Episode 9: Value-Based Care Takes Flight

It’s hard to think of a bigger paradigm shift than the onset of value-based care. It has the potential not only to affect the quality of care but also to change everything about how providers get paid. Debra Stevens, executive director of marketing and communications for Arizona Care Network, gives a primer on accountable care and takes us to the leading edge of next-gen ACO’s – from the innovations of blockchain to the challenges of infrastructure. Learn the true definition of care coordination with a heartwarming story of social workers who went to great lengths to ensure a homeless man gets the mental health help he needed.

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Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans, and many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys, and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together, and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your Paradigm Shift.

Michael: Welcome to “The Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts, here today with my cohost, Jared Johnson. On today’s episode we’re talking to Debra Stevens, Executive Director of Marketing and Communications for the Arizona Care Network, an accountable care organization and clinically integrated network that improves healthcare and reduces costs by actively managing care for its patients. Hi, Debra, and thank you for coming on the show.

Debra: Hello. Thank you.

Jared: Hey, Debra, it’s Jared. Nice to connect with you again. You and I have known each other for a few years now. It’s kinda nice to say that, you know, it’s nice have both been here, involved, and both be passionate about healthcare. And, but rather than me introduce you, let’s just let you introduce yourself, tell us a little bit more about yourself and kind of where you are now. And we’re gonna dig into accountable care and value-based care, and we’ll get into that, but let’s give you a chance to introduce yourself first.

Debra: Absolutely. So I’ve been in healthcare marketing for close to 15 years now. I spent 11 of those years at Phoenix Children’s Hospital, where we met, Jared, and then most recently with Arizona Care Network, which is an accountable care organization that is actually co-owned by Dignity Health and Tenet Healthcare. So two competitors who came together in a joint venture in the same market to help improve care and reduce the cost of care. So it’s quite an interesting model.

Jared: It really is, and I think it’s a model that, at least from my standpoint, I’m still learning a lot about what this even means, you know? What the model is and what the value is, and all the stakeholders involved. I think when we talk about the theme from this show, from the program, from previous guests, we have focused a lot on literally on the paradigm shifts, on the differences in the way that different stakeholders even think about caring for patients these days. And so accountable care organizations themselves, I mean, right there, there’s a paradigm shift.

There’s a type of organization that has not always existed and has caused quite a shift in the landscape for providers, and administrators, and payers, and patients. It seems like just about everybody. So maybe we’ll start…

Debra: Has there been a bigger paradigm shift in healthcare? Because we’re asking providers to go from their traditional fee-for-service model, I provide you services and I get reimbursed for it, to a pay-for-performance model, and that is a huge shift for providers.

Jared: Yeah. I can’t wait to hear your standpoint on that, your perspective on it, and maybe that’s a good place to start. Let’s just talk about ACOs in general, if you could…we’ll set the stage there. You know, what is it? You know, the short version of that, and then how do they benefit some of those stakeholder groups, providers and patients?

Debra: Yeah, you bet. So why do ACOs even exist? I think some people might even ask that, so if you think about our healthcare environment in a broad level, healthcare is really in crisis, right? Healthcare costs are rising at unsustainable rates, and right now nearly close to five cents of every federal dollar goes to healthcare, and it’s growing faster every year.

So if we have to put that kind of money into healthcare as a federal government, that means that that same money is not available for our needs for education or defense or infrastructure, or culture, and other things that we as a society deem are important.

So it’s in everyone’s best interest to transform this broken healthcare system. So it’s not likely that anyone could significantly reduce the price of care. What we do seek to do is slow down the rate of increase the cost, or as we say, bend the cost curve.

Jared: Got it. So what are some of the ways that that happens? Like, how does an ACO help do that?

Debra: Yeah, how do you manage the rising cost of care without sacrificing quality of care or, God forbid, rationing care, right? Or put another way, how do we drive more value into the healthcare system? So accountable care organizations tie provider reimbursement, at least a portion of it at this point in time, to outcomes. So quality metrics and reduction in total cost of care. So it’s a pay-for-performance model versus the traditional fee-for-service model.

So what ACN does is our care network, we bring together carefully selected doctors and healthcare organizations. We place the patient at the center of the healthcare delivery system. We share clinical information, we provide care coordination, assist patients in getting the right services in the best setting to better manage their health, catch health issues before they become bigger and more expensive to treat. So all of these activities are intended to not only deliver better outcomes for patients, better overall health, but also they reduce the overall cost of care. So that is a very simple description of what an ACO does.

