During a daylong virtual meeting of the Population Health Delivery Council, hosted by 

, a panel of experts discussed population health, unmet needs in digital health, technology solutions to support data transparency, and opportunities for collaboration between industry and health care stakeholders. It was moderated by Dennis Scanlon, PhD, director of the Center for Health Policy Research at Pennsylvania State University and editor-in-chief of 

Paul Tang, MD, MS, adjunct professor, Stanford Clinical Excellence Research Center at Stanford University, kicked off the discussion in the morning session by posing the question of how we should think of populations—or whether we should think of them at all. Most evidence-based medicine for populations is based on randomized controlled trials, he explained, which removes confounders and leaves a homogenous population. In a large practice, that will represent only a very small percentage of the actual population they treat.

“If we base our evidence and guidance on 1 in 20 people, what should we do for the other 19?” he asked.

Ochsner Health organizes around populations of customers with similar needs, explained Kenny Cole, MD, MHCDS, Ochsner’s vice president of clinical improvement. Because individuals who are healthy have very different needs than individuals with chronic conditions, Ochsner reorganized its care delivery around those with chronic conditions based on those who have multiple health determinants versus those with fewer. In this way, it has redeployed its resources.

Dave Chokshi, MD, MSc, vice president and chief population officer of NYC Health + Hospitals and clinical associate professor at NYU School of Medicine, considers population health as a proactive approach to addressing avoidable human suffering.

“I think it’s really important, particularly when we talk about patients with chronic conditions, to focus on the idea that our ultimate goal is to figure out how we can address and potentially prevent some of that suffering,” he said.

An important element of population health can be identifying what can be done to intervene earlier and in a larger way to make a difference at the individual level. This means addressing the factors underlying chronic illness for a population, which requires understanding why some people develop, say, diabetes or asthma in the first place and try to prevent it.

“I think that requires a little bit more of a life-course perspective,” Chokshi said.

In addition to prevention, MGB Partners, composed of Brigham and Women’s Hospital and Massachusetts General Hospital, decided to see how it could tackle complex patients with multiple comorbidities, explained Despina Garalis, PharmD, RPh, director of population health management programs, Partners Community Physicians Organization, founded by the hospitals. They set up care teams including nurses, social workers, and community health workers, and they used this team approach to help patients with direct outreach.

For outreach regarding prevention, Garalis’ organization utilizes its information-rich electronic health record (EHR). They’re still tweaking their process to better understand how to tackle social determinants of health.

“If you don’t handle and tackle some of the social determinants, you really can’t help with prevention, and then it just leads into [patients becoming] medically complex,” Garalis said. But there are challenges: “Are you limited with the community resources? How does a primary health care system deal with social determinants when you don’t have the community to kind of help with that?”

In using data to better understand their population, Cleveland Clinic found that untreated behavioral health needs are among the biggest drivers of care, as are unmet social determinants of health, such as health literacy and financial support, said Jessica Hohman, MD, MSc, associate medical director, Cleveland Clinic Accountable Care Organization (ACO); investigator, Center for Value-Based Care Research; and research associate staff, internal medicine, Cleveland Clinic.

The lack of patient engagement, another driver, is related to poor outcomes for patients as well as high spending for Cleveland Clinic, she added. Cleveland Clinic is not only trying to understand which patients are not engaged, but why they aren’t engaged.

“How do we engage patients?” Hohman asked. “How do we meet them where they are? How do they want to be engaged in their care to really move their care forward?”

The fee-for-service system remains among the biggest challenges to adapting to value-based care and population health, but there are also operational difficulties. Getting meaningful data in the hands of the provider in real time is crucial so they can use the data in the context of decision-making, Chokshi said.

“I think by and large…most providers want to do the right thing,” Chokshi said. “They often know what the right thing is to do, [but] we just haven’t set up systems to allow them to achieve that.”

Juliann Molecavage, DHA, associate vice president of quality and primary care at Geisinger, added that the old way of operating—in which payers would provide monthly reports on the population of patients—overwhelmed providers, because they didn’t know what to do with all that information. Now, providers can look at the diseases faced by the majority of their patients and determine the evidence-based preventive measures they can take that can make a real difference. Those real-time data are right in their EHR; claims data prompt providers at the point of care with actions to take.

Each panelist provided some real-world examples of how their organization has used different approaches to identify patients who need help and provide them with appropriate care.

For instance, ChristianaCare launched a pilot to care for patients with uncontrolled diabetes that included embedding behavioral health consultants in each primary care practice, explained Amanda McMullen, PhD, RN, CPHQ, vice president of population health and value-based care for ChristianaCare and eBrightHealth ACO. The primary care providers identified which patients needed help and referred them to the behavioral health consultants, who talked them through their medication regimen. The consultants also taught the providers the strategies they were using. As a result, all the targeted patients saw an improvement in their diabetes control.

In focusing on heart failure, Cleveland Clinic found that some of the tools for capturing and targeting patients with this condition were sometimes inaccurate. The first task, then, was to identify these patients accurately and create a standardized way to capture them in the EHR, explained Hohman. They also focused on transitions in care, not just when patients were leaving the hospital, but also when they were going in and out of skilled nursing facilities and long-term care facilities.

Cleveland Clinic also found that their mortality rates for heart failure were much higher than their hospice utilization rates. In addition, the length of stay of patients who did get referred to hospice was generally very short. “They were being referred right as they were actively dying, and we have worked hard to change that,” Hohman said.

Patient engagement was another important piece of the puzzle for organizations doing population health work. Anthony Keck, MPH, chief population health officer of Ballad Health, noted that at the South Carolina Department of Health and Human Services, where he was previously director, a program existed to manage high-utilizing uninsured populations, and part of that was an engagement screening to measure patients’ feelings of responsibility for their own health. The department found that the members of high-utilizer populations felt similarly engaged in and responsible for taking care of their own health as people in any other populations. The issue was that these high utilizers had barriers.

