Dr. Andrea Gelzer:
AmeriHealth Caritas really is continuing to make positive strides to help transition providers from a fee-for-service model to one of our value-based alternative payment models. Across our markets, almost 90% of our members are receiving care from a provider that participates in one of our alternative payment, or as we pin them, “perform plus” programs. In 2020, we continued to see more providers actually advance to more advanced alternative payment models, in a category three or four payment model. And that’s a metric that has increased significantly year over year since 2017. We still continue to see the largest growth in the 3A models or the shared savings models. In 2020, nearly 15% of our value-based arrangements were in categories 3B and 4. So those are the advanced payment models where providers begin to take downside risk. And that’s a good improvement I would say. We anticipate that this is going to increase for our 2021 LAN APM measurement survey results next year as well. We’re seeing some health systems interested in category 4 APMs and also some interest from specialized provider types including substance use disorder providers and behavioral health providers who are ready, to accept downside risk. I think that’s exciting. Unfortunately, that’s not the case for all, and provider interest in downside risk for a Medicaid population continues to be a significant hurdle we have yet to overcome. Today we’re leveraging our perform plus programs to improve social determinants of health, health, equity, and access to healthcare in the communities we serve. We’ve incorporated incentives for reporting of Z codes for social determinants of health into our value-based programs, and really continue to see an increase in provider reporting.

Karen Dale:
One of them, for certain, is even though providers may be engaged and interested, how do they build that into their workflows and their offices and their practices? FQHCs (federally qualified health centers), they get kind of the funding they need already in many ways to have team-based care. And you may see that as well with some of the mid-size providers. When we get to the much smaller providers that becomes more challenging. How do we create the best synergy between what a payer offers and can do to support practices and giving them more ability and funding through the alternative payment methods to do things differently and adjust their workflows? One of the places that payers can be extremely useful is the data and information that we can provide. We have to serve it up in a way that’s easily consumable and leads to the providers taking action at the point of care doing a visit. Today, it’s a little uneven. We’re still working through how to do that well; however, that does present a pain point: how to make this work in a way that works for the provider, works for their patient, our members that are presenting for care. Data is another piece. Andrea mentioned “Z” codes. Though we add an incentive in our methods for paying providers or reimbursing them for that, sometimes they say it’s too much. It’s one more thing to do. How do we make it as easy as possible for that to occur? Finally, providers really … some of them don’t have the bandwidth to look at the data, to use it, they say that makes things longer, they’d rather spend more time with the patient. So, we’ve got to figure out in the technology space, how do we make it easier? How do we make the data transfer more democratized so that we get what we need, they get what they need, in a way that moves us forward with what our patients need? And today we’re still all working through that. I’m a fan of HIEs (health information exchanges) that are well-funded in states that allow for that place and space where rather than people having to go into several different systems to get information about what is going on with their patient, our members, that there’s more of a place where anyone and everyone that is part of the healthcare delivery system can go. And then if I think about payers, that’s another component where the more we are aligned across payer type, so that the things that we are asking for or using, from a provider facing standpoint, it reduces that provider administrative burden and allows for them to probably be more interested in participating and making changes.

Dr. Andrea Gelzer:
I would just add to that Karen, that, we’ve been talking about care transformation and the LAN for quite some time and giving providers the right tools, giving them the right data, putting them in a position to truly succeed. Not only from a financial point of view, but also succeed in improving health outcomes through moving to these more advanced models. And I would say one thing that the pandemic has shown us is that providers are truly resilient, and they have embraced telehealth, they’ve embraced virtual care. So, I hope that they are embracing, and I know that they are embracing different ways to incorporate all of these important elements to assure and improve healthcare from an equity basis going forward.

Dr. Andrea Gelzer:
We work a lot with federally qualified health centers, and I think that National Association of Community Health Centers and in the primary care associations in the different markets we serve have been really helpful in supporting their membership. We also have implemented programs where we actually embed health plan staff in a practice like one day a week, or however much they need us, to try to work with the staff ourselves. So, it’s really a combination of external sources and also the AmeriHealth Caritas resources to help bring providers along.

Karen Dale:
Where we’ve seen providers really make great strides is when we’ve had embedded staff because they’re right there helping to problem solve, to engage with members, to follow up, make the necessary connections and reinforcements. And so again, it frees up some of their provider resources. So that’s been really successful. The other component is, it’s all about making it easy, right? If a provider simply needs to let us know what they found in a visit — that someone is housing insecure, food insecure, whatever the challenges are. When we can easily pick up on that thread and address a need, providers find that incredibly useful because they’re not necessarily staffed other than some of the FQHCs to make those things immediately happen. So, it’s that partnership and collaboration of us picking up and doing what we do well, which is connect the dots and perform expert care coordination. That really helps to move us towards equity. It helps providers to lean in knowing that they have that stable support and engagement as well.