Jared: Well that’s good. That’s probably the level that a lot of us are still at in terms of understanding all the pieces of it. And how has that change over time? How do ACOs look different now compared to when they first came into existence?

Debra: Well, it’s certainly shifting. It’s that paradigm shift you mentioned. So, ACOs were created by the Center for Medicare and Medicaid services, so Medicare…and they had an Innovation Center, and this first started taking shape in 2011. So this was originally a part of the Affordable Care Act, and they introduced this innovative payment and service delivery model that would reduce program expenditures, so they were looking at the rising cost of what it requires to cover Medicare and other federally-funded benefits in our healthcare system, but they also wanted to preserve and enhance the quality of care for their Medicare members.

So the very first, they’re called pioneer ACOs, operated under the model in the 2012 year, so that model here, and in that first year there were 32 pioneered ACOs that served about…under 700,000 beneficiaries, about 650,000. So as an innovation hub, it’s in their name, CMMI, Center for Medicare and Medicaid Innovation, is constantly testing and refining and reintroducing new versions of this type of model. So after the pioneer model came MSSP, Medicare Shared Savings Program. After MSSP came in Next Generation ACO.

So Arizona Care Network, my company, is one of just 41 next generation ACOs in the country. We have about 35,000 beneficiaries nationwide. It’s about 1.2 million Medicare beneficiaries who are under a next gen ACO, and what’s interesting about next gen is that all of the models up to this point have been upside only, meaning you get a bonus or an incentive payment if you beat the benchmark and…so you meet your quality goals and beat the benchmark in spending.

Next Generation ACO is an upside/downside risk contract. So now all of a sudden these 41 next gens in the country, if they don’t hit the mark on their quality and their cost savings, they will owe the federal government money back.

Jared: Who typically starts the ACO, or did they all kinda start around the same time, or can any provider out there decide to start talking to…who typically gets it going?

Debra: Well, you can imagine the infrastructure required to accomplish this, especially in a downside risk environment. So who starts it? Mostly hospital systems. They were the first ones to come forward and say, “We see benefit of driving loyalty within a community of providers.” We…if the doctors within the network are primarily within their own system, then by virtue of being the employer they can dictate how care is delivered and presumably bring better control around some of the high expenses and change the behavior of providers.

So a lot of them are hospital-based. Some are affiliations like Arizona Care Network is. Some were actually created by groups of providers who banded together and decided to do this on their own. And the reason they’re moving forward on it is Medicare has instituted push and pull levers to make this happen. So there is a bonus that providers can earn starting next year for having been involved in certain qualifying ACOs. There will also be a penalty on their reimbursement rates for Medicare being instituted within the next year or two. So those different levers they’re pulling to drive providers toward this value-based medicine model.

Jared: So how is this model received out there, like by patients? How do patients benefit from it?

Debra: Well, in all honesty, I don’t think a lot of patients know whether they’re part of an ACO or not. So that is one of the challenges that we face, of course, is having them understand what it is, and it’s super complex. There’s not really a short elevator speech to tell a patient about an ACO. Most of our communication’s really with our providers, because we give our providers the services and resources that they need to succeed in value-based care, and by virtue of that success the patient benefits.

So patients don’t know a lot about it, but how do we…we’re doing a lot of things to help them understand how this benefits them, because we can actually measure our quality outcomes, our cost-of-care reductions, the results of our care coordination, all of those things can be measured as improvements to the patient. So I think they will start building awareness, but if you think about back in the early days, doctors have been practicing medicine in the same way for a long time.

Obviously, new technology and things come along, but the way they operate their practices has been very similar for decades. So now we come in as ACOs and say, “We wanna reimburse you not for the services that you provide on a day-to-day basis to your patients, but we want you to give up a part of that fee-for-service and wait, in some cases with Medicare over a year, for the plan year to run out and then for all the adjustments that have to be made, and then, if you were successful in providing high-quality care and reducing the cost of care, you will share in that success. You will earn a gain share.”

So that’s a long game, right? That’s a long time to wait for reimbursement. So you can imagine how hard it was for doctors to understand, “Why should I pursue a value-based medicine model, or why should I be part of an ACO?” So it was very much an educational process, and then these incentive and disincentive levers that I talked about the Medicare instituted, building awareness that that was coming. So we have a smoldering platform but not really a burning platform.

