Ways of the RAES: Introducing the RAEs with Laurel Karabatsos
The first 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 Laurel Karabatsos, Medicaid deputy director, about the Accountable Care Collaborative and the introduction of the RAEs.
The next five episodes of The Checkup will feature interviews with leaders from each RAE. The episodes were recorded in the months immediately before and after the RAEs were launched in July 2018.
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.
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.
This is the first episode of The Checkup. We’re planning to explore a range of topics in this podcast, including what health issues come up in the legislature and what health looks like in different Colorado communities.
But we’re starting with something a little different. Our first few episodes are going to take a deep dive into Colorado’s Medicaid program – and one new development in particular.
Colorado is trying to help residents on Medicaid get access to more efficient and effective health care. One way it’s doing that is by introducing Regional Accountability Entities - or "RAEs” – that will manage physical and behavioral health services and help patients with their long-term needs. The RAEs launched in July of 2018.
There are seven RAE regions, each in a specific part of Colorado. Two organizations are managing two regions, so there are five RAE organizations. The state’s created incentives aimed at helping the RAEs reduce costs and improve the quality of care. This is all part of a bigger reform effort known as the Accountable Care Collaborative. You can read more about it on our website, coloradohealthinstitute.org, in a paper called “The Ways of the RAEs.”
We talked to the leaders of the RAEs throughout Colorado to understand how they are moving forward with the plan and what they hope to achieve. Those interviews make up the first six episodes of our podcast.
Our first interview is with Laurel Karabatsos, deputy director of Colorado’s Medicaid program, and she spoke with Jeff Bontrager, CHI’s director of evaluation and research.
Jeff: Laurel welcome. Thank you for being here. We want to start with a question about what drives you personally to do the work that you do at the Colorado Department of Health Care policy and financing and specifically within the state's Medicaid agency.
Laurel You know for me what really drives my work is just working hard doing a good job. Seeing the results of what we're able to do. The fact that we are able to have a positive impact on more than a million members their families and the communities they live in by improving access to health care and the care that they receive is really motivating to me.
Jeff: The regional accountable entities represent a pretty big shift in Colorados Medicaid Program. And it's all part of this sort of Second Step called Phase 2 within the Accountable Care Collaborative. Could you talk a little bit about how the RAEs fit into the overall vision of the ACC and Colorado's Medicaid Program.
Laurel: You know seven or eight years ago when we embarked on this project, we thought a lot about health care and Medicaid and what needed to happen and uh felt like there were many areas that needed Solutions because of the rising cost of Health Care and the fragmentation of the system and the complex needs of our clients, but we felt that trying to solve all those issues at one time. Was not a reasonable solution for Colorado. So we intentionally designed a program that would be iterative by starting with uh primary focus and then moving from there.
So the first phase of our program was really focused on Primary Care. And ensuring that all Medicaid members had a focal point of care or trusted primary care provider, with Phase 2, we are moving on and building on from that initial vision, and now really integrating Behavioral Health into uh, the structure of our program and that is the key role that the RAEs will have and that they will be one accountable entity responsible for both physical and behavioral health in our program.
Jeff: So you mentioned reducing costs. I know one of the other aims of the RAEs is to improve the health of coloradans that are enrolled in the Medicaid Program. What are some of the ways that you think the ACC will be able to accomplish those goals of reducing costs and also improving?
Laurel: Well from the beginning of our program our goals were just that: To try to improve health and reduce costs. And under the first seven years of the program we've been successful in making progress toward these goals, but we really believe that having one accountable entity for both physical and behavioral health will increase the ability of our regional organizations to achieve those goals combining the administration of physical and behavioral health allows the RAEs to treat the whole person in a more effective and efficient manner. It removes some of the fragmentation and silos between systems and will hopefully improve communication and the exchange of information that's needed to reach out to and treat our members.
More specifically we've also changed a number of our policies in areas that we think will help reduce costs and improve health. For example. We're now allowing short-term Behavioral Health Services in the primary care setting. We believe this improves access to Services where the individuals seek their care and will prevent more costly Services down the road and improve both physical health and Behavioral Health outcomes by getting individuals the behavioral health support they need. We've also added requirements that a RAE broaden their reach to include other providers in their health neighborhood and overall community. So the focus isn't just on primary care and Behavioral Health, but will include uh Specialty Care long-term services and social service providers, and other type ancillary providers and supports. Iit's our belief that sometimes getting our members the social services and supports they need can be the most cost-effective way addressing Healthcare needs.
