Fred Roth will lead daily operations as new Medicare supplement president.
Humana's Medicare Supplement (Med Supp) division has a new leader with expertise in operations, organizational strategy, program readiness, and employee productivity: Fred Roth.
To HealthLeaders, Roth stated: "We are focused on developing strong relationships and simplifying processes and introducing automation to continue removing barriers to entry and growing our broker distribution footprint."
Roth lends agent and broker experience from his prior role with Aetna, where he began as national director of Medicare Supplement New Business and Broker Contracting & Commissions. His later roles for the organization included executive director and COO for Med Supp.
Roth alluded to this agent focus in the Humana announcement: "I'm so excited to be part of this Humana team, largely because we strive to put the member first in all we do, but also because I know how important it is to Humana to support the careers of the agents we work with."
Roth's new role includes expanding Humana's range of Med Supp policies and plans.
Roth adds: "Humana is dedicated to having strong offerings that meet the unique needs of each individual member, whether they choose a full-service Medicare Advantage plan or Original Medicare with a Medicare Supplement policy. About 10,000 seniors age into Medicare every single day, and it is my job to ensure those who opt for a Humana Medicare Supplement Policy receive long-term value and top-notch support from our team."
Humana is the nation's second-largest Medicare Advantage insurer, with more than five million members, and with the seventh-largest Med Supp enrollment at 320,000.
From the press release, Roth also stated: "Humana is a leader in Medicare because we understand what seniors need, and we deliver on that every day."
The insurer now holds Medicaid contracts in 30 states, representing nearly 25% of total market share.
Centene now holds Medicaid business in 30 states with its most recent award in Delaware, announced last week.
Centene is the nation's largest Medicaid insurer, with more than 15 million members, including four of the largest states: California, Florida, New York, and Texas. In Q1 2022, Louisiana and Indiana re-awarded its statewide Medicaid MCO contracts to Centene
In the company's press release, Centene CEO Sarah London stated: "We look forward to building on our nearly 40 years of Medicaid experience to improve health outcomes for Delaware residents and provide better value to the state."
The Centene award expands Delaware's Medicaid MCO count to three. Highmark Health Options Blue Cross Blue Shield has been in the state since 2015 and AmeriHealth Caritas since 2018.
In an agency release, Delaware Department of Health and Social Services Secretary Molly Magarik stated: "These companies not only will offer more choice to our Medicaid members, but they also understand Delaware’s commitment to value-based care, and to the critical services that our Medicaid members need and deserve."
Delaware Medicaid overview
Diamond State Health Plan (DSHP) is the name of Delaware's Medicaid program, which integrates physical, behavioral, and long-term care, the latter as a part of DSHP-Plus. Total enrollment is roughly 300,000.
Delaware is one of only a few states with all-payer benchmarks — Medicaid, Medicare, and commercial insurers — for quality and spending. Delaware is also a Medicaid expansion state, with Medicaid/CHIP enrollment increasing nearly 24% during the pandemic (February 2020–March 2022) per data published by the Kaiser Family Foundation.
President and COO Brent Layton added: "It is a privilege to be selected by the state of Delaware to provide local healthcare services and programs that address social determinants of health and remove barriers to care for Medicaid members across the state."
Centene's Medicaid projections
While Q2 2022 performance is forthcoming, Layton anticipated the following in Centene's first-quarter investor call:
Redeterminations: "Our Medicaid growth continues to be aided by the ongoing suspension of redeterminations … [W]e anticipate the return of redeterminations in August … and are confident in our ability to retain and attract membership."
Exchange business: "So [in] the 29 states where we have Medicaid health plans, we have the exchange or our Ambetter product in 25 of them. So we're able to overlap the counties and in a lot of ways, overlap the provider network."
Medicaid pipeline: "There's no doubt the Medicaid RFP pipeline is reopening. It's much more like a 2017, '18 and '19 … [W] we have prepared for these [reprocurements] … But we also see a lot of new opportunities."
Layton cites Centene's close relationships in the states where it does business, commenting in the Delaware award release: "We are excited to work with the state and providers on proven models of value-based care to deliver transformative healthcare and improve the health of Diamond State Health enrollees."
The company Unite Us' Social Care Payments platform provides the tech infrastructure for the health equity ecosystem.
East is east and west is west and ne'er the twain shall meet. This could describe how healthcare payer and social service infrastructures have historically operated. But things are changing and, in a technology-enabled way that supports community-based organizations (CBOs) without "medicalizing" their operations.
"Medicalizing the social" — expecting CBOs to operate like payers and clinical providers — isn’t feasible for health equity initiatives. Melissa Sherry agrees. "That is accurate and spot on," says the PhD and vice president of social care integration for Unite Us, an enterprise technology company connecting health and social care.