Jared: Nice, nice. Well, one thing I’ve heard you talk about with ACOs before is just the types of innovation that they kinda naturally encourage and cause. Like, there’s a lot of innovation that happens as a result of these types of collaborations. What are some of those types of innovation that ACOs have introduced?

Debra: Well, I can speak on behalf of Arizona Care Network, but I would say that one of our first innovations was our Provider Rewards Program. So we call it PRP. But I talked about that long time that doctors would have to wait for any share in the savings that they helped generate. We helped bridge the gap of that long year to year and a quarter by instituting a provider rewards program. We actually set incentives.

Those incentives are leading indicators of how we will do in our next generation ACO contract or model, and we incentivized them, and those incentives help shift behavior. So what might that look like? We have five different quality incentives. So we want them to pick up their annual wellness visits with their Medicare members. We want them to ensure that they get A1C levels on a regular basis, and more regular if they have a diabetic patient. We wanna make sure that people with high blood pressure are on statin therapy.

So there’s all these different clinical measures that, if we follow those, all evidence says that their patients will be healthier and will cost less. So in addition to those quality measures would be things like we pay an incentive for seeing your high-risk members on a quarterly basis versus just an annual basis. So we wanna get high-risk members in frequently so that we can better…help our providers better manage their care. We…also part of the incentive is conducting your care within the network of providers, within the network of providers of ACM.

And the reason we do that is if care takes place outside our network we have no idea it’s happened, we don’t have the data on that because it’s not in our network, so we can’t help manage the care and improve the health of patients. So that’s another metric. So by paying out this quarterly reward based on patient attribution we’ve helped bridge that gap and keep providers focused on the metrics that matter most, and shift their behavior to this very systematic prevention program that helps their patients improve their health.

Michael: Debra, this is all incredibly fascinating, so thank you for sharing this information. I’ve been jotting down notes as you’ve been talking here so that I don’t interrupt your…and some interesting thoughts here.

The company that I work with, we do a lot with orthopedic providers in particular. So we were at a meeting earlier this year where they were talking about, “Hey, ACOs are here. Here’s how it’s impacting everybody.” And a lot of it was even more in a cautionary tone. Here are all the changes that are coming, especially if you’re an independent practice, now you’re having to work with other providers at a level that you’ve never had to before.

Everybody’s being held accountable for all this information. I think, and it sounds like, it kind of answers a question that we’ve had come up in past shows, where one of the challenges that patients face today is sometimes that feeling of getting lost. You get that tough diagnosis and you don’t necessarily know what the next step is. But it sounds like the ACO is really designing to help alleviate some of those feelings of just not knowing where to go next, not knowing how you’re gonna get help.

Debra: You’re absolutely right. So there’s two ways that ACOs do that. So one is, because your providers are all part of a network, and they are referring within the network, procedures are taking place with in-network hospitals, that means all the data is going to one data warehouse, and a provider, say a specialist, could find out what a PCP knows and vice versa after different appointments. And so each provider is better-equipped to know what’s going on with the patient and have insight when that patient is sitting in front of them. That’s one way.

Another way we benefit patients is really everything that an ACO does is very data-driven. So ACN is ingesting data from multiple different systems. So we get…the state health information exchange gives us data on admissions, discharges, and transfers. We get feeds from the…electronic medical records from some of our providers, and others we get through claims data. But we’re ingesting all of this data, and we’re doing risk stratification so that we can identify patients who need help the most.

So think about one of these issues. If we…when we tell a provider, “We want you to spend more time with your patient. We want you to work on prevention with them, and we’re not gonna reimburse you fully for it for over a year,” what do you think a provider’s gonna say about that? They’re gonna be incensed, right? They can’t do it, and they’re all so busy right now, and so it’s, “I can’t do that. I can’t possibly see more patients and see them longer.” So how an ACO can help them is through our data, and this risk stratification and its identification of not like high-risk patients, but also rising-risk patients.

We can say, “All right. We know you can’t do that for everyone, but here are the people…here’s your regular list of high-risk members, and these are the people that it’s most important for you to see on a regular basis and spend time with.” How would a doctor know that otherwise? Especially an independent provider. So if I went to my doctor today and I said, “Doctor, how many of the women aged 50 and over in your practice are overdue for their mammogram?” What do you think he would say to me? “I don’t know.”

