Hello, everyone. This is Jacob Emerson with the
Becker's Payer Issues podcast. Thrilled today to be
joined by a special guest. Doctor Todd May
is vice president and medical director at Health
Net. Doctor May, thank you so much for
taking the time to be with me on
the podcast today.
Jacob, thank you for having me. I'm I'm
very pleased to be here.
I'll just mention,
importantly that I am a practicing family physician,
and I've been practicing
primary care for over thirty years. So I
I have deep, deep experience in the in
this area and, a lot of interest. Fantastic.
And I appreciate you you diving in,
to your career background, Todd. And before we
get started with everything you want we wanna
talk with you about, can you tell us
a little bit more about your current role
at Health Net and what you do?
Sure. Sure. I,
I am the executive representing the commercial line
of business. I am involved in in all
things,
clinical, sup supporting supporting the business.
I'm very deeply involved in population health management,
which is our,
approach to optimizing the care for,
all of our members, across all lines of
business,
deeply involved in quality improvement,
health equity,
looking at,
member engagement platforms, digital tools,
that kind of thing to to
maximize engagement
of our members in their in their own
health care.
Fantastic. So, Todd, we're we're here today to
talk with you about a really big and
special initiative.
If multiple insurers are are coming together to
or or have. They've launched a shared value
based payment model for reimbursing primary care physicians
in California.
That initiative includes collaboration from Aetna, Blue Shield
of California,
and, of course, HealthNets
along with 11 providers
across the state.
So talk to us a little bit about
this. What what does this mean? What were
some of the key factors in bringing all
these stakeholders together?
Well, Jacob, first, thank you for recognizing how
big of a deal this is. This is
unique, innovative,
groundbreaking work.
And and, you know, there's been we have
a we have a fragmented health care system.
Right, and there's been realization for the health
plans
for some time that to have a real
impact on broad systems like health care delivery
and primary care specifically
that we can work together to align with
a cohesive multi plan strategy.
And and this demonstration project
stems from a partnership,
agreement that we made, in July 2022
with HealthEd and, and, and several other payer
organizations.
And we've all been deeply engaged, in this
work,
from the very beginning.
It was
California
Quality Collaborative, the CQC,
and Integrated Healthcare Association, IHA,
who brought us together. They were the conveners,
of this group, and they can continue to
facilitate
the project.
And,
you know, there's real value,
in this approach when
offering provider organizations a cohesive, aligned strategy
that really helps them transform
into becoming higher functioning
advanced primary care practices.
And and a high functioning primary care
is is a foundation for a high quality
and cost effective health care system.
And when this happens, we're better able to
meet the needs of patients and improve health
outcomes
that really matter. For for example,
you know, the sweet spot for for primary
care
are are managing chronic conditions like
diabetes and and high blood pressure. And,
you know, why are these important? Well, these
are
two of the most prevalent conditions in The
United States and their
underlying causes of cardiovascular
disease, which is the primary,
cause of,
death in our country. And we also focus
on
prevention, like cancer screening vaccinations,
that kind of thing that really impacts impacts
health.
Absolutely. And and, Todd, let's dive into this
a little bit more because this new model
is shifting
individual payment systems to a single shared system
that rewards
high quality care.
How does that approach differ from the traditional
fee for service models we all know,
and what are some of the specific metrics
or outcomes that are being used to measure
and reward,
physicians' performances?
Yeah. You know, value based care differs from
traditional health care by prior prioritizing patient outcomes
and the quality of care over the volume
of services provided. And that and that means,
our providers are financially rewarded for achieving positive
health results for their patients
rather than the number of services delivered.
In the traditional long standing fee for service
models,
providers are paid for the volume of preserve
services they provide. And, you know, that that's
irrespective of the impact
on or or outcomes that they achieve. I
mean, whether they do any good or not
doesn't actually factor into the equation. They get
paid for
doing things.
So this shift,
really encourages a more holistic and proactive
approach to patient care. We're focusing on preventioning,
prevention, mind managing chronic conditions,
and really looking at the overall overall health
status of patients
rather than just treating acute issues or or
whatever they, happen to come in with that
day.
