Podcast Episode Transcript: A COVID-19 silver lining? Overcoming roadblocks to innovation

With L. Gordon Moore, MD

Dr. Gordon Moore: Welcome to the 3M Inside Angle Podcast. This your host, Dr. Gordon Moore and with me today is Samantha Olds Frey. She’s the Chief Executive Officer of the Illinois Association of Medicaid Health Plans. Welcome, Samantha.

Samantha Olds Frey: Thank you so much for having me. I’m so excited to be here.

Dr. Moore: Thank you. Tell me what is your association?

Samantha: We are the Illinois Association of Medicaid Health Plans. We represent the full industry of health plans contracting with the State of Illinois for the Medicaid program in Illinois. It is really fun because we focus solely on the Medicaid program; how do we improve the lives of the over three million folks that are enrolled in Illinois Medicaid and how do we move the Medicaid program forward.

Dr. Moore: You have any insurer that’s working with covered lives with Medicaid is going to be part of your association?

Samantha: Yes.

Dr. Moore: Tell me pre-COVID, what was important to you guys, and where were your members going at that point?

Samantha: We started pre-COVID looking at the 2020 really focusing on implicit bias within healthcare and how do we have a conversation about improving maternal outcomes within the Illinois Medicaid program.

In Illinois, Medicaid covers about 50 percent of our births in the state. We felt like we were in a real unique position, the majority, or largest payer for births in the State of Illinois to really drive, improved outcomes, and improve the lives of families. That’s what we were focusing on pre-COVID.

Dr. Moore: What was the percent of birth’s you were covering in Illinois?

Samantha: Eighty percent.

Dr. Moore: That’s a pretty big market share of births, if you will. Tell me then, COVID hit. Has that changed your priorities and perspective?

Samantha: I don’t think it’s necessarily changed our priorities, but it definitely changed what we were dealing with at the moment. When COVID hit, we had to figure out how to reimburse for things in different ways almost immediately.

Pre-COVID, Illinois Medicaid had a pretty narrow telehealth package. We had to expand telehealth within weeks and we had to tell providers how to bill for that. We had to tell them what they could bill for, what they couldn’t bill for. We expanded coverage for certain CPT codes that historically weren’t covered. We had to stand that all up and educate providers in a matter of weeks. We also had to provide billing guidance for how do you bill for COVID testing? Where can you bill for COVID testing?

There was a lot right away. We, in Illinois, stood up field hospitals that we ended up, luckily, not needing in the first wave, but we had to figure out how are we going to track members who get transferred to a field hospital; how is billing and reimbursement going to work for them. There was a lot of immediate operational focus that we had to work on that delayed some of our conversations around quality and transformation because there were these urgent questions that needed to be answered.

Dr. Moore: We’re sadly some months into the pandemic and we’re going through another surge right now. Have you learned things that head you in different directions now?

Samantha: I think what we have seen more than ever is that our original focus, our original priority, which is racial disparities in healthcare, are key. It’s something that we need to talk about in Illinois and nationwide. We are really looking towards 2021 to start to have those conversations to start to track our quality metrics and breaking them down by racial and ethnic groups to see those disparities and to be more purposeful about that. That’s still going on.

We also really took time within the pandemic and, I think, we’ll see more of that again in the coming months, unfortunately, of investing in social determinants of health for our members, realizing that traditional healthcare components—what we think about can you get to the doctor; can you get your medications—critical, obviously.

But there were other things that are impacting our members that we need to address as well. Do they have access to healthy foods? Do they have a way to safely clean their clothing and do their laundry? Because oftentimes, we were in a shutdown and our members needed laundromat and it wasn’t really the right format for just basic necessities.

We had health plans step up and invest and pay for laundry services. We’ve had health plans donate food and work with local restaurants to donate food to members and have home-delivered services. Trying to find ways to meet the social determinants of health that our members are facing and are often exacerbated due to this pandemic is something we did throughout the spring and summer. Really, what I anticipate to see throughout the fall and winter as well.

Dr. Moore: A conversation that I’ve had pre-COVID, and I’m wondering if it’s still true. You’re describing some really radical departures in a way from the typical stuff that we’re paying for in healthcare delivery. I remember, when I was on the provider side doing some innovation stuff, having conversations with some health plans—none of them in Illinois, so this has nothing to do with your members.