Michael: “I’ll have to go find out.”

Debra: He doesn’t know. She doesn’t know, right? There’s no way they have that data. So multiply that across diabetics, and COPD, and heart failure, and frail elderly, and it’s mind-boggling. There’s no way…they don’t have the systems and the technology in an independent practice. Now, probably a big healthcare system does, but most of our…90% of our doctors are independent practitioners in this marketplace, so they don’t have the technology to be able to figure that out.

So one of the biggest benefits to them is actionable data. So we produce regular lists of their high-risk members, which ones are overdue, which ones have care gaps, which ones have had an admission, or have a discharge, or have to be at the skilled nursing facility. We provide them all that data, and our doctors can do the right thing when they have that data. They will see the patient, they will reach out to them, they will make sure they get them in for a visit, even if they’re busy, because we’re giving them data that they need to provide the best care to the patients who need them most. So that’s actually one of our second innovations that I wanted to talk about, and that’s this risk stratification. So we created a predictive risk stratification that can identify patients before their health deteriorates.

So if we see someone who’s overusing urgent care, overusing the emergency department, or has had a high A1C in the past and hasn’t had their blood tested in six months, we know those people as a population. So population health metrics tell us that those people are the ones that are going to have incidences that impact their health and cost more to the system. So we intervene earlier by taking that list, that list of the patients who need their help, to our doctors based on their attribution, or we help them find a provider if they’re not attributed to a provider, and we get them seen more quickly. And that is like doing the basics well, but doing the basics well takes a lot of infrastructure and technology, right? And…

Jared: Yeah, it really sounds like it. And some of this we might have already answered, but we’ve been talking about the ways that data is driving a lot of the decision making and a lot of the outreach that happens with patients. But are there other, like, major keys to success in value-based medicine that anybody else that’s considering moving to this model should be thinking about?

Debra: Well, I think one of the keys to our success has been aligned incentives. So I talked about the provider rewards program, our way of incentivizing providers to keep their focus on the metrics that matter most, and then the technology to provide them their patients lists, their high-risk patient lists. So those things are not easy to create, I mean, it definitely takes some skill and experience to be able to create those systems, but one other thing that we’ve done pretty recently is introduce a technology built on blockchain that we have introduced first to our providers.

So we have a big vision for this and we’re taking baby steps to make sure that it moves along in the right way, but our first, we call it Care.Wallet. So it’s a mobile app based on blockchain, so it’s absolutely secure and very personal, but it is on your own device. And the doctors get their data on how they are doing on our provider reports program, which is equivalent to how they are doing in taking care of providing high-quality care to their high-risk patients.

So in the past in our provider rewards program, every quarter we would go out to our practices with a check and a cover sheet, and we would say, “Congratulations. Look how well you did over the last quarter on your quality metrics. Here is your check,” and it was very retrospective. What we’ve been able to do now with blockchain is the cover card in their Care.Wallet actually is a trend line. So it says, “Here’s how you’re doing today, and if you continue on this path that you’re on now, doing things the way that you are doing them, then here’s how much you can expect to earn at the end of the quarter.” Then we also put in big red letters, “Here is how much you would be leaving on the table.”

So this is very prospective. So we’re telling them in time that they can actually make behavior changes to improve the care that they deliver to their patients and earn a fair incentive for doing so in a proactive way. So blockchain allows us to do that. We also now pay out our incentives, rather than going out and hand-delivering a check, we actually drop CareCoins, so it’s our own proprietary Bitcoin, we’ll call it, and drop CareCoins. Each CareCoins is equivalent to a dollar, and we do transfer the money to them in real US dollars, but they get this…on the day that all of the data is verified we drop the CareCoins and you can hear cheers all across the valley.

Michael: That’s awesome. So I think that’s a pretty good incentive. You’re talking about incentivizing, like, that’s a pretty good way to drive behavior change for the providers. How is…especially like the marketing and communications side of the thing, how are you helping drive patient behavior?

Debra: Yeah, so I would say that a lot of what we’re doing in the marketing and communications realm is really definitely more in the communications and education. So in my first two years here I’ve been very focused on provider education and provider communications, so you can imagine that we’ve gotta have the providers on board before we could tell patients that, “This is where you need to go,” right?

