Clinical Episode Payment Models
CLINICAL EPISODE PAYMENT MODELS
Accelerating and Aligning Population-Based Payment Models
Dr. William Shrank is Humana’s Chief Medical Officer. His responsibilities include implementing Humana’s integrated care delivery strategy, with an emphasis on advancing the company’s clinical capabilities and core objective of improving the health outcomes of our members. He leads Humana’s Care Delivery Organization, clinical operations, and the Bold Goal population health strategy. Dr. Shrank most recently held the position of Chief Medical and Corporate Affairs Officer (July 2019-July 2021) during which time he reorganized and advanced our government affairs division. He is a member of the Management Team, which sets the firm’s strategic direction, and reports and to President and Chief Executive Officer, Bruce Broussard. Additionally, Dr. Shrank serves on the Board of National Committee for Quality Assurance and is co-chair of the Clinical Transformation Taskforce for the Health Care Payment Learning and Action Network. Dr. Shrank joined Humana in April 2019, having previously been employed by the University of Pittsburgh Medical Center (UPMC) where he served as Chief Medical Officer, Insurance Services Division from 2016 to 2019. At UPMC, Dr. Shrank was responsible for clinical operations, policy and quality for approximately 3.5 million members in Medicare, Medicaid, behavioral health, Managed Long Term Services & Supports and commercial lines of business. He also developed and evaluated population health programs to further advance the medical center’s mission as an integrated delivery and financing system. Previously, Dr. Shrank served as Senior Vice President, Chief Scientific Officer, and Chief Medical Officer of Provider Innovation at CVS Health from 2013 to 2016. Prior to joining CVS Health, Dr. Shrank served as Director, Research and Rapid-Cycle Evaluation Group, for the Center for Medicare and Medicaid Innovation, part of the Centers for Medicaid and Medicare Services from 2011 to 2013, where he led the evaluation of all payment and health system delivery reform programs and developed the rapid-cycle strategy to promote continuous quality improvement. Dr. Shrank began his career as a practicing physician with Brigham and Women’s Hospital in Boston and as an Assistant Professor at Harvard Medical School. His research at Harvard focused on improving the quality of prescribing and the use of chronic medications. He has published more than 250 papers on these topics. Dr. Shrank received his medical degree from Cornell University Medical College, and completed his residency in internal medicine at Georgetown University and his fellowship in Health Policy Research at the University of California, Los Angeles. He also earned a Master of Science degree in Health Services from the University of California, Los Angeles and a Bachelor of Arts degree from Brown University.
Karen Dale is the Market President for AmeriHealth Caritas’ Medicaid managed care organization in Washington, D.C. In addition to her role as Market President, Dale was appointed to AmeriHealth Caritas’ newly created position of Chief Diversity, Equity, and Inclusion Officer. Having held multiple positions of leadership during the past two decades, Dale has worked with a broad group of stakeholders to address policies and other key factors impacting the delivery of health care services. In addressing the range of needs experienced by the nation’s vulnerable populations, Dale has cultivated a focus that has helped AmeriHealth Caritas concurrently innovate, while meeting the highest levels of quality and service. These efforts include the use of digital tools to aid in the management of chronic diseases, peer-to-peer outreach using community health workers and peer specialists, and the use of a human-centered design member engagement approach. Dale’s vision is notably reflected in key programs addressing Black maternal health, racism, housing, transportation, violence interruption, and food insecurity. In addition, her philosophy that healthcare must evolve into a health ecosystem that promotes, wellness, without barriers, starting where people are, has led to several collaborative relationships with providers, community partners, philanthropists, and businesses to implement sustainable, scalable solutions with high impact.
Ms. Dale was a member of the Leadership Greater Washington Class of 2003. She serves as a board member for both Volunteers of America National Services and the Volunteers of America National Board, as well as the Access to Justice Commission.
Ms. Dale holds a Master of Science degree in psychiatric mental health nursing from The Catholic University, Washington, D.C., and a Bachelor of Science degree in nursing from George Mason University, Fairfax, Virginia.
Andrea Gelzer, MD, MS, FACP has had the roles of senior vice president medical affairs and corporate chief medical officer at AmeriHealth Caritas for more than a decade. At AmeriHealth Caritas, she has been responsible for the development of the company’s integrated care management model, deployed new approaches to alternative/value-based provider payment, developed many innovative population health management strategies for vulnerable populations and built corporate infrastructure to sustain significant growth. She serves as the key clinical spokesperson and policy advocate for the company.