What I was often hearing back was, “What’s the return on investment for doing that work?” So, when you think about your members doing this stuff—and budgets are not easy and they are going to get a lot worse—I’m going to come back to that part later.

But how do they deal with this ROI thing? Is ROI even on the table when they’re talking about doing these things?

Samantha: Illinois did something really interesting. Our state and our Department of Healthcare and Family Services worked with us and they said, “We understand that HEDIS measures for 2020 just aren’t going to be where we want them to be. You’re not going to be able to audit your providers.” Offices had closed. It’s just not normal; it is not a normal year.

“What we’re going to do as a state is, we’re going to return your entire quality withhold to you as plans and we’re going to do it this year. We’re not going to make you wait. In return, we want you to invest at least 50 percent of that—and some plans did more—in the community. We want you to help our providers weather this storm; we want you to help your members navigate this space. We want you to serve these communities in a way that they really need it.”

That gave the plans in Illinois flexibility. They turned to corporate and they said, “We have these dollars and this is our expectation. We’re expected to do this, so we have to do this. We have to report on it.” But it gave them a real opportunity to do things that they wouldn’t have to justify historically what is the ROI on a laundry service; what is the ROI on food boxes, but this year, they were able to just do it first and now, look back and say, “What was the benefit of that? What did we see?”

What a lot of plans are seeing is increasing engagement with their health plans. A recognition that they’re there to serve. We had plans donate Chromebooks to students to make sure they could go to—the ADA always does a diabetes camp for kids. I don’t know if you’re familiar with it, but it’s amazing. Our plans have historically sponsored kids to go to these camps. This year, obviously, they couldn’t go in person, but they wanted to sponsor to do the virtual camp.

What they found over and over again as they wanted to do that, is that the members didn’t have the technology to even participate virtually in these camps. So, the plans stepped up and got them Chromebooks so they could not only use it for the ADA camp, but they could use it for school.

In Illinois, a lot of our schools, especially in Chicago, opened virtually. What they’re seeing is more engagement in their healthcare through being able to attend the ADA camps. They’ve seen great improvement through that, but then, also being able to stay engaged in school; improvement in mental health and a recognition that the health plan is there and is a part of their team, which I think is just invaluable.

It’s not something we often measure or think about, but at the end of the day, you’re not going to get—especially for a higher and moderate risk families—you’re not going to get them engaged and really participatory and empowered with their healthcare if they don’t see you as a real partner and [US 09:08] investments allowed us to break through in a real different way than historically been able to do.

Dr. Moore: That example just thrills me because it touches on so many parts that are fascinating about this. The opportunity embedded within this crisis pandemic, which is that the state says, “These are extraordinary times. Here’s your quality withholds, but I’m going to hold you to a standard to do something really good.” Plans were then be inventive around that and they’re doing some really cool things.

The Chromebook example is specifically for the ADA camp, but it then has this rollover effect on school attendance. That is brilliant, which makes me think about this concept of stepping back and looking at broader budgets that are hitting taxpayer dollars and how we can think about that.

If I’m engaging with kids who might otherwise be bored or whatever, are they at less risk because they’re not engaged? Are we seeing less of other impacts? Maybe they’re less at risk in the street or going to and from school. There are so many benefits. Are you seeing any discussion or interest at the state level about thinking that broadly and thinking about the impact on multiple budgets and doing interventions like this?

Samantha: We have not yet had the conversation when you look at it from a state budget, but we are having conversations on the state more and more saying, “We want you to be creative. We want you to work with partners; we want you to work with providers to think beyond the clinical space. And we want to measure you on that.”

HEDIS is critical. Nobody’s going to say that it’s not, but how we look at other outcomes as well. How do we look at food security? How do we look at housing? What does that mean in the long run? I think we’re starting, hopefully, in a small space of looking at our various metrics and breaking it down by race and ethnicity and seeing where those gaps are.

Then also, starting to really tie that to social determinants of health and tying that in with in Illinois, we’re doing healthcare transformation projects where we’ve been having this conversation for years about how do we invest about $150 million at the state level to transform healthcare in neighborhoods and regions that have a high social vulnerability and deaths. How do we improve healthcare in those regions?