Sherry's interview with HealthLeaders included the macro concerns of payer-CBO partnerships and followed the March 2022 introduction of Social Care Payments, which Unite Us describes in its press release as the first integrated social care payments platform "designed to bridge the gap between healthcare funders and [CBOs]” and “the only end-to-end solution for social care that streamlines the implementation and management of paid social care programs."
As these programs increasingly involve public and private payers, Social Care Payments is designed to help funders and CBOs partner, each in their own lane of expertise, to expand community impact.
The coding, claims, and billing conundrum for CBOs
The typical CBO wheelhouse does not include medical coding, claims, billing, or provider contracting. To join payer networks it will have to, but that's not something that most CBOs, if any, have the expertise or resources to build themselves.
"The biggest challenge we solve for community organizations is that we simplify billing," says Sherry, who also discussed the current state of medical coding for social needs.
"Social coding and diagnoses are in its infancy. Z codes are the 'What's going on?’ codes, but they are broad and to date haven’t been used systematically. The same is true for CPT® codes [Current Procedural Terminology] for social care services. Some states, California for example, are assigning HCPCS codes [Healthcare Common Procedure Coding System] for their community supports services, which represents the ‘What’s the solution?’ codes."
Sherry further cites the social coding standardization work by the Gravity Project, of which Unite Us is a sponsor and committee member along with multiple private payers.
Speaking on billing and claims, Sherry notes: "As a tech company, we create bridges, turning CBO services and documentation into claims for the payer so the social service organization can get reimbursed for services and focus on what they do best — again, not medicalizing the social, but enabling the two to do what they each do best."
Health plan medical-social service tech integration
Health plans are taking different approaches to medical-social service alignment.
"Some health plans are telling CBOs, 'If you want to join our network, you have to use our system,'" says Sherry. But if payers are not "thoughtfully and carefully integrating the medical and the social," it won’t be effective.
This group now includes North Carolina Medicaid, which launched a $650 million Healthy Opportunities Pilot program in quarter one 2022 "to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety to high-needs Medicaid enrollees." The pilot is currently using Social Care Payments.
Unite Us created Social Care Payments as an alternative to homegrown systems. "Thoughtful rollouts and integration" — those that solve problems for payers and CBOs alike while protecting their lanes — "are part of our technology goal," says Sherry.
Without a careful integration strategy, Sherry worries that more disparity could be an unintended consequence if some CBOs are favored over others.
"If only the wealthy CBOs participate because they're more sophisticated, it will put smaller ones even further behind," she states. Noting that smaller CBOs may serve even more disadvantaged populations, Sherry adds that Unite Us works to support small organizations, help them build scale, and practice at the top of their license.
Another organization working to do this is Healthy Alliance, which connects the underserved to a growing network of organizations—big and small—that provide services that are essential for a healthy life. Healthy Alliance is a Unite Us client and understands the importance of not medicalizing the social, while also using components like cost, encounter data, service volume, and prediction to help CBOs scale.
Healthy Alliance created one of the first social independent practice associations (social IPA) in the nation, taking the traditional IPA model—i.e., allowing independent providers to share resources and gain collective contracting power with payers—and applying it to CBOs instead of medical providers.
CFO/CAO Michele Kelly notes: "We're able to provide backbone infrastructure analysis … on individual costs to evolve a new model for system intervention design that allows us to start to projecting volume."
Healthy Alliance VP of strategic partnerships, Kristen Scholl, also notes: "We'll always need encounter data, and we don’t expect a food bank provider to do this. Michele’s team has translated data to an encounter file that managed care understands."
Avoiding medicalization but achieving more
The tech infrastructure that organizations like Healthy Alliance and Unite Us provide can help CBOs achieve something important: attracting new funding via new access to data on spending, services, and outcomes.
"With Social Care Payments, CBOs don’t have to be medicalized while funders get the data they need," says Unite Us' Sherry. "You have all the pieces and the data in one place: who to screen, what services to provide, setting up the interaction and tracking it while bringing the billing component into population health management programs."
Unite Us Senior Vice President of Insights + Growth, Kurt Waltenbaugh, adds that the Social Care Payments platform "identifies and predicts, drives community investment, and connects the dots.
New research shows Medicare consumers need help. But how should you interpret high rates of both overwhelm and confidence within the Medicare population?
Creating a better consumer experience for health plan customers has launched many a startup, from those that offer new products to those that sell them. With Medicare Advantage (MA) enrollment set to eclipse traditional Medicare within the decade, it is a bull market for organic MA growth — most of all for companies that make understanding, shopping for, and buying coverage easier.
In an exclusive with HealthLeaders, Dan D’Orazio, CEO of Sage Growth Partners, notes: "This report has surfaced a very uncomfortable set of findings, primarily that those who may need healthcare the most, and who also have to balance financial stability in their later years, are very vulnerable."
