Podcast Episode Transcript: Bringing successful whole person care to high needs/high cost patients

With L. Gordon Moore, MD

Gordon: This is the 3M Inside Angle podcast. This is your host, Dr. Gordon Moore, and with me today is Dr. Theresa Brown, who is the CareMore and Aspire Central Region Chief Medical Officer and Dr. Vibin Roy is the Associate Regional Medical Officer for CareMore Health. And I thought it would be interesting to have a conversation with them today because I’ve heard a lot about the CareMore Model which works in Medicare populations and has some very, very interesting and impressive results in terms of how they work with Medicare beneficiaries to improve outcomes.

And I was at policy meeting and hearing some policy folks talk about the lack of any care delivery systems that were that advanced working with Medicaid. And then I heard somebody from CareMore Health describing that, and I reached out and said, “Oh my gosh. I would love to hear what you guys are doing with Medicaid.” So, thank you very much for coming to our podcast. Welcome Dr. Brown. Would you tell me a little bit more about your role? And then, I’m going to ask Dr. Roy to do the same.

Dr. Brown: Thank you so much for having us. We’re excited to talk about all the good work we’ve done and our future plans. A little bit about my role, Vibin and I both started in Texas with the Medicaid market in Fort Worth. And I recently took a different position as the CMO for the Central Region.

My role, currently, is being defined, but for the most part, what we are trying to do is take the really, just innovative, wonderful programs that have been done by CareMore and Aspire in about 13 states in the Central Region, and expand them. Get them fine-tuned clinically and get them up and running in new areas where we have need. And also, be able to expand new products that, maybe, we have used on the east or west side of the country and offer some of those products into the Central Region. So it’s really and opportunity to expand the good work we’ve already done in the Medicaid regions and the palliative care arena and then, also, with our REACH program through Aspire which is our top client preset program.

Gordon: Excellent. Thank you for that. And Dr. Roy, give me a little bit about your role within CareMore.

Dr. Vibin Roy: Great. And thanks, again, Gordon for having us. It’s such a pleasure to chat with you today. So, as you mentioned, I’m an Associate Regional Medical Officer at CareMore Health. And, so I had the pleasure of helping launch the Texas market almost two years ago now. And in my role, I helped design and implement the clinical strategy and operations for our market to provide compassionate and high-quality care for a really vulnerable and at-risk population here in Fort Worth, Texas.

Gordon: You know, as I mentioned up front, I’m aware of the work of CareMore Medicare environments. This is different. What was it that caused CareMore to think about moving to work with Medicaid recipients?

Dr. Brown: Yeah. So our organization has a very rich history of taking care of complex, high need and vulnerable patients dating back, roughly, 25 years with Medicare Advantage plans. And I think that it just made sense that, in particularly, the Medicaid population with their needs and then, their complexities, that we could make—we could help. We could make an impact in that population using some of the tools we developed over those 25 years. Just to give you a little bit of background for those who may not be familiar with CareMore and Aspire. We have an integrated care delivery system, and it’s really designed to take care of high risk, underserved populations.

CareMore was founded in 1993 by a group of physicians. They all shared a similar belief which was: There’s a better way to do care of seniors, especially seniors with complex health needs and those with chronic conditions. So that’s our foundation for CareMore. Aspire was founded in 2013, and they had a similar purpose. They sought to reinvent home-based palliative care for patients and families, particularly those who life-threatening illnesses. So it made sense for these two companies to come together and be able to offer our services.

So last year, we began to integrate CareMore and Aspire to expand our model and also give a lighter continuum of care between complex cases or complex chronic diseases all the way to the palliative care spectrum which many times overlaps. We’ve been really well-established in the Medicare model. 2015, the company recognized that we could take some of the lessons we had learned working those— with the patient population and apply it to the Medicaid population. So we launched a new Medicaid model. It was initially in Memphis, Tennessee and Des Moines, Iowa.

And we, recently had—well, not recently, but in 2018 we’re able to collate data and show the type of impact that we really have on the lives of our patients in these two markets. So for nearly 10,000 Medicaid patients in Des Moines and Memphis, in just one year, we reduced cost by 15 to 20 percent. We reduced hospitalizations by 11 to 21 percent and our ER visits by 18 to 24 percent. So CareMore’s Medicaid population in Tennessee actually incurred an annual total cost of care that was almost 5 million dollars lower than the comparable population in the same geography. And in Iowa the cost savings somewhere in the ballpark of around 12 million. So given our experience in those first two markets, it made sense to expand. And that’s how Fort Worth, Texas got added to that list and also Washington DC.