Jeff: So you talked a little bit about individual members and I want to dig a little bit deeper into what will it mean, uh for individual members say in Aurora or in the San Luis Valley.
What will be different about their interaction with Health First Colorado, which of course is the the name for Colorado's Medicaid Program, what will be different about their interaction with that program or with their doctor as we move into phase two.
Laurel: That's a very good question. For the most part there may not be a lot of changes for our members. Those who already have a primary care provider or Behavioral Health provider will continue to receive care from those providers and it will be business as usual for the most part. They'll have access to the same covered benefits and choice of providers. For those members who are new to Medicaid or have not been connected to Primary Care the process will be different in that they will be automatically enrolled in the program and assigned to a primary care provider, even if they don't have a history with a primary care provider yet. This will facilitate them getting connected to the program more quickly.
We also have new processes and requirements in place that will help the RAE identify clients that may have unmet needs, such as our health needs survey and some population Health Management requirements that we've added. These policies are intended to facilitate increase Outreach to members by the RAEs.
Jeff: So I imagine that we may have some providers that are listening to this podcast - Doctorss Hospitalss, Primary Care practices, behavioral health professionals. What will be different for providers in Phase 2 of the ACC?
Laurel: Again somewhat like clients. there are a lot of things for our providers that that won't change. Medicaid will still cover the same benefits will provide clients a choice of provider and will pay for medical services in much like we pay for them now.
One change is that all providers in the Primary Care Network and behavioral health network will need to contract with our new Regional organizations. So there's a new contract process that they'll need to go through. But we've streamlined the contracting for our primary care providers so that each primary care practice location only has to contract with one Regional entity rather than multiple entities across the state.
Behavioral Health Providers, however will need to continue to contract with multiple RAEs as we require our RAEs or Regional organizations to have statewide behavioral health networks.
Jeff: And you mentioned other providers like long-term services and supports or , Social Services agencies or local public health agencies. Who will they be contracting with?
Laurel: This is another area where providers may not see a lot of changes in that Medicaid pays for its physical health care services on a fee-for-service basis. So hospitals long-term service and support providers still need to be Medicaid-enrolled providers and we'll will the department for the services they provide we've just added requirements to the RAE where we want them to work with those providers and coordinate care for our clients across those systems.
Jeff: So let's move to talking about particular Concepts or initiatives or ideas that are happening as part of phase two that you think the listeners would like to know about. What's really innovative or what do you think of in terms of uh, particular initiatives that uh, that may be of interest.
Laurel: There are a few key Concepts that we've attempted to emphasize more and the second phase of the program. Uh, the first I've already mentioned and is fairly basic but it's the idea of integrating the administration for both physical and behavioral health under one entity.
We've had a very successful Behavioral Health carve out program for more than 22 years in our state. So this is a big change for Colorado Medicaid and we're really excited to see how bringing physical and behavioral health together can improve the outcomes for our members and increase access to Behavioral Health Services for those who haven't accessed them in the past.
Jeff: And a carve-out, could you explain a little bit about what that means?
Laurel: Yes, basically our behavioral health program was a sort of self-contained program where we paid for services on a capitated basis and contracted with Managed Care organizations. So it was a comprehensive program, but really self contained and managed by entities other than the Managed Care organizations on the physical health care side.
Jeff: I see
Laurel: Another concept, uh that I believe I also mentioned is that of the health neighborhood and the broader health community Community.
They're two key Concepts that will be part of phase two.
Our program is built on a medical home foundation – those providers that are the focal point of care for our members. And we're really taking that a step further by asking the RAEs to engage a broader Health neighborhood.
Many Medicaid members have complex health care needs and complicated life situations and so being able to coordinate and provide more than just comprehensive primary care is really important to these individuals and that concept of neighborhood and community helps the RAEs bridge systems in treating individuals.
The other concept that I would mention is that of population health management.
We've added requirements for our regional organizations to create population health management strategies to stratify their population and to identify specific interventions for their entire population. This is to ensure that there are appropriate interventions for individuals across the Spectrum, not just those with high Health Care needs. We also want to engage our healthy members and keep them healthy and have access to Primary Care and preventive care.