Understanding that vulnerability is just the beginning of a mixed picture that includes both consumer confidence and overwhelm while unpacking the consumer decision-making process.
Six key statistics
Sage-Healthpilot statistics show:
Medicare-eligible individuals don't understand Medicare. Only 20% and 31% respectively correctly identified original Medicare versus MA components.
Medicare advertising is too much. 63% are overwhelmed by ads.
Consumers are confident. 75% strongly or somewhat agree are confident that their plan decisions meet their needs.
Wait, no they're not. Only 31% strongly agree that their Medicare decisions are effective.
Maybe that's why they stick with what they've got. Less than 40% shop for a new plan annually.
Most do not completely trust the advice they receive. 53% of shoppers had a medium-to-some-to-no level of trust in what they were told about plan options.
These results are from a survey of 1,142 Medicare-eligible individuals that included other data on the consumer shopping, enrollment, and re-enrollment experience.
A critical eye is important
While the Sage-Healthpilot research states that it's "critical to help Medicare-eligible individuals select optimal plans," the optimal "plan" may be original Medicare, supplemented or not with Medigap coverage. Unpacking the following is also important:
Overwhelm vs. confidence. Decision-making is hard in general, as highlighted in a March 2022 Life Kit feature by NPR. Confidence may come from the best choice or on okay one, so long as it's done. In addition, a October 2021 APA survey found that 36% of respondents found day-to-day decisions more stressful — 35% for major decisions — than before the pandemic.
Attract vs. choose. Customers will be attracted to an insurer that advertises zero dollar everything — premiums, copays, generic drugs — for a large percentage of plans. What is advertised, however, may not be what is available in their service area and the Sage-Healthpilot research shows that customers search more (81%-83%) for whether their doctor or drug is covered.
Age, it turns out, is more than a number. While 58% overall stay with their plan, most of these customers are older. More than half of those aged 70-75 (52%) and nearly 60% older than 76 keep their current plan.
What the research does strongly suggest is that consumers, at any given time, could very well be making better choices. As HealthLeaders covered in November 2021, one of Healthpilot's unique selling propositions is its use of data science — claims data, AI, and risk analysis — to create a better experience for not only shoppers but the payers and providers that partner with them.
Sage's D’Orazio adds: "I believe that providers and health systems have a tremendous opportunity to differentiate themselves, their services and their plans in what is becoming an increasingly crowded MA world."
A new study combined with an innovation pressure test shows how the entrepreneur's company could disrupt the Medicare Part D value network for private payers.
New analysis shows that the Mark Cuban Cost Plus Drug Company (Cost Plus) could not only save Medicare billions, but it may also qualify as a disruptive solution that could "transform the entire value network of Medicare Part D coverage." These latest findings are based on the Christensen Institute’s six-question test that determines whether innovations are truly disruptive compared to existing offerings.
Study shows significant savings
As HealthLeaders reported in June, an Annals of Internal Medicine (AIM) study found that Medicare could have saved $3.6 billion on a subset of generic drugs if purchased from Cost Plus versus private payers — the Medicare Part D market currently dominated by UnitedHealth, Humana, and CVS Health. This 37% savings would be generated from 77 drugs bought at maximum quantities. Purchasing minimum quantities of 42 drugs would also have reduced spending, by $1.7 billion or 18%.
As noted by Christensen Institute research associate Jessica Plante, MPH, this new data shows that "the cost-savings for Cuban’s pharmacy go beyond the individual and have the potential to impact larger-scale payers."
Six-question innovation test suggests further disruption
The Institute makes clear that disruptive innovations "are not breakthrough technologies that make good products better. Rather, they are simple, affordable innovations that replace expensive, complex systems and products, thereby increasing accessibility and affordability for all."
The Institute identifies potential disruptive innovators by applying the following six questions, quoted from its website. Paired with these are the Institute's answers as applied to Cuban's company:
Does it [the product or service] target nonconsumers or people who are overserved by an incumbent's existing offering in a market?
Yes. The Institute notes that Cost Plus targets nonconsumers, specifically the nearly 30% of Americans who don't take their medications as prescribed because they are too expensive.
Is the offering not as good as an incumbent's existing offering as judged by historical measures of performance?
Yes. The Institute assesses that Cost Plus is "not as good" because brand-name drugs "often carry more reputational weight [than generics] … despite being far more expensive." An offering viewed this way, however, has disruptive potential because it deviates from historical standards.
Is the innovation simpler to use, more convenient, or more affordable than an incumbent's existing offering?
Yes. Not only can Cost Plus medications be ordered online, but its costs are also transparent to a degree that is unheard of. The previously cited AIM study notes that Cuban's generic drug costs are based on " the cost of ingredients and manufacturing plus 15% margin, $3 pharmacy dispensing fee, and $5 shipping fee."