Gordon: Those are really impressive stats. Give me an example of the kind of intervention that is CareMore and Aspire, maybe not unique, but in you doing well, you think that leads to those numbers.

Dr. Roy: So, I think we could take a step back and talk a little bit about some of the changes that really needed to understand about this patient population in order to be able to design the current interventions that we found really inventive. And, so, we had this first experience with Medicare. We can take a lot of lessons from that experience of how to take care of vulnerable patient populations, but in Medicaid it’s just a higher prevalence of certain issues such as behavior health issues, substance abuse issues, SDOH issues such as housing or food and security.

And, so, in order to service the Medicaid population well, we needed to provide care that was not only convenient but also truly comprehensive. And provided by clinicians who empathize deeply with their needs, they had the resources to be able to address each fundamental barriers to health. So, while we’ve always reinforced whole person care, expanding to include Medicaid patients, really allowed us to expand our model to fully integrate behavioral health and support addressing social determinants of health, and you can see this in a few different ways.

We talked about our experience in Fort Worth, in particular, and what our team looks like there. There we have physical office team that’s composed of the primary care physicians and their practitioners. And we’re collocated with a robust behavioral health team that includes both a psychiatrist, a nurse practitioner therapist, we also have an ambulatory pharmacist. A really strong care management team which include social workers, case managers, community health workers. And we utilize the team and we’re able to deliver our care to a variety of aesthetics. That’s the traditional brick and mortar that we think of in some of our clinics.

But we also have a mobile care component. So we can bring care to our members who can’t come to the care center. And our team will travel to see our high-risk members whether that mean their home or nursing facilities. So it’s really taking all these different elements and looking at it from a holistic approach to meet our patients’ needs, I think, has allowed us to be really successful.

Gordon: When I think about those interventions, it’s the kind of thing that I imagine primary care colleagues in practices who are dealing with stressed and vulnerable populations and they’re just crying for resources. And I hear you describe a whole bunch of resources that sound phenomenally useful and helpful, but how do you afford them? How do you launch that?

Dr. Roy: That is a great question. I mean, I think the challenges are when you work in traditional fee-for-service system, you’re not able to perhaps invest in those additional resources. And because we work in capitated and risk-based arrangements we can choose how we want to invest our dollars and be able to put those dollars to where we think it makes sense. So we really take an in-depth analysis of what we think our patients need and then, take those dollars to be more creative and investing it in those additional resources. So I think a traditional fee-for-service environment is going to be very challenging to get those other additional resources that you mentioned.

Gordon: Man, that makes a lot of sense. Then, I think about—you talk about integrating delivery and having collocated resources that match the needs of the population for whom you are working. But it also makes me think about the rest of the health care delivery system. Do you go so far as to own hospitals and imaging centers? You have pharmacists, but do you also have pharmacies? How far does it go?

Dr. Brown: Yeah. I mean, I think you have hit upon the key question that our health system is trying to solve, right? How do we collaborate? And in that question, I hear that collaboration across many different partners is needed. And we, within our own walls, have collaboration. Obviously, between our behavior health and our social workers and the team that we have there. But we also collaborate with community partners. I think, at this point, it makes sense to do what we do really well and then lean on those partners who do what they do really well, so our community health workers, our case managers are in contact with our partners.

So whether it’s the food bank or whether it’s the hospital working with discharge planning for our patients, whether it’s—you know, during COVID we actually leaned on our pharmacy partners to help us with some of our behavioral health injectable medications that we use. So, I think, what’s key to your question is the ability to create good partnerships. I don’t think, at this point, CareMore could accomplish what we do without good partnership within our walls and good community partners. And I think that’s key to having our good community health workers and robust case management, is that they help form those relationships.

Gordon: Wow. Okay. I’m hearing all the right trigger words, triggered in a very positive sense. But I think, that again, working with stressed populations one of the interventions that I’ve heard about, and see, that is very effective is having people in the community who are interfaced with the health care delivery system who help facilitate access to care and also access to other fee-for-services. It sounds like you’re really intentional about putting that system together, and its way beyond the typically four walls of the medical office practice of here’s a prescription and an order for an image. It sounds like it’s essential. How do you guys spend, like, 80 percent of your day in meetings putting this together, or how does that work?