What we are talking at IAMHP and what our FQHC partners are talking about and our advocate partners is, you’re not going to improve health outcomes in those areas until you talk about social determinants of health. Access to a psychiatrist, access to the OBGYN, access to clinician—critical. But they don’t have access to healthy food or secure housing, you’re not going to manage their diabetes. They’re still at risk for a pre-term birth. They’re still at risk for increased stress and adverse mental health outcomes.

Until you approach them as a human being and where there are human needs, you’re not going to move the needle. That discussion is ongoing and something I’m really excited about in Illinois of tying all of the pieces together, aligning health plan quality metrics, aligning the transformation dollars. Then my hope is the next step of that is exactly where you alluded to, Dr. Moore. What are our priorities or what are we saying are our priorities in the state budget and how the Medicaid program reimburses? By that I mean, do we have incentives and/or disincentives for providers that are limiting how they’re practicing and how they’re caring for patients.

Dr. Moore: Do you have some ideas or examples?

Samantha: I do. In Illinois—and I’ll tell you that Illinois is a special state, but we have incredibly low reimbursements for prenatal visits, like under $50. Because every year when we’ve invested in birth outcomes or invested in OBGYN, it’s always been on labor and delivery codes. We’ve kept ignoring and kept ignoring prenatal visits.

We have a labor and delivery reimbursement and a payment there that does not at all align with what we really want, which is robust prenatal care. We’re shortchanging prenatal care and the OB that’s doing all that work quite a bit and almost creating a disincentive. We’re talking about do we do a bundled payment, much like you see in the commercial space or you see elsewhere for labor and delivery and prenatal care and maybe have some quality outcomes, of course, tied to that as well.

Right now, it looks as though the State of Illinois doesn’t care about prenatal visits to the level they do other services. Obviously, that’s not the case. It was an oversight, but it creates a disincentive.

Dr. Moore: Yeah. One of the things that’s interesting to me about that, obviously, here’s Illinois Medicaid, taking care of 50 percent of births in the state, unintentionally underfunding the prenatal care, which has positive benefit, hopefully, on a health delivery at term.

One of the traps in some of the episode payment is that right now, there’s financial incentives—unfortunate ones, where if things don’t go well, it actually brings down bigger payments. So, if I have to go to a C-section and there’s complications, there’s a lot more payment that comes with that stuff.

I’m not saying that that’s anybody’s intent, but there’s an unfortunate signal in that that makes me wonder about how you would think about measuring rates of C-sections and complications in delivery and looking at are there ways that we can actually provide financial and quality signals that say, “We don’t want complications. We really, really want health at term deliveries.”

Samantha: Yeah, we’re thinking the same thing. How do we have that discussion? How do we share at practices? How do we communicate with our providers? How do incentivize them? Obviously, complications happen and no provider wants complications. It is unfortunate, but an outcome that will happen from time to time.

How do we engage them and give them the tools that they need and the resources they need to provide interventions, maybe not clinical interventions potentially— and avoid some of those complications? How do we train some clinicians to engage on is a mom utilizing substances and does she need substance use disorder treatment? How do you get that mom in care in other ways? How do we work together as a team? How do we build that trust?

I think some of it is just starting with things we historically haven’t tracked in Illinois. Tracking it across the board by provider; by region; by race and ethnicity; by health plan. Finding, of course, the areas where there’s real opportunity, but also, where’s the best practices and what are the clinicians and the clinics FQHCs that are doing great work and what are they doing? Who they worked within the community; social determinants of health. What social determinants of health are they addressing? What community-based organizations are they engaging and what can we mimic elsewhere?

There is a lot of work to be done on this space and another thing that we’re just looking at is implicit bias training for clinicians, for nurses, doctors, and PAs across the state every few years part of their certification.

Dr. Moore: There are so many places I’m thinking about resource allocation. As you were describing that in labor and deliver perspective, it occurs to me that we actually have some models that are well known and interesting around how it is we pay for people with higher illness burden.