For instance, “they felt just as responsible to take their medications on time, but they couldn’t get to the pharmacy to get them refilled,” Keck said, “or they didn’t have the money to pay the co-pays.”

Keck added that much time spent discussing patient engagement amounts to a “dog whistle for folks to blame the patient,” yet in his experience, in working with several programs, he found that background factors help create barriers that prevent some high utilizers from fully engaging in their health. They don’t “make a choice to simply give up on their own health,” he said.

Cole added that patient engagement also comes from trust in the people providing care. In an organization in which he previously worked, the word “noncompliant” was banned and “nonadherent” was viewed as being just as bad. The result of this mindset was usually that the care team members’ ability to earn trust successfully affected their ability to foster patient engagement.

Empathy and the ability to identify with patients is a critical skill, Cole said, perhaps even more so today, when George Floyd’s death has resulted in nationwide protests over racial discrimination and, along with the impact of the coronavirus disease 2019 (COVID-19), has put an increased focus on racial equity in health care. Health care organizations have to think about the employees hired by practices, with whom the patient is asked to engage. In some cases, community health workers are being used “as a patch,” he said, because they reflect the population being treated more than the doctors and nurses do.

Treating patients based on their individual symptomatology can be at odds with what is needed in population health, which requires scaling something with a degree of standardization, said Devdutta Sangvai, MD, MBA, executive director for Duke Connected Care; associate chief medical officer for Duke University Health System; and assistant professor of family medicine, pediatrics, and psychiatry for Duke University Medical Center. However, in working one-on-one with patients, team members can uncover unanticipated issues that may be of prime importance to that sole patient.

“Until you find a way to move forward on that [individual life issue, patients] aren’t going to pay attention to their heart failure or their diabetes,” Sangvai said.

The program then shifted to the area of linking value to reimbursement; Scanlon asked the panelists what they believe that actually means. Cole noted that value should be the outcomes that matter to patients divided by the cost of delivering those outcomes, but Scanlon played devil’s advocate and pointed out that the outcomes that matter to patients are likely to be varied and diverse. How would a system standardize that?

Cole responded that health outcomes can be categorized in larger buckets. For instance, capability is related to functional outcomes; comfort is defined as the alleviation of physical and emotional suffering; and calm is when patients achieve capability and comfort in an appropriate environment free of mayhem and confusion.

The challenge is making sure that providers ask patients what they really want and listen to the answers, according to Molecavage. Instead, providers usually go in with an idea in mind of what they want for the patient. Garalis agreed, saying that patient goals are not always the primary focus because there are so many external pressures.

Payers have set hundreds of goals for different disease states, added Keck, which is an artifact of the fee-for-service system. Moving away from that system would give providers more time to engage with patients on what is actually needed to improve their health.

Taking a step back, population health has been developed and shaped by external pressures, Garalis said. If, instead, the system had begun with a patient-first foundation, it would look quite different, she said: “If I could start it all over again, I would say, look at the patient and see what that patient needs holistically, then build off that.”

Tang agreed, adding that he would “just like permission to do the right thing.” If all the perverse financial disincentives were removed and if we measured what matters most to individuals, then the United States would get the most beneficial and least costly system by “tapping into the intrinsic reward system.”

Chokshi said that although he agrees with the fundamental importance of payment reform to advance population health, he is disappointed with how little the needle has moved in the last decade of payment reform. Looking ahead to the next decade, he stated, organizations need to be able to identify and stratify their population; there needs to be greater utilization of high-quality community-based care, pushing the focus away from hospitals and further into neighborhoods and homes; and health care needs to do a better job of meeting patients where they are.

Sangvai’s wish list for a health system that uses population health management requires a degree of tolerance, because “such a change won’t happen in 1 or 5 years. It’s going to be a long-term approach.

“I think to do population health management the right way, you’re fundamentally changing the health care system,” Sangvai said. “That takes time, patience, and accommodation.”

In the afternoon session, the conversation around population health took a deep dive into asthma, a chronic condition that affects nearly 24 million Americans. Scanlon first asked the panelists to answer a poll question on whether their institution has a formal disease management program in place for asthma. He was surprised that only 40% replied that they did; 60% said no.

Garalis noted that while her organization does not have a formal program, it does monitor adherence to medications and reaches out to nonadherent patients. Sangvai added that his institution’s focus on asthma was not quite a formal program, per se, but asthma interventions have been created that aim to decrease patients’ medication burden.

Hohman outlined the components of Cleveland Clinic’s program: It employs a multidisciplinary care coordination team to reach out to patients, ensure they have adequate supplies of medication, and regularly update their asthma action plans. Although care utilization has decreased, Hohman noted the challenges of attributing any changes to the intervention, as patients were not randomized into the program.

Similarly, Chokshi’s team identified patients with poorly controlled asthma based on utilization criteria and sent community health workers to conduct home visits and connect families with needed services such as mold removal or pest control—even providing new pillowcases and cleaning supplies to help reduce potential asthma triggers in the home.

“Even though we took a very clinical and utilization-oriented approach to identifying patients, the patients who we enrolled in the program were predominantly from low-income neighborhoods, families who are living in poverty, and often racial and ethnic minorities,” Chokshi noted.

Scanlon next asked the panelists to discuss how they approach patient engagement, which often involves the whole family in cases of pediatric asthma. Cole stressed the importance of gauging a patient’s health literacy and self-efficacy beliefs to “understand from a 360-degree view” any barriers that might stand in the way of their using an inhaler effectively. According to Molecavage, Geisinger provides an asthma action plan that allows patients to identify their “phase” of symptoms as green, yellow, or red; the plan outlines steps they can take to prevent themselves from reaching the red phase.

When Scanlon asked about critical unmet needs in the asthma space, Tang identified medication management as an important issue, especially for older patients. He suggested that daily pill packs may simplify patients’ regimens, but pill packs need to be made more affordable to ensure equitable access, perhaps through partnerships with industry. Keck took a broader view, focusing on the accountable care community’s efforts to address upstream drivers of disease. “There is a correlation between adverse childhood experiences and asthma, especially with violence in the home and poverty in general, so…we’re trying to get much deeper into the social determinants to set them up for later on down the road,” he said.

