sustainability of value-based care, and ultimately, the ability to deliver accurate, coordinated care for patients with complex chronic conditions.

  continue reading

82 episodes

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Today we revisit an interview with Tim Gallagher, a leading voice in Medicaid transformation and value-based care. With Medicaid policy currently dominating headlines, it is important to hear from someone with firsthand experience as both a policy expert and a parent navigating the system. Tim offers sharp insight into how managed Medicaid can drive equity, improve outcomes, and create sustainable partnerships.…
 
In this episode of the Move to Value Podcast, we take a deep dive into one of the most impactful updates in healthcare risk adjustment: the transition from CMS-HCC Version 24 to Version 28. Our guest, TaSonya Hughes, CHESS Health Solutions’ Manager of Coding and Documentation Education, explains what the shift means for providers, coding teams, and care managers—and why now is the critical time to prepare. CMS-HCC Version 28 introduces new disease classification categories, retires thousands of existing diagnosis codes, and emphasizes greater specificity in clinical documentation. TaSonya walks us through how these changes affect Medicare risk adjustment, the financial sustainability of value-based care, and ultimately, the ability to deliver accurate, coordinated care for patients with complex chronic conditions.…
 
In this episode of The Move to Value Podcast, guests Jennifer Houlihan and Jennifer Gasperini join us for a deep and wide-ranging conversation on the evolving landscape of value-based care. We explore North Carolina’s leadership in Medicaid transformation, the critical role of provider voice, and the infrastructure needed to support long-term success. From navigating administrative burdens to anticipating federal policy shifts, we also discuss how health systems can stay nimble, build smarter data strategies, and engage patients in more meaningful ways. Whether you're a provider, policymaker, or system leader, this episode offers timely insight into where healthcare is headed—and what it will take to get there.…
 
CMS Changes and the Future of Value-Based Care Jennifer Houlihan and Jennifer Gasperini of Advocate Health discuss the impact of new CMS and CMMI leadership, current challenges in value-based care, and the future of ACOs, ECQMs, and Medicare Advantage. A timely conversation for anyone navigating the evolving policy landscape. Welcome to the Move to Value Podcast, powered by CHESS Health Solutions. In this episode, we’re joined by Jennifer Houlihan, Vice President, and Jennifer Gasparini, Director of Policy, from Advocate Health’s Population Health Team. Together, we unpack the implications of the recent administration change, explore what new leadership at CMS could mean for value-based care, and hear their perspectives on the legislative priorities they hope to see take shape. Thomas Royal Jennifer Houlihan, Jennifer Gasparini, welcome to the move to Value podcast. Jennifer Gasperini Thanks for having us. Jennifer Houlihan Happy to be here. Thomas Royal So you both just attended the NAACOS conference? Can you tell us what are some of the hot topics that folks were talking about? Jennifer Gasperini I can get us started. I think it's always great to see colleagues at the NAACOs conference and was also great to see Kim Brandt, who is the deputy administrator and COO at CMS, come and share some of Doctor Oz's priorities. For CMS and I think a lot of those priorities align really well with value based care. So they they really spoke a lot about tackling fraud and abuse. And as you know, ACOs are really the early identifiers of fraud. And so really was pleased to see them talking about that and also using technology and better data really for beneficiaries and providers to advance care. And I think ACOs obviously are very focused on that goal as well. Jennifer, do you have anything else to add there? Jennifer Houlihan Yeah. There, in addition, there were some really good sessions on the new team model, the transferring Episode Accountability model as well as guide and a lot of thoughtful conversation around how to integrate these models into the ACO and a clearer path for outcomes there. So I think there was a great discussion and got to give kudos to Jennifer. She was part of a really well attended and fantastic panel on how ACOs are adapting ECQMs and MIPCQMs and some of the kind of demands and multiple issues that are impacting ACOs on how to do all payer adjustments leveraging some of these requirements. So a lot of really timely topics and I think then the kind of final was Specialty Care integration, I think continued to be a recurring topic that we need to think more deeply about that and and how those get nested within cost, so hopefully we'll see more about that in the future. Thomas Royal So there is new leadership in place at HHS, CMS and CMMI. What does NAACOS think this might signal for the future of value-based care? Jennifer Houlihan Sure, I I can. I can jump in on that one first, so I think you know, looking at Abe Sutton, you know, as as Jennifer mentioned, Kim Brandt was there from CMS. But we've also seen with Abe Sutton's appointment, who's been a strong supporter of value-based care. I think the mood was mostly positive, that there has been sort of a lot of statements, whether it's in some of the confirmation hearings, or direct statements that value-based care and the need to achieve savings is is one of the priorities. I think there's gonna be some different thinking about more aggressive requirements for more savings and as as as we've seen already, some of the model review that's already taking place. The ability to kind of end models early if they're not achieving the outcomes and the savings. So I think the mood in general is Value is still a strong part of CMS and CMMI’s agenda just the way some of the models will shape up and some of the strategic priorities, I think we're still waiting to see what that looks like. And Jennifer, I don't know if you have more to add on that. Jennifer Gasperini Yeah, Ditto on all those points. And of course the new leadership is very focused on MAHA or making America healthy again. and I think value really fits in that lens. And so hopefully we'll see more focus on prevention and Wellness and maybe even some new models that are introducing new concepts around prevention and Wellness as well, hopefully, but we do expect to see more from the new leadership team at CMMI on their strategy in the coming months and that will be really telling, I think, in terms of what their spin on value and their focus will really be. Jennifer Houlihan And I'll just talk. I mean, we did one of the first signals we saw was in the new the the 2026 proposed inpatient rule and team. The team model is is remaining as a mandatory model. And so I think there were, there are some early signals, but as Jennifer said, we're really waiting for that strategic refresh and then more really frankly announcements on any what the, the future model changes will be. Thomas Royal Interesting. So. So my next question is a bit duplicative, but I'd like to know what stands out to you about the new head of CMMI and how do you see his vision shaping programs like ACO REACH? Jennifer Gasperini Yeah. Yeah, I think like you said, you know, I'll be a little repetitive here, but I think well, Abe Sutton, you know does have experience in value models. So that is very helpful and has experience working in the first Trump administration. But I I think his knowledge of value based care will help shape the new strategy at CMMI and the agenda at CMMI and tying that work obviously back to Maha goals is something that we really expect. Jennifer Houlihan I mean, you asked specifically about ACO reach and I think we've been hearing lots of rumors. We've heard everything from the could ACO REACH be extended. Will it be replaced by something like the a revised Geo contracting model? I think there's a lot of what if scenarios right now. So it's hard to say. But as Jennifer said, Abe Sutton does have a lot of experience. He was the architect of some of the kidney care models. And so I think that's where we're wanting to also see what's next for full risk models, but again also with an eye towards how are we thinking about specialty integration and some of these full risk models. And so I think there might be some good alignment opportunity there as well. Thomas Royal So historically, how has leadership turnover at HHS impacted innovation models and payment reform initiatives? Jennifer Gasperini Yeah, I think so, the impact has been pretty minimal in the past. There's always a period of reorganization, of course, when new leadership comes on, they identify new priorities. They typically issue a lot of RFI’s or requests for information to gather feedback from stakeholders, and we're really already experiencing those things now. I do think we'll have a lot of opportunities to share input on future direction and maybe what we feel hasn't been working, especially in the vein of regulatory relief. That's an area they've been really focused on initially, but you know, obviously we are losing some staff that is has a lot of institutional knowledge. And so, I think. Time will tell in terms of, you know what the the true impact is on the programs. Thomas Royal Yeah, 'cause, there's definitely been a wave of layoffs across the healthcare policy space. And so how are these reductions in force impacting value based care programs, especially ACO reach? That's one thing that's that's come up as as we've been out having conversations with folks, boots on the ground and how that's going to be impacted. You have any thoughts about that? Jennifer Houlihan I mean some of the impacts in addition to staffing are coming through changes or directives from the executive orders. So I think that is having an impact and maybe that is to the extent that we're seeing it now, maybe that's a difference between previous administration turnovers and transitions versus now is the amount of executive orders and some of the directives. I mean I think for ACO REACH, I'm not as directly involved with it, and I know Jennifer is more so maybe can speak more directly, but I think some of the staff is definitely still there and they're trying their best to follow like new leadership direction executive you know. Executive order implementation and so I think there was some pause and communications early on, but I don't know, Jennifer, from your standpoint if that seems to have kind of resolved and it’s business as usual, of course. Again, waiting for any, you know that model I suspect is under review. Like all the other models have been under review and we could expect to see more changes. Jennifer Gasperini Absolutely. And you know, like MSSP, they have lost some staff with a lot of institutional knowledge. And so I think there will be a transition period. Will they hire up then and hopefully get some some new smart folks into those roles. They've also done, you know, some pulling back of the ACO coordinator positions in an effort to centralized so most of those positions were in the regional offices, previously and we're seeing CMS move to a more central approach and and therefore we've lost a number of ACO coordinators and so for MSSP and and ACO reach but as Jennifer mentioned, I think we're starting to see things level back out and I hope to see some return to normal programming. Thomas Royal Only time will tell. What do you see as a major driver, particularly in MA and MCR from a policy and financial standpoint? Jennifer Houlihan Yeah. So I mean MA I think has is one of those hot policy topic areas where we're watching. We know some of the new policy leadership within CMS has a lot of experience and thinking around how MA should evolve and this administration is also considered to be very MA friendly. But that being said, there have been some signals, such as doctor Oz mentioning in his Confirmation hearing that up coding is a key factor in cost, and we know that medpac their latest report shows that MA enrollees spend more than traditional Medicare. And then of course, we can't forget denials and some of the big concerns that we're seeing across health systems and down coding and denying both on and patient and AD perspective. So there's a lot of swirling, I think policy within that MA space and that's where we're trying to understand even within the new rule making there were a lot of pieces deferred. So what will this mean for the future of some of CMS or CMMI models? Will we see more alignment between traditional Medicare and Medicare Advantage? Will we see some significant changes around some of the coding intensity? Benchmarking risk capture methodologies. I think all of those seem to be up for conversation. And again, I think time will tell of of how the administration continues to move forward on that. We we do know for some of the policy briefs out there through groups like Project 2025 and Paragon, who've written extensively on MA that there are a lot of proposals to strengthen MAs presence in the healthcare landscape. So at this point, what we're doing is kind of watching and waiting and looking for signals such as, you know, the the recently reduced rules and and what we might expect. And Jennifer, any anything to add on your end? Jennifer Gasperini I think just that, you know, Jennifer mentioned earlier the geographic direct contracting model that we saw under the the first Trump administration, which is very MA friendly and we we do expect to see a resurgence of that type of thinking or that type of model in this administration as well. Thomas Royal Well, as, as we're all aware, there's been quite a flux in the economy recently, do you think the current economic pressures, or reshaping how health systems think about pop health investment? Jennifer Houlihan You know, we're we're still in a time of I hate to use the phrase two canoes, but given all the progress we've made, we're we're still in my opinion, in very much in a fee for service world with fee for value but fee for service still very much dominating the the reimbursement space. And I think we're also just in general in a time of, you know, tremendous change and transition with so many other policy lovers outside of pop health impacting where healthcare systems may be going, site neutral changes on the horizon potentially around Medicaid space. So I think I think in one hand pop health is viewed as still as the future forward of how do you get away from Fee for service. But on the other hand, we're we're still sort of a component in a very large health system that has a large footprint of hospitals and we have to balance between the revenue models. Thomas Royal Well, so looking back at ACO reach, under the current administration's first term, what progress was made and what programs or policies do you expect will be continued or changed under the second term? Jennifer Gasperini That's a great question. So, you know, I mentioned that the first Trump administration originally released that Geo Direct contracting model. It came under a lot of scrutiny and and was later cancelled, you know, under the Biden administration as a result of that scrutiny. And I think there was a lot of pushback. I think it's likely will see a return of a similar model under this administration. What that looks like exactly, I do not know. I think there's a a lot of questions unanswered right now around that, but I do expect I think a lot of others expect return of a similar type of model under this administration. Thomas Royal Well, can you tell us about the legislative efforts to reinstate and extend bonuses for providers participating in risk based models? And they view these incentives as essential for sustaining and expanding value based care? What is the latest? Do you think this push has any momentum? Jennifer Houlihan I it was definitely one of our policy priorities and there was, I guess, was at the end of last year, Jennifer, Bell introduced to extend the APM bonus? But the latest that we were hearing again, this could now be outdated information was that it is not currently part of reconciliation, but that it may be brought back up in the fall, Jennifer, I don't know if you've had any latest updates, so it's it's still out there as a priority, but overall not seen a lot of traction right now. Jennifer Gasperini Yeah. And I know it was devastating to see that bipartisan agreement come together end of last year and then really fall apart at the at the last moment and not get passed so that the bonus has expired as of today. But it is still a really big priority for Advocate and for a lot of stakeholder groups like NAACOS and others. I think there are spending pressures in Congress that are really going to make it difficult given the current environment. But I do think Congress is still committed to tackling the issue of broader reform of incentives and payments for value. Even the MIPS program is something that has been highly criticized over the years, is not living up to its intended goals, and, you know, having a lot of regulatory burdens associated with it. So I think there is appetite for broader reforms, but the timing for this year in particular I think are going to be difficult, so. But I am hopeful that maybe in the in the coming years we'll see a turn to attention on a broader reform. Thomas Royal That's great. Well, back in January, bipartisan legislation titled The Health Care efficiency through Flexibility Act was introduced in the US House, and this bill proposes delaying the mandatory ECQM reporting requirement for ACO’s until January 1, 2030. What's your take on this delay? Is it necessary breathing room or a missed opportunity? Jennifer Gasperini Yeah, that's a great question. And I know Advocate has committed a lot of resources to making ECQms a reality it takes an enormous amount of time and money and work, even ongoing work to to to do this. And in talking to other ACOs, I think there are a lot of ACOs that do need more time. And what dawned on me at the NAACOS meeting is that I think frankly, we're still debating the details because there were many very smart people at NAACOS. And some discussion and differing opinions about how can you report ECQMs the technical details of you know what the file has to to be, for example, and what constitutes data completeness. So as some examples, I think this really signals there's still some confusion out there and lack of clarity around these requirements. So I think having a backup or more time is not a bad thing for anyone. Given the uncertainty. However, I think it's important that we don't lose momentum since so many people, including Advocate, have already invested a lot into making this transition. And I do think looking to a less manual, more digital quality reporting process is a good goal for the future and we want to continue to make those. Investments. So it's about getting the details right, making sure there are reasonable expectations, so exclusions that allow for, you know, really kind of common sense exclusions that allow for things that we can expect to happen during the year, like transitioning to a new EMR or other challenges that do pop up realistically to not really take down your whole effort. Thomas Royal Was quality reporting broken? I mean, what's working? What's not? How do we fix it? Jennifer Gasperini So I can I can start here. I think so quality reporting is extremely costly and time intensive. Even when you're reporting ECQMs. So I think there are a couple of camps of thinking on this topic, though some think we should move to a REACH approach or model where ACOs are only evaluated on a small number of mostly administrative claims measures. Those don't revolve involve any reporting. But others think that that wouldn't accurately measure the quality of care that we're providing to patients. So I think yes and no. Is it? Is it broken? I think it can be improved for sure. How to fix it? I don't have those answers, but I I do wanna note that the proposed 2026 inpatient rule did include an RFI on this topic and so I think that signals that CMS is open to hearing what's working now. What some of these challenges are and and where we think we wanna go in terms of the future, and I'm really interested to see what the new leadership at CMS is thinking on this topic. Thomas Royal Well, we've come up against time, but there's still so many unanswered questions that I have for the both of you. Would you be willing to stick around for a few more minutes so that we can continue this conversation? Jennifer Gasperini Sure. Jennifer Houlihan Yeah,...…
 
