Move to Value

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 CareJennifer 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 GasperiniThanks 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 GasperiniI 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 HoulihanSure, 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...

In this episode, Kari Curry, Medicaid Care Coordination Hub Supervisor at CHESS Health Solutions, shares how CHESS delivers high-touch, high-impact care management within a Medicaid Clinically Integrated Network (CIN).Kari walks us through a patient journey that highlights how CHESS uses real-time data from NCHIE, comprehensive social determinants of health (SDOH) screening, and structured care planning to reduce ED utilization and improve health equity. She also covers CHESS's success with AMH Tier 3 audit readiness and payer collaboration—proving that value-based care in the Medicaid space is not only possible, but measurable.

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/bettercareYates 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 PhelpsYeah. 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 LennonYes, 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...

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...

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 careThomas 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...

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 seeare 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...

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...

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...

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...

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,...

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...

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...

In this episode we hear from Chris Weathington, Director of Practice Support for North Carolina Area Health Education Centers, about how his organization provides training and resources to enable practices to focus on value rather than spending time on administrative burdens, thereby freeing up providers to better focus on patient care.Chris Weathington, welcome to the Move to Value podcast.Well, thank you for having me.Great. So Chris, for our listeners that may not be familiar with you, can you give us a little bit, tell us a little bit about yourself and your background?Sure. Well, I, I'm the director of practice support at North Carolina Area Health Education Centers, otherwise known as NCAHEC. I'm originally from Eastern North Carolina in small town called Winterville in Pitt County. My background is I've been working in Health Administration for a very long time, mostly working in a large health system but working largely with primary care and in the field of practice management and business development over the years. I've worked extensively in rural health helping providers figure out how best to survive and thrive with value-based care. So my educational background is about a master's in Health Administration and Bachelor of Science in public health from UNC Gillings School of Public Health. So, I'm a true Tar Heel, but I've been in North Carolina my entire life.Great. That's great background, Chris. Thank you. And go Heels. So, you mentioned currently you're the director of NCAHEC practice support. Tell us about NCAHEC. Give us a little bit more and specifically what your role is and what your team that you ever see does.Sure. Well, North Carolina, AHEC was established in the early 1970s. It's been around for about 50 years. It's a state agency. Our program office is based out of the UNC School of Medicine and we have 9 regional AHEC centers located throughout the state, many of them part of large health systems and some that are independent 501c3 not-for-profits. So they're geographically dispersed in Asheville, Charlotte, Winston Salem, Greensboro, Raleigh, Wilmington, Greenville, Rocky Mountain, Fayetteville, and Greensboro. And the mission of AHEC is to recruit, train and retain the state's health workforce. As you know, we have significant health workforce challenges if we didn't have them already prior to COVID. So practice support is one of several offerings or service lines, if you will, to fulfill that mission. So in practice support, we are committed to helping train and retain the state's health workforce. So working largely with practices in rural and underserved areas, primary care safety net providers such as FQHCs and rural health clinics and health departments, specialist and behavioral health providers, helping them to stand on their own two feet and working in doing that in partnership with accountable care organizations and CINs such as yourself over at CHESS. So that's really what we're all about. And in the value-based world, while practices are working in the Fee-for-service model, which still is around maybe a little bit less, but it's still largely there, helping practices not only function in that environment, but also survive and thrive with value based care. And that's hard and it's hard work, but that's what we're committed to do.That's a great mission and, and you guys do great work. I love meeting with you and hearing about how things are going throughout the, the state and healthcare. You guys have a great pulse on that always. And as you mentioned, one of the things that you guys or one of the areas you really focus on really is in the rural communities. And as you know, much of the care in North Carolina is...

In this episode we hear the second half of the conversation with Franklin County Public Health Director, Scott LaVigne, in which he shares his views on the role of properly addressing behavioral health, providing a positive patient experience, and the importance of partnerships, and how these elements, and others, work together in order for his team to provide holistic care for patients.I want to go back a little bit to something you mentioned earlier. So we talked, you talked about the needs-based care, what I call the contextualized care and Medicaid is very focused on serving the whole patient, right, which includes some of those social determinants of health. And, and we've talked about access and access to behavioral health is really important. How's Franklin County Health Partner Department partnering or attempting to partner with other agencies to address these needs?Well, one of the things that when I first came down here that that I just said we really needed to do was get our medical staff. And by that I mean everyone from the person that greets somebody when they walk in the door and checks them in to the person that works through everything with their, their claims and submitting and all the financial pieces of all that interaction from start to finish and everything in between that we had a trauma informed and, and with a focus on integrating behavioral health and, and behavioral health is a broad term. I should probably break that down because it's used a lot in different contexts. I don't look at it as a way of, of sanitizing mental health. So I look at it as a collection of mental health and substance use disorder and, and really what we wanted to focus on here and it and it goes to the social or social determinants of health. We wanted to focus on the whole patient, not just one aspect of that patient. I know I don't think I've ever heard of patients say that they felt their life was better because they met all their HEDIS metrics.Me either, by the way.But what, what we did and what I, I did do almost immediately was we purchased an outcome measurement tool because I knew that one of the things that we want to do is we didn't want somebody to have all their screenings done, you know, meet all those metrics like that on the healthcare side, but have housing insecurity and be living in domestic violence and to have substance abuse and mental health problems. Because I know as a mental health provider and a substance abuse provider in my background history that most of the people that show up in emergency rooms with preventable emergency room presentations are people that have mental health and substance use disorders and other things on board or have experience childhood trauma. So we knew that if we didn't look at that whole picture and integrate that in, we were going to have a hard time doing that. So we pulled an outcome measurement tool from behavioral health. It's called the DLA 20 and it, it focuses on 20 areas of a human's existence. And we wanted to make sure that if somebody experienced a good positive health outcomes, that translated into all these other areas as well. And that became our outcome measurement tool. So that was a big piece of what we focused on. Let's see. The other thing I mentioned already was we wanted to do more screening. We, you know, we do screenings routinely as a health department. We have to spend more time with patients because of our funding than providers in the community do. That is a blessing because we have budgeted time to take into account all of what we need to do, and that fits very nicely with a more holistic approach. So it really wasn't causing us to suffer a lot in the volume department. And we focused all our efforts. And I told everybody here, you know, one of the things we want to focus on is the equation of value. And yeah, you got to have a certain amount of volume to make that equation...

Today we hear an important conversation about the role of local government in population health and wellness. Scott LaVigne, Public Health Director of the Franklin County Health Department in North Carolina, talks with CHESS vice president, Josh Vire, about the broad scope of work his team is responsible for and how they are successfully tackling numerous initiatives, including managed Medicaid, to be a safety net provider for community health needs.Scott LaVigne, welcome to the Move to Value podcast.Oh, it's great to be here. We're we're really excited and looking forward to the conversation. Scott, as a public health director, you're responsible for all aspects of the Franklin County Health department from the clinical to environmental services and you balance state mandated services. So for the audience that things like vaccines, basic health screenings, environmental services, and with the expectations of Franklin County government, all while dealing with the critical workforce shortages. Health departments are considered safety net providers in most of North Carolina's counties. Can you share how your team is addressing the specific healthcare needs of the Medicaid population in the county?Sure. Well, after hearing all that, I'm, I'm getting tired. Yeah. That that is a we have a lot on our plate here at the health department and a lot of they're, they're not very often competing interests. But you know, I think what we look at when we talk about healthcare services in general and the overall health of the county, we don't break it up into per SE Medicaid population, although we do focus on that as part of the work that we do. But we, we have 2 broad missions and one is obviously population health and that it cuts across all payers and everyone in the community. And then the other role, which you correctly identified as we're a safety net provider. So in addition to putting out a lot of population health initiatives, we're also a provider and we're involved in a lot of the initiatives that all the providers in the community are involved in. So, you know, that gives us a unique position and we get to tailor some of our initiatives as a healthcare provider based on what we know the community health needs are. So it's, it's, I'm going to be honest, it's not very easy to do all of that. I would say we, as I said, we don't just focus on the Medicaid population, but we do have a lot of initiatives that cut across all of that.Great. What are the specific issues that that I think you have a lot of experience in close to 30 years of behavioral health experience with much of that coming in New York. Can you describe the changes in public health that you see in your career and maybe also for the audience contrast the differences between the public health in New York and North Carolina. What are the differences you've seen?Sure. Well, when I was in New York, I was a a mental hygiene director for a county and, and when I came to North Carolina, I became a public health director. But we were actually in the same building in New York with our public health programs and we had a very close relationship with that program. But there are some significant differences, but a lot of similarities. You know, the some of the big differences though relate to some of what we're talking about. Medicaid managed care being a big one in New York. Medicaid managed care started first with medical care and then they brought behavioral health and IDD into the picture. In North Carolina, they did it the exact opposite. And so that that was a, a big difference. When I came down here, we had a mental hygiene system that had already made the conversion and was and, and medical care, which is what I was now in, we had to make that shift. So, I would say that was a, a big difference. But in New York, most of the public health agencies had gotten out of...

In this episode, we hear the second half of the conversation between Kris Shepard, Senior Vice President at Advocate Health, and CHESS President Dr. Yates Lennon, as they discuss how physician networks and primary care services are the backbone of the value movement in healthcare. So Chris, welcome back to the Chess Move to Value podcast. Look, look forward to continuing our earlier conversation.Awesome. Well, had a good time so far and I'm expecting nothing less for the second, second-half.OK, great. Well, let's start out the second-half here. Just let's talk a little bit about some of some business development goals, both from the lens of the MSOVSO and from Advocate perhaps as well as if I'm an independent physician in the market, whether that's the Carolinas, Georgia, Wisconsin, Illinois, what should I be thinking about? So come at it from both sides.It's a great, great question. The, the starting point for me is really an acknowledgement that the healthcare industry is changing. And you know, we've, we've talked about change and transformation in healthcare for a long time. So this is I think part of that broad continuum in the future, I expect that there will be increasing, it would be increasingly important for the ambulatory enterprise to take on more of the care delivery then perhaps we have historically it's more and more expensive to build hospitals. I think you, you know, you see a lot of commentators talking about hospitals becoming more focused on kind of higher acuity, higher complexity things. And so you know, they're always going to be here. And we're, you know, we are building broadly in facilities across the advocate enterprise and investing in, in improvements in the facilities. And at the same time, it's going to be increasingly important for the ambulatory enterprise to take to take on more and more. Some of that is is is has a regulatory dimension to it. So for example, CON laws being loosened or removed in in South Carolina, North Carolina, perhaps other places. I think those those kinds of regulatory changes, reimbursement changes that that encourage certain certain types of procedures and certain care to move out of facilities into the ambulatory setting. All those I think point us toward a future where to for a health system we are going to need to be successful in that ambulatory space as well as as as with our facilities. So what does that mean from a physician you know, or a clinical enterprise development lens, a physician partnership lens? I think those relationships become even more important and and in some ways more challenging because there there are a lot of organizations, whether they're payer backed organizations or private equity backed organizations or public companies like an Amazon who are moving into that ambulatory space. There's almost nobody going into the facility areas, you know, not a lot of new money or new entrants, if you will, into in building hospitals, but they're definitely a lot of new entrants rolling up ambulatory practices. So, you know, from a strategic lens advocate can either, you know, choose to focus on, on the facilities or, you know, alternatively, what we've done is, is really geared toward building a significant ambulatory presence. And you know, we, we already have thousands of physicians employed, you know, hundreds and hundreds of clinic sites. We, we have a significant ambulatory presence already. But it's going to it's going to be increasingly important going forward to do that. And I think, you know, some of the some of the discussion we've already had about what's the right relationship within it with a given group and a given specialty is those, those questions become more significant when you think about how the industry is, is trending.Yeah, Yeah. Let's let's head toward, I mean MSOs/VSOs are networks in and of themselves. But let's talk a little bit about physician...