And, you know, HealthNet and other health plans
have been engaged in
in this value based purchasing,
arrangement for some time. This is not a
new concept.
But we we all did as individual plans
with individual models and priorities,
you know, so help, you know, provider groups
just have,
a bunch of different health plans,
providing different incentives and that kind of thing.
So so what we're doing here with this
demonstration project
that's that's really revolutionary
is this multi plan alignment.
We're all rowing in the same direction, and
the practices know,
what's expected. And we're we're really amplifying the
impact,
that we have in producing high quality,
high value results.
And, you know, the the health plans all
came together with CQC, NIAJ.
We developed this together from the very beginning
from the conception design payment models.
We developed the metrics, which I'll get to
in a moment.
We got the implementation plan, then we're gonna
assess the outcomes.
Now in terms of metrics,
we jointly developed key performance metrics that reflect,
high quality and high value member outcomes.
And these metrics this is really important. These
are closely aligned with the priority metrics
that our major purchasers
have identified
as well as key leaders in the industry.
So at a high level, these metrics include
health outcomes and prevention.
Talked about diabetes, high blood pressure,
immunizations, and cancer screenings.
We're looking at patient reported outcomes and focusing
on
depression status.
We're looking at patient safety,
looking at minimizing high risk drug combinations.
We're looking at patient experience using industry standard
surveys.
That's really key. We really hope to move
the dial, the the needle there,
and also high value care, which is, you
know, minimizing you know, with with really strong,
primary care, we hope to minimize
emergency departments and, inpatient hospital utilization.
Those are the those are the key metrics
that we are targeting and that we are
rewarding
the practices
for achieving.
Absolutely. And going off of that, Todd, with
everything you just said and and these and
how these metrics were developed,
why were small
independent practices chosen as the starting point for
this new model?
And have you learned any lessons so far,
being only just a short amount of time,
since implementation?
Yeah. That that's a really great question. So
so like I said, primary care is the
foundation of a high functioning
health system.
And we have while while we have
growing
consolidation in in health care delivery,
we still have, you know, a vast, vast
number of small independent practices out there providing
a substantial portion of primary care.
Now this advanced primary care model is an
integrated, comprehensive,
patient centered, team based care model, and we're
supporting these practices
in in adopting
this broader,
broader approach to care. It's not just contingent
on that doctor in the room,
but it's more of a team approach. So
everybody in the office,
can contribute
to, this population health,
management approach. And together, they look at all
the patients,
use data,
identify their needs, and then proactively
reach out to to their patients and close
their care care gaps.
Now we've we've focused on these small independent
practices because they're they're largely under resourced,
and they they lack the size and infrastructure
to implement these changes on their own. I
mean, it takes work. It takes effort to
do this, to to change your,
your, you know, standard way of doing things.
Now larger provider groups tend to be better
resourced,
to enact these kinds of changes. So,
with the with the, demonstration project, we're excited,
with where we're, where we're at and what
we're seeing.
I'll just mention we're calling this a demonstration
project instead of a pilot, and there's a
reason for that.
Pilots are, like, initial attempts to just test
out a new idea,
But this this project is based on science
and experience, and this methodology has been proven.
We we know that advanced primary care works,
so we we are we're moving ahead beyond
just a a test pilot.
And so far, we've,
we've learned that health plans can indeed come
together collaboratively,
get in the same room, elbow to elbow,
align around key innovations and operational interventions,
and, we've been able to successfully
engage targeted practices,
to commit to practice transformation
in in adopting this advanced primary care model.
And we're also finding high interest from these
practices. They're eager to receive support. They wanna
be helped. They wanna do better.
They know it's hard work and and that
they can't do it on their own. So
they really appreciate,
both the financial resources, but also
the the training and coaching,
that we're providing,
to to make this transition.
Yeah. And, Todd, let me follow-up with a
point, one of those last points you just
made that this is really bringing together a
lot of organizations that in the past may
have been directly competing
with one another. So how do you see
this demonstration
project setting a precedent for for other insurers,
for other providers throughout the country?
Well, like I say I mean, this is
what's groundbreaking.