Dr. Andrea Gelzer:
I would say there are health equity initiatives now coming from every state Medicaid agency. But they’re coming as expectations for the plans. So they’re coming not as a request, but it’s like everyone is trying to address health equity, trying to address social determinants, trying to address disparities. And there is certainly a renewed interest. No one has the silver bullet. I think that we’re all working together and, as I started my answer, it’s really expectations that we’re seeing. And I think that every state is looking for solutions to this. So that’s why it’s so important that multi-stakeholders sit in the same room and try to work on these issues to impact outcomes.

Karen Dale:
I agree with Andrea on the kinds of expectations we’re seeing, such as, there has to be a dedicated key position that’s responsible for health equity at a plan level. There’s someone accountable that the state can know must have a plan. We’re seeing requests to have a specific plan with measurable information. There’s some common issues that emerge, such as maternal health outcomes for women of color, that there’s an expectation that the health plans can focus their efforts, align with community-based organizations and policies that help to advance that, such as, whether doulas are being reimbursed. Do you have meal delivery programs, peer supports for moms? How are you building this flexible system that meet women where they are and reduce their risk? In the District, for the first time this fiscal year, our budget was reviewed with a health equity lens. So it said, whom would we leave behind if we didn’t do X? And how do we create not just policies, but how do we create the right momentum by aligning things to ensure that we’re addressing those with the most need? And so it covered everything from what else we need to do around maternal health outcomes to what are we going to do to support the emotional wellbeing for those children who were already experiencing multiple emotional and educational challenges during the pandemic? So that as they go forward, we have a process in place for more in-school support to help close the gap on what may have been eroded during the pandemic. And so, I applaud those efforts, their early days, as we’re all learning how to work together in different ways towards the same common goals and purpose. I’m excited by the fact that we are talking about it. Organizations are leaning in to say, here’s what I can do, here’s what I think, saying that we can do this together. It takes lots of components, certainly, but the pandemic also taught us how quickly we can mobilize to change policies and get things done and hopefully that’s a carry forward.

Dr. Andrea Gelzer:
And I’m excited too that the states seem to be taking a much more realistic approach to this. They’re not telling us we must address social equity in any one way. I think there’s a lot of hope here that this approach, allowing us to innovate, explore, and truly be impactful and may make a difference. We’ve been at this for a long time.

Dr. Andrea Gelzer:
I think we’ve talked about the barriers before, that providers aren’t ready, or as Karen noted, you’re adding on something for them to do that they don’t particularly have time to do because of their workflow issues. I think it’s still too early in the game. I think really, we all need to get better at designing alternative payment models to really deliver the results and to work and respect the providers as well as our members to see that those programs are successful.

Karen Dale:
There’s like a push-pull between what we need or believe we need in terms of administrative things, so how do we reduce any of that to make it more likely that providers can see themselves engaging fully around alternative payment models, especially those that focus on equity? For example, if the concept of “gold carding” was used more often where prior auths (prior authorizations) have been approved 98, 99 percent of the time. Do we continue to ask that provider to do prior auths for whatever the specific area is? Or do we say, based on your history, you’re gold carded, and we’ll do retrospective audits? And that may help the provider to see themselves one, as a partner with the payer, and two, saying, “oh, so the time that was spent on that, I can now free up a resource or get a resource in my office that would focus more on these other things” that are advancing equity.

Karen Dale:
Yes. If to the extent that the data sets were the minimum data sets that are required were clearly articulated. It just makes it easier because then the states would probably align more because of that clarity. And then that would be the expectation set with the payers. Right now, with everyone reinventing the wheel and coming up with so many variations, it’s impeding the rate at which we can get more adoption and then progress. I think starting with the data sets would be a great way to get greater alignment. What are we looking at for social determinants of health? What are we looking at in health risk assessments? Just all of that. If it were minimum, these are the things that everyone must collect, it would help move us forward. And we’d have so much of a better ability to measure and analyze and say what’s working, what’s not and why, if those data sets were consistent.

Dr. Andrea Gelzer:
Oh, I think that’s absolutely right, Karen. And we’ve been a supporter of Gravity since its inception, looking at how we collect social determinant data. I think that’s a great example too of a multi-stakeholder collaborative, where everyone’s sitting at the table trying to reach consensus on how we collect these data.

Karen Dale:
The time is now. We have all the lessons we’ve learned from the pandemic in terms of how swiftly we can move when we have a sense of urgency. So, leveraging that knowledge, leveraging what we learned about the communities that were most harshly affected, we can certainly do better. Many things that we’re doing are at a starting point, even though we’ve been doing them for a long time. They’re not at full scale. And so, my hope for us all is that we keep leaning in and doing the hard work to create better outcomes. The people we serve deserve it, and we’re more than capable to put the energy, the time, the investment to make it happen.

Dr. Andrea Gelzer:
This is a long, but such an important journey. I think we’re making progress and I’m just going to give credit to the LAN. I think the LAN is a big reason for that progress because the LAN is helping us all to move along.