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In today’s episode we continue our conversation with @American_Heart Senior Advocacy Advisor of Health System Transformation Melanie Phelps, who was integral in the recently published study on the benefit of Accountable Care Organizations. The findings support that managed care provided by ACOs not only improves outcomes for the medically complex patient, but also benefits every patient, family caregiver, provider, and healthcare team member. www.heart.org/bettercare Yates Lennon Melanie Phelps, welcome back to the move to Value podcast. So let's try to pick up where we where we finished last time. Melanie and I wanted to go back to really to sort of the heart of your research in the medically complex patient. So we know these folks require hard higher touch and really need coordinated, managed coordinated care. And, wanted to talk about why it's crucial for the American Heart Association to understand and advocate for better models of care for this patient population. And then we'll after that, we'll follow up on sort of how we can work together to do that. Melanie Phelps Yeah. So medically complex patients are of course more complex and more costly. They require a lot more services and the burden of navigating a fragmented fee for service system adds to their already very stressful lives and the chances of things falling through the cracks or delayed care is pretty high in a payer fee for service system, the ACO provides those extra layers of support, communication and enhanced access that really do lead to better outcomes, reduce stress on the patient and their caregivers, which is pretty important. We also believe they are more likely to get the most up to date care under these arrangements because the incentive to do better is there and that is not there in the case of fee for service. So, we all know that there is a pretty significant lag between new innovations and evidence-based solutions and adoption or implementation in reality, and we see ACOs as a vehicle for expediting adoption of those. The other piece on medically complex patients, why we wanted to focus on those is when talking to other patient and consumer advocacy organizations, which is a key target audience of this of this study, there was a lot of apathy and even skepticism about ACOs, OK. They're not involved in the advocacy. They're not steeped in the details and they are very suspicious of ACO’s of value based care. They're thinking there's a lot of stinting going on. They think that they're being, you know, medically complex patients are being denied care and being kicked out of ACO’s. And that certainly was not my experience when I worked with the ACO’s in North Carolina. So, one of the reasons we focused on medically complex patients was to be able to say, OK, you know, are they getting the care that they need? What do they have to say about it? And that's why. I mean these are the people that really need the extra care and support and the results really showed that they were getting much better care and support, which should be important to everybody. Yates Lennon Yes, absolutely. That's that's interesting. I never would have. I guess I never would have thought about that kind of skepticism from consumer advocacy groups around value based care, and certainly my experience has been the exact opposite is the ACO model is a ideal model to have those patients in because you have the sustainable, a sustainable path to provide these wrap around services to both, both the provider and the patient and their families. I can think of multiple instances where these like in our NextGen days and our ACO REACH nursing facility waiver as an example. And while that is great for patients, I think we've had more comments from caregivers and family members about the benefits of that program than we have from patients themselves. It's really interesting that it's another layer of skepticism that we need to breakthrough. So, going a little bit further then, so how can ACO’s, provider groups working with inside ACO’s, how do we get past that skepticism barrier, so to speak? How can we work together with organizations like the American Heart Association to promote ACO’s and the benefits for patients, families and care helping providers? Melanie Phelps So one of our challenges and it was a pretty significant challenge was the fact that to recruit study participants, particularly the patient and caregivers, how do you do that when somebody doesn't even know what an ACO is or that they're assigned to an ACO? I mean you know there are a lot of regulatory requirements around that, and they're not particularly helpful to meaningful communication and meaningful understanding. So how can patient and consumer advocacy organizations help communicating the benefits, communicate the benefits of these this model and similar models? And it's through research like this that comes from, you know, a neutral patient advocacy group that folks can give or use to help communicate the benefits of in a way that is relatable to folks. You know so often we talk about ACOs from the provider perspective, well, providers get paid differently to do that and you know that's not what's going to resonate with patients or their caregivers or their advocates. What does it mean for them? And until we really do a better job of doing that, I don't think we're gonna have a huge cry from patients and consumers and community advocates. And it's a shame because people should be demanding this kind of care, right? Not running from it or not ignoring it. We should be working together to improve a very good and solid model. So that's, that's where we would like to go with that. Yates Lennon Yeah. No, I think you're right. We want to create a Stampede almost for patients demanding access to these kinds of programs. But you're right, folks don't know what they are, and they don't know unfortunately, they don't know when they're in one. They don't know when they're not in one, it's just not obvious. And the communication options sometimes are onerous and restrictive and don't allow sort of the free flow of information back and forth between the providers that are in these models and the patient. So that that's a real challenge. Melanie Phelps You guys are restricted in what you can communicate. We're not. Yates Lennon Right. You're not. You're right. Melanie Phelps So so we are a huge untapped resource and we being the patient and community and consumer advocacy community. But most of us, you know, there's only a handful of us that are engaging in these policy discussions. And so we really need to grow that that table. Yates Lennon So Melanie, given the American Heart Association's clear role in guiding heart health recommendations, does this study suggest that ACOs are a model that should be used to promote these preventive health recommendations more widely for all patients, first of all, but then, particularly as it relates to those who have cardiovascular disease? Melanie Phelps Yeah, simple answer is yes. I think we'd say all patients, including those with CVD or cerebrovascular conditions, should reap the benefits of ACO and similar models. So, but it shouldn't just be patients with CVD or cerebrovascular issues. All patients, especially those medically complex patients, will reap the benefits of these models. Yates Lennon Yeah, I think what we have to be mindful of, I've been thinking about this a lot lately myself is that we need to make sure that the value based care movement, if you will, doesn't get mired down in becoming a chronic disease management solution, only right how do we leverage the infrastructure and the data, the tools, the technology we have to prevent chronic disease, right? We just, I think the fee for service world has just turned into a sick care system, not a healthcare system. And we need to be mindful that we don't allow the value-based care movement to get to become that same to be captured by that same mindset, if you will. Well, as we as we start to round home here, what do you hope that health systems, policymakers and other patient advocacy organizations which you've mentioned take away from this research and how can the association help drive change based on your findings in this study? Melanie Phelps So I hope that all the groups that you mentioned will have a better understanding of what ACOs do, what they are, what they mean to those on the front lines of receiving and providing care. That's the patients, their family, caregivers and all the members of the health care team and how it improves the care they receive, their quality of life. How it saves money by catching things early and avoiding costly trips to the ED and duplicative services. And, of course, its focus on prevention. And finally, you know, again, we really need to see more people, patients, caregivers and healthcare team members in these arrangements. Yates Lennon Yeah. So, what are your next steps for the American Heart Association? More research? Further explanation, I mean, I'm sorry exploration of how ACOs can impact cardiovascular and other health outcomes. Where do you see the Heart Association going next? Melanie Phelps Yeah. So we don't currently have plans to explore the impact of cardiovascular outcomes, at least not to my knowledge. That would be a different section of AHA. That doesn't mean we won't. It just means that I don't think it's been discussed or has not been shared with me. And So, what else is there? Well, there's an outline of a heart failure model that we published in as part of our value in healthcare. Initiative back in 2020 with Duke Margolis. I've heard that there's some interest by the current administration in that, but you know, we haven't been contacted directly about that. We do have a huge food as medicine initiative. It's called healthcare by food, we’re putting millions of dollars into research on food is medicine. And there's I think we might be exploring how food is medicine can be utilized in this these models. How successfully it can be utilized in these models. And then regarding this research, we do hope to further engage and educate other patient and consumer advocacy groups and then work with them and other stakeholders on elevating the patient consumer voice in these models so that they can truly be person centered, right? I mean, we talk a lot about person centered care, but really the patient hasn't been part of those discussions. How do we make that more integral at all levels of decision making on value-based care. Yates Lennon Yeah, absolutely. So that's interesting. Food as medicine. There is a lot of interest I know today around what's called functional medicine and a big emphasis on healthy foods, and it's just so important. And I know from my own my own lifestyle, it's just it's challenging to sometimes know what to eat or how to prepare what to eat. But that's really good to hear that you're working on that. You know the last question I'll ask you, Melanie, is one. I usually come to at the end of any interview and that is we've talked about a lot today, but is there anything that we've not covered today or I've not asked you that will be relevant to this conversation that you'd like to share with our audience? Melanie Phelps I can think of two things. First of all, I think your listeners would be really interested to know that we conducted 29 semi structured qualitative interviews with 31 individuals and that means that two of the interviews included the patient and their caregiver spouse. That's how we got to 31, but we only were able to include in the data analysis, 27. So two interviews with the patient, with individual patients, had to be discarded because there was something was wrong with some of their responses that made me think they were not in an ACO. So after the conclusion of the interview, I was able to go and trace back through their PCP and their PCP practice, whether they were in an ACO or even some other primary care arrangement. And they were not, OK. So how did that happen? And well, first of all, the giveaway why I suspected they weren't in. Well, there were two reasons. The first one, neither one was managed right? And so all the other medically complex patients that I had interviewed, they were managed and these two weren't. They also happened to be sisters, and they were also cousins of the care manager who is helping with recruitment, right? So we had to change. We had a lot of trouble getting patient and caregiver study participants and so we had to change our research protocol. So instead of the healthcare organization getting a HIPAA authorization to give us contact information, we gave them a flyer that they could hand out to appropriate patients to call and you know, on their own, asked to be part of the study and there was $100 visa gift card that was assigned to it anyway. So we had a little this overzealous care manager was giving them out to friends and family. So yeah, so we had to regroup and you know, change again, but it was very interesting that I could tell that they weren't in an ACO that I mean, I would not have expected that. The other issue that I think was really interesting is that you know, at the end of the each interview we asked, you know, if they had any suggestions for improvement? And so the patients for the most part didn't have anything that was particularly helpful. We had one patient that said that they didn't like their primary care had inadequate parking. Another one didn't like their primary care provider, but knew they needed to change. And then the only other suggestion for improvement was from the patients was that external providers who were not in the ACO, there was a little bit more difficulty communicating. No big surprise there, right? So that that was all we got from the patients. So then, but then you go to the healthcare team members and what was really remarkable is there was a cry for more education and communication about the benefits of these models. Not only for their peers, but for patients as well. And they wanted more patients in these models. And one even lamented not being able to provide the same services to patients not assigned to that the ACO. And then we did hear challenges with data sharing with external providers. I mean, not a surprise there, right? There was also calls for multipayer alignment because of all the different contracts and rules and oversights and concerns about the ratchet effect over time of the benchmarks, right? That's being a problem. And then finally. Enhanced payment for primary care services was mentioned, and that didn't even come from the primary care docs. And I probably should let you let you know that on the as far as the care team members are concerned, I did I interviewed four primary care physicians, a specialty physician, a nurse practitioner, four care managers, nurse care managers, two community health workers, two social workers, and a pharmacist. So I had a pretty good diverse make up of. Yeah sample so that's that was pretty interesting, I thought that was pretty interesting to capture that information. Yates Lennon Yes it is. Well, Melanie, thank you so much for joining us today. It's been an intriguing conversation. I look forward to hearing more from you and thank you for joining us. Melanie Phelps Thank you for having me.…
 