Jeff: Let's talk a little bit more about the Regional Accountable Entities or the RAEs. They are such an essential part of the Accountable Care collaborative and in Phase 2 and there's a number of different types of organizations that are operating the RAEs. I was wondering if you just had any high-level observations about the fact that there are such different organizations running the RAEs.
Laurel: You know, when we were first designing the program, we actually thought about this and whether you just have one entity come in and manage the state Medicaid program across the whole state or not. And we identified that we had many key partners in the state and that we wanted to create an opportunity for as many of those partners that were interested in engaging and Contracting with Medicaid to be part of this program. And so we divided the state up into seven regions and we put out a procurement to try to contract with seven different organizations, one for each of those regions.
In the first phase as well as the second phase, we did award contracts to a variety of organizations and we feel that that's part of the richness and the value of the program. In Colorado, you know, our geography is very varied and so having one entity that does care the same way you might do in the metropolitan area versus in the rural areas and the mountains doesn't necessarily make sense. And so this regional approach and having a variety of organizations contracted with the state really does make sense. And then they are able to work with their local communities to figure out what works best in that area.
Jeff: So you mentioned the first phase, ACC Phase 1. What were some of the lessons learned from Phase 1 or some of the successes from Phase 1 that you'd point to?
Laurel: Well, I have mentioned that you know, we designed the program to be iterative and that the idea was to pick a starting point and then evolved from there. I think the lesson we've learned is that the set strategy has actually served us well and that there are many areas where we were on point and headed in the right direction.
And so those items have become our building blocks. And now we're taking a number of those policies and initiatives to the next level. There are several examples. The most basic example is that we started with a focus on primary care, a single area, one component that we were able to focus on attempt to cause as little disruption as possible while also moving the system forward. That has been a good strategy for us and now we are moving behavioral health and reaching out to the broader community.
Another concept that has been part of our lessons learned is that concept of medical home as the foundation of our program. We found that by encouraging members to have a focal point of care, that that has been successful and they have received more preventive services and we've had indications that outcomes are improving and so we have expanded that concept to ensure that all our clients have a focal point of care immediately and that our providers that are medical homes meet enhanced medical home standards.
There are many other lessons I think we've learned from that we're building on, such as tying payment to value and incentivizing performance. Continuing to build on the regional aspect of our program and to try to formalize the lessons that are learned out in the field and local communities. we've learned lessons about the importance of care transitions for our members and tried to build in more requirements into our contract related to that and we've also learned that in some areas.
There's a greater need for transparency and accountability in the program. And so we've also added in requirements there. We've also really learned from some of the most challenging areas including attribution and communication.
Jeff: Say a little bit about what attribution is.
Laurel: So attribution is the process we go through where we identify a member and assign them to a primary care provider and a regional entity. In the past, we've done that just based on their County of residence. But I mentioned earlier that we've streamlined how we're Contracting with primary care providers and changing. Our attribution process is part of that. So now a member selects a primary care provider or we assign them to one if they don't have an established primary care provider.
That drives the RAE or the regional organization that they are assigned to. This is a very tricky and complicated thing to do and it's not unique to Medicaid programs but Health Plans across the country. So attribution, communication with all of our stakeholders, and policy implementation have all been uh challenging areas.
And so we have really been focused on in Phase 2 of managing these areas more aggressively so that we're able to be more successful.
Jeff: You mentioned transparency and accountability. This is the Accountable Care collaborative. Is there an example or two of changes that were made around those two areas that you point to?
Laurel: Sure, a couple things come to mind. One is payment to providers.
We've increased our emphasis on value-based payment. We've also given more Authority and flexibility to the regional organizations themselves to make those administrative or incentive payments to providers so that they can actually incentivize activities that result in improved health outcomes and reduce costs.
Another area that we've added more transparency and accountability is in terms of financial reporting. We have increased our requirements where the RAEs, now that there are managing both physical and behavioral health, we really want to understand what they're doing with those funds that the department pays them.
And so we have a rigorous process where we work with our financial office and going through all their financials and understanding where their money goes and how they're paying their providers. There's also - in the behavioral health program there had been perceived conflicts of interest as providers and Managed Care organizations work together to deliver care.
