Episode Teaser // Amit Pabla (guest): We have a lot of motivated staff and I feel like that's our biggest opportunity that in this new model of care, it'll really allow us to invest in our staff and see their potential and they'll be able to directly correlate the work that they do day-in and day-out to the health of their patients and to really take ownership of that and for that I am the most, most excited. Health Pilots podcast intro:
Welcome to the Health Pilots podcast presented by the Center for Care Innovations. This podcast is about strengthening the health and well-being of historically underinvested communities. Every episode offers new ideas and practical advice that you can apply today!Today we’re talking about alternative payment models. Many of you have probably heard this often in the healthcare space simply as APM. And what this is, is a payment approach that gives added incentive payments to provide high quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population - so there are different ways to approach this. And today, CCI’s own Jessica Ortiz, speaks with Amit Pabla, Chief Operations Officer at Valley Community Healthcare in Los Angeles, about the operations perspective of APM and really thinking through the possibilities of transitioning to an alternative payment model. So, with that said, I’ll pass on the conversation to Amit and Jessica. Amit Pabla, Valley Community Healthcare: Thank you for having me here. I've been thinking about APM for a very, very long time. For me, it's always been how do we get people healthier without being constricted to a fee-for-service or PPS model like we do in California. We have always been leading up to this time in 2024 or whatever year, [and] whichever organizations decide to participate. And we've been doing little things to get ready to turn on that switch bit by bit, PDSAs, through one-time grants to test innovation and see what does the patient need to put them on a place where we're able to optimize their health outcomes. And it's– moving away from volume-based care to value-based care. So from an operational aspect, there's a lot of different components. I don't know if you wanted me to talk through that, Jessica. Jessica Ortiz, Center for Care Innovations (host): Yeah, I'd love for you to dig into that a little bit more. Like what does that look like, at least from your perspective? Amit Pabla: Yeah. One thing has always been around culture. So we have been in a fee-for-service or PPS model since we essentially became designated as FQHCs and we became part of managed care. So there was always a lot of emphasis put on provider productivity and patients coming into the clinic just so that we could keep our doors open from a financial aspect. So we're switching our culture and focusing it on quality to be able to do as much as we can perhaps in that one visit that the patient comes to the clinic for. So when we talk about quality, it's not just about MAs and it's just not about providers, but support staff as well too. How do you get front desk, our call center, your eligibility and enrollment staff care coordinators to focus on HEDIS metrics and clearing gaps in care? And that is a culture change to switch from taking a look at missed opportunities or still taking a look at missed opportunities instead of having the patient come in for a visit, but having to take a look at it as in missed opportunities in terms of clearing gaps in care during that one visit. So there's a focus on really communicating value-based care to your frontline staff and what that looks like from a quality perspective. The other thing that has been on my mind has always been patient engagement. Going back to our question of how do we get people to be healthier is focusing on lifestyle changes and how do you get patients to adopt lifestyle changes if you're really focusing on population health. I do believe that from an operational aspect that our staff do need to be trained up and it's all staff that interact with patients on things like motivational interviewing, and brief interventions, on trauma-informed care as well to really understand where our patients come from, what they're thinking, what different social determinants of health (SDOH) that they might be experiencing... So that is one thing on my to-do list as we transition over to value-based care as well. Jessica Ortiz: A question came up for me when you were talking about kind of patient engagement, helping people with adopting certain behaviors that are conducive to improving their health and well-being. And then you started talking about social drivers of health and how do we make sure that we're collecting that information– using that? And I wonder if you could talk just a little bit more about that and how you see that...I don't know, maybe what an ideal state looks like operationally for that. Because one thing that I think public health and healthcare is talking about a lot is when those social drivers are not addressed, it's really difficult for patients to have the ability and capacity to focus on some of those lifestyle changes that would ideally improve their health if you're not having stable housing, if you're not making enough money to feed your family, and food insecurity, etc. So yeah, I'm just wondering if you could touch on, from an operations perspective, what might that look like in an APM model? Amit Pabla: Absolutely. If there's one thing that I am extremely passionate about, it's about the social drivers of health (SDOH). I think it has a huge impact on whether a patient is going to be successful in adhering to their treatment plan, because there's only so much that we could do in a 15-minute office visit with the provider. The provider themselves are doing the right