Today hear from Kris Shepard, Senior Vice President of Clinical Enterprise Development and Core Market Growth and Physician Partnerships at Advocate Health. In a conversation with CHESS President, Dr. Yates Lennon, Kris talks of how Management Services Organizations benefit patients and creates opportunities for practice growth and professional development for providers.OK, Well, good morning, Chris. Glad to have you on the chess Move to Value podcast. Look forward to our conversation today.Good morning. Yeah, great to be here.Good. So Chris, I'm looking at your title clinic, SVP, clinical enterprise development and core market growth physician partnerships. Tell us what you do.I do a few different things. And as that title probably implies, sometimes I'm working on your plain vanilla physician practice acquisitions. Sometimes I'm working on acquisitions that are not so plain vanilla in a more complicated in a larger scenarios, something particularly unique. And then I work on a range of other physician partnership transactions, professional services arrangements, as well as working on management services opportunities that we see with groups. And we really view that clinical enterprise development as, you know, broadly designed to look at our physician networks across the Advocate enterprise and and pursue what we think will work in a given market, a given specialty. And so that's why it's a fun job to have. I get to be creative and yeah, engage with people in a very different settings and try to put together things that that are appropriate in the right context.Yeah, never a moment of boredom, I would imagine with that much variety. Well, you, you, you touched on managed services. You know, there's a lot going on today with various managed services organizations as well as what you might call value services organizations. Talk to me a little bit about sort of at a high level, what do you think the opportunity is in the MSO slash VSO either or both market today?Yeah. I think I'll, I'll come at it from the perspective of physician groups that we talked to pretty regularly And you know, different groups have different needs. But one of the realities that seems to be hitting a lot of, you know, physician owned practices is that they don't necessarily have the scale to keep up with whether it's, you know, physician practice infrastructure needs or, or it's and, or the value-based care capabilities that they need to be successful. And so, it's, you know, two different buckets that are that can be addressed through management services and value services arrangements. But that's the reality. I think practices used to be able to kind of, you know may do just fine on their own. I think there are a variety of factors playing in to the challenges on independent practices now, payer relationships and kind of reimbursement challenges that exist, the cost pressures that are hitting every everybody, especially in the healthcare industry, kind of inflationary factors. And then there are things like, you know, EMRs are expensive. It's expensive to fend off cyber-attacks, to have the right cyber security frameworks in place, to make sure that you can you can continue in operations, to have the best revenue cycle, the best supply chain options. All those are things that are I think increasingly challenging even for the larger physician practices out there. So there's a, there's a scale factor there, same kind of themes with respect to value services. I think it, it takes a lot. There's analytics platforms, there's teams of people to support, to support a practice in, in delivering care the right way and then being able to record that and have that be a parent in quality metrics that get reported and cost metrics and, and everything else. So I just think, I think it's this moment. And from a, you know, I work for Advocate health for the health...

In this episode, we hear the second half of the conversation between CHESS Vice President of Value-based Operations, Josh Vire, and Wilson Gabbard, Advocate Health Vice President of Quality and Condition Management, who discuss the importance of partnerships with payers and implementing value based care practices with all patients, even if they aren't in a value-based arrangement.Wilson, thank you so much for being willing to stick around and continue this conversation. I really appreciate it. Wilson, you had just talked about on our last episode, you, you talked about clinician engagement, that relationship management and that activation. And, and this is something that I think you guys have been leaders in for a while in the Midwest. You your team not only supports the Medical Group of Advocate, but also support a large CIN that includes a significant number of aligned independent physicians in the area. Can you talk a little bit about the challenges of supporting aligned physicians versus the Advocate Medical Group?Well, absolutely. And thanks again, Josh for inviting me to participate in this forum. So, I think, you know, we certainly don't have all of this figured out. I'd be lying if I said we did, but I think many of our listeners will probably appreciate the challenge that it is to operate in both of these worlds. And in our space, especially here in Illinois, it's especially pronounced. I think we have over 830 aligned clinics that participate in our clinically integrated network. And so the challenge that we talked a little bit about last time or about the data exchange and data exchange barriers is incredible, especially at that scale. But I think true clinical integration is really hard to accomplish without strong data and handoffs. And so I think we've leaned into this space of trying to bridge that gap with data exchange efforts. Again, time back to some of the work we're doing in ECQM reporting to kind of bridge the gap between those aligned DMRS and our data warehouses so that our reporting is as accurate and as timely as possible. That we are reaching out to patients for Medicare Wellness visits, annual Wellness visits. But when we can go in and see in an electronic means that they're already scheduled for those Wellness visits that we aren't, that we build off of care plans when we're doing care coordination activities that their PCT and their instances of EMRs have already documented. And so that is very hard work. And again, we're not completely there yet. If anyone listening has figured it all out, please add me on LinkedIn and give me a call because I'd be happy to hear from CIN who has figured it all out from the provider-based space. But anyway, it's certainly a challenge, but I think that it has applications across what we do in quality or condition management or utilization management. And I think that all of the principles about clinician activation that we talked about last time and kind of building out those teams and points of contacts are critically important to translate those messages that we do. I call it internally, I call it we have one strategy with different flavors, right. We have a flavor that is applicable to our internal clinicians on their instance of their EMR. And we have a different flavor that is applicable to the clinicians who maybe are on dozens of different EMRs.Yeah, that's, that's great. It's I will accept your modesty, but also toot your horn a little bit. That why you guys may not have it figured out. You, you guys just evidence here in this conversation are pretty good at it and are probably more advanced than a lot of the other folks. And, and really impressed every time I talk with you guys about how you approach and work with your line providers. It's not an easy thing to do. We've been at this for a long time as well at CHESS and, and, and I think you highlighted accurately some of those challenges. So I appreciate...

In this episode, CHESS Vice President of Value-based Operations, Josh Vire, talks with Wilson Gabbard, Vice President of Quality and Condition Management at Advocate Health, about how to gather and present meaningful data to providers in an easy and accessible way which enhances their delivery of better patient care.Well, Wilson Gabbard, thank you for joining us on the Move to Value podcast.Thanks, Josh. Thanks for having me. It's good to be here.Great. Wilson, I know you have a wealth of knowledge, both population health and value based care. Can you just start by giving our audits an overview, a little bit about you, your background, where you've been, what you've been, what you're up to today, and your responsibilities at Advocate Health?Yeah, absolutely. Well, again, Josh, good to be here. You know, value our friends and colleagues at CHESS and have long followed all the great work that you all have done. And so, it's a privilege to be here. Again, you know, by way of background, I'm a former practice operator, used to lead clinic operations in Eastern North Carolina and had the privilege of kind of pivoting into a population health focused role back in 2013. So, over a decade ago now helping build out some of this work in a prior life. And you know, over the years it's been really interesting to see the evolution of value and how we've gone to taking on more risk and building out more sophisticated programs and blending together Medicare Advantage and MSSP or different value-based programs together to ultimately really just better serve the patients and clinicians that were really just privileged to be able to serve on a daily basis. So, you know, today what I'm up to is here at Advocate Health, I have the pleasure of leading quality and condition management efforts as part of our enterprise population health structure. You know, we think about value-based work and kind of the formulaic equation that is driven based on three main components, which are quality, utilization and premium and lives. And how we do that, how we operationalize that is really around the two functions that I again have the privilege of kind of serving in or related to the quality and condition management work and have the again opportunity to do that along a really amazing physician dyad, who I feel very privileged to work alongside as we implement some of these programs.That's great, Wilson, thanks for that background and I'm glad to share that with the audience. You mentioned you've been you've been at this for a while, you're very well versed on what drives and improves contracts in value-based care. So really excited about again having you here and could you go a little bit layer deeper in what is condition management and documentation? What does that mean specifically at Advocate and a little bit about what your how your role plays in supporting value-based care efforts.Yeah, great question. I think that our approach to value and again I think value-based care is you know the corollary or antithesis maybe is the wrong word, but to fee for service, right. As we move from fee for service to value, we think about the premium and lives component that I mentioned earlier about ensuring that we are receiving the appropriate reimbursement for the patients that we're caring for. And the way that CMS, our government programs have implemented that financial model and value is through a risk adjusted payment mechanism. But at the end of the day, the way that we think about risk adjustment here at Advocate is that risk adjustment really at its core is just a population health fundamental that ensures that it's really, it's all about ensuring that patients and their conditions are not lost to care. In value-based care, I love that the focus is not about on widget counting, but rather on caring for conditions, ensuring that those...

In this episode we finish our conversation with Rebecca Grandy, Director of Pharmacy at CHESS, and learn how pharmacists can overcome barriers to issues in patient care through tools such as prior authorizations. We also talk about how CMS doesn't consider pharmacists care providers and how resolving that will lead to greater efficiency and better outcomes.So Rebecca Grandy, welcome back to the Move to Value podcast. Glad you could stick around and continue this conversation about pharmacy services with us.Thank you.Rebecca, last time we were talking about all kinds of great things and how a pharmacist is such an integral part of the care team and we talked about collaboration with clinical providers and other healthcare professionals. One of the things I wanted to talk about is prior authorization because that's prior authorization for medication is crucial in value-based care. Can you explain to us a little bit about the process and any, I don't know, administrative burdens that might be there and how do we address these to make sure that our patients are getting timely care?Sure. You know, I think if you were to ask some of our physician or provider colleagues, they would probably say prior authorization is a four-letter word, right? However, I do believe that as we think about value based care and we think about cost effectiveness, we have to have some sort of process or I'm blanking out here Thomas, we have to have, we have to have some sort of process or way to guarantee that the medicines we're using are going to be cost effective. So, when you think about prior authorization, that's really the intent, right? Usually they're for expensive medicines or they're for medicines that can potentially have lots of side effects or that have very specific clinical niches, if you will. And so I do think they're necessary. However, more and more medicines are needing prior authorizations now, and that's really created an administrative burden for our providers and provider offices That has gotten to the point actually where Congress is sort of intervening at this point. And there's lots of legislation over the next few years, you should see that process get better. So for example, if I'm a physician and I want my patient to have a very specific diabetes medicine, so there's some diabetes medicines that need prior authorizations, I send the prescription. And for most of our providers, they're not even going to know it needs a prior authorization until the pharmacy sends either a fax or an electronic prior authorization back to that office. So I may not even know. So my patient has already left the office. I tried to send in their prescription. Now I get kicked back from the pharmacy saying, OK, this needs a prior authorization. So you can already see in this example, you sort of set yourself up for some dissatisfied patients and some for dissatisfied providers. And so once I get that prior authorization paperwork, someone has to complete it. And in my experience, I've actually had experience doing prior authorizations. If you don't dot every I and cross every T, you're not going to get it approved and you're going to get a denial. You may not know about it, you know, for several days or even several weeks, depending on the insurance and depending on the priority. And so now you have a patient that's sort of left in the dark because they don't know why they can't get their medicine from the pharmacy. The pharmacy's saying why I sent the paperwork to your provider. They need a prior authorization. The physician offices has no idea where it is in the insurance queue. And so you take that and you compound it with the fact that every insurance has a slightly different process, every medicine is a slightly different process. You have to log into external portals which are not part of the day-to-day workflow. And so the administrative burden, again, it's just a...