Dr. Brown: No, not 80. Although, my new role, yeah, we’re getting close to 80, I think. Yeah. 80 percent. I think that we lean on the history of the company. We lean on the hard work that was put into the foundation of the company. So a lot of these things have been built upon year after year after year. So there is structure there to support our market because of the work that’s been done over the long history of CareMore. But, I think ultimately, it comes dowel to being able to lean on other—for example, if we find a need in our community and it’s something that, maybe, we didn’t plan for in our market or it’s something that we need to pivot for, there’s a good likelihood that another market in our company has also had a similar issue and has worked through, maybe, some things that have worked for them that we can lean on. So, I think, there’s also collaboration within our company to work together to try to identify new issues and also new processes to help with those things.

Dr. Roy: Yeah. To just echo what Theresa’s saying, getting integrated within the community is just so critical for us to be effective, and it really requires us to go beyond the four walls of the individual clinic. So we spend a lot of time in forming those community-based partnerships and building trust within the community. You know, particularly with the vulnerable patient population there is often many years of distress built up within the healthcare system. So we have to really get out there and show our presence that we’re going to be there to really help them.

So we’ll go to homeless shelters; we’ll go to food drives. We hold—host community events at our care center or outside our care center because in order for us to be effective, we really can’t just say, “Okay. Let’s sit back in the clinic and wait for the patients to come to us.” We really have to go to them. And, particularly, with the patient population that often a lot of other groups run from, we pride ourselves in running towards them. We try meet them for their needs. So a lot of time is spent on developing that trust and the leadership with the patients and community at large.

Gordon: You mentioned the results in Iowa and in Memphis. Those are impressive numbers. What I’m think about is—I’m thinking about that state budgetary [eclipse 16:58] right now, with Medicaid because of COVID and how dire things could be in funding Medicaid, and that’s rippling through our entire economy right now. And I’m hearing the model that does the right thing for people and saves—I don’t know what the total budget is, but it saves, it sounds like, a really significant amount of money, in spite of adding resources and meeting the needs of the population. Is this a solution to what we’re facing in our country with the economic downturn from COVID?

Dr. Brown: So I think that that is, probably, going to be a complicated question and answer. I think one of the things that you’re going to see as we transition through this period of COVID is we’re going to have to be very nimble with our approach to patients and taking care of them. So one way in which CareMore does, I would say, address or was ready to take care of COVID is our staff was ready to start making calls and proactively checking on our patients before it became an emergency. So, you know, those community health workers were—they have a panel and they’re making calls to their impaneled patients. “Do you have masks? Do you have hand sanitizer? Do you have food?” These are the—”Is your electricity on? Are you able to stay in the place that you’re living?” Which were really key questions to be asking because those were going to lead to medical exacerbations of their chronic conditions. So, in that way, there was definitely a pro-active approach during the COVID response. The other aspect, I think, that we have to think about is that it helped us to be able to stay financially sound with the agreements that we have made with the payers in the way that we get reimbursed, right? We didn’t have to bring patients in and see them face-to-face in order to keep taking care of them. And the way that our arrangement is set up, we’re able to do this wrap around care between community health workers and the provider and using telephonic and virtual care in order to take care of patients. And the way we’re set up, we can remain financially viable.

So I think that is, maybe, something that needs to be evaluated long-term for other medical groups and communities. And then, lastly, I’ll just point out that I think one of the major long-term consequences of COVID is likely going to be virtual care. I think that we have found our engagement has gone up with our patients. We are hitting engagement numbers that are much higher than what we would see in face-to-face visits. And I think part of that is the ability to really meet the patient where they’re at. We do do that. We have high engagement with our mobile team where we go out and see the patients at their home or at their facility. But we were really seeing high engagement levels just by telephonic care and virtual care, and I think we’ve seen that across our company.

So I think, that was really an unintended, but positive side effect from COVID, is a new avenue to see our patients and take care of our patients, and I think it’s, probably, going to stay.

Gordon: That’s interesting. I’m hearing from health system leaders who are terrified by the cohort of people with complex, chronic conditions who are not engaging right now because of their fear of going to an office and being at risk of contracting COVID-19. It sounds like you’ve gone the opposite direction, presuming engagement means accepting some contacts virtual over the population, and that’s how you fund that.