Does the offering have a technology enabler that allows it to improve and capture a larger market over time?
No. The Institute notes that while the company could offer more generics in future, "there is nothing unique about Cost's Plus's [digital pharmacy]" and that its "real disruptive potential" is its value network.
Is the technology paired with a business model innovation that allows it to be sustainable?
Yes. Cost Plus is a pharmacy, pharmacy benefits manager, and online retailer all in one "with just enough markup to keep the company running."
Are existing providers motivated to ignore the new innovation and not [be] threatened at the outset?
Maybe. While originally noting that Cost Plus could be potentially be ignored because other startups reduce drug costs (e.g., GoodRx), the Institute writes: "Cuban’s pharmacy holds disruptive potential relative to not only bricks and mortar pharmacies, but also PBMs and private payers more broadly.
Noting that the AIM study "quantifies potential savings, which could incentivize Medicare and other large-scale payers to change how they cover prescriptions," the Institute adds: "Instead of continuing to work with myriad individual health insurers, Medicare could choose to contract directly with Cost Plus Drug Company for all generics. This would transform the entire value network of Medicare Part D coverage."
Erin Barney discusses her new role and how it supports market and enterprise imperatives.
In April 2022, Erin Barneywasnamed VP of Network Solutions for the Blue Cross Blue Shield Association (BCBSA). Barney assumed the role after 17 years of leading multiple divisions for BCBSA licensee Health Care Services Corporation (HCSC), which is also the fourth-largest insurer in the U.S.
Barney recently spoke with HealthLeaders about her new position, what drew her to it, and her unique approach.
HealthLeaders: Describe the role Network Solutions plays at BCBSA.
Barney: The role Network Solutions plays is to convene network executives across the different Blue Cross Blue Shield plans — to focus on how we come together as a system and work across geographies, each of which has its own unique economy, provider makeup, and population, to deliver and maintain creative and innovative networks that meet members' needs. I'm spending time reaching out to each executive, asking them about their own priorities and initiatives, and how they are working on common priorities like value-based care (VBC).
HL: How do you balance unique and shared challenges?
Barney: First, we need understand what the needs are and where can we align on purpose and focus. For example, how to advance VBC through quality and how to help providers to drive outcomes-based reimbursement.
These priorities tie back to what we're trying to accomplish as system, our three pillars: Integrated, affordable healthcare; healthier lives for our members and local communities; and a convenient, seamless experience for members.
HL: What are some specific areas Network Solutions is addressing?
Barney: One is behavioral health. There is a lot of discussion on unprecedented demand and need. At the micro level, the Network Solutions team is having one-on-one conversations with the individual network plan executives. Then, we're looking across the system: If there is a supply challenge, why and how do we address it, including access through virtual care. Or maybe quality of data is an issue.
Another is maternity. There are many things to consider: How do providers help support, engage, and understand patient needs; how effective is the discussion; and are patients being heard?
We're also looking at how Network Solutions can help extend relationships with health equity being a focus. In maternity, for example, the team started asking questions in the BDC [Blue Distinction Center] survey on how race, ethnicity, and language data is collected, incorporated, and applied. The responses help understand the landscape, refine our approach, then require select measures.
Note: BCBSA BDC "are healthcare facilities and providers recognized for their expertise in delivering specialty care."
HL: Can you speak more about the role Network Solutions plays related to metrics?
Barney: One example is the Severe Maternal Morbidity measure. It might not be used for health equity, but could it be? Is there something there? Also with SOGI (Sexual Orientation and Gender Identity), there is new insight and opportunity.
With clinicians, we're looking at what are appropriate metrics, including cross-industry collaboration, and how operations and analytics relate. With measures, you have to be thoughtful because of the implications and ensure validity.
HL: What are some unique aspects of BCBSA's Network Solution org structure and objectives?
Barney: We are able to tap into a bunch of different areas across the organization. I have a team under me that includes clinicians. There is also an Office of Clinical Affairs run by the CMO that Network Solutions works with. There are also groups within the distinct plans that focus on quality separate from what the network executives are doing.
HL: What makes you the right leader for this role?
Barney: I had been with HCSC for 17 years in a variety of roles and have taken a different path than most take. I've been in leadership within local plans but also enterprise roles in sales and account management. In my early career, I was an HR leader; everyone should understand the people side. I've operated in strategic, finance, ops, and reimbursement functions.
I'm just naturally curious. To understand the whole, you have to also understand the pieces. I have an understanding and appreciation of what it takes to make it all work.
HL: What drew you to this role?
Barney: The uniqueness of our Network Solutions work is that equity is a priority. This focus and BCBSA's CEO Kim Keck are part of the reason I wanted to move into this new role.