Today we hear from Melanie Phelps, Senior Advocacy Advisor of Health System Transformation for the American Heart Association, who shares with CHESS President, Dr. Yates Lennon, the motivation and detailed findings of a new study conducted by the AHA which found that ACOs provide better care and outcomes for patients and a better practice experience for members of the health care team than traditional fee for service. www.heart.org/bettercare Yates Lennon Melanie Phelps, welcome to the move to Value podcast. Glad to have you with us today. Melanie Phelps Glad to be here. Thanks for having me. Yates Lennon Sure, of course. So Melanie, recently the American Heart Association, released a study called Understanding Patient Family Caregiver and Health Care team member ACO experiences. Can you talk to us a little bit about what motivated the American Heart Association to conduct this research? Melanie Phelps Happy to. So the idea for the study arose out of a desire to be able to talk about ACOs in a more relatable manner to people who are not steeped in the technical jargon around ACO and value based care generally. We thought the best way to do this was to hear directly from patients, their family, caregivers and healthcare team members who receive or who provide care through ACOs. So from those who are on the ground receiving and providing care, and our hope is to use this information to better explain the benefits of ACOs in a way that's more understandable to more people. Yates Lennon Yes, certainly that, that sounds good. I know. ACO is an acronym that I think everyone of our listeners would be familiar with but when you get outside of the healthcare team member and even within in some settings, it's something people don't understand. Well, the study compares patient experiences in ACOs to the more traditional fee for service models. What were some of the key differences that stood out in terms of patient's experience first? Melanie Phelps Well, the results showed that. The care that's provided through these ACO models is just better in terms of quality and access, because there's a usual source of care through a primary care provider, whether that's a MD or an advanced practice provider. And there's usually a dedicated care manager as well as a team of people to ensure that all their needs, physical, mental, emotional and health related social needs are addressed. So essentially their experience is that they receive better, more timely and coordinated care with added supports that they wouldn't get in a pure fee for service arrangement. And I heard more than a few times that it's better than what we had before. And I also heard that my friends don't get the same level of care, and even some of the healthcare team members who lamented the fact that they can't provide this level of care to all their patients, especially those who are not assigned to an ACO, so. Yates Lennon Yeah. And I can echo that experience. I think some of our care team providers share with us stories of patients they interact with and we certainly hear that same story and even I have family in a different part of the state than the triad. And I can say from personal experience, I wish they were in these models. The American Heart Association conducted interviews like you said, just talked about among patients, caregivers and these healthcare team members. What were the what were their common themes? You just mentioned some common themes among patients, but if you expand that, what were some of the key findings or common themes across all three of those groups, patient, caregiver, and healthcare team member? Melanie Phelps Yeah. So in a nutshell and at the highest level, our study found that patient and caregiver study participants, OK, they believe that the care they receive through an ACO model is better for patients and then the care team member study participants believe that providing care through an ACO model not only is better for patients, but it's also better for the healthcare team members. And before I break this down, I just wanted to make something clear. I think this will be helpful. This doesn't mean that all the ACOs that I interviewed are performing at the highest levels, and in fact there was some variation and level of services and supports that the different study participants reported. I'd say some of the ACOs were really sophisticated. And then there were others that had some room for improvement. But even those that I would say have room for improvement Weren't quite as sophisticated. They had much better supports and services for their patients than someone would receive in a traditional fee for service arrangement. So anyway, now let's go ahead and break this down and I'll start with the patient and caregiver interviews. While the care and services provided across ACOS varied, there were still several common themes that emerged, including that patients in ACOs they received better care and support through a number of factors. OK. And these factors include a dedicated primary care relationship. So all study participants had a relationship with the primary care provider, and those relationships were overwhelmingly positive. We only had one patient who had some issues with their PCP and recognize the need to change, but otherwise they were very positive. Then there's the team of healthcare professionals who helped provide enhanced care and support and that always included a care manager who helps the patients and their caregivers navigate issues and connects them to needed services and supports. The next theme was improved access to care and support, and this included assistance with emergent or urgent issues. Timely responses and connection to needed resources. The next theme enhanced patient engagement. Which includes more time spent with patients as well as co-developed care plans. Then another theme, there were quite a few in this group, trusting relationships that made patients they felt heard they felt understood and they felt valued as a person. Almost all patients reported that they primary primarily relied on their providers for referrals and all the patients and the caregivers interviewed said they primarily relied on their providers for information about their medical conditions and treatment, and then the other two themes. The next one was improved communication, access and coordination with patients and their family caregivers as well as with all the healthcare providers. And then finally, that more holistic approach to care that addresses physical, mental, emotional health, as well as those non-medical barriers to health. For things such as access to healthy food, transportation, housing related issues, financial assistance and other services that contribute to improved health and enhance quality of life. So that's what the study found as far as the patients and the caregivers. Now with respect to what the healthcare team members had to say, let's focus first on why they thought it was better for patients to receive care through an ACO. So all the healthcare team members that interviewed it was unanimous. They agreed that care provided to patients, especially those who have multiple health related conditions, was better because of the extra time, extra attention and the extra support that they were able to provide through the ACO, which led to improved outcomes. So the supports that they mentioned, the themes that emerged was. You'll recognize some of these. Having that regular source of care through a primary care physician or advanced practice provider such as a PA or a nurse practitioner, having a multidisciplinary team based approach to care which really brings in different areas of focus and allows that extra attention, the extra care and support to be deployed to those patients, especially those with the greater healthcare needs. The whole person approach to care. That means the healthcare team can look at all the factors that impact a patient's health and well-being. And they're able to then connect them to needed healthcare related resources and assistance. And then finally that enhances this one's pretty packed enhanced patient engagement education. This includes things that there's greater emphasis on effective communication. Building trust, understanding the patient as a person and the tools that are used or things like motivational interviewing, shared decision making, regular assessments, care plan o-development. It also included greater attention to populations and communities that have historically had access challenges and being able to connect them to resources and assistance with, with need when needed. The other piece which this one I wasn't necessarily expecting, but it came through loud and clear, is that the healthcare team members agreed that providing care through an ACO model was better for members of the healthcare team for health care professionals, and why is that OK? Well, they liked having that team approach to care because it allows different professionals to work together to provide optimal care to patients. It expands access to care by providing additional resources and support to care for those patients that need it the most, and with doing so without overburdening the provider, the, the doctor or the Nurse practitioner or the PA. And then finally it they really felt like it allowed them to be better at that job. So that professional satisfaction that is so often missing. Was quite evident and was mentioned by all of them so. Yates Lennon Yeah, I was hoping you would get to that last one because I I really do think that oftentimes in the old fee for service model providers don't ask questions because they know they don't have, they know the answer, but it puts them in a situation where they don't have solutions and it creates almost like this moral injury kind of conundrum that care team providers are in, I think sometimes particularly physicians PAs and nurse practitioners, so that's very interesting and sounds a lot like the quintuple aim. Does it not? The things you just described as ACOs? Melanie Phelps Absolutely. And you can throw the yes. Yates Lennon Yes, go ahead. Sorry. Melanie Phelps All, all five absolutely definitely hit. Yates Lennon Yep. Melanie Phelps On in. Yeah, that that came out loud and clear. Yates Lennon Yep, Yep. Well, you know the the American Heart Association, I think would be primarily, well known for its work in cardiovascular health and disease prevention, it's interesting that you all focused on medically complex patients for this model as opposed to just, you know, patients with CHF. Can you talk to us a little bit about, you know, how you went about assessing what population you would try to interview? The population of patients and caregivers you would try to interview? Melanie Phelps Yeah. So a lot of people don't realize this, but the American Heart Association also includes the American Stroke Association. So we also have a major focus on brain health. Our mission is to be a relentless force for a world of longer, healthier lives, and our vision is advancing health and hope for everyone everywhere. So it's it's pretty broad, right? Yates Lennon Right. Melanie Phelps And it includes efforts to improve health from all the way from primordial prevention to the, to the end of life and includes everything you know in between. So that's, you know, with respect to why we did not focus on heart or even stroke patients. Our goal was to be able to talk about these models more broadly. And so we wanted medically complex patients, but we wanted them from, you know, covering a diverse population of you know disease conditions. And all the demographic variations that was our goal to get as broad a picture as possible of how these mod this model impacts overall health. Yates Lennon OK, great. And sort of thinking more about the American Heart Association. Its its purpose, its mission, what has been the this sort of a two-part question. So what has been the stance of the American Heart Association as it relates to value based care? How does it align with the organization's broader mission, which you just described? And then lastly, does this research alter your stance the association's stance on value based care is it put fuel on the fire sort of address that for us as well. Melanie Phelps Yeah. So the American Heart Association has published pretty extensively on this topic. And we support efforts to transform to a more effective system that recognizes and pays for better care and outcomes over the volume of services rendered right? We support a health system that is person centered, that focuses on improving individual as well as population level experience and health outcomes that promotes equitable health and rewards our healthcare workforce for how well they do as opposed to how many billable services they can provide regardless of outcome and through value based care and all that it entails including its focus on prevention. We believe it furthers our mission of a world longer, healthier lives and our vision of enhanced of enhancing health and hope for everyone everywhere. And you're the third part of that question I have forgotten. Yates Lennon Does does the research alter the association stance on a value based care? Melanie Phelps Yes. No, I don't think so. I think it further supports our stance, yeah. Yates Lennon Well, you just mentioned you've mentioned preventive Care now. I think with the last couple of comments you made a couple of questions. Was there anything you learned in particular about preventive care in the ACO model that would did it vary among the groups that you assessed and, just talk a little bit more about the AHA's perspective on preventive care. Melanie Phelps With respect to the study findings, I think across the board. From the healthcare team member perspective, they all mentioned the focus on closing gaps in care and that is that is huge. We didn't have a question that really delved into preventive care on the patient caregiver side. You know, but generally they felt better cared for, but as far as the AHA on the focus on prevention is really key. OK? And ACOs are just better at closing those gaps and intervening early and fee for service just failed to do that well, right? So we're big believers in the need to focus on life's essential 8. That means eat better, be more active, quit tobacco, get healthy, sleep, manage weight control, cholesterol, manage blood sugar and manage blood pressure. So under an ACO, these are more likely to get the attention that they warrant. Yates Lennon Yeah, that's right. And I want to, The first one you the first of your eight was I think 8 better. In reading through the study, I may have missed it, but did you have any ACOs that provided like nutritionists or nutritional support? Melanie Phelps That that had diabetes educators and dieticians. But there wasn't a question that asked them to enumerate everybody on the on the care team. So there were some that were really, you know, sophisticated and have a deep bench. And then there were others who did not have such a deep bench of a of healthcare professionals. Yates Lennon Right. So how is the American Heart Association advocating for the transition to value based care? Like, are there certain policies you all are supporting and what strategies are you employing to sort of promote this move to value based care? Melanie Phelps We really strive to ensure that patients have access to the most effective services possible, but in order to for that to happen, patients must first have access to health insurance coverage and that's the priority. This is the Nice to have, right? So access to care and especially access to effective and efficient care theoretically should improve affordability, which should improve access. But that is a step removed from the focus on access to coverage and with some of the changes that have taken place recently, I think that there will be a double downing. We and similar patient and consumer advocacy organizations will be doubling down on efforts on that. Protecting access to coverage. So this might take a step back. Unfortunately. Yates Lennon Well, Melanie, thank you for joining us on the Mood Value Podcast today. I wonder if you would be willing to stick around for a few minutes for us to continue our conversation. Melanie Phelps Of course, I’d be happy to.…
 