A polling question asking if patients’ social determinants of health are predictors of their health outcomes received nearly unanimous answers of “yes,” with Tang asking if he could add an exclamation point to that vote. In response to Scanlon asking the panelists what their organizations are doing to address these social determinants, Garalis explained that Partners identifies patients’ needs during screenings at annual visits and connects patients to service organizations on that basis, but capacity and funding are challenges, she said. Keck added that despite millions of dollars being spent to address these issues, “the connection is so inefficient. It’s really a logistics/distribution type of problem, getting the right patient to the right service at the right time.”

McMullen and Molecavage acknowledged the difficulty of making these connections, which motivated ChristianaCare to invest in the Unite Us platform and Geisinger to choose Aunt Bertha as tools to link patients to community entities based on their social determinants and needs. In particular, Molecavage highlighted the positive effects of food pantries on patients’ cost of care, utilization, and disease management, “and then their families are getting the benefit of it, too, because the education is happening and the nutritious food is being provided to the entire family.”

Stemming from the conversation on social determinants, Scanlon asked the panelists to discuss their organizations’ perspectives on equity and disparities. In the Deep South, Cole said, the mindset of “actuarial fairness” is difficult to move against, but Oschner is doing so by embracing a more progressive mindset, spurred in part by a 

 article addressing health care inequities in Louisiana laid bare by the COVID-19 pandemic.

 Keck added his praise for Oschner’s transformation, noting that the health system did not accept Medicaid when he worked there decades ago. “It was not an easy path,” Keck said, but “it can be done if organizations put their mind to it. It is about organizational leadership and vision and keeping people accountable.”

Chokshi added that COVID-19 has revealed for many organizations that health equity, instead of being a secondary concern, is the “main event.” Referencing a framework from the National Academies of Sciences, Engineering, and Medicine report on health care sector activities to better integrate social care, Chokshi highlighted the 2 most salient of the report’s “5 A’s” as adjustment and advocacy.

 Adjustment is exemplified by Ochsner’s transformation, which was achieved by turning the spotlight inward on its own role in inequities; and advocacy, Chokshi said, is “about lifting our voices together to challenge things like income inequality or mass incarceration or these really entrenched social issues that ultimately we see spilling over into our emergency departments and hospitals.”

Scanlon then asked the panelists to discuss ways health systems can partner with industry. From Garalis’ experience working in retail pharmacy, she suggested trying to find creative ways to incentivize medication access by making drugs more affordable. Cole also suggested working with pharmaceutical manufacturers that are interested in providing tools and resources, but he noted that in order to succeed, every player must be aligned around a value-based payment model.

With the conversation turning to value-based care, Scanlon asked the panelists if they have seen asthma outcomes improve now that the Medicare Access and CHIP Reauthorization Act is in place. Two-thirds responded “no,” and the remainder were unsure.

Chokshi, who answered “no,” explained that the health system as a whole has made progress on the “diagnosis,” as it has reached a consensus on moving from volume to value, but has not yet landed on a “prescription” to fix the problem. So far, alternative payment models have been “hitting more singles than home runs,” Chokshi said, in terms of the marginal shared savings realized, but he is hopeful that in the coming years more “doubles or triples” will occur, by taking into account a broader set of factors and crafting more calibrated interventions within population-based models.

Scanlon then asked the panelists to identify the greatest opportunities for population-based asthma management. Tang mentioned the need to educate the public, including children, about how climate change and the environment affect health, because asthma is too large a problem to tackle through medication alone. Keck brought up opportunities to redirect money wasted on low-value care to more productive efforts, such as early childhood education and lower drug costs for patients.

Educating children about wellness and the environment was repeated by McMullen in answer to Scanlon’s final question about the social determinants that could make the biggest difference in asthma outcomes. Sangvai and Garalis both identified high-quality housing as a crucial unmet need, and Molecavage and Hohman touched on access issues in their responses, with Hohman hoping systems could bring a multidisciplinary approach to asthma to places convenient to patients, such as day care providers, schools, and community centers. Chokshi called for an intensive “kitchen sink” approach that would require cross-sector cooperation to match local organizations with the scale of investment required to operationalize these programs.

Wrapping up the session, Scanlon said that he had learned a lot from the conversation and hoped that all of the panelists had learned from one another.

1. Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among Black patients and White patients with Covid-19. 

. 2020;382(26):2534-2543. doi:10.1056/NEJMsa2011686

2. National Academies of Sciences, Engineering, and Medicine. 

Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health

Articles

The American Journal of Accountable Care

Coverage of the Population Health Delivery Council meeting, held virtually by The American Journal of Managed Care® on July 18.

Population Health Delivery Council Tackles Chronic Disease Management, Patient Engagement, Health Equity, and More

Our practice, Pontchartrain Cancer Center (PCC), is part of a dwindling breed. We are a community-based, 2-location, private clinic in southeast Louisiana that sees 4200 patients annually and employs 1 physician and 3 nurse practitioners. We have been able to weather the storms of sequestration, declining reimbursements, and increased regulatory requirements. Our team takes pride in delivering personalized care to our patients in a warm, home-like setting. Several years ago, we were faced with the same dilemma most community-based independent practices have dealt with: reinvent the practice or join a hospital.

We decided to reinvent, but we didn’t have a clear vision of what sort of a practice we would have to become. How would we compete with services the hospitals and large cancer centers offer that we, as a private practice, did not get reimbursed for? What new services would strengthen our bottom line and help offset the cost of some of the new programs that would be most beneficial to our patients? How would we deal with the other programs we simply could not afford? And lastly, would any of our payers be interested in working with a small oncology practice to develop value-based care (VBC) oncology models? If we did not adapt and evolve, we would be left behind.