My personal philosophy aligns with the overall Blues mission of committing to local communities. The Blues plans were born out of a need to serve people who couldn't afford healthcare in the 1920s. I really think about how we serve our neighbors, family, friends, people we meet in the grocery store or post office. It's an honor to work for this company.
The agency's proposed 2023 Physician Fee Schedule features expanding access to accountable care organizations (ACOs).
The National Association of Accountable Care Organizations (NAACOS) is applauding CMS' potential changes to the Medicare Shared Savings Program (MSSP). The changes, part of the federal agency's 2023 proposed Physician Fee Schedule, include the following six highlights:
Allow ACOs to progress more slowly from low to high risk.
Use a "prospectively projected administrative growth factor" to make ACO benchmarks more accurate and equitable.
Support strong-performing ACOs with large, underserved populations via a "health equity quality adjustment."
Give smaller ACOs faster access to shared savings payments to support the underserved.
Prevent benchmark lowering by accounting for prior ACO savings.
Update quality scoring.
CMS states that the proposed changes to MSSP, if finalized, "represent some of the most significant reforms since the final rule that established the program was finalized in November 2011 and ACOs began participating in 2012."
This would be keeping with proposed changes to other CMS ACO programs, as noted in a NAACOS press release by president and CEO Clif Gaus: "While we are still studying the major changes, policies in today's proposed Physician Fee Schedule will help grow participation in . . . [ACOs], helping realize the CMS Innovation Center's recent Strategy Refresh to have every Medicare beneficiary in a relationship with a provider accountable for his or her quality and total cost of care by 2030."
CMS' Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare, noted: "Integrated coordinated, whole-person care — which addresses physical health, behavioral health, and social determinants of health — is crucial for people with Medicare, especially those with complex needs."
Seshamani added: "If finalized, the proposals in this rule will advance equity, lead to better care, support healthier populations, and drive smarter spending of the Medicare dollar."
Research from the Christensen Institute reveals the messages, models, and metrics that healthcare leaders need to innovate successfully.
"We might all be in the same storm, but we're not in the same boat."
Ann-Somers Hogg, senior research fellow-healthcare at the Christensen Institute, uses this quote to illustrate the importance of drivers of health (DOH)—and to explain why her organization prefers this term over social determinants when describing the "societal, population-level structures that influence health outcomes."
HealthLeaders spoke with Hogg as part of her ongoing research at the Institute—founded by disruptive innovation pioneer professor Clayton Christensen—which links DOH to Business Model and Jobs to Be Done Theories while highlighting stakeholder success stories. HealthLeaders' takeaways include the importance of message, metrics, and business models for DOH success.
Message innovation
In a May 2022 white paper for the Christensen Institute, Hogg provides three reasons why DOH does a better job of capturing human need:
"[T]here are multiple competing definitions for SDOH, all suffering from a high level of complexity and the exclusion of the individual's perspective."
"[T]he causal drivers of people's health and life outcomes … are drivers, not determinants set in stone."
"[T]he limiting nature of the word 'social' — given that that DOH also spans the "social, environmental, and economic systems that influence how people live, work, play, pray, and age."
Speaking with HealthLeaders, Hogg says: "As I was doing the research, something didn't sit right with me." So, she asked herself: "How do we think about the term [social determinants of health] through the eyes of consumer? Healthcare struggles because the consumer lens is not ingrained in the service model."
Hogg continues: "If we are seeking to address drivers of health, we must use language that resonates, and social determinants of health doesn't. Research from The Health Initiative uncovered that people found the phrase confusing, alienating, and demeaning."
The Health Initiative's co-founders have written more extensively about these findings, which are based on focus groups with urban and rural North Carolina voters.
Hogg adds: "That's not to say that some drivers of health are not determined. However, there are other drivers that we can use our agency to impact, and that other entities have the ability and necessity to address."
These entities include the 84 organizations Hogg studied in her latest DOH research, from community, faith-based and government organizations to providers, payers, and payviders to startups and the enablers that "support others' ability to address DOH."
Model innovation
The position that DOH are not simply determined leaves room for two important realities: that better outcomes are possible, and that healthcare can play a role in achieving them.
Enter Jobs to Be Done, an innovation theory that the Institute has applied to multiple industries and initiatives, including healthcare and DOH. Jobs Theory posits that people "hire" products or services to not only achieve functional goals but meet the social and emotional needs that help them make progress in life. "We call this progress the 'job' they are trying to get done, and understanding this opens a world of innovation possibilities."
"Jobs to Be Done has a couple of applications in DOH," says Hogg. "In conducting the research, one of our questions was what jobs were health care leaders hiring DOH for, and why did they incorporate DOH into their business models?"
