Ways of the RAEs: Measuring Success with Rocky Mountain Health Plans
Second in a series of interviews with leaders of Colorado's Regional Accountable Entities, or RAEs. Amy Downs, CHI's former vice president, interviews Patrick Gordon (vice president) and Meg Taylor (program officer) of Rocky Mountain Health Plans about their plans for health care in western Colorado.
This episode was recorded before the RAE was launched in July 2018.
Topics covered include integrating behavioral and physical health care, how the RAE might work on housing issues and other social determinants of health, and how health care organizations measure their impact.
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, 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 Patrick Gordon and Meg Taylor as part of our series on Medicaid’s new Regional Accountable Entities, or RAEs. Meg is a program officer and Patrick is vice president at Rocky Mountain Health Plans, which covers much of the Western half of the state.
You’ll hear both Patrick and Meg speaking with CHI’s former Vice President, Amy Downs.
This conversation covers cover a lot of ground on how you measure and evaluate work on improving social determinants of health, how much a health insurance agency can actually address things like housing, and why health systems still need to address the total cost of care.
Here’s the conversation!
Amy: So Meg, tell our listeners a little bit about how you think the shift to the RAEs will affect members In region 1?
Meg: So I can start from really concrete and then a little philosophical . So one thing would be that members no longer have to figure out who they need to call to connect with a primary care provider, who they need to call to get connected to health services, who they need to call to find out how things are. We have one number. It's one call where they call our call center and we figure that out for them and it's not just giving them a phone number. It's not just giving them a list of providers. It's not just handing them off but we are doing the real connection to the service that they need and helping them with that.
I'm very hopeful that this is going to look really different. That it's no longer trying to scurry around. Our members have enough going on with their daily lives that we need to make this as easy as possible for them to connect to services and we are really committed to no longer handing a list of providers to members when they're in, say mental health distress and hoping that on the other end of it that they can get through a list of providers and get connected.
Amy: So you mentioned connecting them with Primary Health Care Providers, Behavioral Health, housing, are there other types of services or providers they'll be able to get connected to through the RAE?
Meg: So as the RAE, although the physical health services and administration and management of the behavioral health benefit are part of the RAE, we're looking beyond what contractually required in the RAE to work with organizations like managed service organizations for substance use disorder.
Amy: Can you tell people a little bit about what a managed services organization is?
Meg: They're kind of akin to the behavioral health organizations that oversee the capitated behavioral health benefit for Medicaid, but they're specific to substance use disorders and they're funded by the Office of Behavioral Health.
And so it's really working with those organizations so that we're not just saying these are the only benefits that are covered in our RAE and these are the providers that provide these benefits. How are we working across both across different funding streams and across the state and offices to say hey, this isn't a service that's necessarily part of the RAE , but we know and we're partnered with these other organizations and we're going to connect you to these Services.
Amy: Great. Tell us a little bit about what will be different for providers in the future once the RAE is launched.
Meg: So, one of the things that I am hoping for with the providers- So Rocky, as the regional care collaborative organization or RCCO, for the physical health benefit has done excellent job around primary care support and how they support providers and really around practice transformation, creating access to members for services.
And I am really hopeful that we're going to be able to also do that with our Behavioral Health Network, that our behavioral health providers are going to find ease and Contracting and credentialing. That we're not just going to close off our Network, that we are supportive of having an extensive network of specialty care providers with both the Community Mental Health Centers as well as independent providers, and that they are able to call our one phone number as well and get support around what they need to understand services that are covered from members to get health utilization management, and also to get some support as providers be it incentingaround having access to services or practice transformation in the behavioral health setting.
Amy: Can you tell people a little bit about practice transformation I think maybe some of them don't know what that means.
Meg: Well, that's a really good question. An easy way to explain it is, a practice has - they're set up in a way that they are doing a very good but basic level of Health Care. They have a front office staff that can schedule appointments and they can get people into see the physician in the office in there. To see to see patients from 8-5 during the day and that there's this many scheduled appointments. And that's what happens in the practice to a point maybe where the practice wants to have more accessible hours. And how do we do that within the practice to create more accessible hours? Are there in of ways to have some open scheduling or walk-in appointments? Are there ways to have extended hours and how do we help them do that? Are there ways to bring - if a practice is spending a lot of time managing mental health when they're supposed to be - not supposed to be but really need to be - focused on diabetes. How do we help that practice? Perhaps bring behavioral health into the practice? So it's transforming what is maybe typically thought of a primary-care setting, transforming it to more of a whole person medical home-type model
Amy: Sounds like a lot of work.