Right? I mean, who would imagine,
the health plans
competitors, yes, getting together literally in the same
room
and talking this all through, working this all
out, coming to
common
agreements,
with a focus on
you know, we we we keep we keep
the business separate. Right? This is this is
really about
quality. When you get down to it, we're
all it's all about quality, improving outcomes, improving
the care, improving the value of care that
the people of California receive.
And we can all agree on that. Right?
I mean, there there's
we we should we should be
all,
promoting that across the board for all Californians,
and that's what we're doing here. And we
found that through this alignment,
we can really amplify our impact and make
a difference, and it just makes a lot
of sense. Now what we what we hope
to do with this demonstration
project is,
show that, yes, indeed, health plans can do
this. They can align. They can come together
with strength in numbers
and the and the amplification
that we can,
really help practices,
adopt this model and provide,
higher value care
with it. Obviously,
the long term goal here, demonstrate this works,
and then scale it. Scale it across the
across the state, maybe across the country,
get other plans to to come on board
and
and really, really move the dial.
Yeah. I mean, it's really exciting to to
think about the potentials here, Todd. But let
me ask you one last question about some
of the technical
aspects of this model,
because as you've said throughout our our conversation
today, you're really looking to address reimbursement challenges,
improve health equity, and boost health outcomes among
your your members,
particularly those who may have been underserved
in the past. So
how are you specifically addressing some of those
disparities in care, and how does a tool
like the like the Coziva platform play in
ensuring that those goals can be met?
Great.
So
the the key here,
is data.
Timely, accurate, and actionable data is the key
to all performance improvement efforts across the board,
and that's especially,
true with health equity. And so we're making
it easier for the provider organizations to access
their patient data.
You know, we we like I mentioned, we
have a fragmented system.
Our data, our information, our medical records
is equally
fragmented, and that makes it really difficult to
get a comprehensive view
of the care that patients have had and
identify their needs.
So
with this demonstration project,
the three plans together
are providing access to a uniform data platform,
a single source of data, a single source
of information
where the pro practices can view key patient
clinical information for our members
for all of the plans
in one place, on one dashboard.
And
access to and use of accurate data foundation
of health equity work, and the way that
that works is we stratify
data. So we have a you know, look
at a practice. They have their full panel
patients. It's a diverse,
array of folks in in any given practice.
What you do in health equity is you
take that data and then stratify
by race, ethnicity,
language,
and other parameters,
and then you compare the groups. And that
reveals
disparities
in the services that that are provided.
It uncovers
things that you would not see unless you
look at the data and stratify the data.
So then we can identify those gaps in
care,
and then practices
can proactively,
address those gaps to mitigate health, health disparities.
So the, you know, the goal here is
visibility,
see where the gaps of care are,
take action,
proactively
outreach to specific especially
underserved members. Now these are folks who may
have fewer resources
and fewer opportunities to access this care on
their own. So
by reaching out, bringing them in, or delivering
the services to them, we can promote health
equity.
Fantastic. Well, Todd, we've got a lot of
other health plan and health system leaders listening
in right now. Any other final thoughts or
final bits of advice you wanna offer them
based off of everything we've just chatted about?
Yeah. Well, first of all,
watch this. Pay attention to what we're doing
here. We follow this along. We'll we'll obviously,
give status reports as we go, and,
and we'll,
share the results, that we demonstrate. We hope
to show very positive results.
So that's one, keep a close eye on
this.
And two,
don't be afraid to jump in. Don't you
know, it's it I know it seems foreign,
sounds,
sounds counterintuitive
for competitors
to get together
and do good work together,
but it makes sense. Okay. Then we're not,
violating any
any business comp competition practices or
sharing proprietary information. There's none of that. We
are focused on
improving the health outcomes of all Californians, and
everybody can get behind that.
Wonderful. Well, doctor May, thank you so much
for taking the time to sit down with
us and for sharing your insights with our
listeners. We really appreciate it.
Jacob, thank you very much for having me
today.
If you'd like to listen to more podcasts
from Becker's HealthCare, you can visit beckershospitalreview.com.