Today we continue the discussion between Yates Lennon and community health expert Randy Jordan, about how good health is typically achieved through a good clinical home, which has always been an insurance discussion but now should shift to a discussion about the uninsured who need the knowledge about where to go when sick, to increase savings in the cost of caring for the entire population.OK, All right, Randy, thank you for sticking around. Our first conversation was fascinating. Looking forward to continuing that. I think you've touched a little bit on the next question I have for you, but we'll maybe expand a little bit more. Tell us about you talked about the health, the safety net and being that term being used pretty widely and you I think listed out free and charitable clinics, FQHCS, rural health clinics as sort of the network. I think I might have left one out. So fill, fill that in for me. But why is it so important? Why? Why is the health safety net so important? And to one of my earlier questions in the first session, why does it not get more attention than it does?Well, I think added to the list Yates would be public health units and school-based health centers.There you go.You know it. It's a fascinating question that you're asking because I think to those who work in the space, it gets all the attention in the world. It's built around mission minded folks who want to see this issue of the uninsured being taken care of. If, if we just pause for a moment and look at all the energy that was brought to North Carolina recently about Medicaid expansion, it brought all kinds of groups together. But it was in that case, it was for the intention of getting a health insurance card in the hand of people in need. That same passion though, exists for those that are in the business of trying to, to provide healthcare services to uninsured patients. And so at one level there's a lot of attention to it, but at another level, there's, a real absence of attention. I don't think it's because people don't care. I think it's because we've not informed them well enough. And it's one of the things I appreciate, appreciate about the chance to be on your podcast today is when the message gets out, people are good hearted, they'll respond in the right way. But we do need to get the the message out. We need to get it out to policy makers. We need to find ways for that voice to be united. And that's, you know, those are some things that I'm also working on in my spare time.Awesome. So you, you mentioned in the first session the hospital in Jacksonville that worked with the free and charitable clinic. Can you talk to us a little bit about how the Medicaid, the the health safety net can be strengthened? What, what, what needs to happen? What are some ideas and needs for strengthening that safety net?Well, we mentioned a number of times Medicaid already today. One of the strong ideas that came out of Medicaid transformation was a recognition that social determinants of health are important for good health. And so we're talking about housing, food insecurity, transportation, and basically protections against family violence and other forms of interpersonal violence. So the Healthy Opportunities pilots that have sprung up across the state, three of them now have identified and brought together sort of the safety net of social services. It's a wonderful thing and we celebrate it. But it because it applies only to Medicaid, that access to that network is not organized in a way to also apply to the uninsured. And I think that that's one challenge that that lays ahead for us is finding a way to leverage what's being built in the Medicaid system and apply it to the uninsured. Now here's an interesting thing. If you look at the demographic of, of most Medicaid patients, it's very, very similar if not identical to uninsured patients. The it's all income

Today we get to know Rebecca Grandy, Director of Pharmacy at CHESS Health Solutions, and learn how a clinical pharmacist is an integral part of the care team, not only for improving patient outcomes by being the medication expert, but also by developing relationships with patients and using psychology to ensure medication adherence, resulting in better outcomes at a lower cost. Rebecca Grandy, welcome to the Move to Value podcast.Thank you for having me, Thomas.So, Rebecca, why pharmacy? Can you tell us your story of how you came to be in the role that you sit in today?I ran out of time and ran out of options, but it was one of the best decisions that I think I've made in my career. I think like a lot of folks who go into healthcare, when I was in high school, I really enjoyed science, really enjoyed math, was good at it and wanted to use those skills, you know, to be helpful to get back to the community. And so when I was in high school, I actually thought I wanted to be a pediatrician because I loved kids, worked at summer camps. I just thought that would be, you know, a great career to combine the things I was good at and the things that I enjoyed. And so then when I went to college, I remember being in my intro to biology class and I walk in and it's a class of like 400 to 500 people and they all want to be physicians. And I'm like, well, I don't really know why I chose pediatrician. Like it just felt like the right fit. I grew up in a rural community and so I think my knowledge of careers and job options was pretty limited, right? And healthcare physician, nurse, that's what you do. And so after being in that intro to biology class and seeing everyone, wanted to be a physician and I was like, well, you know, I'm going to keep my options open, not put too much pressure on myself and just sort of see where I end up going. And I decided to get a biology and chemistry in undergrad. And I knew that would really prepare me for anything in healthcare that I wanted to do. And so I just spent the next few years in college shadowing, learning, volunteering. I volunteered with physical therapist, pediatrician physical therapist. I did respiratory therapy, I did high risk dental clinics, I did medicine, spent some time in an inpatient pharmacy and really never found what I felt was a good fit. And so in my junior year, end of my junior year, I was like, OK, I was like, I'm graduating in a year and I need to make some decisions here because with a biology undergrad degree, you're sort of limited. I knew I didn't want to be a teacher and I didn't want to work in a lab. So I was like, OK, I got to do something here. Luckily, at the time, my roommate, her boyfriend, and a good friend of mine, his dad was a consultant pharmacist. I had never heard of that. You know, really when I thought about pharmacy, I thought about the folks who work in retail, CVS, Walgreens, you know, Walmart, grocery store, and really didn't know much more about pharmacy. I had spent some time in the inpatient pharmacy at UNC Hospitals volunteering, but I was literally taking expired drugs off the shelf and getting rid of them. That's what they needed. So I was willing to do it, but it wasn't that exciting. And so she was like, well, have you looked into pharmacy? So being the per type of person I am, I go to the library, I pull all these books about the career of pharmacy and I'm reading about all the different options. And I'm like, OK, I'm like, I like science, I like math. This pharmacy thing seems like it could be a good fit because I'd already ruled out some of the other professions. And so I ended up applying and I got in. So again, it was sort of that I had explored lots of options, really ran out of choices. I felt it was something that I could be good at, and there were lots of options. And that's how I ended up in pharmacy school.Nice. And after pharmacy...

Today we hear a conversation between CHESS President Yates Lennon and community health expert Randy Jordan, who is the current Chief Advisor of Impact for Health at Next Stage Consulting. We listen as they discuss Managed Medicaid, funding the health safety net for the uninsured, and how different types of healthcare organizations can work together in a sustainable way.Alright, Randy Jordan, welcome to the Chess Move to Value podcast. We're thrilled to have you here today. Look forward to our conversation.Well, thank you, Yates. It's really good to be with you and with your audience today.Awesome. So why don't you just start by telling us a little bit about yourself, what you do today, and then your journey through the healthcare maze to get to where we are today.Be glad to starting with today's probably the easiest part because the rest is kind of a winding path. But today I'm working as a healthcare consultant with consulting practice out of Charlotte by the name of Next Stage. It's an interesting place to work. They have a great vision and mission for helping local communities and underserved populations and that's why I'm there. But prior to this current role, I had started out as a young man as a pharmacist practice pharmacy in the state of Florida come from a long line of pharmacists. So healthcare runs as a deep strain in my family history. After running a pharmacy, community pharmacy for a while, I ended up going to law school and decided to become a healthcare lawyer and that was a really interesting time in my life. I learned a lot from that experience and then moved on to become involved in nonprofit work and spent nearly 20 years working for an international faith-based charity out of Philadelphia by the name Hope Worldwide. And the last seven years I was that organization CEO. And then most recently, having moved to North Carolina eight years ago, I accepted the role as CEO of North Carolina's Free and Charitable Clinics Association. And that gave me a real great sense of the local flavor of North Carolina safety net. So that's how I got here today through that windy path. Always, always focused on healthcare, Always, as I look back, always focused on trying to help others.OK, that's an interesting story. I know you spent a little bit of time in Cambodia. Can you tell us a little bit about what you did there and then we'll come back to that I think more a little bit later in our conversation, but really curious about what that was about and what you learned there.Yeah, I, I actually never lived in Cambodia, but had a a strong period of work there. It started at the beginning of my time at the international charity, where I started as the general counsel, and the first assignment there was to put together a joint venture between Japanese Shinto priest, a journalist from Time magazine, and the CEO of our charity. And so that was an eclectic mix right there. But the purpose of that mix was to open up a free care hospital in Phnom Penh. Cambodia was named after the king and its purpose was to help people that didn't have access to healthcare. At the time, Cambodia was one of the poorest nations in Southeast Asia. They were spending about $2.50 per year on those that live there. They had undergone a horrible genocide through Pol Pot, and it was a very unique chance to get involved in that country. We brought up that first hospital in Phnom Penh. In the course of that work, there developed three free clinics in order to help support that hospital because some of the patients were able to pay a small amount and then finally open another hospital in the South of Cambodia in a little in a town by the name of Kempat. But all very formative experiences for our conversation today.Wow, really interesting. So in your role as the CEO of the North Carolina Association of Free and Charitable...

Today, we're discussing Care Management in Managed Medicaid with Tammy Yount, CHESS Application System Analyst. We'll explore why it's essential for organizations to tailor their care management programs to fit their own unique needs, so they can holistically focus on the patient while optimizing value in healthcare.Tammy Yount, welcome to the Move to Value podcast.Thank you Thomas, for inviting me and I'm happy to be here.So, Tammy, let's talk about care management in managed Medicaid. How does a care management program save money and healthcare?I would say that saving money is one goal of a care management program. However, I would offer that the goals of a care management program should align with the triple aim that's born out of the 2001 Institution of Medicine report Crossing the Quality Chasm. So that report underscored 3 aims, if you will, one primary aim and two secondary aims. So the primary aim is to improve the health of populations with the secondary aims of improving the patient experience of care and at the same time reducing the per capita cost. So these are lofty aims given our current healthcare landscape and the payment models that we exist in. Not all organizations are the same. You have some large organizations that have a plethora of resources and smaller organizations with very limited resources. So each organization has its own unique structure and individual challenges and there's no one-size-fits-all care management program. So I would say there are many ways to build a care management program that will allow you to achieve the triple aim and organization needs to find the blueprint that works best for them. So when an organization's doing the right things, measuring the right things and focusing on improving the right things, the cost savings should follow. And I believe it was W Edward Demmings that said it best, you know, manage the cause, not the result. That's not to say that the organization doesn't need to have a clear understanding of the underlying processes, cost drivers, the population characteristics. He also said if you can't describe what you're doing as a process, you don't know what you're doing. And my favorite quote for him is in God we trust, and all other things bring data.Tammy, tell me, how would a practice create a care management program?So it's a bit of a chicken and egg conundrum when you're trying to create your care management program, you need many things in the least of which is data. I would say you need to start with the data, but few organizations have the data to inform their program design. Most organizations design their care management program backwards, meaning they design the program around the resources they have versus identifying the resources that they need based on the characteristics of the populations they're managing. So I would say the first thing you need to do is collect data and evaluate the data. So from the data that you've captured, then you would begin to develop your road map for how you're going to operationalize your care management program. And these would be very specific to each organization because each organization serves different patient populations, has different resources and different needs.What are the keys to a successful care management program?It's going to depend on who you ask. So I'm a data person, so in my world, all things starting in with data. But if you were to ask the payer, the nurse, the CEO, the CFO, the CIO, and most importantly, the patients, their families or caregivers, you're going to get a different response and varying perspectives. For a care management program to be successful, it's going to need to combine all of these perspectives. And critical to any successful program is having a mission, vision and values. And you'll need to operationalize your plan with those elements. And so...