Dr. Brown: So for us, engagement is the ability to be a clinician based visit, whether it’s a virtual via—we use Webex, for example, to do virtual visits or whether it’s a telephonic visit, we’re seeing, particularly, an increase in patients picking up their phone and engaging in their care. And some of that is also the proactive part of our community health workers going down their panel proactively and making sure that patients are okay. I think that that adds to the increase of the engagement that we saw during this time.

Gordon: Wow. Is it pretty crazy—COVID makes everything nuts in terms of the data aside. With your coming to Fort Worth, are you seeing a similar trajectory as you experienced in Memphis and Des Moines?

Dr. Roy: The results—it’s still very early in our experience right now in Fort Worth, but the results look really promising. We were fortunate to have a patient population here that was very sick and has a three to four times higher risk than the typical Medicaid patient population, and even with that higher risk level, we’re seeing that we’re able to see achieve MLRs that are even better than the lower risk patient population. And that’s really encouraging and incredible to be able to see that in just a couple of years of being open. So there’s also very promising, and we’re continuing to do additional analyses around this to quantify the benefits of what we’re providing to this patient population.

Gordon: And just for folks that may not know, MLR being medical loss ratio, which is a marker of expenditure. And you guys are going after the unnecessary care delivery by avoiding unnecessary hospitalizations utilization and the like.

Dr. Roy: That’s definitely part of the strategy, right? So we believe that if we do a really good job in our upstream care, that’s going to reduce that unnecessary downstream utilization because oftentimes with this patient population going to the emergency room is just the path of least resistance. They didn’t have good primary care. They didn’t have access or the knowledge or the ability to be able to access it. And one of the things that we’ve been able to do in coming in here, is being able to cut out some of that unnecessary utilization and high cost utilization. And I think that’s where some of the value is really derived from.

Gordon: Fantastic. I’m going towards wrapping up and wanted to give you a chance to point out things that I may have failed to dig into and ask about.

Dr. Roy: I think that one of the things that might be helpful to talk about is our emphasis on social determinants of health. And we’ve got some helpful programs there. Would you like me to dig into that a little bit?

Gordon: Yes, please.

Dr. Roy: Social determinants of health is one of the most popular buzz words in health care now, and rightfully so given that 60 to 80 percent of health care cost can be tied to SDOH factors. And CareMore has really been a pioneer in this area, really from its conception of the company. And we continue to build out programs to support our patients to meet their SDOH needs. So one example is that we’re currently working on a project to complete an in-depth SDOH screening on all of our patients, and that mimics the tool that’s been released by CMS. And this tool really allows us to get a better understanding of all the SDOH domains that our patients are currently living with whether it be food and security, having difficulty paying their bills, housing and security.

And having that information, we’re able to have our community health workers partner with those community-based organizations to help address and navigate those needs. And some of those needs we’re able to meet in real time. So one example of that is, in doing this assessment we found out a lot of our patients were experiencing food insecurity. So in the past, what we would do is we would get resources and tell them various food banks that they could go to to get resources. But, recently, through our partnership with the local area food bank and Amerigroup, we were able to set up a food pantry in our Fort Worth clinic. And so we have a fridge and freezer on site, and we’re able to give out fresh fruits, veggies, meat, dairy, and it’s really transformed our ability to be able to meet our patients’ needs in real time. And our early results from this pilot actually show improved engagement and outcomes in the patients who are accessing our food pantry there. So that is really encouraging to see.

Gordon: Excellent. Any other aspects you feel we should cover? Well, this has been really, really interesting. And again, what attracts me to what you guys are doing is both the long history of being in this space. Long history of working with individuals with high-risk, with lots of needs, and doing it really well. And doing it as a successful business model which I think is really helpful because that’s a really interesting model to consider as we think about all the stresses on health care in the US and how to change business models and how to focus on people’s needs. And think about—what I think of the essence of what you’re doing which is do well by doing good. You’re doing good things for people and it’s paying off. Everybody wins when you do that well. So that is excellent. So thank you so much for your time.

Dr. Brown: Yeah. Thank you so much for letting us have this opportunity, so we can explain the good work we’re doing. We appreciate it.

Dr. Roy: Thank you so much, Gordon. It’s been a pleasure.

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