things of, in terms of what they learned in med school and prescribing the right medication and talking about health education and whatnot. But there are things that are preventing patients to really focus on their healthcare and to achieve true health equity. From an operational standpoint, when I think about social drivers of health and who might be experiencing social drivers of health, I think it's our entire population. The fact that they are eligible for Medi-Cal more than likely means that they've had experienced a life event or that there's a socioeconomic disparity. And that in itself is a social driver of health. When I think about APM, I think about the triangle, and I don't know if people know– people probably know what I'm talking about, but you have population health at the very bottom, which just the majority of your patients. Then you have your population that need chronic disease management, and then you have your high-risk population that is most likely enrolled in a care manager or enhanced care manager program, which is part of CalAIM. So, what we're trying to do is to develop a screening tool for each population. The screening tool that most organizations use is called PRAPARE, and it's a long screening tool, and it wouldn't be possible for us to screen all 30,000 of our patients using this long screening tool. So we are screening, how to operationalize it is those that are enrolled in our ECM high-risk program are being screened using the PRAPARE template. And what we're doing for our chronic disease management patients is taking a look at the different types of social drivers of health or the different types of resources needed, and really refining the PRAPARE template and consolidating it to five or six questions and using that to screen patients to make sure that their needs are addressed as well, too. And then probably we would spread that to our patients in our population health cohort or subset, and use something similar. A tool that's really helped us out is Unite Us, making it much easier to put in a referral for patients electronically and making sure that those patients receive that type of social service. Jessica Ortiz: So I'm curious to dig into that just a little bit more. Some studies have found that patients are not necessarily always forthcoming with information when they are being screened by the health system. There might be historical gaps in trust or mistrust based on things that have happened in the past, either with family, friends, or personally. I am wondering what your thoughts are as far as screening for these social drivers in the health system setting, versus other settings that patients might feel, or people in general might feel in the community more forthcoming with that information. And what are your thoughts about resolving having information being collected in different places? So that might be a community-based organization or partner, versus a health system. I'm just wondering what thoughts you have around the possible fragmentation of where that data can be collected and, I don't know, what do you think makes the most sense? Amit Pabla: Yeah, I think there's a general need to work with our community partners to collect that information 'cause we've identified that patients most likely touch and frequent different places within our community and it's important to partner with, that being said, the more organizations that we partner with, there's bound to be fragmentation because there is, from a technical aspect, it might be difficult to have a hundred percent interoperability. And that's why there are HIEs [health information exchange] and whatnot to share some of that information. What we're doing with the Unite Us platform, and I keep going back to this 'cause I'm a really big proponent of this tool, is other organizations that are interfacing with this patient and say that they're providing housing or they're addressing food insecurity. There's a workflow within Unite Us that allows them to fill out a SDOH screener and we're able to see that from our respect. So, if a patient does feel comfortable with one of our partners, that's also part of the continuum of care, as I say, we are able to receive that information as long as the patient consents to it, is another thing that they must do. So, I hope that answers your question. Jessica Ortiz: Yeah, and just tying that back to the APM - alternative payment model - how do you see that piece in APM or those two kinds of initiatives or focus areas supporting each other? Amit Pabla: We're talking about APM and... Jessica Ortiz: Screening for social drivers– screening and also addressing social drivers of health. Amit Pabla: Absolutely. It's actually one of the principles and pillars of APM. APM is also partnering with another initiative called CalAIM, which is geared more towards health plans. And the awesome thing about all of these initiatives that come - DHCS has their separate population health strategy - is that they do have an aligned mission to improve the quality of care while reducing costs. And we've done so much work, community health centers when it comes to social determinants– social drivers of health have been working with SDOH for years and years before that term even came about. And it is finally now in 2023, 2024, that the last 10 years legislators and those that were influential when it came to developing an APM and CalAIM model took that data to heart and drove policy around it. So when it comes to APM, it's giving us the flexibility to address the social drivers of health, to have staff, dedicated staff to address that. It's incentivizing and allowing health plans to provide funding for it or to provide their own staff that address it and share that information