The PCC team met and brainstormed about our situation. An immediate decision was made to create internal treatment, symptom management, and triage pathways; start a clinical trials program, in-house pharmacy, and Hot Lab for the administration of radiopharmaceuticals; and develop practice-based programs centered around VBC. We went with the thought process of implementing programs and workflows that would help us achieve our long-term goals of improved VBC and, eventually, VBC payer contracts.

While remaining committed to delivering the best clinical outcomes when choosing the appropriate drugs for an individual patient’s treatment regimen, we set about the task of developing standardization within the practice. This process helped deepen the understanding of drug value, not just cost. Biosimilars have played a huge role in our organization’s formulary and pathway decisions by allowing us to provide high-quality drugs at a lower cost. This outcome is magnified when considering patients who are in a cost-share model to be able to afford their therapy.

Most VBC models seek to reduce emergency department (ED) use and hospitalization by shifting care to the less-costly community oncology setting. One way of doing this is by implementing symptom management and triage pathways. In creating these pathways and adapting our workflows, we were able to address changing therapies, deal with nutrition and hydration issues, and even prescribe preventive antibiotics. As a result, we noticed increased practice efficiency because we were all “on the same page” and increased patient care satisfaction because our providers were able to address many of the issues within the practice without needing to use the ED.

In 2016, we launched our clinical trials program. We now have 4 members on our research staff and 20 open phase 2, 3, and 4 trials. The research staff members screen all new patients for possible trial participation. They also work with our local physicians, as well as oncologists from other practices, to keep them abreast of our research program and when new trials become available.

In that same year we also opened our in-house pharmacy. By adding a medically integrated dispensary, oncology clinics can provide a full range of treatment options at a single site. We soon began to experience the benefits of this decision through improved patient satisfaction, improved patient care/oral adherence, increased clinic efficiencies, and a viable opportunity in our goal of VBC. When drugs are dispensed from oncology clinics, the practice’s clinical staff can address any issues or concerns, including adherence and adverse effects, resulting in a holistic view of the patient’s care. If a clinician needs to adjust a medication or dosage, it can be done at the office in real time rather than through a back-and-forth with a mail order or external pharmacy that has limited knowledge of the complexities of oncology care. It also allows our physicians to dispense “short-fill” prescriptions (when allowed by the payer) while we assess patient compliance and tolerance. One of the fundamental tenets of VBC is shared decision-making and care coordination. By utilizing our medically integrated dispensary, we are better able to achieve our goal of care coordination by factoring in comorbidities and medication reconciliation, which increases adherence, resulting in better patient care.

The addition of these 2 revenue-generating initiatives, along with the new staff required to run them, allowed us the breathing room to implement other VBC workflows and non–revenue-generating programs that we believe have tremendous value to patients and their families.

We then tackled additional value-based programs such as advanced care planning, survivorship care, transitional care management, patient/caregiver education, depression screening, smoking cessation, nutrition, financial counseling, and patient navigation. Advanced care planning, survivorship care, transitional care management, patient/caregiver education, and smoking cessation are now part of the advanced practice provider (APP) workflows. Depression screenings and the nutrition risk assessment tool are handled by the medical assistants during triage and communicated to the providers, as needed. Our organization developed a list of mental health providers, which includes accepted insurance/cash prices, location, hours of operation, and area of expertise (eg, cancer patient, caregiver, children of cancer patient) and is updated every 6 months. We also have agreements with local hospitals so our patients may utilize their nutrition programs.

Transitional care management has been very useful in helping us prevent hospital readmissions. Our APPs work attentively to identify moderate- and high-risk patients to bring back to the clinic soon after their discharge. It has also increased continuity of care among the hospital, clinic, and patient, which has led to better patient outcomes.

During patient education visits, the patient now receives a simple 3-ring binder with a monthly calendar in front, followed by tabs that we customize for the patient (eg, medications, adverse effects, symptom management, glossary of terms). They also receive a list with phone numbers and contact names for each department within our practice. We further customize the binder with a list of the patient’s team of doctors and support staff and more contact information. We go over regimens, medications, adverse effects, and any other written materials that are necessary. We update the binder at every visit to include follow-up appointments with us and other appointments we have made for the patient (eg, laboratory tests, radiology, other physicians). There is also a Q&A section for patients and caregivers to write down nonurgent questions between visits. We encourage patients to bring this working document to appointments with everyone on their care team and to have those health care workers add to it as well. We realize that this may not be enough, given that the average person’s health literacy is lower than optimal. It may be necessary to take the extra time and set up another appointment or provide additional or different written materials—and that is OK. Patients with cancer often come to us when they are most vulnerable, and the team felt it imperative to invoke the adage, “Treat others as you would want to be treated.” Interestingly, since implementing this program, we have seen a decrease in “extra” calls to the practice for questions that are answered in the binder.

We had always felt that a cross-trained team is the best team. Rather than hire more staff for these nonreimbursable services, we made the decision to share the additional workload among existing employees. Our financial assistance team currently handles all referrals for patient assistance, including financial, transportation, and other local needs. In researching the roles of patient navigators, we encountered 2 areas of concern: First, how many patients can 1 navigator help? Second, most of the research we could find showed only modest benefit to the patient. Consequently, we decided to let families handle the job of patient navigation—with support from the existing PCC staff. As anyone with a serious illness has experienced, the emotional impact of receiving bad news decreases our ability to receive new information. When we thought about how we could bridge this situation and best serve the patient, we decided the role of patient navigator was best played by a family member or close friend, serving as a second set of ears to help patients recall what was said during the visit. We encourage patients to bring a family member or close friend to all visits.

This team approach to our new programs paid dividends. It allowed us to control the message and the expense of care. Although we have all taken on more work to meet these needs, patient and PCC staff satisfaction has gone up due to the strengthening of the patient/family relationship with virtually every member of the PCC staff.