Today we continue our ACO REACH conversation with Kim Williams, who discusses how this model facilitates enhanced care for the patient. She also shares insights on measuring success, engaging providers, and the broader impact of ACO REACH on healthcare equity and value-based care Thomas Royal Kim Williams, welcome back. Thanks for sticking around so we could continue our conversation here today. Kim Williams Thank you, Thomas. I'm happy to be back and ready to continue our conversation. Thomas Royal So last time you know, we discussed a lot of the nuts and bolts of ACO reach. You know what it is, how it helps us, the various entities that are involved. One of the things that I want to talk about a little bit is the is the patient. So we, you know, previously you mentioned a HealthEquity plans sdoh screenings. What beyond that and including that specific advantages, does ACO reach offer to the patient compared to traditional fee for service models? Kim Williams Yes. So, in ACO reach the advantages for patients are actually quite substantial. Especially in care delivery through waivers or what they call benefit enhancements and incentives. So, for example, with the public health emergency coming to an end, a lot of the telehealth flexibilities that existed during the pandemic are no longer an option after March of this year. So if you were if you are an ACO reach, this is still an option through the telehealth waiver, which removes geographic restrictions and allow patients to get care from their provider regardless of where they are. So you know they can be in their living room doing a check in visit. It is so beneficial for rural communities and patients with mobility issues. I've had site visits with providers that really stress the importance of telehealth because they are in a more rural setting where it's not, you know, good for the patient with mobility issues to go back and forth to the offices. So I think that's definitely a huge plus for those types of population. There is also a financial benefit play that patients can take advantage of, and that's through the cost sharing for Part B services. Now this one allows reach ACOs to reduce or eliminate cost sharing for Part B services and remove financial barriers for things like a primary care visit or your chronic care management, even preventative services. So for instance, CHESS has it set up right now to where we can waive chronic care management co-pays. And so the hope is that. If we're able to waive those co-pays, patients will be more willing to seek intervention. And really participate in chronic care management programs when you know they're not too worried about those co-pays. Chronic care management is just super important in this model, alongside of transition of care management because it focus on preventions. And so I think again this is a win win situation for both providers and patients and also ACOs alike. Thomas Royal Well, that's fascinating. I so I I know that when we talk about there's options of care and financial efficiency for the patient, how does the program ensure patient receives more coordinated and personalized care? Kim Williams Yes, so care coordination plays a huge role in ACO reach. And you heard me mention earlier that implementing the HealthEquity plan requires coordination from everyone. But I want to specifically highlight the great work that care coordination teams put into personalizing the care for our traditional Medicare patients in this population, right? So first the the outreach to the patients are beyond the normal amounts and I'm I'm using our HealthEquity plan as an example here because our care management teams spend more time on the phone with patients, really to better understand why. Why are they not getting their cancer screenings, for example? And often we get clues to help us solve the next piece of the puzzle. So for example, through these phone screens, we learned that one of our patient refused to get a cancer screening because they were scared and it might sound simple, but we didn't know that because typically you will look in the chart and you see that the patient declined but you don't know why. And they weren't sure. In this instance, the patient was not sure that the cancer screening, what that entails, they wanted to connect with their providers more. So, they made, you know, the care management teams really made sure that that patient got that proper visit to where their providers can set aside time to explain to them the importance of this cancer screening and how that impacts the patient's care. And and another, you know, another patient that we found just really wanted someone to go with her to get her mammography screening. So, and that's just from a moral support standpoint. So, you know we reach out to family members, we reach out to some church members and sometimes even utilize our community health workers to just be there for moral support. And that's I think how you move the needle in care from this perspective. And that's just a couple examples from that one initiative. There are much more great work care managers do for patients on a daily basis when it comes to transition of care. And I think particularly under REACH, again, transition of care is just key to preventing readmissions and unplanned admissions in the quality measure domain, but you have to remain proactive with these patients. You have to offer social support and going back to the goals. In our REACH acronym because access and equity is part of this model. There are personalized efforts that we have to do for these patients in order for them to receive the right care at the right time and at the right place and I think REACH really shines a light on how we personalize some of those care for our patient populations Thomas Royal That's great. That's a lot of good investigation, discovery and support that's happening for the patient. Kim Williams Yeah, for sure. Thomas Royal I think that that's awesome. Kim Williams It was a lot of leg work in the beginning, but definitely worth it. Thomas Royal Yeah, it's great. It's great to hear those patient stories that really that really makes it real. A lot of times we get we get caught in some of the conversations about how things work and financial benefits and hearing, hearing the impact on the patient. Kim Williams Mm hmm. Thomas Royal I mean, that's why we do this. Kim Williams That's right. Thomas Royal And so does the provider. So, let's move on to what the key steps are for a provider or a health system interested in joining an ACO REACH program. How would they join and and what advice would you give to providers or systems considering participation in ACO reach? Kim Williams Yes. So, for providers who are interested in joining, let me just walk you through both the practical steps and the financial considerations. So for ACO REACH, there are no more application periods. If you want to be in this model, you would have to join an existing REACH entity like CHESS Genesis. I think this is also beneficial to know that you have to understand what appetite you have for taking on risk. So you want to assess your practice or network situation. Are you more advanced in risk taking? Do you know how to take care of traditional Medicare patients and do it well? Next, you would want to weigh your options. So there are two risk tracks in ACO REACH. The first option is the professional track, which takes on 50% upside and 50% downside. And then there is the global option that is full risk and that is 100% upside downside. And so for CHESS, we offer the professional track. So, if you're newer or not yet comfortable with being in a risk aggressive model and and ready to take on 100% of the risk. Then the professional track is a great option for you and that's something that we offer. But beyond the dollars, my advice is really to look at your patient population, your quality metrics, and your care coordination processes. Do you have success stories? Do you have those transition of care programs that you're comfortable with? Do you know what gaps you have in your network that you may want to use those upfront payments to achieve, and I really encourage you to reach out to us for more information, any of our CHESS subject matter experts can supply you with more information and run through different payment scenarios with you. Once you feel like you're ready, we have an awesome team of dedicated staff and compliance experts that can get you signed up into the model and work with you to implement it from from start to finish. Thomas Royal That's great. So. I'm a provider, right? I'm not. But let's let's just metaphorically say that I am for the sake of this argument, 'cause I can have I can assure you that a lot of people will confirm that I am not. So I'm a provider and I'm willing to take on risk and invest in new achievement and transformation. What resources or tools are available to me to ensure successful implementation and and how does, you know, specifically, CHESS support my practice or the health system that I work for in navigating ACO REACH. Kim Williams Well, one thing that's really impressed me about REACH is the support system. In contrary to other traditional Medicare models, we get a lot of reports for ACO REACH participants and we're able to do some really cool things with those reports over time. So here at CHESS, we've built an ACO REACH quality dashboards that looks at provider level performance month over month trends and it even has patient level information that we send out to our what we call our value partners on a regular cadence. We have predictive analytics tools that also identifies those rising risk patients and patients within various risk categories, whether it's high, medium or low. And we have that specifically for care coordination efforts, right. We can supply those to your care coordination team, or if you want us to hub your services, then we can definitely help prioritize which types of populations to target for gap outreach and just where to prioritize your work. We also do financial modeling. So again, if you're interested in joining ACO REACH, we model those financial scenarios for you. We will look at your historical performance and tell you how you could perform in the model and I think another important thing to call out is the claims reimbursement support because of the innovative payment structure that you heard me mention earlier. That requires some setting up to do, and so we have subject matter experts that can work with you to get these advance payments to your ACH account. We help you build out the workflows to ingest the files and be able to have this ongoing support from a revenue cycle perspective. And so I think we're also open to innovative payment structures at the NPI level. So if you think that you want something more innovative and want to incentivize certain NPIs, we can definitely work with you to build that out from a revenue cycle perspective as well. Thomas Royal That's great. Well, OK. So now I'm I'm in and I'm doing the right things. I'm I'm I have an open mind for new workflows et cetera. All of the things that that I'm I'm doing to transform my practice. So now how do I measure the success? What milestones should I look for, should I aim to achieve for this? Kim Williams So I think achieving shared savings is part of the equation, but because the model is so comprehensive, you heard me talking about SDOH. You heard me talking about HealthEquity planned. I see success in ACO reach really beyond hitting the financial targets. We look at the quality measures, were we able to avoid utilization? Did we perform in line with our peers when it comes to preventing readmissions and unplanned admissions? If yes then check I define that as quite successful, the HealthEquity plan, Needless to say, if you are moving the needle on your targets, even if it's just 1% or 2%, I think that is successful because that is a start. We are going somewhere and our patients in these vulnerable geographic locations are getting the care that they need. So that's a win in my book. For CHESS, we're celebrating the fact that we hit our goals this year in the HealthEquity plan and increasing our breast cancer and colorectal cancer screening rates by 3%, so I think it just it depends on you know what is it that's important for you, your patients and your community and that's how you measure success in, in, in this program. But there's several levers that you can pull to define success and you can start with some of these. Thomas Royal Yeah. I think to me that sounds like true success because that that's when everyone wins, especially the patient, and I think that's awesome. Kim Williams Yeah. And I also, Thomas, you know, I also think about provider engagement. I think about our wonderful provider champions and how they were with us every step of the way in implementing this type of program. You know, they had invested interest in HealthEquity from the beginning. A few even volunteer to go through the leads list and call every patients on the list so we can achieve our goals. We had providers that encouraged us to look at a different perspective when it comes to timely follow up visits because they knew that their offices are booked and so access was going to be a challenge. Well, if access is a challenge, how can you get patients that are timely follow up right? And so they push us to think about telehealth options and these are the things that makes me love what I do. And I love that the ACO REACH program really sparks conversations around things that matters to the patient. So I think any of those things can be defined as success and wins. Thomas Royal Agreed. That's that's very collaborative model. I really like this. OK. So let's pivot a little bit here if I may. I want to. I want to know more about what you think, so I'm going to use the old crystal ball metaphor, if you don't mind. If you had one. If you had a crystal ball, Kim, what do you see in the future for ACO reach and if it does go away, what lessons did we learn from it that can be applied to other value-based care models? Kim Williams Yes. So, with ACO reach, it does run until 2026, but I see the principles of ACO REACH becoming more ingrained in how we deliver healthcare regardless of what they decide to call the model in the future, right. The lessons we're learning about addressing HealthEquity coordinating care beyond the clinical settings and also focusing on those preventative measures are all fundamental shifts and those things are here to stay. So even if the model evolves these core principles, in my mind, you know the equity, the access, the Community health, I think we will continue to see components of this in future iterations. I also think that under the new administration we will see CMMI try and add additional values and additional levers, maybe giving us more waivers to create a more Medicare Advantage competitor in the traditional fee for service market. So I could see some of these models, maybe not an ACO REACH, but others becoming mandatory, assuming that the new administration wants to get every beneficiary or patients in a value based care model by 2030 and that's, you know, that's been the goal that the CMMI and CMS has had for a very long time is to get these patients into a value based care model by 2030. Thomas Royal Fascinating. Well, we'll see. I'm very confident in your accuracy because of your expertise. So what's one thing you wish more people understood about the potential of ACO REACH Kim? Kim Williams Well, I think we touched on this, but with the right collaboration, it has the potential to really disrupt the fee for service game and it has to be felt from top to bottom, right. Everyone would have to understand how this is driving change to the national culture of reimbursement model that's been in place for decades, and I'm talking about that fee for service. So, ACO REACH is, you know, it's just that pathway to practicing medicine the right way. And how we've always wanted our health systems to do this, and now we have the flexibility to address the root cause and do something about it, but we need to do it together and in much more collaboratively. Thomas Royal Agreed. Well, well, Kim, I always like to end with asking what's something that I haven't asked? What questions am I missing in in terms of the nuts and bolts of ACO REACH, the impact on the provider, the system, the patient, the payer, what's one thing that you want everyone to know or to touch on before we wrap up today? Kim Williams I think we've highlighted all of the operational levers and the financial impact of this model, but I also, you know, encourage everybody to think about this from the patient perspective, especially if you are, you know providers within a system. Think about where Healthcare is going, right? There's been a lot of different models over the years. Now we're looking at a new administration, so we're expecting for things to change, but you don't want your patients to kind of fall behind. And so as you are thinking about participating in ACO REACH, just know that there are so many substantial benefits that patients can receive from this type of model. And you definitely have support teams at CHESS that can help walk you through what that could look like for you. Thomas Royal Outstanding Kim, this has been great. I appreciate your time today. Kim Williams, thank you for joining us today on the move to Value podcast. Kim Williams Thank you, Thomas. It was a pleasure to be here. Thanks for having me.…
 
In this episode we hear from Kim Williams, Senior Manager of Government Programs at CHESS Health Solutions about the value of ACO REACH. She shares her expertise on what it is, why it was created, and how it benefits the patient and provider by being a care collaboration model that improves quality while incentivizing health equity. Kim Williams, welcome to the Move to Value podcast. Kim Williams Yeah. Thank you so much for having me. It's really a pleasure to be here. Thomas Royal So Kim, today I want to explore some of your knowledge that you have and your expertise. So let's talk about ACO reach first. Can you explain what ACO reach stands for and how it differs from the other ACO models? Kim Williams Sure, I'm happy to. ACO REACH stands for realizing equity access and community health. And really, the differentiator of this model is in the name itself. It's looking at HealthEquity and getting patients access to care in a timely fashion, but it's also looking at social needs and also working with community health providers to have a more coordinated approach in the patient's care journey. And so a lot of the programs requirements that we see are centered around those core principles. And this is a huge shift away from your traditional fee for service model, where everything is based on quantity of services to now looking at value. Now we are looking at not just at the bigger picture. We're looking at the entire picture. We're looking under the rugs and we're addressing root causes in this ACO reach model, also part of what makes this model unique is in the innovative payment structure and that is what I call a capitation-like model. So this means that CMS will give us a prospective payment upfront and providers have the flexibility to structure that payment however they want to do that in a multitude of different ways. So one option is that a provider can elect to do a fee-for-service pass through where you are paid 100% of what you Bill to Medicare. Or you can elect to get 90% of what Medicare pays you. With an option to earn back bonus payments. Or if you don't want any of those options, you can also say, hey, just pay me a per member per month payment upfront. So that's called pmpm. Pay me that amount monthly or however they want to structure that arrangement with the ACO. So there's a multitude of different ways that you can go about this, and really the idea is that if the provider knows how much they're receiving up front to care for their beneficiaries, then they will be motivated to stay under that threshold and that benchmark. And that's really where the shared savings comes in. So I think the ability to select these payment options based on what you're comfortable with is not something you typically would see in other models outside of ACO reach. Thomas Royal Oh, that does sound pretty unique. Kim Williams Yeah. Thomas Royal So he touched on this a little bit, but I'd like to dig a little bit deeper and and if you could tell me what are the core goals of ACO reach and how does it align with the broader shift towards value based care and how does this model prioritize Health Equity and patient centered care in its design? Kim Williams Yeah. So, earlier you heard me mention that the goals of this model are centered around Health Equity access and community health. And so I want to camp on certain components of those levers. So I want to expand on why that matters and talk about the Health Equity for example. So as we're moving away from again the traditional fee for service and moving towards value based care, you see more and more payers prioritizing patient, HealthEquity and social determinants of health. Or SDOH initiatives that are designed to impact care outside of the clinical settings. And that's because we know if a patient does not have transportation or if they have food insecurities, for example, well, they may not be interested in going to get their cancer screenings or their medication refill and so this impacts their health and it contributes to the total cost of care that we don't want in our healthcare system today. And so as we shift to value based care, we have to look at the whole picture. We have got to solve for social issues and to figure out what that means for your community. You do have to look at the inequities within your region and the ACO reach model. Really prioritizes this mindset. So the Health Equity plan, for example, that is a requirement under this model that allows us to target the problems in our backyard that we know exist today. But because of the lack of resources or conflicting priorities, even the processes that we have today to take care of our vulnerable patients and these populations has not been maximized to its fullest potential, right. The Health Equity plan in itself is very patient centered, and it's crafted with specific solutions to what we know about our patients today. But that's going to require that you do your research to figure out what disparities you have, so that means looking at the data, figuring out solutions for what you want to solve. And under this requirement, they're going to ask us to write up an implementation plan that tells CMMI how you plan to make your health disparities better. What types of resources do you think you're going to use? How are you planning to mitigate risk of further exacerbating this disparity and and how do you want to measure and define success, right? So if you think about all of that, it's not a one-size-fits-all approach and it's not something one person or one organization can accomplish. The Health Equity plan is not going to be very successful. If you don't engage your executive teams, your community leaders and your physician champions. So it's going to require that everyone from the top down prioritize and collaborate together to make this happen. And that's what chess has had experience in doing in ACO reach. We knew we wanted to impact patients in certain geographical settings really in those vulnerable territory. So, you know, think about. Your low income housing zones. Your flood zones. Think about the areas that has a lack of access to transportation, and so we brought all of this data. All of this information to our physician leaders and our executive leadership teams. And we said, well, here's the data. Here's what we know. Now, how do we want to work together. What types of interventions do you think are best for our patients? And so I think it it all begins there when we're wanting to target Health Equity. Now thinking about the broader shift to value-based care. Here I also think it's important to call out again that innovative payment delivery that this model offers. So I think the model creators know that there are communities who face significant risk factors like the ones in our Health Equity plan and and probably more outside of that as well. And so that's where they will give you this upfront payment so you can invest in resources to help wherever you think may be helpful, right? Maybe you want to invest in a risk stratifying tool to figure out who's in the high risk or rising risk category. With this upfront payment you can implement these tools, or if it's not technology that you need, you can hire more social workers and or care management teams to support whatever it is you think can further your journey and value based care and is best for your patients. So I think REACH is really designed to sustain transformation and population health and now we're tackling deep rooted issues that would otherwise be swept under the rug by maybe a lack of resources or lack of awareness, and that's really going to reshape how we deliver care today and in the future with this model. Thomas Royal That sounds really beneficial for the patient, Kim. That sounds like it's it's a shift away from. You know how things have been going as far as the determinants? I think that's really important. And I heard you talk about the upfront payment. Kim Williams Yeah. Thomas Royal So I mean you, if you include that in, how does participating in in the reach impact a day-to-day operations of the provider? And what are some other key financial incentives for those participating? Kim Williams Yeah. So I want to break that down into two different buckets of how that's going to impact the providers and the practices, right. Thomas Royal OK. Kim Williams One from an operations standpoint and one from a financial impact standpoint. Operationally I think of ACO reach as a care collaboration type of model in one area that the collaborative effort comes into play is how we impact the three claims based quality measures in this program. Thomas Royal Alright. Kim Williams Now, in MSSP and other contracts, we see more clinical quality measures that were being held accountable to. But in Reach 3 out of the four measures has to do with keeping patients out of the hospital, preventing readmission and unplanned admissions and getting patients their timely follow up visits, post discharge and so operationally, providers and staff, they do need to work together to help their patients avoid these hospital visits. But we also want providers to do those comprehensive disease management programs, those transition of care. But we want providers to lean on their care management Staffs and their teams because those transition of care supports are just really, really critical in the success of this program. And strategically, CHESS has had experience in implementing strategies that really target these utilization types of measures. And so yes, we do want providers to help us see the patients and and open their schedules for these patients to come in, but we also want to help we from the ACO level can really help build an infrastructure in place that could maybe alert offices that their patients have been admitted in discharge. We can evaluate your admission, discharge and transfer data feeds to see if there are blind spots and come up with solutions to make sure we don't miss the opportunity to reach out when these patients are, you know, in their most vulnerable points because that's how well how you do well in this model, right? Thomas Royal Hmm. Kim Williams And so that's operations, but from a financial perspective and I think I alluded to this earlier, but ACO REACH offers that upfront payment if for some providers that stability in payments offers a predictable income upfront and you don't have to wait for your fee for service claims to be processed sometimes that takes a while. And So what you could do is potentially use this upfront capital to invest in resources for your practice, so you could use some of this capital and hire more care coordination team members or community health workers. From a financial perspective, the hope is that if you know your allowance for this patient is, let's say, $500.00 for example. You'll try to take care of them for less than that amount, so just don't go over that 500 and that's where your shared savings is going to come in. That's your incentive for participating. Thomas Royal Well, that's that's very interesting. And and you know when we talk about the benefit to the provider, we talk about the benefit to the patient you know and when you mention utilization and access. So how does that how does ACO REACH create those opportunities for health systems to enhance those value based care initiatives and and in what ways does it help address cost while maintaining or improving quality metrics? Kim Williams Yeah. So in REACH there is this benchmark methodology that looks at communities that serves more complex and or underserved patients. And so there is this benchmark play that reflects that reality. So what they do is CMS will allocate more dollars to the benchmark for those providers with high need patients to take care of them. So that in itself gives health systems opportunity to expand care to more traditional Medicare patients. Maybe they're in rural settings and you know, maybe they're in those Health Equity population setting that I spoke to earlier in the flood zones and areas where there's a lack of resources, but again, receiving those prospective payments upfront, for example, if you know that you have a large population of patients with diabetes within your health system, where you can use those prospective payments to invest in diabetes education, you can hire a nutritionist or partner with one in the community and maybe do some type of incentive plans that can better coordinate the care for your patients across their care journey. And there's just so much flexibility in how you want to spend the funds. And the model understands that sometimes the best medical intervention isn't necessarily medically related. So think about your social determinants of health infrastructure, and maybe allocating dollars to those types of programs we know. Thomas Royal Hmm. Kim Williams SDOH can help address the cost of care and really improve our quality metrics. But it also improves our patient's quality of life. And so I think from my perspective, it's just a win, win situation if you spend these dollars wisely and ACO reach gives health systems the flexibility to do that and and really make it work for your network and only health systems know that best. Thomas Royal Agreed. Well, we we've talked about patients, providers, the health system. But we haven't talked about the payer. How does the program promote collaboration amongst all of these groups amongst the health system, payer and the provider? Kim Williams Yeah. So I think REACH really breaks down the traditional silos in healthcare. So in the ideal world you would have what I like to call a medical neighborhood where your primary care providers, your specialists, your community based organizations, or CBOs as they're called, they all talk to each other, so while we're not quite there, where everyone can communicate in the same platform. You know, this model gets you thinking about these things, both from a health system perspective, both from a payer perspective. So these medical neighborhoods and really getting to think about why it matters to the patient. So one of the area that I think promotes the most collaboration in this model is the requirement to screen SDOH and we also see this in the Health Equity plan that we talked about earlier but with social determinant of health screenings, because this model requires you to screen all of your patients every year there has been sparks of conversations from providers on how to get help for patients who has a positive SDOH screening. So for example, if a patient is identified as having food insecurities, we're seeing more provider engagements and making sure that they communicate to the social impact teams to their social workers to get help for for these patients. And sometimes it could be a referral to community based organizations and then the community based organizations would send, you know, community health workers to the patient's homes. They'll bring them food and they'll do their health screenings then and there, right? So I think we're in this building block phase right now where this is all new, but we're seeing a lot more questions, a lot more “well, what if this scenario happened?” And I think that's really exciting to solve for and I think the goal of ACO REACH is to get those conversations started. So meaningful change starts with meaningful conversations, and I think even from a payer perspective, we're helping them collect this SDOH data. So they can evaluate resource needs that they would need to help implement in order to move the needle in value-based care. Because if you think about our CBOs, I mean, they're great. They're willing to work with patients that screen negative for these social needs, but they are also limited on funding, and so the data that we collect can again start those conversations from a payer perspective on how much resources are needed, where and why, and I think I think that's a beautiful start and I think we're also going to see some similar concepts from ACO reach being kind of translated into other payer programs and future model iteration and the participation in ACO reach for providers is really just going to propel you forward of you know, what's the common in value based care in the future. Thomas Royal Outstanding. Kim, we've we've come up against time, but I I'm hoping that you can stick around for a little bit and we can have some more conversations around ACO REACH and perhaps delve into what it benefits for the patient. Would you be willing to stick around with us? Kim Williams Absolutely super happy to be here.…
 