So a lot of the provider communication has been through webinars, in-person education, we have assigned field teams to different micro-territories around our region, monthly newsletter, , education sessions, all of the kinds of things. So all that was to set the stage for being able to bring the patients along on our journey. So with patients, the primary patients that we’re reaching out to right now are those who need additional assistance outside their doctor’s appointment to achieve their best health.

We have a program called N Compass, letter N Compass, and this is our care coordination team. So our team has RNs, navigators, behavioral health coaches, we have a population health pharmacist, social workers. So we have this team, and more than half of our employees are on this N Compass care coordination team. So we have the teams who work here in the office. We also have teams embedded in our high-volume clinics, and that way they can see the patients right there.

The key to getting a patient to say yes to care coordination is when their doctor recommends it. So this is a joint venture with the doctors where we tell them, “You have a patient who is food-insecure, who is missing their appointments so they have care gaps because they don’t have transportation. Or they have a mental health issue and they don’t understand the importance of getting to their appointments.”

So our care coordination team wraps them in these additional services that actually help resolve social determinants of health, so that the care the provider is giving is actually effective, right? Because so many things affect our health that are happening outside the doctor’s office, so we want the doctor to be onboard. They will deliver great care, we help with care coordinations, other services that help resolve some of the really difficult things in these people’s lives.

I can give you a wonderful example that just happened in the last 10 days here at Arizona Care Network. We have a provider who has a patient with mental health issues, and this person is homeless. The gentleman had been to the office a couple of times, needed to come back for some follow up care. And the doctor said, “He doesn’t have a home. I don’t know where he lives, but here’s where he told me he hangs out.”

Our social workers, two of them went together to an underpass in the middle of this heat to find this gentleman. They found him, they helped him get access to the services that he’s already entitled to because of his income and his status. In investigating all this so that they found him a place to live, they got him back to the doctor’s office, and in the process of the research that they did for him they found he had $20,000 of federal benefits available to him. He didn’t know it. Nobody knew it.

So I find that this N Compass team, they’re the unsung heroes of our organization. They do the leg work needed to get whatever that patient needs to achieve their best health.

Michael: That’s so exciting. We’ve had so many conversations, whether it’s here or just in other, you know, Twitter chats or whatever, but there are so many things you just touched on with just that one story that reflect broader problems in America’s healthcare, and so it’s exciting to see an organization be able to put together that story from beginning to end. We do work with various sizes of medical practices.

I’ve worked in the past with nonprofit organizations, but to have the coordination to get all the way through that, and not only get them off the streets but…and on and on, that’s fantastic to hear. Very exciting, and it’s something that just in situations that I am around as a father of a patient, as a son of a patient, we have better…I’ll say, like, better home scenarios, but there are still those gaps in care where there’s not a clear path forward. So…

Debra: Oh my goodness, yes. So…

Michael: So many moments where you just…

Debra: Yeah.

Michael: …don’t know what to do next, and so that’s very exciting to hear that’s being addressed.

Debra: Yeah, patients with a chronic illness, you know, we can come alongside them for a long period of time, but let’s say I’m headed to knee replacement surgery in the next couple of years, which I am, right? So I’m gonna have a temporary episodic need for care coordination. I can call in to the N Compass hotline, the concierge line, and tell them, “I’m having this surgery. I wanna make sure that…and I know my surgeon is in-network, because I checked, but I wanna make sure that my anesthesiologist is in-network.

I wanna make sure that the ambulatory surgery center that I go to is in-network. I wanna make sure that the rehab center I go to is in-network, and all along the way I wanna make sure that I’m using in-network providers because I know that will help me as a consumer save money. It will also help improve my care.” And I might only need care coordination for two months, a month, whatever it might be. I might not fit for chronic illnesses. So, you know, you don’t have to be homeless and chronically ill to use care coordination. Certainly, N Compass can help anyone who has a healthcare need.

Michael: That’s so exciting. I hope this catches on, let’s say, in more areas, because it’s a very, very incredible plan towards trying to solve that. Debra, thank you so much for your time today. I feel like we could go on and on with this. We do need to wrap the show, but thank you. This is really…it’s encouraging to see systems getting behind these kinds of problems and solving them in very sustainable ways. It’s not just a one-off kinda solution. So thank you for that.

Debra: You’re very welcome.

Michael: “The Paradigm Shift of Healthcare” is brought to you by P3 Inbound. You can find our full archive of episodes and interview transcripts at https://www.p3inbound.com/resources/podcast.php, and recommend a guest or topic on Twitter @p3Inbound.

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