Ways of the RAEs: The Colorado Community Health Alliance on Sharing Data and Improving Connections Between Systems
Sixth in a series of interviews with leaders of Colorado's Regional Accountable Entities, or RAEs. Jeff Bontrager, CHI's director of research and evaluation, interviews Ken Nielsen and Dr. Patrick Fox of the Colorado Community Health Alliance (CCHA) as part of our series on Medicaid's new Regional Accountable Entities, or RAEs.
This episode was recorded before the RAE in August 2018.
Topics covered include CCHA's plan to partner with different agencies and the "quadruple aim."
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This transcript is edited from an automated transcription of the recording. It may contain typos. Please reach out to firstname.lastname@example.org for clarifications.
Jackie Zubrzycki: Hi and welcome to The Checkup, the Colorado Health Institute’s podcast about health in Colorado and the policies that affect it. I’m your host Jackie Zubrzycki, the communications specialist here at CHI.
Health First Colorado, the state’s Medicaid program, just launched five new Regional Accountable Entities, or RAEs, as part of an effort to improve care and reduce costs. The RAEs are managing physical and behavioral health together for the first time. We recently published a paper on the RAEs, which you can find on our website www.coloradohealthinstitute.org.
We wanted to get a sense of what’s going to change across the state now that these new regional organizations are managing care.
On this episode, we’ll be talking with Ken Nielsen and Dr. Patrick Fox as part of our series on Medicaid’s new Regional Accountable Entities, or RAEs. Ken is the interim executive director of the Colorado Community Health Alliance, and Patrick is the medical director of the Colorado Community Health Alliance.
They spoke with Jeff Bontrager, CHI’s director of research on health access and coverage.
We spoke with Ken and Patrick about working with different medical providers, on using data to inform health decisions, and on the overlap between behavioral health and corrections in the state.
We're here with Ken Nielsen and Dr.. Patrick Fox of the Colorado Community Health Alliance. Thank you both so much for being here today. So Ken, I want to start with you and uh talk a little bit about these Regional accountable entities or raise their part of a big change that's happening at Health First Colorado, which of course is our state's Medicaid Program. How do you explain what A RAE is to someone like a family member or a friend who may not know very much about it.
Ken Nielsen: Yeah, we know around here explaining anything in healthcare and Healthcare Systems is very challenging for people that don't work within it.
So really with this program, I would start just with the definition as defined by the regional accountable entity and we focus on the word account ability. Because we really do see our work as being partnering with the state and being accountable for what we call the Quadruple Aim in the industry.
And the Quadruple Aim is pretty simple.
One is focusing on the populations health and improving that the other uh is really focusing on the patient and their satisfaction and we look at the quality of the services that they're receiving.
Thirdly that we have to focus on costs and bending the cost curve. Because health care costs historically have gone up unmanageable pace and we need to manage that.
The fourth fourth is more new to our vernacular, but it's really focusing on the provider satisfaction and we focus on that because the provider network that works with the Medicaid population, um is challenge sometimes and it's the fees just aren't what they're used to. Really what we're trying to do is increase the access and so if we can't manipulate the fee schedules as much um, we need to be able to make the experience for the provider better so they'll increase their access and see more members throughout their region. So if we we boil it down and put it down to four bullets that's how we'd explain it.
Jeff: Patrick turning to you you've been involved in the state's approach to providing Behavioral Health Services which includes Mental Health Services and and substance use disorder Services to Coloradans for a while and now you're involved in the regional accountable entities the RAEs and in Medicaid. what drives you to do this work?
Dr. Patrick Fox: This is a real exciting time, uh for Medicaid in Colorado and an exceptional opportunity. We could to act on those things that we've always believed that the integration of physical and behavioral health care is crucial to the well-being of the members the partners that comprise the Colorado Community Health Alliance have been leaders in physical and behavioral health integration both regionally and nationally and we hope to bring that expertise to continue to promote a better better health care delivery system, one that's more coordinated. more seamless from the members' perspective, and where providers feel like they're connected to a larger Health Community when they're delivering care for one of our members. One of the ways we intend to do this is actually to focus on the social determinants of health, which are those aspects of an individual's overall well-being that are not classically thought of as health such as access to food, access to stable and safe shelter, access to appropriate clothing, access to transportation, employment opportunities, and a positive social network.
Jeff: The Colorado Community Health Alliance or CCHA is unique in some regards because you have two regions of the state that you're overseeing as RAE. So could you tell us a little bit about those two regions?
Ken: Of course. It is quite diverse. Region 6, which is uh, our traditional region that we have the RCCO contract with over the last six plus years. It is mostly urban population, a high density of population, but we do still have Clear Creek and Gilpin Counties that are very mountainous and health care delivery is less common up there.
Region 7 has some similar challenges. You have El Paso, which is again the second largest metro area compared to Denver. A lot of services, a lot of providers, a freestanding ED on every corner. But that's quite different than Parker and Teller, where we struggle to even find a single provider on the physical side and behavioral side really to provide the services that we need.
So we're going to have to become a little bit creative.