Meg: Yeah but it's good work.
Amy: So are there any populations within the region that you're particularly concerned about or you have special strategies you really want to implement?
Meg: Absolutely. work is already being done across the state which is great. But we do have a lot of work we can do especially with Medicaid expansion around for populations of individuals involved in criminal justice. Oftentimes, members that are in prison became eligible for Medicaid while they were there, and they have no idea how they can use their Medicaid benefit. And it's really on us as the RAE to go into these Correctional Facilities and help our members learn about their Medicaid benefit and help them transition out and get connected to care.
It's critical and the work we're doing now is focused on it and we need to continuing that.
Amy: Will that look any different in the future.
Meg: I think that we've learned a lot and the Department of Health Care Policy and Financing has worked on policy in order to help us get the data that we need to do that work. So I'm really excited to see what that will look like in the future.
Amy: Excellent. Well Meg, I want to thank you very much for your time. Sounds like you have committed a lot of of time to this project and there's more work to do. For July and I think right now we'll transition to your colleague Patrick Gordon.
So I'm with Patrick Gordon who's vice president of Rocky Mountain Health plans, and I want to start Patrick by asking you about integration. We've heard a lot of the RAE leadership talking about integration. What does integration mean to Rocky Mountain Health Plans?
Patrick Gordon: I think that you know, the starting point is the focus on the integration of Behavioral Health Services with broader Health Services, which is still fundamental to everything they were doing. But I would take a step back and say that if we're looking at all drivers of Health, there's a community integration component as well.
So. Again, leveraging local leadership, working well outside the traditional health behavioral delivery system framework is key. But at the end of the day where they talk about community integration or Behavioral Health integration or any kind of integration I think it's important to remember that there are many facets to it.
We very often get focused on clinical integration. So how do people access different types of services, how can we bring them closer to where they're most frequently accessing services and reduce the need for referrals and so on. That's clinical integration. But for that to really work give me the host of wide array of other supports. And that would include financial integration, meaning that the multiple funding sources that support services are brought together and coherent and purpose directed way. Data integration meaning that we're sharing data efficiently, we don't have data silos and accessible so that we're not repeating activities that have already been covered or asking a person to tell his or her story multiple times- that's unnecessary to the extent that we can share better data.
The idea of one phone number for people to call and serve 20 different phone numbers simple concept and actually entails a lot of work behind the scenes to bring out off and then finally, leadership. So you can't drive this from any one sector of the healthcare system or the community system.
You've got to have a process in which multiple voices for multiple sectors are empowered and not just advisory capacity but natural governance capacity. And so without that leadership Vision without the leadership support is very difficult to break down some of these barriers ultimately where I think we'll get is.
To a place I call cultural integration and for me, sustainability that any new is not so much about financial models or favorite models. But when does something become The New Normal so when does integration of the normal clinical practice and IT training when does integration becomes a normal in healthcare delivery and financing?
That's when we'll know we're successful. We don't notice it anymore.
Amy: So Patrick, can you tell us a little bit about. Of the different approaches you're planning to use to meet the health needs of First Call Health First Colorado members or anything particularly promising or Innovative. You think that listeners should know about yeah.
Patrick: Well, I think there's two things. The first is kind of a a focus on Basics or Back to Basics, which is primary care, of course is foundational,to any other water Health Care system or form. As Meg noted, I think we made a lot of progress in the last couple of years. We still have a ways to go.
We're kind of shifting from a development and learning in piloting phase two again a new normal So within our RAE, we have formal criteria by which we and assess um, the comprehensiveness of each Primary Care partner in the region their Readiness for additional investment, their need for Supportive resources and so, what's new is that we have a formal process that recognizes those competencies and we'll do that on like basis up to this point. It's grandstand Investments Pilots remove Pilots to operations and that's that's an important shift, but then the really Innovative stuff I think is looking well outside the realm of health care itself.
So we know that oftentimes, Behavioral Health gets given this characterized or misperceived as physical health needs and likewise. I have observed that very often, went occur like Behavioral Health needs are actually social needs but. Why is the person anxious well maybe because they don't have enough to eat or they don't have a safe place to sleep tonight or something is happening with their kids anyone will be anxious in those areas.