In today’s episode, we revisit our episode with Josh Vire, Vice President of Value-based Operations at CHESS Health Solutions, where he discussed what has been learned during the move to managed Medicaid in North Carolina and what CHESS brings to the table with its 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 better outcomes. Now we were fortunate that we had a sister company that focused solely on Medicaid for a number of years. So over the last year, our focus has been on adopting the knowledge, building the care management capabilities, the platform, our data and analytics capabilities of our senior of our sister company into the CHESS environment. And so I'm actually pretty excited to announce that that transition was completed earlier this month. So Chess has now reached our goal of being an all patient solution for practices in North Carolina. That’s outstanding. Congratulations. I know that there there's a lot of hard work that went into that. A lot of hard work, a lot of hard work, a lot of lot of commitment from a lot of great folks on our team. It's been, it's been a journey but we're super excited about it Outstanding. So Josh, formerly Medicaid, let's talk about delegation for a second, so Medicaid practices were delegated as Carolina access one and two and now practices are called advanced medical home or AMH. So what are the differences in the AMH tier 1-2 and three and how would a practice move from 1 tier to the next and is it possible for practices to be downgraded? Sure. The answer, short answer is yes, it is possible. And when we look at the AMH tiers, there are kind of two factors really to look at. One is who's primarily responsible for the care management and then there's the level of care management service that's actually being delivered. So if you look at tier one, which is the lowest tier, health plans are primarily the ones responsible for ensuring that patients receive care management services. And on that continuum of care management intensity, this offering just tends to be more broad and generally targeted. So looking at getting folks in for annual Wellness visits and follow-ups, but generally more less targeted. for Tier 2, typically the health plan continues to remain primary responsibilities for care management, but the interventions tend to be a bit more targeted to specific populations. And then there's Tier 3, which is the highest tier and that's where we really want practices to be because it allows for practices to assume primary care management responsibilities either directly or through a partner such as CHESS. And then Tier 3 also allows the practice to receive higher payment than the other tiers. But the requirements are more stringent. So for example, practices have to be able to receive claims, meet data and security requirements. They have to be able to risk stratify patients, provide complex care management and provide transitional care management. So while it is the where we want to get practices to in terms of the tier, there's a lot of requirements that come with that. And so that's sort of the determining factors. And so yes, a practice could work with either build internally the capabilities or again work with a partner's CHESS to reach to Tier 3 or if they choose to not receive those Tier 3 payments, they could pare down and move to a up and down that Tier to a Tier 2 or to Tier 1 performance category. Interesting, Josh, in your mind, what has been the biggest hurdle you've seen in entering the managed Medicaid market and how has chess overcome these challenges or these barriers? Yeah, it's, I would say there's many little hurdles as opposed to one big hurdle and a lot of it has to do with just sort of the newness of managed Medicaid and that transition. So as we've been working with the multiple health plans, the PHPS to get into this space, what we're learning is that communication is, is challenging because they all sort of talk about things in a different way. There doesn't seem to always be a cohesive way in which they're talking about their contracts and how they're set up. There's also then a lot of administrative burden that is placed in, in doing managed Medicaid. There's requirements that are pretty stringent that cause sort of operational challenges. But in general though I again as I mentioned before we've been very fortunate that we had the sister company that who has been dealing in Medicaid for a number of years and being able to transfer those people, those resources, that knowledge into CHESS to be able to enter into this market has been a been a huge benefit for us to overcome. And I think is what is allowed me to say that we don't have a big hurdle they're just little minor hurdles that we're working through as we're entering into this market. That's great. Well, what are the three core services that CHESS offers? Yeah. So in speaking with practices, what we learned is that as they as they have sort of evaluated their services in in getting to Tier 1, Tier 2, Tier 3, where they should, where they should be going, what they should be putting in place that there's specific gaps that they that they faced that didn't allow them, that may not allow them to maximize the opportunities available in the managed Medicaid program. So what we've tried to do is to design our offering around these specific gaps. So just quickly the first gap that a lot of practices said that they would have in in entering into managed Medicaid is information systems and data aggregation capabilities to be successful when managing their Medicaid populations. And so we offer a comprehensive population health platform that manages all data integrations including those from the payer and other disparate data sources. And this platform is designed to meet all the AMH Tier 3 requirements, so we can handle that for practices or licensing that to them. Another area we heard that practices lack the ability is to staff the full scope of care management services that are required for the Medicaid population. So what we've built is a full care management delegation offering where CHESS staff leverages our again decades of experience in care management, care coordination, and transitional care services and apply this to the Medicaid population. And then finally we heard that the administrative burden on practices from the contracting, the payer relationships, the routine auditing is, is a gap that practices have. So we're so our offering is to help to support practices through our CHESS Medicaid CIN, where in this offering CHESS not only does the negotiation & holds the contracts with the with the payers but we're also then on behalf of those practices can meet with the payers and joint operating committees and act as the liaison to solve any of the hiccups or issues that may arise between the providers and health plans. So I think those are really the three core services that we offer in Medicaid that we feel will really fill those gaps for practices that are engaging in managed Medicaid. That's great. You know I know that CHESS has been an innovator and a leader for many years in in a lot of the components of population health. So, I I'm curious as how chess is supporting those big three components of population health for Medicaid and of course this includes reporting, data, and care management. I know you just spoke to that a little bit, but I'd like to hear more about the support that's provided. Yeah, absolutely. So again, this gets a little bit more into our, our comprehensive population health platform that I referenced a minute ago. And so if we start with data, our data activation platform leverages a myriad of data sources. If I'm recalling correctly, I believe it's somewhere around 200 prebuilt connections to IT vendors that that we have that we can integrate together and while providing the highest level of data and security per HIPAA and the state regulation. So we can offer that and then offer advanced analytics that can drive insights that can improve health outcomes and reduce that total cost of care. And a little bit deeper then in the reporting is when it we offer an analytics tool that allows for you know data visualization, risk stratification of the population, also allows for any SQL data and retrieval manipulation if so needed. And our platform allows practices to drill down then at the practice physician and patient level and there's several built in dashboards that that we can report out on performance from the providers, total cost of care drivers, network lease leakage, contract performance and medication management just to name a few. So very robust reporting suite and offering that we have in our platform. And then of course our platform supports the documentation and delivery of the important care management information including assessments and care plans. And we have over 20 plus assessments that assess physical, behavioral, social determinants needs. We can also identify care gaps and can help coordinate the proactive interventions by utilizing a pre-existing library of customizable assessments and care programs. So this comprehensive platform really kind of is intended to focus on those big areas of data reporting and care management because we know those are what's really important to drive improvement in the health of those Medicaid population for those providers. I know that that's really helpful on the provider level navigating some of those really big hurdles and overwhelming things that that folks are having to go through with Medicaid. So, if a provider group is interested in getting support with Medicaid, what are the engagement opportunities? Yeah, it's a great question. And one of our sort of overall goals at CHESS is you know, we often say we're not a rip and replace shop. We try to meet providers where they're at, leverage the existing capabilities and staff that they have if they're happy with those. And so we've designed our engagement opportunities, our engagement models within Medicaid to fit that, to fit that thinking. So the first and sort of basic offering is a licensing of that population health platform that I just mentioned. So with that provider could have access to the to the platform which has all the IT and security requirements. We then handle also the any full delegation of the audits that are required. And so that's really beneficial for those who have built the care management capabilities. But to get to those level or that Tier 3 payment requirements really need a robust platform that meets all of the requirements that are recall required by the state Medicaid program. The next option is our full care management delegation. So in that instance practices would have their own contracts with the with the health plans and then they would delegate care management activities to CHESS care managers. And of course we utilize our platform to document, provide the assessments, the care plans and everything I mentioned before and manage those patients, all the patients within a providers panel. And then we have what we also call our CIN model which is essentially very similar to the care management delegation engagement model I just mentioned with the primary difference being that in this model Chess would negotiate and hold the contracts on behalf of the practice with the PHPS. Care management is delegated to CHESS staff and we will manage that population. But then we also go further in helping to support and be that liaison between the practice and the health plan in providing panel and roster management support and again any support with issues that may arise. And then also create a learning collaborative with other providers in the state to collaborate and discuss what's working well, what's not working well, where there's some ability to collaborate and to help manage the populations better. So those are our three primary engagement models for Medicaid. That sounds pretty comprehensive. Josh, you've been doing this a long time, and you know you you're well known throughout our industry as being an expert. So, I would like to get some free advice from you for myself and any of those who would be listening. And as you, you know your deep immersion over the last few years into the Medicaid space here in North Carolina, what advice do you have for practices who are looking to get into the managed Medicaid space or for that matter, value-based care in general? Yeah, I so thank you first for the for the kind words. I appreciate that. And having been on you know in practice management being on the practice side, I would say my advice is for practices to really do your due diligence and make sure that you're whatever path you're seeking to go on that you understand what the requirements are so that you're really maximizing the opportunities within the managed Medicaid program. Because the intent there again as I mentioned, as we talked about the payment models really is to create and incentivize better ways to manage those populations. But they do come with requirements. So you need to know those. You need to be really do your due diligence and if you decide to work with a company like CHESS to support you on this journey, just make sure that you're working with somebody who's really acting as a partner. So make sure that they're providing you with regular touch points and discussing the patients, what are they doing with them, what are they seeing, what are they in need of and sharing that back with your with your physicians and your providers, that they're providing regular reporting to address those social determinants and those needs of the patients and that they're supporting you in managing those relationships with the health plan. There's again one of the hurdles that we have found as I mentioned is really that communication and understanding how the how one health plan is talking about something and what their goals are versus another health plan and you really need it can be a daunting task to really have to manage that on your own and so I'd say you know while it can be daunting you don't have to go it alone or settle for a less than optimal support. There's options out there obviously being CHESS I think we do it as well if not better than anyone else out there and I'm happy to help them support and provide that advice to practices whether they end up going with us or not. We want to be there and be a support for the practices in North Carolina. Outstanding. Josh Vire, thank you for joining us today on the Move to Value podcast. Thank you, Thomas.…
 