It's patient experience week here in the United States, and we have asked CHESS President Dr. Yates Lennon to share his story about how, as a practicing provider, he took the time to listen to feedback from his patients and implement changes which not only led to better patient experience scores but shed new light on the importance of value-based care. Doctor Lennon, welcome to the Move to Value Podcast. Would you share your story about being a provider and how you came to realize the importance of the patient experience in health care? So, my name is Yates Lennon and I am an ObGyn by training, practice, private practice, obstetrics and gynecology from 1993 to 1998 in Hot Springs, Arkansas and then in 1998 moved back to North Carolina, which was home, to practice in a small private practice in Asheboro, North Carolina. From 98 until 2008, we were a small independent group for physicians at at most. And in 2008, our group really saw the early, phases of value-based care coming. We saw, the landscape of regulatory requirements, changing quickly and, and understood that keeping up with that was going to be a significant challenge. We were one of the first ObGyn practices as a small group to go on to, electronic health records. So, we did that, and actually we did that in 2002, I believe. But then in 2008, as we really sort of started seeing the handwriting on the wall, we felt like we needed to join forces with a larger organization that could really help us keep up, stay abreast of what was happening while we continued to focus on delivering care to our patients.So in 2008, we merged our practice into what was then Cornerstone Health Care, based in High Point, as we merged in and became a part of that organization around 2011, I had expressed an interest to the leadership at that time of becoming more involved in an administrative capacity of some sort, did not have a particular path in mind, but but knew that I had always enjoyed the administrative side of medicine and, and running a small practice. So, I was asked at that time if I would consider taking on an overhaul of the patient experience for the Cornerstone Group. So, we formed a multidisciplinary team, included, physicians, advanced practice providers, CMAs, nurse assistants, nurses, office managers, front desk staff. The throughout the whole organization, through all levels of the organization came together and formed a group, that later was named peak, patient expectations are key. And in the course of that, I really began to see, how important patient experience really was. And, and even though I had practiced for a long time, I never really thought that much about the patient experience of care. Fast forward another year or two. Cornerstone had begun the their first efforts at a patient experience survey, which was done online.Prior to that, it was a paper survey, and it was handed out at the desk to patients. So not incredibly random. We employ a employed, a large provider that, did these online surveys. And I was actually very excited to see my first survey. I had a large patient panel, had a good reputation in the community, and was excited to see these first results. Unbeknownst to me, when they came in, our office manager took it upon herself to post them at the back door, and I came in and saw my scores and they were by far the worst of anyone in our practice, and I was devastated. I went through all of Kubler-Ross stages of grief in the span of about 15 minutes. But following that, I decided, you know what? There's a message here. So, what is that message? What What are my patients trying to tell me? are kind enough to fill out the surveys, tell me how I'm doing. I need to be wise enough to listen. So, I started assessing what a visit in my office actually looked like. I thought the the highest standard was efficiency, that if I was efficient and always on time, that that would be what made everyone happy....

Today we listen to a conversation that began at the North Carolina Hospital Association's winter meeting between Bamboo Health Senior Director of Growth, Ellen Solomon, and CHESS Director of Value-based Operations, Rachel Holder. Ellen and Rachel get together for the podcast to continue the discussion on the topic of Navigating Value-based Care through Real Time Intelligence.RH: Thanks so much, Ellen, for joining us today. So can you give us a really brief introduction about yourself, your role, and tell us a little bit about Bamboo Health?ES: Yeah, sure. Thank you so much for having me, Rachel. It was great getting to chat with you at the North Carolina Healthcare Association winter meeting. But for folks that don't know me, my name is Ellen Solomon. I'm senior director of National Health System growth at Bamboo Health. I've been here for six years and I currently live in Charlotte, but I always love calling out to my North Carolina customers. I was born and raised in a small town of Reidsville, NC And so in terms of what we do, folks in North Carolina may remember us as patient ping or Appriss Health. We've since come together and rebranded as Bamboo Health back in 2021. And I'll first start again with sort of who we are at a very high level and then I'll go into North Carolina as well as obviously how we work with you guys, Rachel. But in one sentence, Bamboo Health is an intelligent care collaboration network across all 50 states. The problem we work to solve is that as you know better than me, healthcare was built on silos. Those silos could be the EMR that you use, your geographic location, state lines or the setting of care, whether that's acute post, acute, ambulatory. And those silos make engaging patients and coordinating care in real time very difficult. And even more difficult when you're actually trying to bend the cost curve and improve patient outcomes like readmissions, Ed utilization, post acute length of stay and many others. And so in short, I compare Bamboo Health to expedia.com. You have all these hotel chains, you have all these airline companies that are competing for your business. They operate their own platforms, their own tools and they don't really want to share with each other. But Expedia brings them together in a really simple way and that's where Bamboo Health sits. And so today in North Carolina, we support our customers really in three use cases. The first one which we'll drill into more I believe in, in this discussion and how chess uses Bamboo is we enable value based care use cases through our engaged admission discharge and transfer or ADT network. And in North Carolina specifically over 80% of the hospitals in the state participate. We have over 800 post acutes, over 50 provider organizations. And this actually started back in 2017 when we partnered with NCHA who's really been instrumental in helping us build out this ENGAGE network. That network does extend to all 50 states. Secondly, we partner with the state of North Carolina as well as 45 other states to support prescription drug monitoring or PDMP program to help continue to curb the opioid epidemic. And then lastly, we're rolling out a behavioral health referral network also known as BH scan in the state. So I think the, So what their common thread between all those use cases is it's real time actionable and through an engaged network. And so Rachel, I know when we spoke at NCHA, Chess has been such a long standing bamboo partner. You all have really been with us from the beginning. I'd love if you could share more about some of the challenges you're hearing from your value partners as they're transitioning into more risk and value based care.RH: Yeah. Thanks so much Ellen. So I think gone are the days that just a high AWV rate and some...

In this episode, we listen in on a conversation between Mountain Valley Hospice Senior Vice President of Strategy and Innovation, Maria Hayes, and CHESS Health Solutions Senior Director of Clinical Operations, Dr. Kim Vass Eudy, about End of Life Care, the difference between palliative care and hospice care, and how Providers can utilize these services.KVE: Well, thank you and welcome to the Move to Value podcast. I am really excited to bring a guest with me today. Her name is Maria Hayes. She is the Senior Vice President of Strategy and Innovation at Mountain Valley. I am excited to speak with her because in my clinical team, we are working towards bringing advanced care planning to our value partners and their patients. And Maria and I have been working kind of behind the scenes talking about this. So I really want to bring that conversation out forward Maria and I'm really glad to have you here today.MH: Thank you. I'm super excited to be here. Thank you for the invitation.KVE: I was hoping you could kind of kick this off by telling us a little bit about palliative care and Hospice care. I know as a clinician, when I make a referral, sometimes I just do a bucket referral, I say just give them palliative or give them Hospice, whichever one this patient qualifies for. So maybe you could help me understand and our listeners understand the difference between the two.MH: Absolutely. And I can actually start off by kind of giving you a little bit of an overview about Mountain Valley, if that will be helpful. And then I'll kind of go into Hospice versus palliative care. So, Mountain Valley is a Hospice and palliative care organization serving 18 counties across North Carolina and southwestern Virginia. We were established in 1983, so we just celebrated our 40th anniversary. Headquartered in Dobson, NC, we provide care in a large service area with six Hospice offices, 4 serious illness specialist locations and two inpatient Hospice care centers. We also have two Hospice thrift stores. We call them the Humble Hare and those stores actually benefit our charity care programs.Palliative care is a little bit different than Hospice care. So palliative care is a specialized medical care for people living with a serious illness. This can be cancer, heart failure, lung disease, dementia, Parkinson's disease or ALS. Patients in palliative care may receive medical care aimed at easing their symptoms along with treatment intended to be aggressive or curative. Palliative care is meant to enhance a person's current care by focusing on quality of life for them and their family. In addition to offering support to ease symptoms, the palliative care provider also specializes in leading and navigating the goals of care discussion, which we kind of referenced earlier. We help patients consider or even complete their advanced directives as well. Our palliative care providers are serious illness specialists who add another layer of support and work as a part of the patient's medical team. So that's kind of how palliative operates in, in that form or fashion.KVE: I was going to ask you a lot of times, I know that a patient may start in palliative care and then transition to Hospice is and I know you're going to explain a little bit more about Hospice. Is that a pretty natural transition for a lot of patients?MH: It is sometimes for patients. We see a lot of patients that truly can be Hospice, but they actually choose palliative because they feel more comfortable still kind of seeking their curative approaches, still seeing their medical doctors still treating their heart failure with the heart failure medications and they really kind of they're just not ready for that Hospice conversation. And but typically I would say palliative and Hospice, we really like to focus on the six months or less for their life span kind of looking at all those factors and then...

In today's episode, we visit with Josh Vire, Vice President of Value-based Operations at CHESS Health Solutions, who shares his insights on managed Medicaid and how CHESS leveraged years of experience to enter into Medicaid to create an all patient solution.Josh Vire, welcome to the Move to Value podcast.Thank you, Thomas. Thanks for having me. Pleasure to be here.So, Josh, let's talk about managed Medicaid. First, can you tell me what is managed Medicaid?Sure. It may be easiest to start by sort of describing how traditional Medicaid works. In traditional Medicaid, typically this operates under what's called a fee for service payment model. This model is going to reimburse providers directly for every service that they provide to Medicaid beneficiaries. And generally the upside to this model is that it's going to allow for the flexibility and provider choice for the beneficiaries. But what we often see is that this leads to fragmented care and ultimately the incentives in this fee for service type model really incentivizes the volume of services over outcomes. So, in contrast to that, Managed Medicaid utilizes alternative payment models including capitation and what are called value-based payments. And the way that the capitation works is that a managed care organization or a MCO as they're referred to will receive a fixed monthly payment per Medicare beneficiary that's going to cover all their health care needs. And then that fixed payments are paid regardless the amount of services that are provided. And then those MCOs are going to use those funds to incentivize providers to be more cost effective in their care as well as incentivize sort of tighter coordination of the care. And then what they can layer on to those, as I mentioned, is the value-based care payments which are intended to reward providers based on the quality and outcomes of care rather than just the quantity of services provided. And so in theory, right, this would encourage more efficient, high-quality delivery of care. In addition, managed Medicaid may employ other payment models that are along that continuum of value based care payments, which could be like pay for performance or bundle payments. But really the goal there is to align the incentives to focus on driving down total cost of care as well as improving health outcomes for beneficiaries.Well last December North Carolina made the transition to managed Medicaid and Chess spent the year prior to that establish establishing the infrastructure and beginning to make preparations to offer this service. Can you tell me why this decision was made and a little bit of the story about how Chess built this service line.Absolutely. CHESS has a decades plus long history of working with providers to transform care delivery to value based care. And historically our focus has been on traditional Medicare, Medicare Advantage and commercial contracts. But as we went through our engagements with our value partners and then as we began to have discussions with providers across the state, we heard consistently that one of their pain points was the need to work with of having to work with multiple enablement companies to serve all their patients. So some enablement companies only work with MA or maybe the traditional Medicare options or commercial. But no one was really acting as sort of a one stop shop in in serving the entire patient population for these providers. So our decision to expand our services to include Medicaid was really driven by our desire to be what we call an all-patient solution, which essentially just means we want to be able to align incentives across the provider's entire patient population. And really that's because we believe this is how true transformation can and will occur, not in certain segments, but by treating all patients with an eye towards that cost containment and...