with us too. So when I think about social drivers of health, something that we've been doing for a very, very long time, it's coming hand-in-hand now, finally. And I'm super excited. Jessica Ortiz: Yeah, that's exciting. And for those that are operating in California are probably really familiar with CalAIM, and for those of you are not, CalAIM is a five-year plan to transform Medi-Cal in California. It stands for California Advancing and Innovating Medi-Cal. It's a far-reaching, multi-year plan to transform the Medi-Cal program in California and to make it integrate more seamlessly with other social services. And so that's why we're talking about APM and how that intersects with the CalAIM plan. I know we took a little bit of a side-step into diving deeper with patient engagement and social drivers of health. We can pick up there. I know there were a couple more things that you wanted to talk about when you're thinking about operations and alternative payment models. So what else do you have for us, Amit? Amit Pabla: Another item that has been in my mind is that as we transition to value-based care, I keep telling myself that there's no timeline and deadline. You do not need to have the perfect APM model on day one of participating, that you could continue to do PDSAs and continue to pilot different strategies and build on those strategies even when you're in the middle of your first APM year. And the system in itself allows us to do that because there's none or limited penalties for doing so. So, I'm really glad that the state is focusing and allowing us to do that. Going back to patient engagement is as we transition to this value-based model and providing alternate visits that may not look like traditional visits, visits coming from nurses, from pharmacists, visits going through email and secure messaging is to really communicate with our patients regarding the new value of care. Because from their perspective they're probably not familiar with this transformation that we're doing and they are still expecting a visit with their primary care provider. So that's not going to go away. We still need to have access to visits with their provider. But I think one strategy around patient satisfaction is to really educate our patients about receiving more convenient care, receiving care from different modalities and how it will help them in their perspective of their care, both for our staff understanding that model and our patients as well, too. And we're going to continuously hear feedback from our patients. The operations team is and continue to refine our services in terms of: does this meet your needs? Were you able to receive these services in a timely manner? What is your perception of care? The other point that comes to my mind is documentation, which is sometimes the bane of our existence. But as we continue to document care in the 15 or 20 minute visit with the provider, it's going to be just as important to capture alternative services such as workaround social drivers of health (SDOH) in the patient's chart so that we could show those that are administering APM and our health plans and the state look at all this work that we are doing. So, there are CPT codes around alternative services that we're going to need to either incorporate technology that reminds our providers that we need to capture the service, but also coach our support staff to capture services that we've always done, but we need to document now. Other aspect has always been about staffing and workforce. We know that the workforce has changed because of COVID and really engaging them. There should be a revision of job descriptions as well too, as we think about staff maybe taking on a different role or being accountable to administer care in a different way. And then space is always an item, too. When we think about delivering care remotely, will that free up space from an operational lens? Also, can we think about when– there's always construction projects going on in clinics, but when we're thinking about space, think about space for team-based care, whether it's in-person or remote, and to really develop that infrastructure around team-based care for our staff so that they're able to work with each other effectively. Jessica Ortiz: Amit, I heard you use the term value-based as well as APM. I'm wondering if you see them as the same or if there are differences between them. Amit Pabla: In order to prepare for APM, I've been listening to a lot of podcasts, which are always effective in my learning to see what other states are doing. And a lot of states across the nation use “value-based care” to kind of term what the name for their APM in their respective state is. I do think that APM is a form of value-based care. There's probably things that APM and CalAIM didn't cover that still adds value to the patient that we might decide to adopt. So they can be interchangeable, but I think that value-based care can be a lot bigger than what APM currently is. APM will continue to work towards becoming more and more valuable, I think, as the state determines. Jessica Ortiz: Yeah, yeah. One of my colleagues has referred to value-based care as the elimination of low value services. And so really focusing on what brings the most value, whereas at least from my understanding, APM is just the way that we're paying for things and how we incentivize paying for those value-based services. Amit Pabla: That's a really good perspective. Jessica Ortiz: Do you agree with that? Amit Pabla: Absolutely. Jessica Ortiz: That's my colleague, Ray Pedden. [Laughs]. He’s always got good thoughts. Amit Pabla: I'm going to use that moving forward. Jessica Ortiz: So, Amit, a second ago, you were talking about staffing and workforce and looking at job