You can weight groups of people within a plan and say that these people, because of their predisposing factors and illness burden, they’re going to require more resources. That’s well known and that’s the way we set up payment weights for populations.

Then, it occurs to me that that is then, useful to look to provider groups that are taking on high illness populations and saying, “You need more resources for that work.” That’s a model. I wonder if we can now layer on top of that other disparities that are clear in the data.

Because now, we can also adjust for illness burden and we can see different outcomes and we can see that on the illness burden, there may be two groups that look identical from illness burden, but one is severely disadvantaged for other reasons. We can say, “We need to apply more resources and that may be around transportation, housing, food, support for engaging people because of their lack of understanding or complexity in how they address that access healthcare or other services.”

That model of adjusting payment and weighting it based on the burden of need may be really useful in that. Is that kind of pie in the sky? Do you think that it’s time that that conversation actually is likely to happen?

Samantha: I think it has to happen because if you’re thinking about transitioning to value-based care, from my perspective, and I’ll take off my health plan hat and think about it if I were on the other side, if I were a provider. If you’re not adjusting in an alternate payment model for perhaps FQs based off of illness burden and also if I love pulling in that adjustment for social determinants health, obviously, we’re all talking about Medicaid. Especially, like the regionality, there’s still variance of social determinants health, even within the Medicaid population that your clinics have to adjust for.

Then, you’re under-resourcing those who need it the most and you’re not going to get those outcomes that you really need. I think that sort of ties back into that one size fits all—treating everybody and treating every community the same. You don’t get the outcomes that you need because you continue to under invest in areas where there has been historic under-investment. You’re not going to get people the level of care that they need unless you acknowledge where they are today and where that community is today.

Dr. Moore: Where is your organization going now? What do you think needs to happen as your members are moving forward maybe in the next six months or so? Do you see any big mountains you have to climb?

Samantha: Yes. We are finalizing our 2021 quality metrics and trying to set some baselines. We’re using 2019, obviously; we’re not using 2020 given the pandemic with the data disruption we would see from that.

Once those are all finalized with the state, we’re going to start putting in our CMOs and our provider partners to have discussions around best practices; around barriers. We’re going to focus on three specific areas in the coming year: Vaccine, maternal health outcomes, and racial healthcare disparities specific to chronic diseases around diabetes, COPD.

Those three are our main focus and then, of course, there is an underlying current through all of this discussion of mental health and substance use disorder. I think you can’t come out of 2020 and not talk about mental health and substance use disorder. You really can’t talk about Medicaid and not talk about mental health and substance use disorder, as we are also the largest payer in the state for mental health and substance use disorder treatment.

Dr. Moore: That makes total sense. When I look at Medicaid data, it’s the most stark jump if I look at a group of people with the same illness, diabetes for instance of moderate severity, and then we layer on opioid dependence disorder and then, you layer on schizophrenia, you’re looking at a three X or nine X increase in medical resource utilization by an individual when you start adding those things in.

We look at cohorts of adolescence and you add in suicide events and an opioid use disorder and, again, you’re looking at a five X increase in medical resource utilization. It’s so important to be able to understand how to layer that on because then, you know, “This is the resource need,” and if you norm that over a large population, you can begin to see best practice, where people with that configuration are actually doing really well.

You can ask the question, “What are you guys doing in delivery that made that so effective?”

Samantha: Right, and I like what you said, they’re layering it all on versus silo. I think sometimes folks think about mental health and substance use disorder as a separate conversation and then, will talk about diabetes and then, we’ll talk about maternal health outcomes and then, we’ll talk about COPD where they’re co-occurring.

It’s one individual and you really can’t tackle their diabetes unless you deal with their mental health or their substance use disorder. You have to see it as a common thread throughout the program.

Dr. Moore: It’s a person; right? That’s it. It’s a person who has these things and we have to address the person because that’s, if you will, in this bizarre way, that’s the unit of treatment. I’m working with this person. If I only address an aspect, then we have a coordination issue and, unfortunately, all too often, a mis-coordination issue.

Samantha: Yeah.

Dr. Moore: Samantha Olds Frey, I want to thank you so much for your time today.

Samantha: Thank you, Dr. Moore. It was a wonderful conversation. Thank you for having me.

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