Over the last several years we have successfully participated in the Merit-based Incentive Payment System and utilized our electronic health record and practice data analytics to track our quality and cost performance as well as patient survey outcomes. Within the past 18 months, we have used this information to successfully negotiate our first VBC contract and we plan to participate in another by end of 2020. There are more than 40 alternative payment models either currently or coming down the pipeline. Each model differs in the type of risk to be assumed by providers, the level of care coordination, and the emphasis on cost and quality measures. In the past 5 years, our organization has undergone a large degree of change to achieve our goals of practice transformation and VBC. We reconstructed our entire operating model and systems in real time. From the daily practice of our clinicians to the shape of our workforce, from learning how to use our data to understanding the myriad of measures applied to performance, from the expanding network of professional relationships to managing the increased burden of risk and investment, everything has changed, and it will continue to evolve while we continue to deliver high-quality care for the patients we serve.

 Pontchartrain Cancer Center, Covington, LA.

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design; analysis and interpretation of data; and drafting of the manuscript.

 Kathy Oubre, MS, Pontchartrain Cancer Center, 120 Lakeview Circle, Covington, LA 70433. Email: kathy@pcclouisiana.com.

In the past 5 years, a community-based cancer clinic has undergone a large degree of change to achieve its goals of practice transformation and value-based care (VBC).

The Road to VBC for a Small Community Oncology Practice

The idea that a crisis is an opportunity for improvement couldn’t be more true now that coronavirus disease 2019 (COVID-19) has made it easier to see the problems in the American health care system while also reminding us of some of its best parts. Most critically, it is further revealing inequities for all to see as some populations, particularly communities of color, are disproportionately burdened by systemic factors such as poverty, racism, lack of access to quality health care, and more.

 There is a dire need to demonstrate leadership in newer ways to transform and reenergize the structures and systems we depend on, from hospitals to health plans to governments that shape our health care system. Amid the current devastation wrought by the global pandemic, as a nonprofit health plan in California, we feel obligated to fight through the systemic deficiencies by engaging in innovative cross-sector partnerships, leveraging new technology to target key needs exposed by COVID-19, and addressing health inequities through technology-enabled community health workers (CHWs).

Traditionally, health plans have been viewed as necessary but not particularly benevolent actors, and they can be perceived as a siloed segment within the health care ecosystem. As our health care system is plighted by unsustainable cost, member and provider dissatisfaction, and data challenges, Blue Shield of California is working to pave a way forward toward improvement. For example, we are collaborating with companies in new ways to lower drug costs, working to offer virtual assistance services to allow providers to work at the top of their license, and enabling a secure statewide data exchange of health information benefiting both members and providers.

 These cross-sector partnerships are just a few examples of how our health plan is working in novel ways to build a sustainable health care future. As the COVID-19 pandemic has accelerated the need to innovate, new collaborations such as these are timely and needed to improve care during and after a COVID-19 world.

Although the pandemic has shone a light on the shortcomings of a system focusing mainly on disease management, it has also revealed the promise of agile technology such as telehealth. As hospitals, clinics, and drive-through testing sites quickly mobilized to address the influx of COVID-19 testing demands, there was an immediate uptick in telehealth. We recognize that this service is not novel in itself, but COVID-19 has highlighted its critical role in care delivery; it is now being utilized as a frontline health care option to provide indirect patient care when medically appropriate, and health insurance companies such as ours have waived out-of-pocket costs to access such virtual care services in the midst of the pandemic.

 In addition to telehealth, digital technologies have also been leveraged in this fight. For example, Blue Shield of California has offered a digital COVID-19 screener and triage tool to its network hospitals, and members can be directed to the proper medical setting based on their answers to screening questions.

 As support for newer technology-enabled solutions grows, the ability to move the health care industry forward through innovation continues to accelerate.

People are not affected equally by COVID-19, nor should our response be equal. In order to eliminate inequities, reduce pandemic prevalence, deploy adequate prevention techniques, and address underlying conditions that perpetuate COVID-19 and many other health issues, all stakeholders must understand their populations. For example, Black and Latinx communities are disproportionately affected by the health and social impacts of COVID-19.

 There are also issues in accessing not only health care but also health information, technologies, and resources. Language preference, immigration status, and distrust of systems are other factors that need to be taken into account when looking to mobilize an appropriate response.

 Currently, we are working to gather meaningful data to enhance our approach in reducing these health inequities, and this effort that started prior to COVID-19 must continue for years to come. The impacts of the lack of data sharing are becoming all too obvious in this health crisis, and we are committed to working with our partners to drive the system forward.

Over the past few years, there has been a move to focus outside of the health care system, where there is a connection to approximately 80% of health outcomes, many of which come from the social determinants of health: the food we eat, the schools we attend, our job opportunities, and more.

 COVID-19 has a clear social impact on health, and one of the ways Blue Shield of California is addressing this is by working to understand how social determinants of health interact with COVID-19 in marginalized populations. We are beginning to leverage community health advocates or CHWs who are uniquely equipped to identify those at risk to directly provide support to address the whole person, COVID-19 and underlying conditions alike. Although the CHW strategy is not new,

 it has not been fully adopted into health care practice. We are now arming CHWs with data to understand where at-risk individuals live so the CHWs can connect them to resources in their community to improve their health. This example, along with partnerships to build a technology-enabled local resource network across the state, shows the reliance and interdependency among key stakeholders caring for an individual and the community. This is important because health plans may not have the relationships that CHWs have to allow for more frequent in-person, in-home, and in-community visits. This synergistic approach not only amplifies the voices of the members, families, and friends we serve, but also allows us to partner and leverage networks and resources in meaningful ways in collaboration with like-minded organizations. This approach not only differentiates efforts from those of the past but also works to reduce disease burden by integrating behavioral, medical, and social responses to address the whole person, the whole community, and the whole state to move us closer to equity.

As we collectively continue to fight this pandemic, we are already seeing hopeful signs through new cross-sector partnerships, rapid adoption of digital and technology solutions, and empowering community engagement, which only echo the idea that a crisis is an opportunity for improvement. Rather than focusing on restoring a health care model performing less well than it should, this pandemic can be a call to action for all health care stakeholders to create a new system. The attributes we mention must be broadly embraced to guide the recovery to a more equitable and higher-performing health system in California and the United States.