So as you are well aware, at CHESS we often refer to the seven pillars of value-based care. What are these pillars and how does each impact fee-for-value? So, we’ve tended to use these pillars, if you will, to think about the process. Really, it follows our implementation process in many ways. So, I would start with practice transformation. So, that involves ensuring that physicians, advanced practice providers, office staff from CMA to nurses to even front desk staff, has some awareness of value-based care, understand why it is important, and then are engaged in the process of transforming that practice to a infrastructure that supports the delivery of the value-based care models and success in those models, both clinically, which is ultimately what this is really all about, and financially. From there, you can begin to layer on other services or pillars if you will. These don’t necessarily have to happen in this order, but we often start with thinking about quality. Most organizations today have some quality efforts already in place just due to primarily to the fact that CMS and other payors are pushing those. And most people have at least some pay-for-performance type of arrangements, where they’re paid for closing quality care gaps. But quality goes beyond just thinking about closing quality care gaps. For our quality team, we’re thinking about optimizing the annual wellness visit so that the template within the EMR is just capturing data points and discrete fields. That makes reporting easier back to CMS as well as to the private insurance companies, Medicare Advantage, as well as commercial. We think about Care Coordination and as we define care coordination, that includes, for our teams, nurses and CMAs. They work together to assist also in quality. So, the CMAs help close quality care gaps throughout the year. They schedule annual wellness visits, that’s a big emphasis in the first half of the year. If you can already tell, that annual wellness visit is a key component of value-based care because it touches on so many different elements of value. The other role for Care Coordination would be moving with that patient, tracking that patient, outreaching the patient between transitions of care. So, patient is admitted to the hospital, discharged to the skilled nursing facility, then discharged home. Our Care Coordination teams are monitoring that patient as they transition through those different sites of service and ensuring that each transition is as safe as possible. We all know that medication errors, in particular, are a massive problem through transitions of care. So, ensuring that patients know what medications they’re taking, or supposed to be taking, and that they can afford those medications. If they can’t, then connecting them with the resources to be able to provide those medicines for them. They also perform Chronic Care Management. So, that’s identifying. So, we can go back to population health, identifying a group of patients who are either at high risk or rising risk of a complication or with a certain disease state. Identifying those patients, and then on a regular basis, setting up telephonic or even telehealth outreach to those patients, so that between those four office visits a year, that a chronic patient might have with a provider in the office, someone is touching base with them throughout the year. As a clinician, I always think that way. That for an average chronic care patient, I might have an hour or two hours a year of face time with a chronic care patient. Whether that’s diabetes, hypertension, the combination of the two. That’s really not very much time over the course of the year. And so, when you think about the Care Coordination team being able to touch those patients in between those visits, you really are improving the patient’s experience of care. You’re extending the provider’s reach and ability to impact the patient in between those visits. So that’s a huge component of it. Those are the areas to date that we have largely focused. There are other services that can be provided, but those are kind of our building blocks. We also think of another pillar as Pharmacy. So, CHESS, we’ve got a team of clinical pharmacists, PharmDs, as well as pharmacy techs. Those folks together as a team are focusing on medication assistance, so again working with a Care Coordination team, identifying patients who have trouble with affording medicines. Trying to ensure that we connect them with resources. Whether that’s community resources, or drug companies that have low-income subsidy programs, grants, foundations, other ways of accessing medications. Focusing on medication adherence, so in the quality component of the value-based contracts, medication adherence is about half of your quality points in a typical Medicare Advantage contract. They tend to be triple weighted, which means they have even more importance. So, it’s very, it’s critical to success that your patients are adhering to their medication regimens. So, that the team supports that work also. But then going beyond that, thinking about groups of patients who are at risk for certain complications with medications. One that always comes to mind first for me was something called a daily oral anticoagulant report our pharmacy team runs. Looking at patients with a new evidence of renal compromise that would indicate they may need to have their oral anticoagulant adjusted. If that doesn’t happen, then that patient is at risk for a gastrointestinal bleed. If they were to fall, at risk of an intracranial bleed. Those, both of those, lead to hospitalizations and even worse, potentially death. So, trying to identify those problems before they ever occur. Work with the patient’s physician to make a dose adjustment in their medications and avoid that downstream negative event. We think and talk a lot about accurate coding. So, there’s a lot of emphasis on that. Has been for several years. It has gotten significant negative press as well. But it is very important that providers are accurately and completely documenting, first of all, a patient’s conditions, addressing those conditions, and then coding that. That helps align the resources to care for patients with the patient’s disease state. But it also, we remind providers constantly that in many ways today, the medical record serves multiple purposes. I’m old enough to remember paper charts and I was writing notes essentially to myself for that next visit, so I knew what I said, I knew what the patient’s problem was, and what we talked about, and that note was just for me. But today, it serves multiple other purposes. It’s a legal document, it’s a financial document, it’s a medical document. A lot more emphasis is placed on that documentation by the physicians and the advanced practice providers. There’s, within CHESS we have an operations team. So, if I go back to practice transformation just a second. And that never is over with implementation, but that’s a big focus of implementation in the early phases as we prepare providers to onboard to the services I just discussed. That transformation is ongoing but after a period of time then our operations team steps in, picks up that physician group, and then shepherds them forward through the various contracts. Making sure they understand how the contracts work, make sure they understand how care is being delivered to their patients, and that the services we are providing are impacting the patient’s care as well as the financial performance within a contract. That really is implementation passing off and saying to the operations team, here’s the ball, you keep going. And then I think finally, and this is not certainly not least, I’m just listing it last. At foundation of all of this is data and analytics. So, being able to ingest clinical data into a platform, pull in claims data from the payors as well as data from other sources, so HIE (health information exchanges), ADT feeds through vendors that are that have in their possession ADT feeds from various hospitals. Because we need to know where our patients are and be able to identify when they hit that facility. Especially if it’s outside our network. So that we know what’s going on and can reach out to that patient in a timely manner. And I think that’s the seven pillars. I think you asked me also, why is it, why are these things important or how do they impact providers and patients. And we can talk more about that in just a moment, but to me this is work, most of this work is work that does not get done in a fee-for-service environment. There’re just not the resources, there’s not the infrastructure to support it. So, when you do this and do it well, you’re improving the patient’s experience of care and you’re also improving the provider’s experience of care, and extending their reach in a way that they would not ordinarily have to do it in a typical office setting. What questions should physicians and health systems be asking themselves as they undergo the transformation from fee for service to fee for value? Well, I think I would start with who are the beneficiaries for whom we are accountable. In our prior days, in fee-for-service, you didn’t really think that way. We were thinking largely about who’s on my schedule, is my schedule full, if it’s not full can we get it full. In this new world, we should be thinking about who’s not on my schedule that should be. If the patient is in a value-based agreement and attributed, or assigned, to the providers that have the agreement with the payer, then you’re responsible for those patients and their cost of care and their quality of care regardless of whether they come to see you or not. And so, I need to know the patients who are not seeing me for whom I am responsible so that then I can deploy my care teams to reach out, see if we can understand any barriers to seeing that patient, get them in, and get them the appropriate care that they need. We just never thought that way in a fee-for-service world. I’ve alluded to this earlier, the next question to me would be where are our patients receiving care? We often get the answer, well I know when patients are discharged from my facility. And that’s probably true. But we don’t always know when they’re discharged from other facilities. It’s a blind spot for most health systems. That is improving today but we need to make sure that we are capturing data points, to the degree we possibly can, to understand that patient’s journey through the healthcare system not just the health system. Because if we don’t have insight into that, then we’re not able to respond appropriately when they’re making their transitions, whether that’s hospital to home, or hospital to skilled nursing facility. Whatever that may look like. We need to also think about clinical and cost needs. So, what clinical situations do they have that would be driving costly or high-cost care? How can we intervene? Are their behavioral health issues or concerns that we may need to address? Do they have poorly controlled diabetes or poorly controlled hypertension? So that we can get them to the right cost of care, the right site of low-cost care to intervene. Taking that a step further, what beneficiaries are at current or future risk of complications that could lead to high-cost spend. And then understanding what gaps in care exist for patients. That might mean screening tests that are open, that could be disease-state management, A1c and hemoglobin A1c is a great example of that. But it could also be patients lost a follow-up, patient doesn’t have the ability to afford their medications. So, addressing, identifying and addressing those gaps in care, whatever they might look like, is another important question that we need to ask as we, sort of, take that shift and shift our mindset over to a new set of questions. In summary, you know, understanding where care is received, not just within our system, integrating that clinical and financial data together so we have a 360 view of the patient, and then beginning to use that to do some predictive modeling, both clinical and financial.…
 
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 disease-specific quality measures that they should have addressed, like hemoglobin A1Cs, or blood pressure under control? Those types of quality measures. And then finally, lowering the cost. So, I go back to Care Coordination again. Thinking about chronic care management, transitional care management, trying to reduce readmissions. And also to try and prevent unnecessary admissions as you engage with patients in the their the management of their disease states. I think the other thing that value-based care does is it puts the right incentives in place for provider access. When I’m talking to physicians and they ask, you know, what do we need to do, there’s always one answer that you can do tomorrow, and that is improve access. So, the idea that we’re going to be open 8 A.M. to 5 P.M. and shut our phones off at lunch is a bit antiquated. That might be ok for a fee-for-service world, when your schedules full, and that’s the thing that matters most. But, in fee-for-value, if you can provide access to patients when they need it, so that they can receive care for non-emergent conditions in a non-emergent setting, then that saves money for the system and will loop back to the first thing I talked about, and it improves the patient experience of care. I don’t think there’s anyone, very few people if any, that enjoy sitting in the emergency room waiting. And, if you’re condition is not an emergent one, if you don’t have an emergency situation, then you tend to be triaged to the end of the line and you spend more time there in the waiting room, which is not good for patient experience, which is not good for provider experience, which is not good for patient experience ratings for the provider. So, it’s kind of, it gets to be a snowball effect. And you know, a few years ago, I’m not sure who gets credit for this, but physician burnout we all know is a huge issue and COVID has not done anything but accelerate that problem. And so, someone term the quadruple aim, adding physician or provider experience as the fourth arm of the quadruple aim. And we’ve already touched on this a good bit, but from a physician’s standpoint, value-based care aims to implement team-based care. So, they’re not the same, but they go hand-in-hand. In team-based care, the purpose, the aim there is to be sure that everyone on a provider’s team, those people in the office, those people behind the scenes who may be in a hub somewhere or perhaps embedded in their physical facility in a room where they’re not focused on the patients who are coming in and out each day, but those patients who are at home, they’re trying to outreach. All of those people together, working at the top of their license, is what we aim to do in value-based care. For physicians, we would like to see them doing the things that only physicians can do. The things that other people on the team can do, then let’s let them do those things. And let’s use protocols and evidenced-based guidelines to direct care for the 80% of the population, I always laugh and say the 80% of the population that’s read the textbook, and they kind of behave according to the textbook. There’s 20% of the population that don’t. And that’s, you know, the medical background and training that physicians and APPs have. Decision making comes into play there. You can’t necessarily follow an evidence-based guideline for whatever reason. We know that everyone won’t just fall into a nice, neat, little box. So, really putting their decision-making skills, their assessment skills, their diagnostics skills to work in that part of population that won’t fit the rules. And then, I just learned recently that there is now the quintuple aim, which is adding in health equity. And as I think about what we’re trying to achieve by improving the outcomes of care for all patients by removing barriers that they face and typically those are, you know, social economic barriers. Value-based care is set to address that. When I look at the patient stories and hear the patient stories that come from our care coordination, pharmacy, social work hub, they are constantly working with individual patients to identify barriers to improving their care and ensuring that they have outcomes that are equal to those who are not facing the same barriers. Value-based care is perfectly set up to address each of these stakeholders. When I think about, you know, the medical industry, if you will, in it of itself, but also the providers, the patients, and the folks around them that we would call their care team. I’ve heard you say that making the move from Fee-for-Service to Fee-for value, aka value-based care requires a new way of thinking. Can you elaborate on this? Sure, be glad to Thomas. So, I go back to the old fee-for-service world. The world I grew up in. And I still remember asking myself that question the first time I sat through a meeting about value-based care. And, as an OBGYN by training, this was 12 years ago now. I went home after that first meeting and I thought, now what do I do differently tomorrow. And I struggled for a little while to understand the only thing that I could come up with was continue to deliver high-quality care, have access for my patients, and, you know, don’t sent people to the emergency room or labor and delivery unless they need to be there. See them in the office if its possible. But as I understood the concepts more, I think there are several areas that we can call out and kind of make a comparison between the two worlds. We’ve touched a lot on consumer experience or the patient experience already. So, in the old world, confused, frustrated, you know, not knowing what’s going on. Provider A is not talking to Provider B. Provider A didn’t get the referral letter from Provider B when the patient was sent to the orthopedic surgeon, the cardiovascular surgeon, or the endocrinologist. And communication is just not taking place between providers. So, this leaves patients trying to navigate a very complicated system on their own. In a fee-for-value world, that patient experience should lead one to feel valued and engaged. So, there are resources at play from the care coordination teams, the pharmacy teams, our quality teams, we’re just reaching out, pulling that patient in, and making sure they feel supported throughout their care journey. From a care delivery standpoint, we’ve always been reactive. So, we’re responding to illness in a fee-for-service world traditionally. Now, there had been progress around preventive medicine and addressing cancer screenings, for instance. Colorectal cancer and breast cancer screening. And a lot of that work has been done and is important, but I wouldn’t say that’s really geared at overall health so much. And, even in the fee-for-service world, we still were largely reactive. In a fee-for-value world, we’re more proactive. So, we’re using data, we’re using our various teams to identify patients. Like I said earlier, not just who are at increased risk today, but who we believe are at risk in the future of some untoward event. Whether that be clinical, or clinical and financial. And so, that shift in focus for deliver of care is very critical. Care coordination, just by virtue of the term, almost didn’t exist in the fee-for-service world. We didn’t have technology. We didn’t have data and analytic. Again, paper charts, telephone calls, that was about it. In this fee-for-value environment, our infrastructure’s set up to give us access to much more data, which we can then use to identify patients to be more proactive. Finally, just thinking about cost, so I believe that a strict fee-for-service environment really is a bit of a perverse incentive. I mean, you, people say you, whatever you incent is what you will receive, what you will get. And incenting people to do more usually gets you more. And that’s the way the fee-for-service structure was set up. It’s set up to do more. See more. So, the important thing was, you know, who’s on my schedule, do I have enough people to see, am I seeing as many as I possibly can. In a fee-for-value world, the financial construct is more conducive to seeing the right patients, at the right time, and in the right location, and doing the right thing. So, it’s not necessarily doing more. But it again focus on doing the right things for patients. And so those are, there’s certainly more ways, but in my mind, those are some of the big differentiators between how we think in a fee-for-service world versus how we think in a fee-for-value world.…
 