Hogg found that healthcare leaders seek one of three types of progress:
Job 1: "When the current system is about reacting to illness, help me capture the market opportunity to keep people healthy and out of the hospital, so I can make a profit."
Job 2: "When the current system is about reacting to illness, help me focus on people's health, so I can help them treat the root causes of their problems and live better lives."
Job 3: "When our financial future is evolving and the way we get paid is going to change, help me design a transition plan so I can remain financially viable and continue to serve the community."
Hogg's research also noted: "The jobs that led health care executives to hire DOH, or to incorporate them into their business model, informed the business models they built."
Metric innovation: Humana
So which payers are executing DOH well?
"The first I think of is Humana, its Bold Goal, and new success measures," says Hogg.
Humana launched its Bold Goal in 2015—a population health strategy articulated currently as "Addressing the needs of the whole person," to be achieved by "[c]o-creating solutions … for our members and communities."
As noted in the Christensen Institute's white paper: "This goal required Humana to establish new measures of success. To assess the impact and effectiveness of its DOH efforts, Humana started using the CDC's Healthy Days measure, a four-question, self-reported questionnaire where individuals assess the number of mentally and physically unhealthy days they had over the last 30 days."
When Humana applied its Bold Goal to Medicare Advantage (MA), individuals and communities reported fewer unhealthy days in 2020 and during the height of the pandemic:
2.4% change in physical unhealthy days for MA enrollees.
2.2% change in overall unhealthy days for Bold Goal MA communities.
.
A decline in unhealthy days across Humana populations, ranging from -6.3% for low-income subsidy members to -2.7% for dual-eligibles.
Progress across multiple Bold Goal communities.
Communities with fewer unhealthy days in 2020 versus 2015 included San Antonio, Baton Rouge, New Orleans, and Knoxville.
Hogg's research notes: "By tracking the impact of its DOH efforts on the outcomes that matter to individuals, Humana is able to target and iterate interventions to improve both individual and community QoL [quality of life]."
Speaking with HealthLeaders, she adds: "What sets them apart is how they measure success thorough consumers' eyes" as opposed to conventional quality measures.
"Traditional measures may be precursors," adds Hogg, but whether a person can play with their two-year-old grandchild tells a broader story. "Healthy Days reflects self-reported consumer data and looks at multiple aspects of health," which she believes is a better way to measure the impact of DOH efforts.
Innovators versus incumbents
The Christensen Institute notes that the most innovative business models effectively incorporate DOH by:
Addressing consumer/customer needs for progress
Creating payment models that support these needs
Measuring what matters to those they serve
Linking disparate ecosystems
Examples from the Institute's research show that the organizations that most effectively address DOH innovate their entire business models: value proposition, resources, profit formula/priorities, and processes.
"[O]ld business models can't deliver on a new value proposition. Traditional business models impede progress toward a healthier future for people and a financially sustainable one for organizations."
Traditional ways of describing the drivers of health as social determinants may do the same.
A peek into the conversation between Blue Cross Blue Shield of North Carolina, Clover Health, and CVS Health during the Healthcare Workforce of the Future roundtable.
What is it like to lead human resources decisions for a disrupted workforce when you're disrupted too? Ask Fara Palumbo, Tanya Taupier, and Jessie Wusthoff, people management executives from three very different organizations who discussed their pandemic pivots and discovered how much they had in common.
Each discussed how internal COVID-19 response teams sought their leadership and at a time when other high-level executives were new to their organizations.
"Leading the people team, we took center stage very often, and I think that was very different for folks in our role," says Palumbo. "I think much of our workforce was relying on me personally … It was really an interesting phenomenon."
Taupier adds: "I was on the top of the agenda every single day. Anything related to human capital, talent, safety, security—you're it. So just a tremendous accountability for HR, in a way I've not seen before in my career."
Wusthoff adds: "I'd already been hearing my name a thousand times a day for different reasons … A lot of us learned a lot about ourselves, I definitely learned about myself. [Clover] needed to provide our people with the resources to support their well-being [and] … to be able to perform in the delivery of their job the way they wanted to."
CVS' response team expanded and elevated HR and other roles, while adding new voices to executive decision-making.
"The epidemiologists were forecasting the models [for pandemic impact] and it was frightening because it was showing years, not months," says Taupier. "So, I asked the CEO if we could bring the epidemiologists and the models to an executive leadership team meeting to discuss the implications. That shifted things in terms of our daily COVID response."
How change changes
As viral weeks have become viral years, Wusthoff noted the importance of organizational scaffolding when crisis accelerates.
"To me, it's less about navigating uncertainty and more about the scaffolding you create around it—so people can stand on that scaffolding and feel a little more solid."
Noting of Clover that "a lot of things didn't change—our objectives were the same, our goals were the same," Wusthoff also states: "People had to stop saying at some point, 'but that's how we've always done it.' And it's so hard in well-established roles . . . to just keep doing that."