In this episode we continue our interoperability conversation with CHESS Vice President of Health Informatics, Mark Dunnagan. Last time, we focused on the importance of shared data in value based care and the need to overcome any barriers. Today we talk about the logistics of interoperability and the modernization of data exchange.Mark, last time we left off talking about data exchange There always seems to be ongoing conversations in this topic about APIs. Do you feel like more improvement in APIs could be a potential solution?I do I use the metaphor of a quiver of arrows quite often when describing you know interoperability. I think you know it's my job as you know the head of a team that that must figure out how to get data and get it in a timely fashion and in a way that fulfills our contractual obligations and our obligations to the patient. I think APIs is one more arrow in the quiver. You know it gives us a programmatic way to access you know large volumes of complex data, but it's not necessarily the only way. You know when we sign on a health system let's say to one of our ACOs, you know I can pretty much rest assured that they're using one of a small number of vendors and you know those vendors are fully capable of producing certain constructs that that my team can consume. Same with most payers. Although you know, the outputs may differ certainly. But as I work my way down the chain, particularly in working with ambulatory clinics and what not, you know, I gosh last time I checked there are over 200 EMRs here in my home state of North Carolina. Each one of those with a slightly different interpretation of certain standards. Not all of them have viable API interfaces, you know, not all of them have the same way of communicating with them. So, I have to be open to old school HL 7, which is kind of the equivalent of opening up a channel and typing over it. I have to be open to flat file exchange. I have to be open to various forms of XML, JSON, and it truly depends on what that endpoint can offer. So again, APIs are extremely valuable but they're not the only tool that a team like mine has to has to be able to wield to be interoperable to be successful in the exchange of healthcare data.Interesting. So as someone who's spent a career in the data and informatics space, can you share how these analytical tools help control the cost of healthcare?There's many answers to this. I would say again I'll draw back to what we do which is value based services. You know I need to know when something happens and I need to be able to inform our performance improvement teams and so that they can communicate with the providers. I need to inform the care managers when something of interest when someone is checked into a hospital, someone has sought, you know, specialty care outside of network, when someone has been discharged, they need to know that and I need to inform them, you know, not only that it's happened, but give them enough descriptive information that they can intervene appropriately. I would go further to say that I need to glean enough good information, rather my team has to be able to accumulate and collate enough information to get ahead of what might be coming. You know, we're making some very powerful strides, you know, not only in, you know, intelligently stratifying our population to kind of know who to intervene with first, but also in quantifying rising risk and rising cost. Who do we think based on what we're seeing happen now? What do we think's going to happen to them tomorrow? And can we get ahead of that in time to affect that? Can we keep them out of the hospital? Do we know there's a costly intervention or fall coming, and can we intervene or get them some community based services in time? So, you know it's a large part of what we do and and again something that at least on the value side we have to contemplate every day.Do...

Today we are here with Mark Dunnagan, CHESS Vice President of Health Informatics to talk about Interoperability, what it means, why it matters in health care, and how better access to patient data for the entire care team will lead to improved outcomes for patients at a lower cost.Mark Dunnagan, welcome to the Move to Value podcast. Thanks, Thomas. Glad to be here.So, Mark, today I want to talk a little bit about interoperability with you. So, can you first off explain what interoperability is?Well, in the in the simplest terms, interoperability at least in in my travels is a is a metaphor for a conversation. Think of it like provider A wants to talk to provider B about patient Mark and it's a means of making that happen.And why is interoperability important for healthcare?Well, I think in line with the metaphor of the conversation, you know, I think fifty, seventy-five, a hundred years ago when you only had one physician and they knew everything about you. You know, maybe it made sense, but in modern times with you know the various ways of receiving care, you know it, physicians don't know everything about you and there's no way for those forms that you fill out, you know, annoyingly so, when you go to the physician's office can express everything that has happened to you. Interoperability is, is the key to that. Again, to know where Mark's been and what happened to Mark and why it may have happened.Well Mark, can you share a real world example of how interoperability provides value to healthcare?So, I can and it's part and parcel of that what we do on the value side literally every day. We receive what we call ADT feeds. It's basically a notification that you know one of the patients under our care has recently checked into a hospital or has recently depending on the depth of the ADT Feed perhaps been seen out of network or gone to specialty services or whatnot. But that ADT Feed that notification that that one of the lives that we care about has been touched in some way by healthcare entities around us gives us information that we need to know to intervene appropriately. That if someone has been discharged home that we can you know abide by our contractual obligations to check in on them. That if someone has been seen out of network perhaps you know seeking high cost, high value services that we can make sure we understand what and why. And again provided you know the appropriate care management or interventions to help them with that. So again you know that is part and parcel what my teams deal with every day in a in a huge part of of the services that we provide. Without that form of interoperability we would struggle to provide the value that we do.That's fascinating. So, so we've established that the need for patient data exchange between providers is very important. How can we, how can we continue to close this information gap, how can we make this a better exchange?There's a million answers to this. I think I think that the foundational elements to make interoperability real or are there and to be honest with you have been there for some time Now, granted, what becomes interoperable meaning the data that we need to share continues to expand. You know of late; you know care plans and then the ingestion or the sharing of perhaps behavioral health information, you know the breadth of the data continues to expand. But the notions of interoperability have always been there as far as the structure, you know, the, the shape if you will, of the data and how it's exchanged and then kind of the language, the nomenclature, the codified values there, there are at least examples and standard terminologies that can be used for most everything. I think you know, for me the struggles, if you will, continue to be around, you know, adoption and certainly EMR technologies take...

Today we talk with healthcare consultant, Tim Gallagher, who works with clients that serve the uninsured and underinsured. He counsels in navigating emerging models of care, leveraging better system solutions, tying into public sector funding, and forming value-based partnerships. Tim's work in the NC Medicaid Managed Care Transformation efforts have placed him at the forefront of navigating a new care model in this state. Tim Gallagher, welcome to the Move to Value podcast.Thanks, Thomas. Glad to be here.So, Tim, it, it seems like you've got a varied background. You've done a lot of really cool stuff. So can you tell me a little bit about that background in healthcare and how you became involved in Medicaid?Sure. After college, I actually started helping some local physicians figure out how to build their claims electronically. There was a CPA who had a practice full of physicians and there were requirements for billing the federal programs like Medicare. Physicians were actually required to start submitting their claims online before everything had been paper. So that was like 30 years ago, now as it turns out, and I made a career out of that healthcare revenue cycle, all of my strategy work has involved how we pay for things and sometimes it was more public sector focused like Medicaid or Medicare or Veterans health and sometimes it was commercial and private pay.So can you tell us the story of the Medicaid transformation efforts in North Carolina?Sure. I became exposed probably a 10 years ago as I was volunteering in the free clinics in and around the Winston Salem area and they were concerned about how the impact of Medicaid expansion might have on their operations. Much like the Affordable Care Act in 2010 diminished the need for uninsured to seek access in free clinics, they thought Medicaid expansion would also diminish their demand.And so, from that perspective, I watched the state roll out a whole bunch of things. At the same time, my family was actually transitioning our daughter who has IDD intellectual and developmental disabilities and we were transitioning her out of, you know, school based supports into whatever was next. Alex qualifies for various benefits under Medicaid after she turned 18. And so we were unpacking how best to translate her benefits into actual services. You could say we're a card-carrying family on North Carolina Medicaid.Outstanding. So, you get that first-hand experience, that's I bet that was that's very helpful when it came to really learning the pain points of what was involved with Medicaid. What opportunities are there for managed Medicaid to accelerate value-based care?Yeah, the opportunities are really just beginning. There was a white paper that the state put out probably back in January of 2020 and they articulated what they thought was a glide path for getting more provider arrangements into what they call alternative payment models. And the first year they knew it was just going to be a baseline for value based contracting and the state then encouraged people to move providers mainly to move towards quality and value via care coordination payments and pay for reporting.And we're just now getting into the fun part of like pay for performance and arrangements that allow meaningful differences in compensation in terms of higher quality provider groups. If you recall, only about 1.6 of the 2.2 million eligible for Medicaid transitioned in to managed Medicaid initially and Medicaid expansion and tailored plans this summer, the number has you know continued to increase. So Medicaid not only is rolling out value based, but more people are moving into the system. I would say today there's about two million within the standard plans out of a 2.9 million who are the total population receiving Medicaid benefits.What do you see

In this episode of the Move to Value Podcast, we finish our recap of the Move to Value Summit – Nursing Edition which was held on Dec 6. Today we hear from CHESS Senior Director of Clinical Operations and practicing physician, Dr. Kim Vass-Eudy. As a practicing physician, Dr. Vass-Eudy has a unique perspective on Falls, Risk Assessments and Prevention of Injury. Her presentation covers who is at risks for falls, strategies for fall prevention, and falls risk assessments.

Today on the Move to Value Podcast, we continue with part 2 of a presentation on Diabetes Medication Management, given by CHESS Directory of Pharmacy, Rebecca Grandy, who includes helpful information, updates and reminders.

In this episode of the Move to Value Podcast, we continue with our recap of the Move to Value Summit – Nursing Edition which was held on Dec 6. Today we hear part one of the presentation from CHESS Directory of Pharmacy, Rebecca Grandy, who shares information, updates and reminders around Diabetes Medication Management.

In this episode of the Move to Value Podcast we revisit The Move to Value Summit Nursing Edition that took place on December 6, 2023. This is an event where our team of subject matter experts present best practices in value-based care to an audience of nurses. This year we had well over 100 attendees. Today we will hear from CHESS Director of Care Coordination, Shannon Parrish, BSN, RN, CCM, who shares the importance of patient education and how to equip patients with the skills to advocate for themselves.

In this episode, we talk to Denise Tedder, former teacher, ED Nurse, and now Quality Programs Manager specializing in Medicaid for CHESS Health Solutions about North Carolina's transformation to Managed Medicaid Care, Medicaid Expansion, and what healthcare can do to prepare for the influx of a new population of patients into the program.Denise Tedder, thank you for joining us today on the move to value podcast!Thank you, Thomas it's a pleasure to be here.I have a couple of questions for you about Managed Medicaid. So can you tell me a little bit about the move to Managed Medicaid in North Carolina?Sure. Well it started back in like 2015, they passed legislation transitioning Medicaid from a fee for service to managed care and what that means under managed care the state contracts with insurance companies, which are paid a predetermined set rate for each enrolled person to provide the services. North Carolina Medicaid Managed Care actually started back in July 1st 2021. So now our patients have options to choose a health plan and get care through the health plans' network of doctors. Fast forward to now, effective December 1st, North Carolina has passed Medicaid expansion which will provide an estimated 600,000 more North Carolinians with access to health care coverage. That sounds like a really good opportunity for a lot of folks to get the healthcare coverage they need. Yes, it's going to be amazing for our communities!So what opportunities are there, you know because CHESS is in the value-based care space, right? So what opportunities are there for managed Medicaid to accelerate that?So, one of one of the key features of North Carolina's Medicaid, Managed Medicaid program is the requirements of all the pre-paid health plans to align their population health and prevention strategies with the state's goals. The ultimate goal is obviously to make everyone healthier under Medicaid but there's opportunities to reward providers for keeping their patients healthy. This expansion means more people will have access to healthcare which improves their health and that's what it's all about. What does that do with the improvement perhaps of health equity in our communities?So, it just means that everyone has the opportunity to be as healthy as possible. It gives patients increased access to preventative care for things like well visits, immunizations, screenings, and it also causes for better management of chronic conditions. So having this equitable access to healthcare means we're focusing on keeping our communities healthy which will positively impact health outcomes.So, how does this address the social determinants of health?So, Medicaid programs are increasingly focused on social determinants of health needs, including food insecurity, access to housing, reliable transportation. I recently read an article from the CDC which said 40% of a person's health outcomes are driven by their social determinants of health. So, I mean no one can focus on a health problem that they have when they're worried about housing or food for their family. With a focus on these needs we can put them in the best position to be successful.And what are your thoughts on how prepared providers are for this December 1st expansion deadline we have?Well, one of the big challenges for providers will be a sudden increase of all the patients seeking care. So, we have 600,000 across the state and most of our providers are operating at or near capacity. So, it could cause short term delays in scheduling appointments, but having this, you know, this previously underserved population access to care, I think providers are ready to make a difference.That's great! Well, according to “North Carolina for Better Medicaid,” 82% of Medicaid...