 Healthcare & Community Health Transformation, Blue Shield of California (SC, EJ), Oakland, CA.

 Ms Cosgrove and Dr Juhn are employed by Blue Shield of California.

 Concept and design (SC, EJ); drafting of the manuscript (SC, EJ); and critical revision of the manuscript for important intellectual content (SC, EJ).

 Edward Juhn, MD, MBA, MPH, Healthcare & Community Health Transformation, Blue Shield of California, 601 12th Street, Oakland, CA 94607. Email: edward.juhn@blueshieldca.com.


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6. Artiga S, Garfield R, Orgera K. Communities of color at higher risk for health and economic challenges due to COVID-19. Kaiser Family Foundation. April 7, 2020. Accessed April 24, 2020. https://www.kff.org/disparities-policy/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/

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Amid the current devastation wrought by the global pandemic, a health insurer in California has demonstrated leadership in fighting through systemic deficiencies by empowering people, process, and technology to address coronavirus disease 2019 (COVID-19).

A Health Plan Showing Up in New Ways Amid COVID-19

: Most studies of accountable care organizations (ACOs) have focused on contracts with commercial payers, Medicare, or Medicaid. This study contributes to the literature by describing implementation of an ACO for public employees, contracted by a state government under a federally funded State Innovation Model grant.

 Over a 2-year period, we conducted 17 semistructured qualitative interviews with 20 clinical and administrative representatives of 5 participating health care systems.

 We used an abductive qualitative coding approach to identify key themes in ACO implementation, with a focus on the role of state government.

 Interview participants discussed conditions for ACO adoption, components of implementation, likely effectiveness, and expectations about sustainability. The state government influenced ACO development by creating opportunities for innovation in care delivery, leveraging purchasing power, providing data, developing and maintaining strategic contracts, and encouraging public employees to enroll in accountable care plans. In some organizations, the ACO may have had a spillover effect, improving care for patients who were not public employees. Findings indicate that this state-led ACO shared traits with other public ACOs contracted under Medicare and Medicaid.

 By implementing an ACO for public employees, state governments may catalyze improvements in health care and influence the direction of payment reform.

Across the United States, health care stakeholders have formed accountable care organizations (ACOs) to reduce fragmentation and provide higher-value services.

 It has been argued that ACOs must include certain components, such as information technology, performance measures, and mechanisms for sharing financial risk.

 At the same time, evidence indicates that variation has emerged in ACO implementation.

 One important factor that varies is the type of payer or purchaser that holds providers accountable.

Studies have classified ACOs based on whether contracts were established with private payers, such as commercial insurance companies, or public payers, as with Medicare and Medicaid.

 One survey found that ACOs with private payers were more sustainable and efficient compared with those with public payers and that public payers can act as stewards to catalyze reform.

 However, often overlooked is the case of ACOs involving state governments, outside of Medicaid, which is jointly administered with federal government. State-led ACOs merit attention as a potentially distinct category due to the relative autonomy of states in the American federalist system and states’ power as health care purchasers for public employees.

Very few studies have documented state-led ACOs. One conceptual model for evaluating ACOs included the state policy environment as a contextual factor, but it did not discuss the state as a party to contracts.

 Another analysis argued that states can drive payment reform through public employee insurance plans

; this report listed challenges to implementing ACOs for public employees—development of data systems and new care processes, cost management, and alignment with other ACOs—but did not deeply analyze the influence of state government in implementation. To date, the only state-led ACO for public employees that has been studied in depth is the model developed for the California Public Employees’ Retirement System (CalPERS). However, descriptions of this program have mainly focused on the role of commercial health system partnerships rather than state government.

We provide a new perspective by examining key factors in the implementation of an ACO for public employees in Washington state, with special attention to the role of state government. In 2014, Washington state received a $64.9 million State Innovation Model (SIM) Round Two Model Test Award from the Center for Medicare & Medicaid Innovation to increase value-based purchasing and improve population health and care coordination.

 In 2016, the state established 2 Uniform Medical Plan Plus (UMP Plus) accountable care insurance plans available on an opt-in basis as a subset of health insurance options for public employees.

 Those who chose to participate had lower premiums and cost sharing but a smaller network of covered providers compared with the standard fee-for-service plan.16 Each UMP Plus plan offered a different set of in-network providers in different counties, although a small number of counties and providers were in both. For this study, these plans are referred to together as the UMP Plus ACO. In January 2019, there were 30,906 public employees enrolled in the UMP Plus ACO, approximately 8.1% of those eligible to enroll.

The UMP Plus ACO represents a valuable case study for state government and health care leaders interested in accountable care for public employees. To inform future ACO development, we applied qualitative methods to explore 2 questions: (1) What factors did leaders of participating health systems identify as most significant in implementation? (2) In what ways did leaders of participating health systems believe that state government influenced implementation?

In January-March 2017 and March-April 2018, we conducted 17 semistructured interviews using a purposive sample of 20 administrative and clinical leaders from 5 large health systems participating in the UMP Plus ACO (

). Participants were asked for their perspectives on ACO implementation. 

 provides sample questions. We conducted 2 rounds of interviews, 1 in each year, to assess points of consistency and changes in perspective over time. Except for a single organization that was represented only during the second year, at least 1 representative from each organization was interviewed in each round. When possible, the same organizational representative was interviewed in both years. Interviews lasted 48 to 90 minutes.

Interviews were securely stored, transcribed, and coded using Dedoose version 8.1.8 (SocioCultural Research Consultants). We used abductive coding—a combination of deductive and inductive coding—that entailed developing themes and categories to expand on existing theory.

 First, 2 researchers coded each interview using a priori codes derived from the interview guide, which was based on concepts theorized to be important in ACO implementation.

 Then, the coders used open coding to identify subthemes, allowing for new insights and theory generation. Coders discussed disagreements to reach consensus, and additional team members reviewed deidentified results to validate findings. The Washington State Institutional Review Board (project D-071416-A17.01) approved the methods.