descriptions, and you also touched on not needing to have all of the kind of “APM-able” positions that you might ideally want on day one and doing that over time. I wonder if you could just share a little bit more about from your perspective as a COO, what are the operational challenges with your workforce now and knowing that information, how are you thinking about how APM might help address some of those challenges? Amit Pabla: That's a really good question. So like I mentioned before, I do feel like the workforce, I want to say evolved during COVID. COVID is still going on, but since 2020 it's evolved where we rightfully believe in work-life balance. We want to have the flexibility to work from home and be able to deliver remote care. So those are some of the challenges– or opportunities, let's call them opportunities – that we're going towards and adjusting their job descriptions for a work-from-home approach. So what APM is going to allow us to do is to deliver care via patient portal, to deliver care via definitely through telehealth and telephone appointments and things of that nature. And to really take a look at all your resources and your employees in saying: how much of that is appropriate, how much of that is requested by the patient, how much of that is clinically appropriate to deliver care in a non-face-to-face? It can't be 100% of our visits. If it is going to be 20% of our traditional visits, how do you manage coverage across the clinic for in-person and remote healthcare? So those are the items that what's going to help us get there. COVID definitely did, but taking a look at that data during COVID and applying that and scaling that up so that it's part of our new model of care and that we're applying it to all 30,000 of our patients. One thing that's really, really going to help us is – as we think about shortages of healthcare professionals, and it's not just providers, like there's shortages amongst medical assistance, even call center operators, front desk staff – APM is allowing us through their payment model to give us at least what we were able to generate off of a PPS model, that minimum payment, and that is going to give us protection against the risk of losing a provider and not making up those visits – if that makes sense. So, as we anticipate, we're putting in strategies to drive up the workforce training programs to train our staff to become PAs and nurse practitioners and everyone working at the top of their licensure. But what the alternative payment method is allowing us to do is through these securities around reimbursement and the per-member per-month that if we do end up being unable to recruit or retain physicians specifically, that it'll allow us to increase the scope of practice for our allied professionals, for our medical assistants, for our nurses, in order to accommodate the supply and demand. Jessica Ortiz: Yeah. Really with the focus on how do we meet the needs of the patients given what we have. And that allows for that flexibility without the risk of it all falling apart. Amit Pabla: Which is really, it's a security blanket, especially for organizations that are jumping into APM - going back - and that's where I give props to the state and the health plans to really allow for this to organically happen. Jessica Ortiz: What do you see, this is my final question for you. I like how you frame the challenges as opportunities, so I'm going to run with that. What do you see as the opportunities for APM moving forward? I guess in the context of what have been the blockers and what do you see as the opportunities to accelerate that? Amit Pabla: I think the opportunities lie with our staff. If you talk to our staff, they want to grow, they want to learn more, they want to do more for their patients. They went to school for a reason and I think in our previous model weren't always given the opportunity to work at the top of their licensure. So for an eager workforce that even want to work independently and manage their own programs around health education and care coordination, we have a lot of motivated staff and I feel like that's our biggest opportunity that in this new model of care, it'll really allow us to invest in our staff and see their potential and they'll be able to directly correlate the work that they do day-in and day-out to the health of their patients and to really take ownership of that and for that I am the most, most excited. Jessica Ortiz: Thank you Amit, for sharing that. This has been a great conversation. I always have a good time talking with you. Thanks for being with us and taking the time out today and sharing your perspective and your expertise and some things for us all to think about as we move forward with these large initiatives, not only just in California but across the country. Folks are thinking about this. Thank you so much for your time. Amit Pabla: Absolutely. Thank you so much for having me. I just want to say that we're all part of the same team. As we go into this new transformation, I know that I have the support of my other colleagues from different community health centers as well as from CCI. I appreciate all the support and I love being here. So, thank you for this conversation. Health Pilots podcast outro:
Thanks for tuning into Health Pilots hosted by the Center for Care Innovations, with podcast production services by Wayfare Recording Company. If you like what you heard, please spread the word and be sure to subscribe where you listen to podcasts. For more information about the Center for Care Innovations or for upcoming programming, events, and funding opportunities, please visit our website - careinnovations.org - and connect with us on LinkedIn. We’ll catch you here on the next episode of Health Pilots!