And so getting Upstream towards Route drivers is really that the core of what we hope to take on.
Amy: Can you give us some specific examples about how you'll be able to address some of those really really challenging needs?
Patrick: Sure. So first one is housing. You can't care coordinate your way out of housing instability.
If somebody doesn't have a place safe place to sleep, a safe home for the family. It's very difficult to do anything else. So permanent Supportive Housing is a key aspect of Health Equity. It's fundamental to equity generally in our community and what's exciting about it is it's one of the.
We are is where the financing at the opportunity are pretty well aligned. So what I expect will be doing and what will happen around the stage forward is that will get Upstream on housing names meaning that we will instead of sort of at the tail end of housing projects and programs and figure out how to integrate services will look from a health needs and Health Equity standpoint where the gaps are invest in new housing capacity.
We can take advantage of low income. Housing tax credits to do that. The simple financing is that those programs allow us to take Capital that would otherwise be an urgent and put it to productive use for social good and those Investments stand on their own but where they really need to pay off about the health of business of a social standpoint is that you can work with local leadership to align Housing Voucher and eligibility programs so that you get the um support and housing supports to.
Relations are trying to serve. And then at the outside integrated services on the ground so that people get access to behavioral health and other support services that stream of activity planning and investment produces huge positive externalities and Health Care system and health for several other budgets.
So I would call out housing among several other things as a priority for our way.
Amy: It sounds like a lot. Of work does the RAE have the capacity to engage in housing in that way?
Patrick: Well, you need a lot of Partners, right and you certainly benefit from local leadership. It is it does take a significant one way to go project off the ground a lot of local leadership political will and so on but frankly, as as my organization and others more of these the process by which you get from the start to the Finish becomes clearer, the opportunities become clearer and and the ability to kind of create shovel-ready opportunities accelerates.
So in Colorado, nited Healthcare is already done two significant, permanent Supportive Housing Investments one Larimer County a couple of years ago and more recently, uh, just a couple of weeks ago Globe bill. 30 million dollars, , that's just a part of the overall financing but a significant part and again as as we gain experience in putting these Partnerships these programs together that activity will accelerate because one it's the right thing to do.
It's consistent with our Bishop, but it also makes Financial sense to do.
Amy: Great. So thinking about the July 1 launch date and everything. You've done thus far to get ready for this. Can you tell us a bit about some of your main challenges that you've been confronting in preparation?
Patrick There are so many.
Amy: give us the top two
Patrick I think that the single biggest issue is that it is no small thing to integrate the traditional Behavioral Health into this broader structure. A lot of the financing model has remained the same and I'll touch out what I would suggest we could work on going forward with the financing model the organizational administrative model of population model is fundamentally different.
yeah, so there's a lot of opportunity inside of all that but they've been a lot of challenge, assuring that we maintain appropriate access Company New care that we become more efficient unless providers in the Medicaid system. and that we communicate clearly what's going on because.
During significant process of change like the one we're in when you can't share the clear information of what's going on people start making up their own answers. And that takes on a life of its own so we have been challenged, to work through all that. I you know, we're very fortunate to have strong leadership and I region strong partners and Mental Health Community and Community Partners at Reservoir trust frankly that old never allows us to navigate those issues.
But, there's so much to communicate at so much change and so much opportunity for people to become confused that we have to work very hard to stay ahead of it. So when we hit our July first start date will be ready. we have a pretty robust, network of mental health providers that we brought together.
and then we'll work on an ironing out the financial issues quickly as we go.
Amy: Great. If you fast forward three, four years from now looking back how will you know if this was successful
Patrick well, I think it goes back to something I said, earlier which is. How normal and boring will this become right painting that right now, uh, there's a tremendous amount of work to integrate behavioral and physical health Delivery Systems and financing models to create better transparency, uh to move for data and budgets to hold data budgets and three to five years from now, if we're successful, those edges won't seem so sharp. well what , well have have said we will have strengthened and built upon the community leadership of the trust that's driving this program forward, will be sharing data and be a ways that , three to five years from now. We'll see routine. But today seem quite novel or scary. that we don't only work force. So one of the things that I think we kind of forget to notice is that in order to deliver care in a different way you need new roles and competencies and certainly. Peer Based Services community health workers in a wide array of community service providers that are really more in the Health and Human Services space will play a very active role in healthcare delivery.