Participants responded to questions about 4 key aspects of ACO development: (1) adoption, (2) implementation, (3) effectiveness, and (4) sustainability (

Participants highlighted 3 main conditions that led their organizations to join the UMP Plus ACO. First, participating organizations were largely uniform in their objectives of controlling cost, improving quality, developing partnerships, and growing their organizations. At least 1 participant from each organization felt that their organization’s goals and objectives aligned with those of the UMP Plus ACO, an understandable precursor to participation. Second, participants discussed the importance of organizational leadership setting a vision for accountable care. One or more participants from each organization highlighted leadership as a facilitator. Third, participants from each organization emphasized formation of interorganizational provider networks as an important step toward adopting the ACO contract. Network development included inviting providers “to be part of this journey by contracting and agreeing to the goals,” and sometimes extended to creating “a formal legal entity…a joint venture” with organizations in the geographic region. Respondents reported similar conditions for ACO adoption in both rounds of interviews.

The state government encouraged adoption by creating compelling opportunities for organizations to develop in ways that participants viewed as desirable. For example, an administrative representative from organization 2 described it this way: “Seeing how the industry is shifting...we thought it was best to get in early.” Although interview participants demonstrated awareness of other ACOs such as those under Medicare, most emphasized the importance of this state-led opportunity and commented sparingly on other contracts. Several participants also explained that their organizations were motivated to participate due to a perception that the state government was a large and important purchaser—thus, participating could open new business opportunities. An administrative representative of organization 1 stressed the importance of “the Health Care Authority’s role as both the biggest purchaser in the state, in addition to being the policy maker.” An administrative representative of organization 2 similarly described their motivation as “gaining market share.”

Participants described 4 focus areas for implementation after adoption. First, nearly every participant highlighted data and information technology as critical, and there was a desire for more complete and timely data on cost, quality, and utilization. After patients enrolled in a UMP Plus ACO insurance plan, participating organizations attributed ACO members to in-network providers based on treatment history. Timely claims and utilization data thus proved essential for accurate attribution—an important foundation for care management and attainment of cost and quality targets.

Second, at least 1 participant from each organization discussed partnership and collaboration as part of implementation. Participants considered partnerships among providers with a range of specialties to be important for providing breadth of services to attract patients to the ACO. Third, participants emphasized the need for patient engagement to improve cost and quality. Through outreach and the design of the benefits package, organizations engaged patients to keep them in-network to control costs and to encourage them to seek preventive care and manage chronic conditions. In the second round of interviews, participants from 4 of the 5 organizations placed increased emphasis on the importance of strategic benefits design for program success. Fourth, 1 or more participants from each organization discussed provider engagement. Provider buy-in was viewed as central to attaining cost and quality targets.

During implementation, participants saw an important role for the state in making real-time data available. As an administrative representative from organization 5 described, “Not getting good data in a timely fashion…makes it difficult for us to try to manage and be held accountable.” Additionally, participants saw their contracts with the state as creating both challenges and opportunities. For example, a clinical representative from organization 2 commented, “The state’s reporting requirements and measures are exceedingly difficult, much more difficult than any other contract.” Not all participants expressed concern about the contracts, but most emphasized the importance of partnering with the state as an opportunity to improve care delivery. For example, the same participant from organization 2 noted, “We have the intention of using [the contracts] to create the integrated care, to benchmark data, the quality improvement that we know needs to happen.” Similarly, the administrative representative from organization 3 stated that “we wanted to invest in this space…the contracts gave us a reason.”

In both rounds of interviews, participants speculated that the UMP Plus ACO would have the strongest and most immediate beneficial effects on care quality, along with moderate but still beneficial effects on cost, population health, and patient experience. Participants viewed cost and population health improvements as a long-term endeavor that would require more time. However, they were optimistic that the program would attain these benefits eventually because of unique incentives for the state to succeed as a public agency with limited resources. For example, a clinical representative from organization 1 noted, “The state has [a] pretty tight budget…an intrinsic interest to slow down the cost growth…maybe even more so than private purchasers.” In the second round of interviews, participants discussed the importance of population health management more than in the first round, indicating that organizations may have elevated their focus on population health outcomes.

Although the state contracted with participating organizations to deliver accountable care for public employees only, organizational representatives observed a spillover effect on care for patients not enrolled in the UMP Plus ACO. However, participants also noted that due to resource and data limitations, some care processes were restricted to enrolled public employees. For example, basic practices like checking body mass index prior to elective procedures were typically extended to all patients, whereas more intensive services like high-risk care management and certain types of customer service were available only to ACO members. A clinical representative from organization 3 commented, “Many of our care transformation initiatives affect all patients.…Some…currently target [accountable care] patients only. Over time, as the transition to value-based payment continues, these programs will expand to an increasing share of the patient population.”

Because the UMP Plus ACO was established under a time-limited SIM grant, an important topic was whether and how the program would be sustained after the grant ended in January 2019. Interview participants typically viewed sustainability as necessarily independent of the grant, and they highlighted 4 strategies to accomplish it. First, at least 1 representative from each organization discussed the importance of financial viability. As the clinical representative from organization 1 described, “We have to demonstrate success…[and] achieve our cost savings.” In the second round of interviews, 2 organizational participants shared their learning that success had to be demonstrated externally. For example, an administrative representative from organization 1 explained, “There has to be a leap of faith amongst payers and purchasers.…We need to publish our outcomes…of programs like this to help encourage them to implement.”

Second, and related to the emerging theme of demonstrating success to others, participants from all but 1 organization discussed how building relationships with health care stakeholders (eg, purchasers besides the state) could sustain the program. Organizational representatives expressed interest in engaging with other employers to create accountable care contracts and to align metrics across contracts. As an administrative representative from organization 4 summarized, “We’re going to need more than the state to do it, right? We’re just going to…need purchasers, we’re going to need the payers, we’re going to need the employers.”