Dr. Gelzer currently serves on several influential industry committees Health and Human Service (HHS) Health Care Payment Learning and Action Network (LAN) Care Transformation Forum (CTF), the Core Quality Measures Collaborative (CQMC) Steering Committee, and the executive committee for the Gravity Project. She is a member of the Board of Directors for the American Telemedicine Association (ATA) and is the immediate past Chairman of the Board of Directors of HealthShare Exchange (HSX), Philadelphia’s regional health information exchange. Dr. Gelzer earned her undergraduate degree from Tufts University, her doctor of medicine from St. George’s University, and a master’s degree in preventive medicine/administrative medicine at the University of Wisconsin, Madison. She is certified by the American Board of Internal Medicine and by the American Board of Preventive Medicine in clinical informatics.
Karen Dale is the Market President for AmeriHealth Caritas’ Medicaid managed care organization in Washington, D.C. In addition to her role as Market President, Dale was appointed to AmeriHealth Caritas’ newly created position of Chief Diversity, Equity, and Inclusion Officer. Having held multiple positions of leadership during the past two decades, Dale has worked with a broad group of stakeholders to address policies and other key factors impacting the delivery of health care services. In addressing the range of needs experienced by the nation’s vulnerable populations, Dale has cultivated a focus that has helped AmeriHealth Caritas concurrently innovate, while meeting the highest levels of quality and service. These efforts include the use of digital tools to aid in the management of chronic diseases, peer-to-peer outreach using community health workers and peer specialists, and the use of a human-centered design member engagement approach. Dale’s vision is notably reflected in key programs addressing Black maternal health, racism, housing, transportation, violence interruption, and food insecurity. In addition, her philosophy that healthcare must evolve into a health ecosystem that promotes, wellness, without barriers, starting where people are, has led to several collaborative relationships with providers, community partners, philanthropists, and businesses to implement sustainable, scalable solutions with high impact.
Ms. Dale was a member of the Leadership Greater Washington Class of 2003. She serves as a board member for both Volunteers of America National Services and the Volunteers of America National Board, as well as the Access to Justice Commission.
Ms. Dale holds a Master of Science degree in psychiatric mental health nursing from The Catholic University, Washington, D.C., and a Bachelor of Science degree in nursing from George Mason University, Fairfax, Virginia.
Frederick Isasi, J.D., M.P.H., is executive director of Families USA (FUSA), one of the nation’s leading nonpartisan, nonprofit health care advocacy organizations established to ensure that all people receive high-quality, affordable, consumer-centered care.
A national thought-leader and subject matter expert on the social issues and solutions related to driving value and equity into health care and providing high-quality coverage, Isasi draws on decades of experience in the health care industry, public policy, and law. In doing so, he advances a pragmatic and intersectional policy agenda for achieving better health at lower costs and reducing systemic inequities in the American health system.
Under Isasi’s leadership, FUSA advocates for issues such as fair drug pricing, racial equity, maternal and child health, and ending surprise medical bills. He also works to strengthen and protect policies such as the Affordable Care Act (ACA), Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and Oral Health for All.
Isasi founded FUSA’s National Center for Coverage Innovation to help state and federal policymakers and consumer leaders develop and implement pragmatic, nonpartisan approaches to expand and improve health care coverage. He also founded and directs FUSA’s Center on Health Equity Action for System Transformation, the only national entity exclusively dedicated to developing and advancing patient-centered health system transformation policies designed to reduce racial, ethnic, and geographic inequities.
Isasi’s work and experience flow from his life-long commitment to achieving high-quality, affordable health care for all. That passion stems from growing up in North Carolina as the son of Cuban immigrants. He saw first-hand the health care barriers families in poverty, people of color, people with language barriers, and rural communities generally experienced.
Isasi’s passion for change drove his extensive academic accomplishments. He was a Powers-Knapp Scholar at the University of Wisconsin, where he earned a B.S. in Cellular Biology. He earned a Master of Public Health from the University of North Carolina and was inducted into both the Delta Omega and the Frank Porter Graham honor societies. He obtained a J.D. from the Duke University School of Law, where he was a Pamela B. Gann Scholar and a staff editor of the Duke Journal of Gender Law and Policy.
After receiving his Masters in Public Health, Isasi worked as a senior policy advisor at the District of Columbia Primary Care Association, working on issues such as the Master Tobacco Settlements and Medicaid reimbursement. After law school, Frederick joined the international law firm Powell Goldstein (now called Bryan Cave LLP) as a health care attorney with a practice that focused on representing public hospitals and health systems, immigrant health care issues and state Medicaid programs.