Today we wrap up our conversation with Dr Ehab Sharawy and Dr David Cook of OneHealth by discussing the differences of the “big v” and the “little v” in value-based care and the positive impact of direct collaboration between the individual, the primary care provider and the specialist. Well good afternoon gentlemen and welcome to the Move to Value podcast. we're back for episode #3 this afternoon, it's good to have you. Well listen we've really not talked that much about value-based care in our time together, so I'd like to start this session off with a question framed around some of the things I've heard you all say over the last year or so and oftentimes when we talk about value and value based care I've heard you say there's value with the big V and value with a little V and doctor Sharawy you want to take that and tell us what you mean by that?Dr. Sharawy: Sure, so I'm going to leave the big V little V to the expert over there across from me, Dr Cook. Nobody articulates it better than he does, but I'll just start I think with some kind of real life analogies, because the word value means something different to everybody and within healthcare I think it means something different. When you talk about value if you talk about from a health system lens it's something different than it is from a payer lens than it is from a physician provider lens from a consumer lens, you know those are the kind of things. So just think of an analogy of you know folks that are lucky enough to be able to afford going to let's say a with two star Michelin restaurant, you know where you're going to go in and know it's going to be costly. OK let's just say it's $300 a head to go there. But when you get in there and let's just say that's the best food I've ever eaten you know in my whole life I've never tasted something that and somebody said was that good value for you if you're going to say yeah it was fantastic great value because you were so happy with the quality and all that and the cost was not the factors mitigated by not mitigated but overcome by the fantastic experience that you had. Then if you flip it to the other side and you say listen you know I got a family of four and I'm on a fixed budget and you know I want to go out and have a nice meal so I'm going to go to a restaurant where the cost is very reasonable I can afford it and by the way the food was good you know it didn't knock my socks off but it was good and we enjoyed ourselves have a good time. That would be defined as value and those are two different experiences but both of them have satisfaction. What I always think in Healthcare is for so many people that situation is just upside down and really when we talk about value in healthcare we got to figure out how to make it right for everybody so everybody gets value in that regard. I want to let David expound on that.Dr. Cook: yeah completely agree with Dr. Sharawy I mean that what a great anecdotal or model to look at because it's very hard to understand value in healthcare. Except I would say this I heard Don Berwick say this one time a long time ago and I'll start my conversation with big V and the little V with this is that there really is no value in healthcare delivery. There's only value in health. OK you're not thinking about hey I love taking my car to the shop and getting it worked all the time. No what you like is your car running really well for a long time right and so when we talk about the big V, Dr. Sharawy and I have always said this is what really matters. it's health it's longevity I'm going to say this again longevity it's the human experience, it's quality of life, enjoyment of life doing things you like to do, feeling safe in your healthcare journey. It's really experiencing something that's unique in your healthcare journey. The third piece is reduce suffering and I'm going to use this term reduce suffering, both mentally and emotionally, physically and financially, OK That's...

Today we hear Advocate Health's Don Calcagno, Senior Vice President and Chief Population Health Officer for Value Operations and Terry Williams, Senior Vice President and Chief Population Health Officer for Partnerships and Strategy who provide insight into Advocate's participation in the Medicare Shared Savings Program and share with CHESS President and host, Dr. Yates Lennon, the successes that have been achieved along with some of the lessons learned.Well, Don, Terry, thank you for joining us on the Move to Value podcast today. Glad to have you. If you don't mind, Don, we will let you start and just take a few minutes to tell our audience a little bit about yourself. And then Terry, you go next and the role you play at Advocate Health.DC: All right, thanks Dr. Lennon. My name is Don Calcagno, I'm currently the Senior Vice President, Chief Population Health Officer for Value Operations for Advocate Health. I also serve as President of Advocate Physician Partners, which is a large, sophisticated, clinically integrated network in the Chicagoland area. Personally, I'm a lab tech by training, completed my schooling in 1992. I have an MBA as well from Northwestern Kellogg and I've been with Advocate for quite some time in various roles from lab tech to others. But I've been a vice President, Operations, Senior Vice President on OPS and I've been either the President or a Senior Vice President of Population Health at Advocate, Advocate Aurora Health since about 2015. So thanks for having me Dr. Lennon. Look forward to the conversation.Glad to have you. Look forward to it. Terry?TW: Hi, I'm Terry Williams, Chief Population Health Officer with focus on partnerships and strategy for Advocate Health. And in terms of background, I was Chief Strategy Officer at a couple of health systems for about a decade as well as started Population Health at one of them that we'll talk about a little later today and I'm also responsible for looking at how we can tie together the academic enterprise and some of the innovations that are happening there into what we're actually doing in population health. So, to give you one example, there was something called the EFI Electronic Frailty Index that was developed in the School of Medicine. It's the single best indicator we have found for predicting future utilization. And so, we use that to we think really do some unique work in our population health work by incorporating that measure.Yeah, familiar with the EFI and I think you just opened the door for a couple more podcasts right there in that one, one statement. So well, one of the things we wanted to do today with you all is to talk a little bit about the MSSP program and Advocate's participation in that. I know we look forward to hearing about some of the successes as well as the challenges that you all have and are facing. It's interesting the program now is what, 11-12 years old and NAACOS just recently at their fall conference released some stats and I'll read some of those to you. So since 2012, ACO's have saved Medicare 21 1/2 billion dollars in gross savings and 8.3 billion in net savings. So that's since the beginning of the program. For '22, It was the sixth straight year that ACO's delivered net savings to Medicare. 84% of ACO's in 2022 saved Medicare money and almost 60% of them were in two-sided risk arrangements. So when you think about where this program started and when it started, it sounds like success right, we're moving in the right direction. With that...

In this episode, we hear the second in a series of conversations between Dr. Ehab Sharawy, Dr. David Cook, and Dr. Yates Lennon, where they discuss “Modern Primary Care” and how greater access to care generates savings and makes for a healthier, happier patient.Welcome to the Move to Value Podcast. Dr. Ehab Sharawy, Dr. David Cook. Welcome. Glad to have you this afternoon. So, we're back for our second session together and where I would like to begin is with modern primary care. I've heard you both talk about this now for quite some time, but I've never ceased to learn something new when I hear you describe it and your vision for modern primary care. What you're trying to build at OneHealth. And so, I don't know which of you guys wanted to take it and run with it first order. Dr. Cook, so we'll start with you and tell us what you mean by modern primary care.Dr. Cook: Modern primary care. You know, Doctor Lennon we've talked about this almost like taking a step back in time. Umm, you know, one of the things that we saw with healthcare over the past 12 to 20 years is again the erosion of that primary care individual relationship. That part that partnership with the patient. It became less than what it should be as a sacred connection and advocate for care. Partly because of how health systems, PE, VC, retail primary care is perceived. Partly because of what we did to ourselves as primary care physicians and partly because of the environment around us. It began to erode away, and there were so many things that were being done, and I used this often and I'm going to do it now because it's a great place to use this analogy, it's like the Titanic. We move the deck chairs around a lot in healthcare and the Titanic is still going down. Healthcare costs are going up, quality is going down, longevity is going down. So, when you look at some of the data across the United States, including the Dartmouth Atlas data, wherever there's a lot of primary care involved in care of the community and the individuals, quality goes up, cost goes down. But there's never a lot of money that follows that. Right? There's never been big money in primary care until recently. And it's, I always say, it's sort of a fault-centered way to get payment from primary care now. So, Doctor Sharawy and I began to look with others, that are now part of OneHealth leadership, and said what have we been doing for 30 years that that really is different. Besides the for all mission, besides the knowing the color of the individual's eyes, besides some of the basic things that we thought and basic tenets of care that we thought were the right things to do. Well, it was that care evolved out of the primary care, uh, patient relationship. And we kept that sacred. We made it really sacred. And we almost built this hub and spoke mechanism, I always say that, where you have the provider of primary care, whether it be OBGYN, internal medicine, pediatrics, or family medicine, and the patient encircled by a team of people that that compress that relationship together. And from that relationship, you had ancillary services evolve out of that, you had home health, you had Hospice, and palliative care, and specialty care, and hospital care. But it all evolved out of that relationship. And so, it created this connectivity for the patient to someone who was always there for them. Not only in the moment for care, but long-term care. And the things that I saw escaping primary care were minute clinic work. Well shame on us primary care physicians, we couldn't be minute clinics for our patients. Urgent care work, well I've always shown my patients up or done things to mitigate their acute crisis, why could we not do that. Mental health, we gave that away, we weren't able to do that. It's a muscular skeletal work, integrated specialty care work. So, as we began to develop OneHealth over the past, really it...

Today on the Move to Value Podcast we have the first in a series of conversations between OneHealth Co-CEOs - Dr. Ehab Sharawy and Dr. David Cook, and CHESS Health Solutions President, Dr. Yates Lennon, about a “For All” philosophy of practicing medicine and the necessary connection between the patient and provider that benefits both.Good afternoon, gentlemen. Welcome to the Move to Value Podcast. Let's start and go back in time a bit. I would love for you to spend a little bit of time telling us what caused you to want to go into the medical field and to become physicians. Dr. Sharawy, let's start with you.Dr. Sharawy: So that could be a 20-minute conversation, or it could be a three hour conversation, but I'll try and make it even smaller than that. You know, I came from a medical family. So, my dad immigrated here from Egypt on a Fulbright scholarship, and you know I was in the household and my mom was a dentist. And I had multiple family members that were in the medical field. So, I'm always drawn to it, you know, but never forced into it. And I think that's really important. But I think when you start thinking about the medical field as your career, I think it's really important I think it drove all of us, or most people, that do it, you got want to help people, you know. And I feel like that's something that was stuck with me for a long time. So, I cannot remember the time where I didn't think I was going to be a doctor. Even in the 5th grade, 6th grade, I can remember that. And it was really about that drive. You know, say look, you know, how can you make the biggest impact um in your life. And boy, I'll tell you it's an admirable thing to think about improving, being there for the people when they need you the most. And that's in their healthcare. And then just to conclude on it, I never thought in the world I'd be an OBGYN. And Yates, you know, yeah, can relate to that. And so, seeing that ability to take care of people from literally the time that they're in their childbearing years, even before that to the time that they're in their twilight years, was very attractive to me to do that. And then really, I enjoyed the fact of being able to take care of people throughout their healthcare journey but also have the procedure type stuff that kind of excited me right at the time.I think as a fellow OBGYN, it's the perfect balance of primary care and surgery. So, Dr. Cook, what about you?Dr. Cook: A little bit different background. I was the first on my dad's side of the family to go to college. And, but yet, same, I do know Doctor Sharawy's family, and they're the same ilk. And Doctor Lennon, I can only imagine yours is as well. From as small as it was, I could remember them giving back to humanity, giving back to others. In fact, one of the things my dad once told me is the only thing you can take when you leave here is what you gave away while you were here and it's better to give that to other people than take it yourself. And so, I learned from them about several things I believe that that brought me into medicine. One was this thirst for knowledge and understanding science and you know bettering myself that way. The other was how can you reduce suffering with those around you in multiple ways. And as I went into college, I was thinking should I be a veterinarian? Because I did do a lot of