The communities are also differ in the resources they have available and it certainly proves that in many ways health care is still local because the counties are different. And El Paso County certainly operates differently than Boulder County.
And so we can't just fully replicate what we've done in the past. Um, we are going to have to create new artnerships, learn about the counties, educate them on what we can do and then come to an agreement on how to best partner.
Jeff: So Patrick, Ken just talked about some of the unique characteristics and and even some of the challenges that are in your two regions. Could you talk a little bit about some of the approaches that CCHA may be taking to really fulfill its goals as a RAE within those two regions.
Ken Sure, CCHA is bringing an Innovative technology platform that includes Advanced data analytics so that we can analyze population Health as well as health for the member across many different domains. And this data is so crucial so that we can get a sense as to not just where that member is accessing care and services or where they have needs that falls clearly within the scope of what the regional accountable entities is responsible, but also those other unmet needs. /and that by attaching a care coordinator a person who will form a real relationship with that member to say hey when we analyze the data we see that there may be some issues with your ability to Access housing, we'll work with you to help you to access local housing resources in your area by drawing on county and state resources. That's the kind of unique, um touch approach that we are bringing to the members that the member will experience and so this is not where data and analytics is operating in a in an Ivory Tower, and it's affecting the person's life without them knowing it.
By analyzing the unmet need we're actually then able to deliver resources specifically for that person to directly change the course of their life and their and their health plan.
Jeff: So Patrick, you've talked a little bit about how members will be impacted by care coordination and the use of data. Could you talk a little bit more about what will be different for Medicaid members moving forward?
Patrick: Sure, as a manager under the new RAEof both physical and behavioral health benefits we're able to expand our provider network and improve access to care and services for our members will also have more access to the data that will help us to better understand the member population. And we use this combined with enhanced communications with members their family members and caregivers to understand their unique needs and preferences.
This approach will allow us to integrate and implement member specific family specific approaches and strategies that account for that person's life stage, the health condition, their health related behaviors and those social determinants of health I've referred to earlier. And we expect that all of that will improve the member's outcome and I think I think primarily it's really about putting the member at the center of their own care, they're the quarterback for care. So the old traditional model where you went to a physician and the healthcare provider basically told you what was to be done to you based on the condition that you have were we're really, um changing that Paradigm and saying no you're the member, you're in a particular stage in your life. You have certain social circumstances that constrain your access to care. Do I go to that doctor's appointment to manage my diabetes and risk losing my job or do I go to my job and jeopardize my physical health. Those are decisions that only the member can make we want to know from that member what those challenges are so that we can figure out ways to reduce those barriers.
Maybe there's a way we can reschedule your endocrine appointment for a different time of day. Maybe there's a way we can ensure that you have transportation that will get you there or childcare so that you can go spend those four hours at that Health Clinic to address this need what we realize is if we don't address. The barriers that prevent the member from accessing the care that they want but are constrained by the circumstances of life. It costs everyone in in the long run.
Jeff: And do you have an example of how that might happen how you might address some of those barriers to care in your region?
Patrick: Sure. Uh, there's there are opportunities for members to take advantage of non-emergent medical transport that member may not even be aware of. And so it really means sitting down with the member and not just talking about their health. But what are all the things that are considered by them in determining how best they're going to um to manage their health. And if we find out that transportation is an issue or child care is an issue will then work with agencies to see to what extent we can reduce or eliminate those barriers to enable them to have that that access to care.
Jeff: So Ken what have been some of the challenges so far or what challenges do you anticipate as this second phase of the Accountable Care Collaborative rolls out within Colorado's Medicaid Program?
Ken: There's certainly been some common challenges I think amongst all the RAE contractors. Number one would be attribution.
The attribution is the method for how members get assigned to a medical home or a PCP and that changed within this teration and the Phase 2 of the ACC program. And so we continue to work on making sure that it's correct and that the both the members and the providers are happy with the attribution as it stands right now.
Jeff: And again attribution is this process by essentially which the the members the Medicaid members get assigned to or or connected to a primary care provider. Is that right?
Ken: That's right. And one way that happens is they look at claims history. And if there was a history of a contact between a member and a primary care physician, then that's an easy attribution to make. Where it becomes more challenging is if the member is new into Medicaid and they have no claim history that is visible and so attribution can just happen by proximity to the provider.
And so we need to educate the member who they're connected to at that point. Because they've never seen that provider and vice versa, the provider's never seen the member. And so we work heavily on that within the first 90 days 120 days is going to be a big push.
Number two for us is just building provider trust.
We're new and to region 7 and it's a challenge. There's a lot of contracting that needs to take place. There's a lot of data agreements that need to take place. And we have a lot of learning to do and so we're continuing to build that trust with the provider network. That's been a challenge because it's new it's different and it's not not uncommon for those especially as I said in region 7 where we're a new participant.
So we're building that trust.
And lastly it is just learning the communities. Who are the agencies that we've talked about that are going to help us down the road. Do we have a contact with every food bank? Do we have a contact with every religious group that we need to have? And while challenging this is part of the work certainly for the first 90 100 days.