Isasi then joined New Mexico Democratic Sen. Jeff Bingaman’s staff, serving as senior legislative counsel for health care to the Senate Finance Committee and the Committee on Health, Education, Labor, and Pensions. Isasi was Senator Binagaman’s principal negotiator throughout closed-door, bipartisan negotiations. He was also the Senator’s advisor and chief negotiator for the CHIP Reauthorization Act of 2009. And he directed Bingaman’s efforts to address Medicare and health care challenges systematically caused by low-income, cultural and racial disparities.
Upon leaving his Senate position, Isasi became vice president for health policy at the Advisory Board Company, a leading international organization that advises 3,100 hospitals, health systems, provider groups, and payers. He founded its health Policy Department. Under Isasi’s leadership, the company leveraged the power of health system data and developed evidence-based policy solutions for modern health care challenges. He also bolstered the company’s work with policymakers in Congress, the Obama Administration, and the states to improve health care transformation efforts across the nation.
After leaving the Advisory Board, Isasi led the health division at the bipartisan National Governors Association’s (NGA) Center for Best Practices. He worked directly with governors of both parties and served as the organization’s national voice on health care delivery and payment reform, improving Medicaid and health exchange planning and oversight. He also directed technical assistance for states as they navigated changes to their health care systems due to national policy shifts.
Isasi frequently testifies on health policy issues in both the Senate and House of Representatives. His public, private, and advocacy work gives Isasi deep expertise in Medicaid, Medicare, private health insurance, health equity, payment, and delivery reform, and the social determinants of health as they intersect with health care quality and payment and equity issues. A skilled communicator able to explain complex issues clearly, he is a sought-after national speaker on health care affordability issues, Medicaid, state health care innovation, health system transformation, and behavioral health.
Isasi has served on a myriad of panels and boards at institutions such as the National Academy of Medicine, the Brookings Institution, the National Committee for Quality Assurance, Duke University’s Margolis Center for Health Policy, Catalyst for Payment Reform, the Health Care Payment Learning & Action Network and Bipartisan Policy Center. He is regularly featured in national outlets, including The New York Times, NBC, Bloomberg, The Wall Street Journal, and The Washington Post.
A Cuban-American, Isasi is a proud member of the LGBTQ+ community and resides in Washington, D.C.
Marshall Chin, the Richard Parrillo Family Professor of Healthcare Ethics at the University of Chicago and a practicing general internist and health services researcher, has dedicated his career to reducing health disparities through interventions at individual, organizational, community, and policy levels. He has elucidated practical approaches to improving care of diverse individual patients and addressing systemic, structural drivers of disparities in the health care system. Through the Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment and Systems Transformation program, Dr. Chin collaborates with teams of state Medicaid agencies, Medicaid managed care organizations, and frontline healthcare delivery organizations to implement payment reforms to support and incentivize care transformations that advance health equity. He also partners with eight urban and rural communities to integrate medical and social care to reduce diabetes disparities through the Merck Foundation Bridging the Gap program.
Dr. Chin is a former President of the Society of General Internal Medicine (SGIM) and has won mentoring awards from SGIM and the University of Chicago. He was elected to the National Academy of Medicine in 2017.
Dr. Chin is a graduate of Harvard College and the University of California at San Francisco School of Medicine, and he completed residency and fellowship training in general internal medicine at Brigham and Women’s Hospital, Harvard Medical School.
Focusing on appropriateness, care variation, and person-centered care for all patients through dissemination of best practices.
Reducing disparities and improving health equity through reallocation of resources to address SDOH (e.g., housing, food insecurity, transportation).
Improving predictability for providers through improved risk adjustment for complex patients, offering stronger incentive structures for Medicaid beneficiaries, and flexibility on waivers.
Providers who are successful in FFS may lack a compelling reason to transition to APMs, but may be unable to compete with the person-centered care delivered by providers in APMs. Introducing APMs through multi-payer pilots in these markets (particularly for independent and smaller providers) may increase competition and reduce FFS entrenchment.
Ensuring providers adopt timely data and analytics capabilities, combining multiple data sources (e.g., electronic health record and claims data), to enable successful participation in value-based payment models.
Providing patients and caregivers with cost, quality, and appropriateness of care data in an actionable, easily understood, and accessible manner. Ensuring that electronic data can be easily shared meeting advanced technology standards (e.g., HL7 FHIR) to improve care delivery.