In this episode of the Move to Value Podcast we continue our conversation with Dr Kim Vass-Eudy, Senior Director of Clinical Operations at CHESS, about Advance Care Planning and how to document those patient interactions.Dr Kim Vass-Eudy, welcome to the move to value podcast, it's good to have you back!Thanks Thomas.So last time we talked about a lot of the factors that go into advanced care planning, how the provider sometimes has to wrestle with decisions, perhaps feel some discomfort with acknowledging end of life and that it perhaps goes against all of the training that a provider has. Before we left, you touched on some of the financial components that are involved in advanced care planning and, you know, as uncomfortable as this conversation might be to have, talking about the financial component might be just as uncomfortable.Exactly.But I do think that there is a good motivator to have these conversations with patients beyond the benefit to the patient and that would be how the provider would be compensated or reimbursed for having those office visits, which we all know is is part of the business of healthcare. So it it's been said that the success of an accountable care organization is not about whether physicians should give their patients more care or less, but it's about having the right conversation with the right person at the right time and being able to act on that person's wishes for their health. So as we move away from, you know, the discomfort of those conversations, I just want to touch one more time on how having these conversations, before a patient before they're actively dying, how they impact the metrics for success and value, like patient satisfaction, quality, utilization, and cost reduction. That's a long question, I apologizeVery big very I might have zoned out for a minute there.OK, I apologize for that so I think what we're trying to really distill this down and to being is having those conversations do impact value and can you tell me maybe how that is how and why that is so?Yes I can.Thank you.You're welcome, let me save you from yourself Thomas I appreciate that, thank you thank you – verbose, that's what we are.So within ACOs, so an accountable care organization, our goal is really to give, like you said, the right care at the right time to the right person, and in doing so sometimes you have to look at the cost of the care. That's the bottom line. We spend too much money in healthcare, and we need to make sure that we're spending it properly and on the right people and making the most impact on the people that we're touching. So that being said, when it comes to end of life that is the most expensive time of our lives when it comes to our health care cost, and it doesn't have to be some of the reason it is is because people have not laid out what their desires are for their end of life and their family members say do it all. You know, give them do everything that you can possibly do for my family member, my loved one, when maybe that person did not want those things done. Maybe they had a different vision of how their life would process or become you know their life their end of life would occur. So, having that conversation what is it that it looks like to you at your end of life? Do you want every machine? Do you want every antibiotic? Do you want every intervention? And the patient can really make that decision ahead of time they don't have to wait till the last minute, they don't have to rely on their family members in a moment of feeling very vulnerable and upset and emotional. That it can all be laid out ahead of time and that would save money. Now, here's the thing. Patients, this is kind of an interesting statistic, so patients who've had an advanced care plan discussion within three...

Today we talk with Kim Vass-Eudy, Senior Director of Clinical Operations at CHESS and practicing Doctor of Osteopathic Medicine about the importance of Advanced Care Planning and strategies for starting those conversations.Dr. Kim Vass-Eudy, welcome to the move to value podcast!Thank you, Thomas, it's good to be here.So today I want to discuss some things that I know are of great importance to you, which is advanced care planning. Can you tell me or tell us what that is and what it consists of? Sure. It's basically a discussion with patients about their plans for their future. It's about what they want to do if something were to happen to them and they couldn't speak for themselves. It's about end of life care, in a lot of ways, making their wishes known. It's a discussion that can occur between a provider and their patient and their patient's family members or someone that they want to make decisions about their care and it really outlines what their wishes are so that there's no guesswork, there's no stress at the end of life. That the patient's wishes are knownThat's fascinating. So, you are a practicing physician, and a darn good one from what I understand!Thank you.So how important do you deem advanced care planning in the care plan for your patients?So I think it's essential. I think as providers, we're just not doing it enough. It's one of those things that they don't teach us about in medical school or in our training or at least I didn't have that education. I've been out about 16 years or so. So no one ever told me how to do this. The goal of being a doctor is to save people and to keep them alive for as long as possible, so having those discussions about end of life care feels very different and probably goes against what my teaching has been as a provider. So when they looked at, they actually asked patients and people if they're having these discussions with their primary care physicians or physicians in general, and 84% of Medicare age patients said that they've never had this discussion with their doctor and these are patients that are in the older generation so no one's talking to them about this. And they also polled Americans in general, so this is not just Medicare age patients but Americans in general said 92% of them said they'd like to have these kind of conversations, that they're interested in that, that they're willing to have those conversations with their patient or with their providers and and to discuss their wishes. 53% of that group said it would be a relief you know if someone would bring this up to them and have this discussion so that they don't have to think about it or talk about it, that they can start making decisions now about their future. So in my practice you know I tend to do these discussions at well visits because that's when patients aren't thinking about anything but just being healthy. So I start saying to them, well what if something were to happen? What are your wishes have you talked about this with your family? And I think it's just as important as talking to them about diet, exercise, vaccines, cancer screening, and the you know one of the drawbacks though is this takes time. That's why I typically do this at the well visit because it takes a lot of time to have these discussions and I give myself about 30 minutes for those visits so I'm able to really discuss it with patients and answer their questions about it. You know for providers, there's a lot of issues because we're not trained and we don't have guidelines. No one tells us how to do this. Providers, one of the things that they say they're most fearful of even having these conversations because they don't want to destroy hope for people. They don't wanna tell them Oh yeah guess what you know the end is near and you better start thinking about it they don't want to take that hope...

In this episode we hear part 2 of the conversation between, Josh Vire and JP Sharp, where they discuss the current and future state of value-based care including primary and specialty care and the recently released making care primary payment model.You've recently in your career focused on integration of behavioral health with primary care. Can you speak to a little bit how critical important that is in on this path of transformation and alternative payment models and those challenges with access to behavioral health and the finances of behavioral health care?Glad you bring that up. It is a trend and for a reason is that our thinking, I think it's caught on in this kind of evolution of behavioral health being much more central to healthcare not this silent thing and that's just a vestige of history is that we as a people in healthcare and in America just drew a line there and said here's physical healthcare over here and there is behavioral healthcare over there and they were siloed off and behavioral health care was often more stigmatized and so it got the short end of the stick when it came to attention and funding and innovation. And so, it it's only through a snowballing of research and public momentum and acceptance of this where stigma of behavioral health and treatment associated with it is being reduced. It's absolutely still there, but just better understanding of it. And it's incorporation into physical health is twofold. It's both from just an evidentiary standpoint and clinical is that they are linked. So the behavioral health impact, if you have say depression, your physical health if you have say diabetes, those are related you know if not like directly in a physiological mechanism but rather if you're depression goes unchecked you're less likely to take care of your diabetes and your physical health, take your meds, see your doctor what have you, and those things it's a compounding exacerbating effect. And so, the thought now is that hey these are these things are so intertwined that evidence suggests treating behavioral health issues first and alongside primary care issues is going to result in better care. And then kind of the other is just purely logical and from a patient perspective like you know, you had a human level like we don't separate these things. If you ask me how I'm doing, I'm not going to there just say Oh my knee hurts and like stop there. If you ask me how I'm doing I'm going to be like well, you know I'm a bit stressed out right now. I've got a lot of things going and you know maybe feeling a bit down from x, y, or z reason. And you know what like my knee hurts and I wish I could run a little bit further than I did last weekend. And so, you know it's like that's like what you know our life experience is, it's not siloed like we've kind of set up the healthcare system to do. So how can we kind of design the system to better appreciate all of these things at a you know patient experience level as well.Right yeah, that's the question and an important one particularly. I appreciate you talking about the stigma and the importance of behavioral health, I know it's important area for you and I think an important one that we get right as we think about this transformation. It's critically important. So, I'm going to ask you to look into your crystal ball here a little bit. Where do you think in the next five years let's say, 5 to 10 years, where will the focus in value based care be in your opinion? Will it still be in the primary care space primarily or do you think it'll shift to, specialty is obviously one that's already beginning to talk about, but just your thoughts on where you think this transformation will be in the next few years?Absolutely. So primary care is not going to go away. I think it's caught on enough people have realized that and that's going to be more about incorporating it into more and more...

In this episode Chess Vice President of value-based operations, Josh Vire, has a conversation with JP Sharp, one of the original architects of the Next Gen ACO model at CMMI and current Chief Growth Officer at Rippl Care, about what it was like at the infancy of the value movement. JP Sharp welcome to the move to value podcastThanks! pleasure to be here! I want to start you have had an interesting path in getting into the healthcare you are a lawyer by training, and you earned your JD from the University of Michigan also received your Master of Public Health from there as well was there a particular moment or experience that got you interested in in healthcare and moving away from the law? Yeah, excellent question. I won't pretend to give universal career advice on how to go about this, so I could tell a little bit about how I got started, which is I went into law school kind of with healthcare in mind. I have a healthcare family from different angles, a veterinarian, oral surgeon, and a pathologist all kind of in the in the family. And I was a little bit of the black sheep and didn't go in directly into the clinical side of things but was still fascinated by it and also just the complexity of it. So, as I was thinking about you know grad school that's when the ACA passed and lots of effort and attention on that unique window of opportunity there. So, I went in thinking I hey let's be a lawyer for a little bit and focus on healthcare and then see what happens. And the see what happens happened most sooner while I was in school and just realizing that great experience, but I wanted to start doing things and being part of this transformation sooner rather than later. So that's kind of where I took that turn to say alright how do I get on the front lines and really start being an actor in this space.That's great. Interesting to sort of hear your thought process there and glad you moved over to healthcare. You've had an expensive career been in a number of places including CMMI, Blue Cross Blue Shield, Optum, recently you've moved over to the provider side of the house. But I'd like to start with your time at CMS. You were there in the in the early days of CMMI and payment transformation and redesign, tell us a little bit what was that experience like being there in those early days?Yeah, it was a lot of fun it was pretty unique. Some people described CMMI as the little innovation group inside you know the government bureaucracy, and a little start up inside the government and it's actually like that both with the people, the mission, and mostly like how we worked physically. It was set in a separate building which, one of those like nondescript you don't know it's a government building from the outside, but you know inside they'd like colored it you know bright colors and had treadmill desks and stuff and so it was like they set it up to actually be a little bit more exciting. And they brought in people who otherwise probably weren't going to be super attracted to government jobs like that you stereotypically think of, you know the bureaucratic of regular day-to-day stuff, but they're able to because of the mission here and the attention that this is getting is just a major off opportunity and moments in healthcare transformation. They brought in people of all walks of life and different backgrounds. So, we had people with Health Sciences, health services researchers with pH D's and MD's and MBAs and MPHs and a few folks with like me with random other degrees just all like get around the table and figure things out from end to end. And so, it was really just like a very mission...