And so we've added requirements to just increase transparency in terms of providers being accepted into the behavioral health network or the governance structure of the organization.
Jeff: What most excites you about Phase 2 of the ACC?
Laurel: I think the thing that I'm most excited about is that we're continuing to build on the foundation that we've established and what we've learned from our regional approach and we are abandoning that to go into some cookie cutter approach across the state.
We've had extensive stakeholder input including our providers and members. We've tried to be very thoughtful about how we move forward. And we've really worked hard to preserve that outcomes focus and flexibility that we had in Phase 1, while also improving the accountability and transparency that I just talked about.
Another big thing for me is that we've made the program mandatory. The department is really committing to that. This is our delivery system and our main program and that means that all full benefit Medicaid individuals will be enrolled and benefit from the program immediately upon their Medicaid eligibility determination.
I'm also excited about what it means for the Department as we bring administration of physical and behavioral health together, and making this our primary Medicaid Program, we can remove some of our internal silos, and support more Cross organization work as we work to Monitor and improve performance of the program.
Jeff: What are some of the biggest challenges right now or what keeps you up at night?
Laurel: I have mentioned these briefly. but what we learned from Phase 1 is that attribution and communication, were challenging and we're continuing to find that these two are biggest challenges in Phase 2. We're developing strategies to address them such as more aggressive communication.
We have a messaging center out there that individuals can access and learn information more information about the program. We've also established an entire team of staff that are working tirelessly on this issue of attribution because we know it it won't be perfect that no one has yet mastered that. We're also finding that operationalizing some of our policies that we’re excited about are very challenging, too. Sometimes there's just not an easy or clean way to implement even the best policies.
So we're working to operationalize them in the best we can given the constraints of our systems and regulations and that type of thing and we're really trying to create open lines of communication so that we can be nimble and make adjustments we need.
Another area that I worry about is the behavioral health system transformation.
Uh, we've been we've had a very successful program, as I mentioned, over the last 22 years and we're seeking to build upon the success of that not caused disruption to the system or our safety net providers. We want to make sure that we hear right away if our actions have Unintended consequences so that we can correct course quickly. Our goal is to increase access to Behavioral Health Services and make navigating the system or easy so that individuals can get the care they need. But we absolutely need our Behavioral Health Partners in the community to help us along the way to ensure that we are on the right track.
Jeff: So speaking of those changes in behavioral health or in the overarching program itself - in three or four years how will you know if these changes have been successful.
Laurel: In my mind success is going to be hitting our goals that we've improved health and reduced costs. Part of determining whether we've met our goals or not. I think is to evaluate the five program objectives we have.
So the first objective is to join physical and behavioral health together under one entity. So we need to evaluate. How that's working and whether uh, that's resulting in improved efficiency and uh easier system to navigate.
Our second objective is to strengthen coordination of services by advancing team-based care and the health neighborhoods. And so I think we want to evaluate to see whether that's happening and all providers are feeling part of the system and connected and able to communicate about our members.
Another objective is to promote member choice and engagement. So that's another area. We will want to evaluate and ensure that members are feeling engaged in the program.
We also have a goal to pay providers for the increased value they deliver and so that will also be an important thing that we will look at. And then of course as I've mentioned we want to ensure greater accountability and transparency. And for all of these we're looking at several ways to measure our progress over time, and looking forward to see how that evolves.
I think the other thing for me is knowing that we're successful is not that we've gotten everything perfect in this phase. but that we continue to iterate, we continue to be open to feedback along the way as I've mentioned and that we continue to adjust and adapt to make the program even better.
Jeff: Well, thank you Laurel for joining us on the CHI podcast and we look forward to seeing what's ahead for the Accountable Care Collaborative phase 2.
Laurel: Thank you.
Jackie: Thanks Laurel for joining us. She’s deputy director of Colorado’s Medicaid program, and she spoke with CHI’s Jeff Bontrager.
You can find to the rest of our interviews with the RAEs at coloradohealthinstitute.org/podcast. We’ll also include a link to our new paper, the Ways of the RAEs, where you can learn more about the Accountable Care Collaborative.
Make sure to follow us on Twitter and Instagram @cohealthinst, and follow us on Facebook. Thanks for listening! I’m Jackie Zubrzycki at CHI.
Italicized questions were cut from the audio recording for length.