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, what are independent primary care providers looking for in a clinically integrated network and what qualities or resources do they value the most? So, I will say in my work as a practice manager and then in my subsequent years as a practice support coordinator for the North Carolina AHEC system, I think one of the things that they go to all the time is the bottom line. So, while money is not everything that drives healthcare to be able to have a sustainable practice, you really do need to realize the financial benefits of this model. So if you don't have competitive reimbursements, reimbursement rates, or opportunities for shared savings in these value based agreements or quality incentive payments and access to other advanced payment models, then you don't have the revenue that you need to be able to sustain your organization and the healthcare practitioners and the healthcare team in those organizations have the resources that they need to deliver the quality of care that you really want for your patients. So that's the next thing they really want a CIN that's focused on patients and the care and the patient experience. The other thing that they're looking for is the data and the analytics support, because you really do need those data insights. You need to be able to identify what's your low hanging fruit. Where do you need to put your resources? And where like what are the things that you need to focus on to be able to identify gaps in care and approve efficiency in your workflows? Also, they're looking for a care management partner one that's going to collaborate with them and not just do the care management in a vacuum, but really work collaboratively with the local care team and understanding the needs of the patients and the resources that they need in managing those complex patients and have tools at their disposal for identifying care transitions and communicating with the care team whenever these patients are accessing care across the care continuum. The other thing is they need practice support. They need the education and insights and assistance in helping them understand the regulatory compliance environment that they're in the quality and reporting requirements and any other contractual requirements that they're obligated to meet their service level agreements or SLAs. Most importantly, I think is also alignment with their values. So, identifying that there's a shared commitment to improving patient outcomes and that the leadership in both organizations value collaboration and input from providers, and that the care team and the organizations that they support. And then of course technology's a big thing. They want one platform, or at least one source of information. One of the things in value-based care now you have multiple CINs for various different contracts and so you might have one for Medicare, one for Medicaid. I think in my work with practices as an AHEC practice support coach, I come to realize quickly that they want one system. They want one population health management system that is easy to understand and provides them with the insights that they need at the point of care. Providers they value CINS that not only address the immediate needs of their organization, but also position themselves for long term success in this ever evolving health care landscape. And I think going back to my first point is that they really want an organization that empowers the providers to focus on what they want to do, which is patient care and help them navigate the complexities in the value based models, but really allow them to do what they do, which is provide patients with quality care. That's a big menu of ideal resources that that are expected from a CIN. So, I guess then my question is it obviously some independent providers aren't getting all of those benefits, yet they still feel still feel hesitant to switch if they are within a current CIN. Why do you think this reluctance exists and what factors might be at play in those decisions. So I think providers are reluctant to change for a variety of reasons, and one is basically, it's better the risk you know versus the risk you don't know. So, they already have these established relationships with their current CIN and whether they're long standing and trusting, it's familiar for them. And also, there's the perceived risk of transitioning. Concerns about like, how is this going to disrupt their current operations or learning a whole new system or adapting to new unfamiliar workflows. Also, there's an unclear risk benefit, so they have difficulty in evaluating what the risk benefit is in determining what the if the benefits outweigh the risk of transitioning away from their current CIN. And then of course they're contractually obligated or maybe contractually obligated in their existing agreements and so there may be some complexities about switching and how tightly they've aligned their financial ties to their current CIN, and I think a big thing is they want to know that the organization that they're, they might be moving to aligns with them culturally. So, does the CIN value the same things as the provider? Is the CIN's mission and leadership approach something that aligns with their approach to healthcare and ensuring that their patients get the best care and it's not just about financial incentives for the CIN. I think to be able to move providers along that continuum and to be able to enjoy a new relationship that would benefit them and benefit their patients is, you know, having an effective communication conduit for communication and then just understanding what their hesitations are and addressing those hesitations like 1 by 1. Interesting. So, let's play a role-playing game here for me. So, pretend that I'm a provider and I'm considering a new CIN. I don't really like where I am with my current partner. What factors should I consider and how can I ensure that I'm making the best decision for both my patients and my practice? So, I think that one of the biggest decisions that you make in evaluating a CIN is like we talked about earlier is alignment with your practice goals. So, what are your goals as a practice and as a provider? And then what you need to do is assess whether the CIN is focused on those same goals, you have shared goals, shared vision, and shared alignment of where you want to go. Understanding that the focus is on value-based care and quality improvements, but it also is centered around patient outcomes, the patient experience and then also the provider experience and the care team experience. Then secondly, thinking about what support services that the CIN offers, so what resources do they have to assist you in making the switch or moving to a different CIN. So do they have payer negotiation resources to help you with negotiating contracts if you need that. What data analytics are available? How successful has their care management care coordination program been? Do they have pharmacy support services? All kinds practice support services? What support services are available? And then thinking about like their financial the financial implications in the payment models like what do they offer? Do they offer upside risk contracts, downside risk contracts or full risk contracts? What are the shared savings opportunities and potential costs associated with being in this CIN and understanding what the financial implications are and how that would benefit your organization? And then I think culturally thinking about again, does this does their mission align with your mission? Do their values align with your core values? How does that culture impact your patients and impact their continuity of care improvement in their patient outcomes, their patient experience? Really just thinking of it from a holistic point of view and not just from a financial point of view. I think a lot of people who are thinking about or entertaining a change in CIN they the first thing that they look to is the financial implications and maybe they don't evaluate all of the other aspects that are going to really help them realize the care that they want for their patients, the outcomes that they want for their patients, the value that their patients receive from being in the CIN and then the value that the providers and their care team are going to receive from being in this new CIN. So Tammy, CHESS has a strong reputation and value based care, I think that's pretty well established. Could you share some of the specific supports that we have available? And can you tell us what makes CHESS uniquely suited to help providers achieve success in value-based care arrangements? So I think chess has what I would entitle like a flexible yet comprehensive and transparent model that enables providers to be successful in this move to accountable and value based care for all patients, not just certain payers. So, CHESS offers support for traditional Medicare, Medicare Advantage, Medicaid commercial and even uninsured populations. They do this through a suite of technologies and service supports through delegated care management, pharmacy supports, quality improvement, practice support, contract negotiation, we talked about earlier. Basically, CHESS meets the providers where they are on the accountable care curve. So we have providers who are still in that learning, investing or aligning and we hope eventually we'll get to transforming. But really CHESS is able to support them where they are and to help them meet the needs of where they are in that accountable care curve and in this value-based landscape. So, I would say CHESS offers a solution for your entire patient population and for your entire organization. So, our solution supports your providers, it supports your care team, it supports your patients and really trying to figure out like how to maximize the financial benefits of taking advantage of these economies of scale and aggregating and distributing the cost across all the payer populations and I think probably if I were to say Why CHESS? I'm going to put it back to the mission vision and values. And that's like CHESS’ mission is to sustainably transform the healthcare experience for not only the patient but the provider and the care team and we do that through cultivating this value oriented, compassionate and health aligned care community and centered around our values of collaboration, innovation, expertise and integrity. And if, as a practice administrator, I think I would choose CHESS for those reasons. Finally, Tammy, for those who are considering a partnership with chess, what makes now the right time to make that decision? There's no time like the present. Now is always a good time to change and if you wait for the perfect opportunity to change, you probably will never make the leap. But the landscape is prime for moving toward value-based care and accountable care and realizing the healthcare transformation that we all seek. Outstanding. Well, Tammy Yount, thank you for joining us today on the move to Value podcast. As always, Thomas, thank you for allowing me to be here.…
 
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 much is preventable. Like I feel really passionate about that. And so when we think about screening is actually one of our quality measures now for a lot of our contracts, especially with Medicare Advantage, but it's called KED and that's the kidney health evaluation for people with diabetes. It involves two different tests, so you have to get a blood test. Most practices and physicians offices are really good at this piece. It's part of routine blood work. Like if you have your basic metabolic panel or CMP, it's part of that. You're looking specifically at your creatinine and your EGFR, or that estimated glomerular filter rate and that's just kind of looking at the kidneys to see. Are your kidneys actually able to filter out waste or toxins out of your body? Again, primary care providers really good at getting that piece. Blood work. The piece that I think we struggle with that's equally important is actually you need a urine sample as well. And so in the urine sample, what you're looking for is you're looking for protein in the urine because that is not normal. To have protein in your urine, and that's called the UACR or urine albumin creatinine ratio. And that again, that's just looking to see if you have protein in your urine because that indicates that your kidneys are potentially damaged and they're sort of leaking, if you will. And so those two things are really early indicators that can tell us if someone's at risk. For chronic kidney disease, cause in general in the beginning, chronic kidney disease doesn't really have symptoms. It's silent and I think I read a statistic somewhere that 90% of people who have it don't even know they have it. In the beginning, there are literally no symptoms, and so you have to screen to be able to identify it. So one of the one of the big challenges that the practices face is getting the urine test that that could be is that the most difficult when you your assessment? That's what. Yeah, that's what I found in my experience. Like, I think that's sort of been multifactorial. Probably really two factors that play into that. You know one, you're the primary care provider, you have a patient coming to you and they may have five different problems they want to talk about I'm guilty of this, right? Like I save up my problems and I want to talk about all the things when I get there. And so you're sitting in front of this person who may have very different priorities than what you think you want to do, or labs that you want to do. So, by the time you're finished addressing what you can address with them, you've just forgotten. About it, right. And so, unless it's really part of the process or standard of care, it's easy to forget about. So, my thought would be everyone needs to have sort of a standard operating procedure around diabetes, if you will, right? You're gonna get their blood pressure. You're gonna get their A1C. We need to start making those urine screenings part of that sort of standard process, you know, allow your team members to help you. Doesn't have to be the provider, it can be the staff. It can be the lab. You can have standing orders, but it really has to become a process issue or it slips through the cracks. So I think that's one of the biggest things. The other thing that I've also experienced in primary care, and so this measure used to be a quality measure many years ago and it was It was slightly different than the one we have today, but I would often hear providers say, well, my patients already on an ACE inhibitor or an ARB, those are the medicines that we use to help protect the kidneys. The oldest medicines we have. So like, why should I? continue screening that's just a wasted test. We are in a very different situation now with some of the medications we can use to help protect kidneys. So, I think part of that piece is just education around those medicines and how to help patients get those medicines. That's awesome. Do you, when it comes to preventing kidney disease, what lifestyle changes and interventions do you typically recommend for patients with diabetes? Yeah, I mean, and the lifestyle interventions are really the same ones that we would recommend to anyone to keep them healthy. You know, part of comprehensive care. So we're going to recommend that people, you know, try to maintain a healthy weight. If people are obese or overweight, that comes with insulin resistance. Insulin resistance comes with inflammation. And so that can lead you into damage to the kidneys down the road. High blood pressure. You know, if you have high pressures that's going to be in your kidneys as well. So that high pressure in your kidneys can damage your kidneys, so you're going to try to manage your blood pressure through maintaining a healthy weight. Exercise and nutrition, right? Things we all should be doing and then a huge one is smoking. So smoking has quite the effect on the kidneys too, because of the inflammation and just changes that happen to like your vascular system when you smoke. And so the kidneys are highly vascularized. And so anything that can affect you know, your vascular system. It's gonna affect your kidneys. So same things we all should be doing. Don't smoke. Maintain a healthy weight exercise and try to eat right. Those are sometimes the hardest things to do. I know, right? If it were easy, we would all do it. That's what I tell people. If it's easy, you would have done it already. I'm really glad we're having this conversation. So can you tell me what a typical screening process looks like for for kidney disease? Walk us through the tests like the EGFR and the uacr and explain their significance. You touched on it a little bit, but you know what does that look like? Yeah, sure. And so, you know, if I'm a patient coming into the office and I would empower patients to do this as well, right? Like part of, you know, taking care of your own health is being proactive and being an advocate for yourself. So if you happen to be a patient listening to this or you know someone who has diabetes, I always encourage people to make a list of all the things you want to make sure you have done and kidney health is one of those. But also thinking about. Your eye health. Your feet. You know your eyes. Your kidneys, your feet are always things you want to think about when you have diabetes. But for your kidney specifically, most patients are going to have blood work. So, they'll get a blood draw once a year through that blood work, they can calculate that EGFR again, it's calculated in mils per minute. It's mainly just like how much blood your kidneys are able to process and filter. Your kidneys are kind of like a filter, just like your car has a filter right with oil and your oil filter in your car is filtering that oil to make sure all the toxins are taken out. That's exactly what your kidneys do. And so that's what that blood test looks at is how well are your kidneys filtering? And then you're literally gonna have a urine sample taken, right? So nothing invasive about that. And when you have that urine sample taken, what they're looking for is protein. Protein in your urine is not normal. There are some things that can cause it to be temporarily in there, like intense exercise. If you have really high blood sugars. Infections like if you have a urinary tract infection. So sometimes you can't have protein in there. And it's just transient. It's going to go away. So anytime you have a urine test and they detect protein in it, you're going to want to get a recheck in three to six months to make sure that protein in there is persistent. That's one of the pieces I find in primary care that's the hardest, even if they do the initial one, confirming it again in three to six months can be really hard because again, you have someone coming in just for the purpose of getting the urine sample and that is looking to see, you know, if your kidneys or if that filter within your kidneys is leaky, should not be leaky, right? It should be there should be no protein getting into your urine, and so that's what that's looking for. Both of those tests in conjunction can tell you if you have early stages of kidney disease and what we need to do differently. Interesting. I never thought about leaky kidney filters before, but that makes sense. I like that. Yeah. So I've heard you talk about other treatment options for kidney disease that are that are being used now more so than in the past? And could you elaborate a little bit more about these newer treatment classes and how they differ from some of the older therapies? I think, and I think this is one of the most exciting parts of this conversation. You know, we should definitely be screening early because it's preventable, but now we have way more medications than we used to have in the past. So some of the early medicines like I alluded to where your ACE inhibitors and ARS medicines historically used for blood pressure, right? So they're your lisinopril's, your Losartan, prils and arten's. That's how you know. And we've had those for a long time. Now we have other medicines that have been shown specifically to protect the kidneys. So there's two groups of those in the diabetes group of medicines. So one is sglt 2s. Those are gonna be your medicines. Like INVOKANA, Farxiga, Jardiance, they work actually, by helping your body get rid of glucose through urination. That's part of what our body does anyway, but they lower the threshold. As part of that process, they also lower the pressure, if you will, inside our kidneys. They also decrease inflammation, so they have a lot of good evidence, these particular medicines, that they can prevent progression of kidney disease. And I have to give a shout out to my VA colleagues. I'll say these medicines work so well, even though they're expensive, this year, and this coming year it's been a focus of the VA to make sure that everyone with these early signs of chronic kidney disease actually get these medications. And if they're not getting them, there has to be a documented reason why. So I think the fact that our, you know, healthcare colleagues in government you know see the benefit of these and the cost effectiveness of them should really. Make a case for them for the rest of our audience as well, who are in the private space. So that's a really exciting group. So if you have patients that have some degree of chronic kidney disease, you should definitely be looking into those medicines. Our GLP 1S, like Ozempic, Victoza, Trulicity, Mounjarro you know the ones that are popular because their weight loss benefit. They also have some early evidence in kidney disease and preventing that progression as well. They work by decreasing inflammation. They have lots of ways that they work, but that's one of the most common ways. So especially if someone wants to lose weight, they have cardiovascular disease. And they have some early signs of chronic kidney disease. Those medicines can be a nice choice. And then now we even have a fourth class of medicines that we haven't had before. There's one called phenerinome. If you're a primary care provider or even a patient listening. This is very similar to spironolactone, which we've used for a long time, except this particular medicine is more selective, has less side effects, and has clinical trials to decrease chronic kidney disease. So there are a lot of options. I mean, we could spend, you know, a whole just discussing the medicines at this point. Yeah, this is wonderful, Rebecca, because I, as a consumer of media. we're remote. We both work from home and so because of our work, our Internet usage, especially mine now involves a lot of healthcare research. And so I also have streaming services for my television. And so my family gets a little disgruntled at these wonderful ads for all of the medications that come in because I'm obviously in the demographic where I'm super sick, I have diabetes. I have heart disease. I have all of these other quality measures that need to be addressed because we're writing about them in marketing and communications, and they do have some wonderful commercials. And I have learned a lot about that. All of the names that you've mentioned, it's really funny because as you're mentioning them, I can I can visualize my head, these, these, these ads which says a lot about we could talk about media consumption and how this impacts the consumer's choice but that's for another conversation. But it was really interesting when you were talking about this, how I in my in my brain, I could hear almost hear the song. I digress. So but as we talk about these, these newer treatments, of course they, they come at a cost and there's often a concern about this cost. So how would you advise clinicians to navigate this when prescribing these medications to patients? You mentioned the VA, but what about those who perhaps fall into the cracks? Sure. I mean, you know the first thing is you just need to acknowledge that medicines are expensive and ask about the cost, because I think that takes away some of the shame and stigma that come with not being able to afford your medicines that our patients experience and there, I think we've talked about this on a previous podcast, but there's evidence that says, you know, 2/3 of patients aren't sharing the fact that they're having trouble affording medicines with their providers. So I think having that open non judgmental like hey, I'm going to put you on this medicine. It's expensive. Your insurance should cover it. However, let me know if it doesn't and then when they follow back up like hey, I know I started you on this medicine. I know it's expensive. What trouble did you have getting it, you know, were you able to afford it? Trying to be as open-ended as possible, so that would be the first step is just to ask the question and acknowledge that these medicines are expensive. The second step to that in my mind is there are lots of resources to help with affordability that patients don't know about, providers don't know about and they may be hard to navigate and time consuming. So, the local ship counselors in North Carolina, S-H-I-I-P. Those are folks that are funded actually through some grants that can help patients specifically with Medicare navigate which health plans are best for them based on their conditions based on their medications. They can also tell you if you're eligible for something called low income subsidy or extra help that can significantly decrease the cost of your medicines, but also the cost of your premiums, so that's where the second bucket that I recommend is looking to if they're eligible for extra help or low income subsidy. And then the third bucket, if that one doesn't work, there are patient assistance programs that we can sign patients up for through manufacturers. So in my experience, through one of those different avenues, we are usually able to get the patients, the medicines that they need and the medicines that the providers you know, think are right for them. Yeah, that's good. That's good advice. So, but if a patient's condition continues to progress despite all of this, what would be the next steps in intensifying their therapy? Like what role would you know, we talked about lifestyle modifications, but when we talk about, you know, a pharmaceutical interventions for blood pressure control and statins, how do they play in this process? Yeah, sure. And you know, like I said, we have several classes of medicines that are synergistic and can be used together. If you look at the ADA, the American Diabetes Association guidelines, they're really nice charts that can walk a provider through how you…
 