In this episode we hear the second half of the conversation between CHESS' own Melissa Pollock and Advocate Health's Vice President of Population Health Midwest Megan Reyna as they discuss navigating the data and quality measures for success in Value-based care.So Megan thank you so much for coming back to the Move to Value podcast. I'm really excited to talk to you a little bit more about population health at Advocate and curious - we did talk last time about ACO REACH. I was just curious a little bit about provider buy-in. How did you message ACO REACH and the model to providers? What did that look like? How were you able to get providers on board with this new innovative model?Thanks for having me back, Melissa, happy to be here. Yes so everything that we do within population health in the Midwest really goes through a strong physician governance model and it is a true partnership with our physicians to participate in in in our value based care contracts. So ACO REACH as well, we really educated the practices who we thought would be good participants based on the data that we talked about last time to participate in ACO REACH would benefit from this program and we had conversations with them, really educated them on this program and the why and what the wraparound services would look like and then we continue to have conversations with them around what where we need to innovate within this model. The Medical Group as well because our Medical Group does participate in both Wisconsin and Illinois again in the areas of Milwaukee and then the South side of Chicago around what their needs are and really um what the practices, that entire care team, is needing umm in order to help patients manage their chronic diseases. And that's a conversation that we have with our practices and we continue to look at our data to say what are we seeing within the data to provide different services as we move forward. It will be a care model that continues to iterate um as we move along within this program to make sure that we're successful and patients are getting the needed care that they need.Did you find it difficult to get providers on board with downside risk or, I know you mentioned in the last podcast that you guys have been doing capitation for a long time, but I didn't know was there any pushback that you felt or any kind of hurdles you had to jump over in those conversations with some of the providers maybe some of the independent ones?So our aligned practices that are participating we did have um intentional conversations around capitation for this population. This is a population we were very intentional with what population we were participating in and this is a tough population that often is not going in to see the primary care provider. And so you know I think COVID also um brought a unique opportunity for our physician practices to think differently about capitation and what are benefits of capitation and so really looking at this population and providing an upfront payment to those practices, we are in total care um capitation for ACO REACH, um really provided them an opportunity to think differently. And I think our strong history with value-based care contracts and success that they've been able to see they were able to view it as a true partnership. And it wasn't a one and done we meet with these practices on a monthly basis and we are continuing to look at the finances and make sure that our model makes sense and that they're successful because if they're not successful within the model then the model isn't successful for us and so they really need to be able to provide the needed services and say something's working or not working um for the success of our entire project participation.So, you guys are really providing data to those providers on a monthly basis of performance I would guess and metrics, is that right?...

In this episode Melissa Pollock, CHESS Director of ACO Compliance and Regulatory affairs has a conversation with Megan Reyna, System Vice President of Population Health Midwest for Advocate Health about how they approach value-based care through wrap around services for the provider allowing better care for the patient.Well Megan thank you so much for joining us on the move to value podcast and we're really excited to talk with you today about the great work that you're doing at the population health at Advocate Health so, can you tell us a little bit about your role at Advocate Health and what you guys do?Yes, thanks for having me Melissa. So I'm assistant vice president with population health in the Midwest region with Advocate Health. We have recently merged, I should say combined, back in December of 2022, and you know population health and moving to value is a strong tenant of Advocate Health and we've been doing this work for some time and excited to share our journey with you.Great! So I know that you kind of mentioned there's been a few changes in the past year or so with Advocate Health, so can you explain a little bit about what's happening at the population health level?Yes. So we are coming together across both the Midwest and the southeast region. I will talk - so Advocate, which is the legacy Advocate Aurora in the Midwest and then Atrium in the southeast - what I'll speak to today is specifically the Midwest, that's really where my history is from and the work that we've been doing there.So can you tell me a little bit about Advocate Aurora the areas that they came from? I know it's two separate states and I always I tend to get them confused so I'm just curious Sorry about that so that's a problem it's Illinois and Wisconsin. We have about 6500 physicians that are participating in value-based care. Wisconsin is mainly an employed Medical Group with some independent tins that that participate in value and then Illinois is a strong pluralistic model with both a Medical Group and independent, what we call aligned physicians, that participate in a large clinically integrated network. We have about 1.3 million lives participating in value-based care contracts across both Illinois and Wisconsin, and we've been doing this as I said for some time. The clinically integrated network in Illinois has roots back to 1995 and became a clinically integrated network, one of the first in the country in the early 2000s. So currently have over 40 different value based care contracts that we participate in. We do have, we've moved a lot towards risk, so we have $1.2 billion in capitation risk that we currently take and that's actually where we we started a lot of our journey taking that risk, so you know and then have moved on to other programs as well within shared savings etcetera. So I'm curious you talked about capitation. What does that journey look like for providers? For your independent providers versus your employed providers? Has that been difficult? Just curious about that that journey for Advocate?So we started in capitation in 1995, so we've been at this for for quite some time, probably a different story than others across the country who have started with the shared savings platform and then moved to capitation or are looking to move to capitation. We really started with full risk and then also as the as the country started to take on more value based care contracts um started to get into those as well. So we have always looked at a support model that has wrap around services to our physicians participating in value based care contracts and how we really help support them be successful, and it's a true partnership between operations at the local level and...

The second half of our conversation with Yates Lennon, MD, President of CHESS Health Solutions who discusses the seven pillars of value-based care and the benefit of moving from fee for service to fee for value.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...

We revisit an earlier episode with Yates Lennon, MD, President of CHESS Health Solutions who who provides a concise overview of value-based care and questions providers should be askingYates Lennon, MD, MMM, currently serves as the President and Chief Transformation Officer for CHESS Health Solutions. He is nationally known for his work in quality, previously serving on the American Medical Group Association (AMGA) Quality Leadership Council and presently on the National Association of Accountable Care Organization's Quality Committee. Dr. Lennon's background includes 23 years as a practicing OB/GYN and a Fellow of The American College of Obstetricians and Gynecologists. He served as Chief Quality Officer for Cornerstone Health Care before joining CHESS in 2018 as Chief Transformation Officer. Dr. Lennon assumed the role of President in 2021. He has a deep understanding of practice transformation and how to engage physicians and their staff. His value-based care expertise allows him to translate his knowledge into initiatives that health care teams understand and can implement to ultimately transform patient care.Episode Transcript: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...

In this episode of the Move to Value Podcast we catch up with Colleen Hole, Vice President of Clinical Integration in Population Health at Atrium Health to learn about the new partnership with the retailer Best Buy, the impact of the merger of Atrium Health and Advocate Aurora Health on the Hospital at Home program and Colleen's experience as a presenter at the global Hospital at Home Congress held in Barcelona Spain.You know, the last time we talked, we talked about the Hospital at Home program, and you gave some great information. A back story. And so, how's it going? Is it still a benefit to the community? Is it still being used in the ways that it's supposed to be? I mean, how is it? How are things transpiring?I would say we're continuing to gain momentum in the program. So, as we talked about several weeks ago, it was born out of the COVID crisis if you will. For that, I am grateful for the pandemic because in most large somewhat risk averse organizations these things don't happen very easily. You tend to meet and meet and meet and then finally maybe put together a proforma and do a small pilot. We bypassed all of that. We did a big pilot, um, out of necessity. So, what we're doing now really is pivoting from COVID, which is now less than 10% of our patients, to other diagnoses which I think I mentioned last time: heart failure, COPD, various infections, but then going into oncology, neurology, surgical trauma. Other patient categories that even some established programs I think are not pursuing. Bottom line is we've not been diagnosis specific in this program. We've been more general clinical eligibility first, by clinical condition, and then what diagnosis fit in it. And then obviously once we've got a clinical clearance, you got to look at the social determinant of health and all social determinants of health and all those other factors that play into whether the patient would be successful. But no, it's going great. We have every intention to scale as far as we need to scale to continue to decompress our hospitals. And, your point, it is making a difference in the community. We get a lot of letters and feedback from patients that say please don't ever make me go back to the hospital, I was so much more comfortable here, I feel safe here, I got to be with my dog. You know, that sounds small but it's not small. So again, as we find our population aging with more and more chronic conditions in their senior years, hospitals can be pretty risky places for those patients who are often disoriented, tend to fall at a higher rate, they're at risk for infections, they don't typically eat as well, sleep as well, and they don't move. They tend to stay in their bed with the door shut. Who wants to go down the hall in a hospital gown? So, all of these reasons in most cases make the home a better place for healing.So, we got some big news that hit the media about the partnership with Best Buy and Advocate Health Atrium. How did this come about and how does it work? It's fascinating.Two very large health systems coming together to be one. And looking for the synergies that happen when you do that. Now there are naysayers out there that say stop the madness, health systems shouldn't be merging. They are in Milwaukee, Chicago Illinois market. We're down here in the South, in North Carolina, South Carolina, Georgia, and a tad bit of Alabama. So, we're not in, you know, competing overlapping markets. They're almost identical in size.So let me back up a tad. Advocate and Aurora merged four years ago to become Advocate Aurora. Now that has merged with Atrium Health. So, the national name is Advocate Health, but each market will retain their brand that is known in that community. So, we're still Atrium Health. What I've been involved in is just integration work around nursing. So, how do we align nursing around standards both...

A conversation with Dr. Elizabeth Vaughan, associate professor and physician scientist at the University of Texas Medical Branch, as well as a Texas Community Health Worker instructor, about her research in health disparities and the role of the Community Health Worker in improving diabetes outcomes in low-income populations.Doctor Elizabeth Vaughan welcome to the move to value podcast Thanks so much for having me, it's a pleasure to be here. So, tell me Dr. Vaughan, how did you become interested in researching the impact of community health workers?Like many things in life, I fell into the interest. I had done the international work since I was in high school and I always had an interest of low-income healthcare, low-income populations. As a 16 year old I went to Ecuador and you know I was a what you call an army brat, my father was in the army, and really a pretty isolated world. And I saw poverty like I had never seen. I realized that Spanish was not just punishment that I had to take in high school that other people were really speaking Spanish and I really fell in love with the people in Ecuador. And then I continued traveling and you know fast forward that 20-30 years now and I've gone most of Central America, South America, and the Caribbean over and then over to Africa and India. And through those travels the people that I worked with were precious and yet I always sensed a distance between the people I worked with and me. And particularly after I finished medical school and I was now doctor Elizabeth or doctor Vaughan, most countries it was doctor Elizabeth, there was a greater separation. So there was a socioeconomic separation there was a cultural separation there was an education separation. And yet I saw the locals and the way they interacted with local individuals, and I thought there's something different here, they seem to be able to reach these individuals. Then when I was in India in 2011 I worked with a group of promotoras, or more referred to as community health workers, in India and I anticipated that I would be the physician going into the villages and the towns and I quickly realized that they wouldn't let me because it was the HIV trip. And so I stayed back in the in the clinic and I taught this group of promotoras. And I at first was disappointed thinking man I don't get to have the fun only to be on the front lines and yet I quickly saw that teaching blood pressure, teaching hydration, teaching triage, led into a world where they could triage patients appropriately and they could reach far more patients than I could ever reach as an individual person. And so then I realized this is something and so fast forward another ten years and I became a community health worker instructor myself, started working and founded some groups here in Houston, TX of promotoras and have just seen amazing work of what they do and how they are able to connect with the patient and bring things about from a patient that I never could bring out and offer insight that I would never have.Tell me why, in your opinion, do you feel like folks respond to other individuals in their community more than they would someone who's a physician. Someone who comes in with the technology and the knowledge from first world country. Why do you feel like there is a barrier there to the to the general population who needs those services?It's a great question. So, there's, different cultures have different barriers. I think in the Latino culture pleasing in and kind of letting the doctor know that that you're trying to do what they said, I think is important. I think there's a there's amount of respect, they say you're the doctor you're and help me and so if they don't, I think there is some sometimes there's a feeling of shame in there. And so, my experience with the Latino culture is, many times the reason they don't - I've had one patient...