"I've loved seeing that unlock," she adds.
Taupier summarized the pandemic response phases, from the "continual focus on safety and well-being" to supply chain and productivity to the sustained need for mental health support: "We just did not have any type of playbook for this."
No one did, including how you move a workforce from office to remote nearly overnight.
From workforce transition to an entirely new HR approach
Palumbo, Taupier, and Wusthoff detailed how the pandemic revolutionized their workforces, including recruitment, retention, and location.
"One of the key strategies for us," says Palumbo, "is offering everyone in our workforce the choice of where and how they work: fully remote, mobile, fully on site. The key is, and we are very serious about this, it is their choice. We aren't mandating any number of days in the office."
"That," she adds, "is a very big deal when you're competing with large companies locally and now even nationally."
Her plan's talent pool was largely North Carolina based, while Clover's was already distributed, with Wusthoff adding: "We had less of a learning curve. We already had a Hong Kong office. We already had a D&I team. We already had employee engagement."
The workforce at Aetna, a CVS Health company, was also largely work from home with high levels of success—except in career development.
Developing leadership remotely
"What I always have said, and I continue to say, is that working virtually or remotely, in a pandemic, is very different than working remotely [under normal conditions]," stresses Palumbo.
Each panelist discussed the pandemic's impact on training, upskilling, and leadership succession, with Taupier highlighting: "How do we take some of our really high-performing clinicians and train them to be good leaders and good P&L [profit and loss] owners of the future?"
"It's about attracting a certain kind of person," Palumbo adds—highlighting the uniquely diverse set of roles health plans must hire for (e.g., nurses, customer service, data scientists) and returning to a key point from the event's keynote speaker, Marcus Whitney: in addition to supporting people, how does the work change?
Digitization and automation are critical—as is mission.
The role of technology and the changing face of HR
"We've needed to digitize everything," says Palumbo, emphasizing her plan's digital learning strategies: "When we send people home and say you can work remotely, you've got to be able to also train remotely."
Taupier noted the need to automate across all functional areas, including HR: "We recruited using AI, digital platforms," adding: "As we think about digital automation, how do we apply that to HR? Because if you didn't have a seat at the table before, you do now. You have a tremendous accountability for thinking about human capital strategy multiyear and enabling the business."
Wusthoff adds: "Mission is a key takeaway for me … [During the pandemic,] the mission did not change; the clarity of how important the mission is only furthered. I think that's really key whether its payers adjusting to technology, recruiting—I come back to the mission."
Scale, no matter the size
Across these companies, employee size ranges from the hundreds (Clover Health) to the thousands (BCBS-NC) to the hundreds of thousands (CVS Health).
Palumbo says that while organizations must consider the policy changes would impact the most people, she notes: "What really struck me in our small group panel is that, regardless of the size of your company … the challenges are fairly similar. They scale differently, but they're really, really similar, at least in our experience."
She adds: "No matter how big or small you are, you're still having to deal with those things that the workforce expects and that need to be aligned to your culture … I've been amazed listening to Jessie and Tanya. The reality is, we're very similar with some uniqueness."
Taupier agreed: "Regardless of the scale, it's really the same types of opportunities and challenges. Whether you're in a market or the U.S. or you're global, I feel like you still have those same dynamics."
More than a pandemic
"It's very important to point out that the last two years have not just been about the pandemic … Health inequity is a great example of an intersection of what so much of the last two years has been about," says Wusthoff, with a personal investment.
"As someone with a disability, I'm very in tune to what has been an act of conversation around flexibility as an accommodation … I'm proud to work at a company that always pursues saying yes."
Yes is something she, Palumbo, and Taupier have been saying their entire careers, solving problems and supporting people, during the most difficult times.
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Healthy Alliance is one of the few companies that has adapted the medical independent practice association model to meet social needs.
As payers and other stakeholders attempt to address the social determinants of health (SDOH), one question, with many answers, remains: how?
Beyond identifying and prioritizing need, allocating investments, and demonstrating ROI, there is the challenge of creating an entirely new infrastructure of contracting, "claims," and reimbursement that involves community-based organizations (CBOs).
In New York, Healthy Alliance is leading these innovations. It has created one of the first social independent practice associations (social IPA) in the nation, taking the traditional IPA model—i.e., allowing independent providers to share resources and gain collective contracting power with payers—and applying it to CBOs instead of medical providers.
HealthLeaders interviewed Healthy Alliance leadership to discuss how social IPAs support different stakeholders, how they contract with payers, the steps required to become a social IPA, and why Healthy Alliance believes their model is better for payers.
Creating a social IPA
"We created the entity, were awarded the IPA designation in late 2018 [from New York state government agencies], and built it from there," says Erica Coletti, CEO of Healthy Alliance.