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 think it's just people are more accepting to get help where needed. And so North Carolina Medicaid and all of the commercial payers and Medicare have come to the table to pay for this. And these are they pay using a fee for service model, but where they pay based on time-based codes that are submitted once a month. And Medicaid pays 120% of the 2022 Medicare for service rates. And even if all your patients are completely Medicaid or Medicare, you actually can cover your cost where a behavioral health care manager who takes on around 70-75 patients in a panel can fully cover your cost. Soon we're getting ready to announce capacity building funds that are going to come from North Carolina Medicaid in partnership with Community care of North Carolina, offering capacity building funds for more practices to ramp up this this new model. The psychiatric consulting is, has been a pretty interesting situation where we have folks, psychiatrists and private practice or who work for health systems that are part of the North Carolina Psychiatry Association and also NC PAL, which is a pediatric psychiatric service that are willing to contract with practices to provide that psychiatric consulting. The care can be delivered on site or virtual. And so there's a lot of flexibility with the model, but AHEC is here to support practices that are interested in doing this. And we anticipate that that interest and adoption is only going to increase with time. When I was a practice manager, we had, we really didn't do anything like this. The only time you would really see behavioral health integrated is if you went to a federally qualified Health Center. But now you're seeing private practices adopted, you're seeing some behavioral health providers now working with primary care more. A lot of licensed clinical social workers are coming to the foray into the space. And so we're pretty excited about it. And I think it has a lot of potential not only for holistic care, but one stop shopping. So when you do go see a primary care provider, you can have all your needs met instead of being referred out. Yeah, great. In my, I recall my practice management days, just as you said, there was very little of anything that was done in terms of integration here. A lot of times because of the sensitive nature of the notes and, and what is discussed in those visits and it made it extremely challenging. It almost felt intentionally separate and sort of isolated. So what would you say to a practice manager or a physician practice who is concerned about one of the things we talked about earlier, which is just adding more administrative burden or challenges, but may be interested in the collaborative care model? And what would their next step be if they were interested? It's a fair question. Anytime you're starting a new service that does take a lot of effort. All I can say is that AHEC is here to provide free resources, both in terms of training and technical assistance to help practices figure out how to do this work. We've seen a number do it that are small, small offices and some very large offices. But what I could say is think about, to me, it's a good investment because it will save time on the back end when your referral coordinator cannot find a psychiatrist to see that child or that adult for things that should be easily managed. That's a problem for the practice. When you see patients constantly readmitted to the hospital or coming into the emergency room because their depression has or anxiety has gotten so significant that it's impacted not only their behavioral health, but also their physical health. And that's a problem. And then so you have all these burdens that materialize on the back end where if you just implemented the service on the front end, it, it would do wonders. And I think also just for a competitive advantage, you see a lot of health systems now embracing the collaborative care model or some form of behavioral health integration. And if the independent practices are going to keep up with that, that that need in the community, they're going to have to offer something like this. So that would be the only thing I would suggest. I talked to a practice manager a few months ago who said, you know, I'm, I'm a little concerned about this. I'm not sure whether it's worth the effort in time. But then she was talking about her son in high school and how he was super stressed and a little bit depressed about all the exams he was having to take and all the, the, the college applications that he was having to fill out. And she was really concerned for his mental health. And I said, you know, if you have the collaborative care in your office, you could probably do something about that. And so she's like, oh, OK, so I think I understand some of the burden, but we're at a heck, we're here to help you with the burden. One of the things we've, we've offered also to practice is if they just want to have a discussion and figure out if, if this is a sustainable model for them, we'll sit down with them and help them with the pro forma and figure that out. And then as they, as they go through the journey of hiring someone to be a behavioral healthcare manager or contracting with the psychiatry consultant, we're here to help them figure out how to solve those needs. And also once they get those people on board, how to make sure they're all focused in a way that makes them most successful with the model because we don't want to have, we don't really have to reinvent the wheel every time with each individual practice. We know what works and we recognize some practices have differences, but if you largely follow the template, you should be able to be successful. So, and I would say finally, one of the admin burdens also often is provider recruitment and retention. And there are a lot of providers coming out of residency these days. It used to be well, everybody had to have a highly a high performing EHR, which is still true. A lot of residents coming out and say, well, when I was a resident, there were behavioral health providers at my fingertips. Well, if you offer that into practice, I think the residents or the new docs that are coming out say, well, great, then I can focus more on A, B, and C and so that I can refer down the hall to someone who can help them with their depression and anxiety. If you ask primary care providers these days, they will tell you it's significant portion of their time. It's just filled in a 10 by 10 room dealing only with behavioral health problems. And when they have that resource under their roof, it makes a big difference, and it makes them happier. And I think it helps reduce provider burnout. And I think it makes for a happier staff knowing that they can take better care of their patients. So absolutely I can hear the passion there, Chris, and the importance. And I told you, I'm drinking the Kool-aid and, and, and you've got me drinking it too. I think I also am a firm believer in this. And, and it's certainly can hear it in, in the way you talk about it and the importance of it. And I love the example that you gave of sort of making a real-life connection there for that, that practice manager. That's great. Well, always, always a good way to convince them to do something is show them the real impact in their life. So sorry, go ahead, Josh. One, one thing is it doesn't have to be hard if someone doesn't want to take the time to recruit someone into these roles. And we do have resources for that. There's also turnkey virtual models out there, some very good companies that have been doing this for a little while and are very good. And so, a turnkey model may be what is best for a practice. If they're not quite comfortable that they can be successful recruiting and retaining someone, they can certainly go with that model and we're happy to help facilitate that as a potential solution as well. So there's different ways to do this work for those that maybe no, I'm going to go the traditional way and hire somebody or I just want to work with a vendor who will help me do this. And, and certainly we learned from COVID that a lot of behavioral health can be delivered virtually. In fact, they're often patients will prefer it for various reasons. And that is also something that's available on the table as well. Absolutely. And that's, I'll plug in that it's one of the things that CHESS can also help with as well services we can help practices that are interested as well. So Chris, looking forward, what do you see as the biggest challenges or changes for private practices in, let's say, the next five years in North Carolina? Well, it's a good question. I'm sure I'm not telling you anything you don't know or that your audience doesn't know, but I'll just reaffirm or preach to the choir. I would say the declining reimbursement across all payers makes it very hard to stay open and provide services while your costs continue to increase, especially in the labor market. Part of that is inflation, but that seems to be a little bit higher these days than it used to be. But it's always been the case. And I would say in addition to that, operating in both the fee for service in a value-based environment can be very challenging. I think three is recruiting and retaining your workforce. So what I would just encourage folks in leadership roles and practices, not to say that I'm perfect either, but I would say think very hard about being creative and being responsive to the needs of your staff. It's not always the money, it's, it's having there are other things you can do to make sure your staff are happy and high performing. And I would say the a lot of the regulation and red tape, there's still a lot of that out there. I think at times either government or even the even private health plans make things unnecessarily complicated. So I would just encourage anyone who's in a, in a regulatory or in a who works for a vendor or whatever, whatever you're doing, if, if the physician practice is your customer, spend a day or a week working in a physician practice. Just watch how they do their work, and you really can appreciate what folks have to go through to get the work done and to take good care of their patients. So I would say the admin burden only feels like it only continues to increase and maybe there's a way to leverage technology to improve that or reduce that burden. But it sure is hard with reimbursement declining and I don't know what the magic answer is for that. There has been discussion from providers about should we go away from a fee for service model to a capitated model. There's some beauty in that with simplicity, but the reality is you're on a budget and your capitated amount needs to keep pace with the rate of inflation. So, I don't know if there's any perfect model out there, but you certainly need enough revenue to cover your expenses and also look at your expenses and see other things you're spending money on that maybe you shouldn't be. I know that gets harder and harder every year because practice managers, if they're doing their due diligence, have really found ways to be creative. But at some point, you hit a plateau and what you can reasonably do so, and I would look for service enhancement opportunities where it makes sense. Staying on top of things, making sure you're offering at least what you're a peer practice is offering it for your specialty down the road. Make sure you're doing that and giving your patients what they want and what they deserve. So Josh, you may have other ideas of what folks should be doing or what they're going to encounter over the next five years. Yeah, Yeah, I was as you were thinking, as you're going through those, I was thinking, man, these could almost all be things from my practice management days, I would say still true today and well, yeah, still true today that that still continue to be issues. And as much as we've made progress in in moving towards value-based care, those incentives to really make a full change in transformation to that is not only scary, but we're not quite there yet to fully have both feet in the in the water with it. So I think you hit on all the things that probably practices are feeling and I'll throw a plug out there for you all that as we've been talking about the work that you guys do, they don't have to do this alone. They have support from you and your team and you guys are amazing at it. So I would certainly encourage anyone listening that if they're having any issues with any of these challenges to reach out to Chris and his team. appreciate that. Of course. Yeah, you guys do appreciate you guys and all you do. So, Chris one last question that we'd like to ask all of our guests on the move to Value podcast is what's an important question that maybe I didn't ask today? So this is your opportunity to, to plug anything or talk about anything else you're passionate about more behavioral health or anything else. What else would you like the audience to know? What I think you've, you've asked all the questions that I can think of. I, I guess what I would ask of you and I together is what, what can we do to help practices? Are there things that we haven't thought of that can make their lives easier? And I don't know what the answer is to that other than what we talked about today. But if, if, if folks could rewrite how practice or how primary care is delivered in a practice setting, how would they build it from the ground up if they had to do it all again from scratch? And maybe there's some things that we just, we've been so much into the box all the all this time that we haven't had the luxury of looking from outside in versus inside out. Maybe there's some things that we haven't thought of that we could be doing. And I would encourage practice managers, physician owners and leaders to speak up for what they think could work if, if they just had some cooperation and help from the ACO/CIN/AHEC/Medicaid/CMS. You know, you never, you're never going to get something unless you ask. So that would be the only thing. And I know that's sort of a generic question, but to me, it's sometimes when you have these conversations, you, we spend a lot of time talking about things we know, but maybe there's something we just haven't thought of that could strike a chord and help someone. So that's, that would be the only thing I would say. Chris, I think that's a great response. And something that I would also echo that as much as experience that I may have had with in practice management with physicians and the work that I've done over the years and, and you have done and your team have done. The reality is it's the, it's the physicians, it's the staff, it's the nurses that are working in these practices that are really going to have the best ideas and the best, they're going to know better than us how and what will work for their communities. And what works in Charlotte may not work in the eastern part of the state. They're up in the beautiful mountains of North Carolina. So we also encourage folks to communicate what is it that you're seeing? What is it that we can help you do to make things better? And sometimes that's just incremental step by step. It's not a change overnight as we talked about, but I think that's a great, great way to end the segment. So Chris Wethington, thank you for joining us on the Move to Value podcast. Well, thank you, Josh. Appreciate all the work you all are doing.…
 
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