Third, participants from 3 organizations discussed increasing patient enrollment in ACOs. Although enrollment in the UMP Plus ACO steadily increased after plans launched in 2016, interview participants noted that the number was still small relative to their overall “book of business.” This challenged sustainability by requiring their organizations to straddle the 2 worlds of fee-for-service and value-based payment. Fourth, participants from 3 organizations anticipated that accountable care would be sustained because new elements of care delivery had become formalized as standard procedures. For example, 1 respondent described the care management associated with the ACO as “hard-wired.” Another emphasized that they avoided hiring new staff just for this contract and instead were “making do with the existing resources” so that “it would be sustainable.”

Participants identified 2 primary opportunities for state government to support sustainability of accountable care in their organizations after the grant. First, many noted that the most fundamental action would be to renew and update the existing contracts. Second, participants highlighted a need for greater ACO enrollment, which could be facilitated by the state government through outreach and promotion of accountable care among public employees and other large purchasers.

This analysis fills a pressing gap in the literature by documenting the perspectives of leaders of health care delivery systems participating in an accountable care program contracted by state government. In addition to shaping the regulatory context, states can influence payment reform by offering accountable care insurance plans to public employees. Interview participants reported that by establishing the UMP Plus ACO, Washington state created a valuable opportunity for participating provider organizations to improve care. At the same time, participants viewed state government more as an initial catalyst than a perpetual source of support, and they planned to sustain the program by strengthening ties with other health care stakeholders and normalizing a value-based approach as standard procedure. These strategies appear to have been successful, as the SIM grant ended in January 2019

 and the UMP Plus ACO was still offered in 2020.

Results indicate that this state-led ACO for public employees shared more traits with the public ACOs of Medicare and Medicaid than with private ACOs contracted with commercial payers. For example, participant views that the state’s ACO catalyzed changes in their organizations align with prior research that described public ACOs as stewards of delivery system reform.

 Participants provide limited detail on why the state ACO program was a greater motivator than, for example, Medicare ACOs, but the perceived influence could be related to views of the state as a large and important purchaser. Additionally, participants emphasized the need to design contracts and ACO member benefits strategically to attain success. It is possible that the state-led ACO provided more flexibility in these areas than other public ACOs. Participant concerns about cumbersome reporting requirements and difficulty accessing timely patient data also reflect prior research that public ACOs tend to score lower on indicators of efficiency than private ACOs.

 Interestingly, prior literature framed the CalPERS ACO for public employees as a commercial ACO in direct opposition to a public ACO,

 suggesting a need for clarity on how state-led ACOs for public employees are classified.

Regarding impact, participants anticipated that the UMP Plus ACO could have a stronger and more immediate effect on quality of care than on cost, population health, or patient experience. This aligns with participant reports of significant organizational efforts focused on quality improvement and with findings of other studies. One systematic review found that ACOs consistently had a positive effect on quality-related measures such as preventive care and chronic disease management but a limited effect on patient experience and clinical outcomes.

 Another study of hospital-based ACOs found that quality improvements were not accompanied by decreased cost growth.

 It is possible that interview participants were familiar with existing literature, leading to biased results. As such, quantitative analysis could be beneficial to confirm whether this ACO truly had a greater impact on quality than other outcomes.

Participants’ conservative expectations for near-term population health improvements are potentially contradictory given the finding of a spillover effect of the ACO into care for patients who were not public employees. There has been ongoing discussion in the literature regarding the ability of ACOs to affect population health, and some have argued that the effect depends on how broadly the population is defined.

 Our results indicate that by implementing an ACO for public employees, state governments may be able to improve care processes and outcomes for a patient population that extends beyond those enrolled. However, this high-value care still may not reach community members who lack insurance coverage or access.

Results should be considered under several limitations. First, the focus on 1 program limits generalizability. Further research is needed to evaluate whether observed themes are present in different contexts. This is especially important given that enrollment was opt-in—provider perspectives could change if patients with different characteristics selected the ACO insurance plan. Second, although repeating data collection across years contributed to reliability, the small sample size limits validity of results. Future studies should consider larger samples to increase depth. Third, this study relied solely on qualitative data and did not include a quantitative component. Although a qualitative approach was appropriate for our research questions, future research could be complemented by quantitative methods, to test, for example, whether participants’ expectations of ACO effectiveness are correct. Fourth, we conducted interviews during early to mid-implementation. Longer-term follow-up would be beneficial, particularly because interview participants speculate that program impact could increase over time.

Accountable care represents an important opportunity for state governments to improve the efficiency and effectiveness of health care. This analysis provides evidence that, like other public ACOs under Medicare and Medicaid, ACO insurance plans established by state governments for public employees can catalyze potential long-term improvements for both public employees and other patients who receive services from participating provider organizations.

 Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles (EMA), Los Angeles, CA; University of Washington School of Public Health (SJW, DAC), Seattle, WA; Perelman School of Medicine, University of Pennsylvania (NBC), Philadelphia, PA.

 The project described was supported by grant No. 1G1CMS331406 from CMS, HHS. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent federal evaluation contractor.

Direct funding for this project came from a subcontract with the Washington State Health Care Authority (HCA). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HCA or other Washington state agencies.

 Initial data were presented, in part, at the AcademyHealth 2018 National Health Policy Conference, February 2018, Washington, DC, and the AcademyHealth 2018 Annual Research Meeting, June 24-26, 2018, Seattle, WA.

 Dr Wood continues to analyze quantitative results under a Robert Wood Johnson Foundation grant with Washington state. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (SJW, NBC, DAC); acquisition of data (SJW, DAC); analysis and interpretation of data (EMA, SJW, NBC, DAC); drafting of the manuscript (EMA, SJW, DAC); critical revision of the manuscript for important intellectual content (EMA, SJW, NBC, DAC); obtaining funding (DAC); and supervision (SJW, DAC).

 Elaine Michelle Albertson, MPH, Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Dr S, 31-269 CHS Box 951772, Los Angeles, CA 90095-1772. Email: elalb@ucla.edu.

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