"We were one of the first," she notes, adding: "Other IPAs that have emerged since are often focused on subpopulations such as individuals with mental health or intellectual and developmental disabilities. We want to work with those IPAs and more broadly, help everyone with essential needs."
Coletti states that the organization's "referral network and IPA convene and collaborate with community partners—from regional hospitals to local food pantries—to address social needs before they evolve into serious and costly medical problems."
The social IPA is one of three affiliates of Healthy Alliance, which connects the underserved to a growing network of organizations—big and small—that provide services that are essential for a healthy life. Healthy Alliance partners with more than 580 organizations across 22 New York counties. The goal is to ensure that every New Yorker has consistent access to the resources they need to enjoy the same opportunity to be healthy.
Coletti adds that "the mission/business model is the same throughout—laying the foundation for Healthy Alliance to improve health and empower the underserved."
Contracting with payers
Independently or as a hospital subcontractor, Healthy Alliance can deliver its social service provider network to New York payers in a streamlined way.
"The IPA was formed so that we can enter contracts with Managed Care Organizations [MCOs] on behalf of our network of social care providers," said Coletti.
Contracting is just the starting point.
Michele Kelly, the organization's CFO/CAO, notes: "We're able to provide backbone infrastructure and analysis to work with payers, CBOs, and other entities on individual costs and services—to evolve a new model that starts to project volume."
Coletti adds that, for SDOH: "Claims don't exist in social services today and we need to work with CBOs to determine how to charge for the services, like establishing a case rate, fee schedule, and how they can cover their costs."
"Health plans have enough to do"
"Health plans are already forming and starting to contract with social care provider networks," says Kristen Scholl, VP of strategic partnerships for Healthy Alliance.
She notes that this is required for the Medicaid value-based payment (VBP) program in New York and that national players like Kaiser Permanente and Aetna, a CVS Health company, are creating their own closed-loop referral networks. Scholl believes, however, that social IPAs convened on behalf of payers, CBOs, providers, and other stakeholders is the better way.
"Health plans have enough to do," adds Scholl. "They're trying to meet so many state and federal regulatory requirements, Medicare Star Ratings, Medicaid quality NCQA/HEDIS—so many requirements and standards"
"You want your membership to be healthy in part to watch your bottom line," says Scholl. "It involves reducing unnecessary hospitalizations and managing total cost of care to improve the health of the people you're covering with downstream benefits."
A better model
Healthy Alliance believes its model allows health plans to move beyond a philanthropic approach to SDOH to one that unifies and streamlines.
It is for these reasons that Healthy Alliance's social IPA model is intentionally payer and population agnostic. Scholl believes this is the direction payers should go instead of creating their own social provider networks.
"MCOs are in an exciting position to develop social care strategy that leverages referrals, data, and resources in a meaningful way," adds Scholl. "This makes a difference for CBOs, who often get stuck in the middle between payers and members."
Kelly adds: "Health plans don't have the resources to provide CBO infrastructure either. They're not set up for that. Healthy Alliance provides monthly, high-touch support."
Kelly also states: "CBOs are being asked to move into space they've never been involved in. Healthy Alliance is helping build the knowledge and infrastructure related to billing, data, and analysis. Why have them take the time to build this on their own?"
Government approval
Becoming a social IPA requires state government approval. In New York, it is the same process by which medical IPAs are authorized: first, by the Department of Health; next, the Department of Financial Services; and finally, the Department of Education. For example, the Department of Health requires that:
The IPA delivers services following the contracts and compensation agreements it has with MCOs.
The IPA can be a business, limited liability (LLC), or non-profit corporation that must identify its leadership, members, and their affiliations (e.g., health plans, healthcare companies).
The states in which the principals (if the IPA is a corporation or LLC) may be "licensed or approved to operate an HMO, IPA, PPO, or to provide health services or insurance."
Unique and shared benefits
Healthy Alliance's stakeholders span MCOs, clinical providers and health systems, and community organizations—the latter ranging from CBOs to schools and government agencies. Scholl notes that Healthy Alliance's core advantages are common to multiple stakeholders.
"In some ways, the social IPA doesn't need to be framed differently for hospitals or payers since the purpose is to contract with HMOs," she says, adding: "Hospitals will have VBP agreements with MCOs that have SDOH components so the IPA can provide social care services as a subcontractor to the hospital VBP contract."
Benefits common to payers, providers, and CBOs include:
Mutual accountability and better alignment
A platform to identify need, track referrals, and outcomes
Improved outcomes and better care delivered at a lower cost
More sustainable, VBP SDOH investments with demonstrable ROI
Streamlined approach that frees each stakeholder to focus on what they do best
Kelly adds: "The goal is to bring up the whole network together."