Jeff: So Patrick, Ken just spoke about building trust among providers. Do you see other changes that will affect Health Care Providers or Behavioral Health Providers as the Accountable Care Collaborative rolls out or evolves to this next phase.
Patrick: I do. Oftentimes providers need specific resources to best meet the needs of the patient that they're seeing in front of them. They don't always know what resources are available in the community to address those social determinants of health as we talked.
Physicians when they go through Medical School know a lot about disease and disease management, but not necessarily about how to access the resources to help that person best meet their own needs and so we want to work with those providers. We have practice transformation coaches that are available to go into those practices to say, hey, we analyzed some of the data and we see that some of these outcomes haven't been all that advantageous. Are you asking your members these specific questions about whether they have food in their house, whether they have access to transportation or why they're not attending your appointments the those why questions.
And also if you're for instance a primary care provider like a family medicine doctor and someone comes in and asks questions and tells you that they're struggling with depression or that they're hearing voices, are you familiar with the available resources in your area that you can refer that person to in order for that aspect of their life and their care to be met? And in many instances those solo practitioners don't know what resources what referral resources are available. Practice transformation coaches and Care coordinators can assist the provider and making sure that the member has access to the appropriate care. And additional providers are sometimes constrained by a lack of available information. There's a wealth of information available, uh regarding an individual's Health Care through the Health Information Exchange.
In Colorado, not all providers have access to the Health Information Exchange or even our even aware that it exists. If they're they've been working in a Solo practice for a period of time. It's making providers aware that there is a data warehouse that secure that's encrypted that you can receive information from and that you can upload information to so that if you're patient gets admitted to hospital.
The hospital doctor at two o'clock in the morning on Saturday can actually have access to your notes. But in order to do that, you have to have an electronic health record add access to the information exchange. We're working with the providers in our Network to ensure that um, as many of them as possible can have access to that crucial information.
Jeff: So I want to know in three or four years how will you know, if the approaches that you've described today will be successful.
Patrick: Data is going to be an essential aspect of that. Ken referred to earlier to the Quadruple Aim. If we want to know about how well we're doing in managing the overall health of the populations we serve, we need data to be able to do that. If we want to know about whether each individual patient in our region, whether their mental and medical and mental health conditions are being adequately addressed. we need data for that. Similarly whether providers members and their families are satisfied with the care that they're receiving under the current system.
And so we're going to rely on data to help to help us know bhow well we're doing and in what areas we need to pivot in order to meet a previously unknown and unmet need.
Jeff: So you mentioned satisfaction. What are some of the specific data points that you're going to be monitoring to to look at your success?
Patrick: We'll be asking, uh more directly questions of members about their satisfaction with their care. That's something that HCPFhas done for years and that we intend to to expand upon that.
Jeff: Are there other uh examples of data points, maybe outside of the the satisfaction realm, that you'll be looking at like use of healthcare services or access to health care services?
Patrick: Yes, we intend to um to the extent permissible to access that information through the Health Information Exchange. The HIE is being adopted by more and more practices. And there are steps within the state of Colorado to see whether or not jails can upload information to the HIE so that we're going to be able to see whether our member is touching different systems of care or management that that had previously been unknown.
So, wow, from our perspective, this person isn't using a lot of health resources or they haven't over the last four or five months. I wonder why that is. Oh it's because they they were arrested and have been in jail for the last four months. We want to know that and we want to know why. What were the circumstances that led to them being in jail? Was it because they were hearing voices that were not being adequately addressed and that they then were arrested and brought into jail and had an evaluation to see if they were fit for trial? Those are reasons that an individual can essentially fall off the grid. From a cost perspective they may be a low utilizer, but they are high utilizer of the whole system in the state of Colorado.
And so accessing data,will enable us to see truly whether an individual is a high utilizer of services representing which for me means that they have a lot of unmet needs. The high utilization of services means we're failing to address the needs of that citizen in our state. It's not that it's necessarily a failing on their par, those social determinants aren't being met. They're are having difficulty accessing care. And so that's what's driving up those costs.
Jeff: Ken is there anything you would add to that?
Ken: Yeah, I would agree data and measurement is going to be critical in this Phase 2 and proving that you're performing. For providers the bar's going to raise on what we have to measure and and that's why it's important for them to trust us so that we can come in and help them some of the other areas that that are softer that we're going to need to measure to gauge our success around the social determinants. Um, right now food banks and finding them are a great example and helping them receive additional resources. The next evolution of this is how many of our food banks are equipped to handle a diabetic population because the food bank isn't great sometimes for a diabetic to show up or somebody with hypertension.
So those type of measurements over the next three or four years will be important. Also I would add that for providers - if a PCP was willing to have a panel of 50 or 100 Medicaid, have they doubled that? If they have then we've expanded access.It's easier for the members to get in and it's probably a win-win for both sides of that equation.
Jeff: Well, Ken Nielsen, Patrick Fox, thank you both so much for being here today.
Ken and Patrick: Thank you. Thanks.
Jackie: Thanks to Patrick and Ken for joining us. They were representing Colorado Community Health Alliance.
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