They'll be networked and we'll be sharing information in a way that is much more effective than the very fragmented that Silo way. We we work today if we work together at all. So I just see something that looks at Kim to wear. It would be a real Health immigration was a big deal 10 years ago.
It was a big struggle five years ago. We still have a lot going on now with the folding of the traditional Medicaid behavioral benefit. But really, we know where the edges are we know where the issues are. We have models and partners and road map, you know, um, when it comes to the social determinants and and , the broader parts of committee systems were just at the foot of the trail on that and um, you know, , It's the next leg of the journey sure.
Amy: Are there any metrics that you're going to be looking at as you think about success as you think about Improvement? Oh, yes, you tell our listeners a little bit about the most important ones to you.
Patrick: So I will , , but let me first start kind of a framing sure. Meg may a roll her eyes a little bit because they say this all the time in our working Rocky but you know in order to know whether or not you're accomplishing something you have to measure it meaning that you need a framework for measurement for pretty much any activity or going to take on.
And I think a lot of times what happens in healthcare Healthcare delivery care coordination is that we do things that sound good. , but we don't have a clear grip on whether or not we're really serving the people we aim to serve, you know again back to Mexico point about the person being at the center rather than the professionals being at the center.
sometimes things sound nice and feel good and move on without any other that's the direction working, , sometimes things fail but you've created such a industry around them. They're hard to change. and so in our work, we first start with a clear understanding of who exactly is we're trying to serve.
Not just the population generally, but specifically what folks with what characteristics and needs. Are we going to work to align our efforts around? And of course people don't fit into neat and tidy little categories, but , it's important to be clear about who's in the group you're trying to serve so you can make sure that the interventions you're going to deliver actually align with their means.
Then if you don't actually have an operational process or what I call workflow. You can demonstrate that you can write policies and procedures about odds are your workers still aspirational and then even if that if you've gotten that far, but you have no evaluation strategy, then you'll never know concretely whether or not what you're doing is working.
And so we focus on what we think of as for killers in all of our measurement activities for the people who are serving. What exactly of interventions is there any evidence for them or they just sound like good ideas. Can we actually point to an operating system with reports workflows and roles and tasks and so on and one of the measures basically the end of that process the impact of your work flow in here in our nation's are measured in the number of people out there touched over the denominator of the population to find an extra measure.
The bottom line. Is that no matter what we do to support people the end goal is to get them to a place of resilience self-sufficiency and self-management. And so, if we can't measure a person's journey along that path we can't really score how well people are achieving competencies and managing their own care.
We're not really doing our job.
Amy: Okay. So Patrick before we close. Is there anything I haven't asked you that you want to make sure people understand.
Patrick Yeah, just a couple of notes. You know, this is great. But none of us will be sustainable unless we bring the total cost of Health Care down. A big part of health and equity and our state and our country as a function of these orbited health care costs and absorbent and Health Care inflation.
And that's no different Medicaid sometimes it takes different forms or the equation plays out in different ways, but it's still the same pressure. And so I think in this phase of the ACC, we need to create. Better accountability across the board for the total cost of care hold ourselves to a higher standard.
Certainly within models that my organization supports in which Financial Risk is transferred from the state to an organization like Rocky Mountain. There's direct accountability for cost to the extent. We don't bring costs down for whatever reason. we we have our Community Partners will suffer financially likewise to the extent that we do bring costs down and legitimately can show that we did it on a value-added basis.
We can retain those savings, retain value, reinvest them. That's a simple framework. We think that framework is to expand. But whatever we do across the state, a greater focus on what the drivers are total cost where an efficiency is why we're smarter financing models smarter payment models smart regulations can make an impact.
I think that needs to be a priority in the next round for this to be sustainable.
Amy: Well Patrick, I want to extend my gratitude to you and Meg is well for sharing your insights today. I know I learned a lot and I'm sure that our listeners did as well. Thank you.
Jackie: Thanks to Meg and Patrick for joining us. They spoke with us on behalf of Rocky Mountain Health Plans, which is the RAE for the western part of Colorado.
You can listen to our interviews with other regional leaders on our website, . There, you can also read our new report on the RAEs and how they work and more of our work on other health policy issues.
Make sure to follow us on Twitter and Instagram @cohealthinst, and follow us on Facebook. Thanks for listening! I’m Jackie Zubrzycki at CHI.