On Belay Health Solutions is a physician enablement company that supports practices in transitioning to value-based care. With a focus on supporting Federally Qualified Heath Centers and other practices working in underserved communities, the company is currently operating in 18 states. Co-founder and CEO Andrew Allison recently spoke with Healthcare Innovation about what he sees as the key to success in this space.
Healthcare Innovation: Could you tell us a little about your background and what led you to co-found On Belay?
Allison: I started my career in the healthcare ecosystem with Iora Health, which was purchased by One Medical and afterwards Amazon more recently. I worked for Aetna for three years, developed their risk contracting playbook for Medicare. I always wanted to get back to the provider side just because I just felt this strong connection to the passion, the mission, the values of these folks that are actually trying to deliver great care to patients. And frankly, they are the underdogs in healthcare. They kind of get taken advantage of and just aren't valued as much as I and many people think that they should. I met my co-founder, Dr. Scott Early, when I was working at Iora, and we have worked together to build this value-based model that focuses on physicians first, care teams first, where I could bring my administrative and contracting skill set and he could bring his physician skill set and care model skill set to combine to create this entity to support providers in a value-based model.
HCI: The name of the company, On Belay, is a climbing term, right? So how does that apply to what you guys are doing here?
Allison: It is. We were looking for a name that evokes this sense of support and helping achieve a great feat and we thought that climbing a mountain and be that on belay mechanism, helping somebody climb that value-based mountain.
HCI: Does the company have a specific focus on FQHCs and other practices working with underserved communities?
Allison: Yes. We do not discriminate against non-FQHCs. We work with a whole gamut of folks. But, for example, Lawrence, Massachusetts, is either the lowest income or the second lowest income city in Massachusetts every year, and that is where Kronos Health, Scott Early’s practice, is based. This is a highly comorbid population, very underserved population that has frankly been overlooked by many health systems and/or payer entities. We started with a foundation of saying we have to support these people that have higher comorbidities. They have higher acuity, they need more support, not less. We have since expanded our relationship and doubled down into that community. We not only work with physicians who are located in low-income geographies, but also very explicitly Federally Qualified Health Centers. We just announced a partnership, with the Association of Clinicians for the Underserved, which has several hundred FQHC members, and we are the exclusive partner to that organization in enabling Medicare ACO models for FQHCs.
HCI: Are you working with practices involved in the ACO REACH program?
Allison: Yes. For instance, we support the Blackstone Valley Community Health Center in Rhode Island in ACO REACH. But we are not just an ACO REACH entity, even though we were one of the original 53 that applied and were accepted and participated. We are also now in Medicare Shared Savings. And we also work across all Medicare Advantage plans in the state of Massachusetts. We work with several other plans in other markets. And we serve commercial beneficiaries in the state of Massachusetts. So really, we are enabling physicians to jump fully out of a fee-for-service model into value-based no matter what payer their patients have an insurance card with.
HCI: When you consider expanding, are some states more attractive than others as far as the commercial or the Medicaid space?
Allison: We have a national contract in ACO REACH and MSSP. With other payers, we're able to expand to any geography once we have some practices that we support. I would say what's more important is whether we have an anchor provider partner that we believe we can grow around and create a clinically integrated network with, because that's where we can do really interesting things, where it's not just focused on a benchmark rate or virtual care. We have care managers who are delivering care or coordinating care in the community, but you need to have more dense markets and more patients to ultimately serve with those types of models, because it just requires higher panel sizes.
HCI: When you have a new practice partner, what are some things you work on initially? Is there a tech enablement part to this? We often hear that FQHCs don't necessarily have the resources or funding to get the greatest population health analytics tools or communications tools with patients. Is that something that you work on with them?
Allison: I would say there is no single approach. This is a partnership approach and there's no one size fits all for all groups. The providers are constantly pulled in several different directions, many of them administrative and things that don't actually benefit the patient. We are trying to take those things off their plate and enable them to really operate at the top of their license. Second, we educate them on value-based models, what's important and aligning incentives to the right things that ultimately will improve performance both from a surplus or savings perspective, but also a quality-of-care and closing care gaps perspective. That ultimately enables the shared savings generation. At the end of the day, these shared savings are going to be critical to support this model.
HCI: The ACO REACH program requires practices to begin focusing on health equity projects to close disparities. Do you have any examples of those types of projects?
Allison: There is a transition into the financial incentives going into next year, but we have absolutely formalized it in working with a subcommittee that's dedicated to health equity. We're starting with three clinics that are geographically dispersed, one in Massachusetts, one in Rhode Island and one in Florida. We decided to focus our initial pilot on congestive heart failure because we determined that underserved communities generally had an unusually high utilization of emergency department and inpatient admits when they have CHF. We've developed a care plan and worked with our executive director of pharmacy to build a clinical toolkit that we leverage to ultimately pilot in these clinics. Our onsite care management team is supporting this as well and jumping into action to coordinate care for these underserved patients. So that's just one intervention among a lot of things that we're doing as part of our health equity plan.
HCI: When you do a pitch to practices, do you sometimes have to overcome a reluctance or skepticism on their part or bad experiences they've had in the past with pay for performance initiatives?
Allison: 100 percent. I would say probably 90 percent of the groups that we work with have had some sort of ACO experience in the past, right? They are not working from a blank slate. But I honestly think that the definition of value-based can be very perverted depending on who it's coming from. And a lot of the experiences of those groups has been negative. They have not had any transparency in their results and how they're doing throughout the year. They have had no engagement from the actual quote unquote, accountable care organizations. They haven't had that on-site presence, that care team extension. And at the end of the day, they don’t understand why they did or did not get a check. It's so opaque. Scott and I said that we need to be fully transparent with our providers. We need to show them every time that we get data from CMS or any other payer. What is it telling us we're doing well, what is it telling us we're not doing well? What are the levers we can pull? And ultimately, how does that translate to performance at the end of the year, and being fully transparent about all of our costs that might be supporting this model? We charge no fees at On Belay and our business model is predicated upon the fact that we need to earn shared savings with these groups.
HCI: Is there anything different you would like to see from CMS or CMMI?
Allison: I want to give them credit because this is a super complex space. It has tons of different stakeholders, and the fact that they've put a stake in the ground of moving all Medicare beneficiaries to value-based models by 2030 is a pretty bold goal, and they're actually putting weight behind it, which I haven't always felt when I've heard those types of goals set. And I think that these types of models are pushing the whole system in that direction, which is great.
On a more macro level, every year since 2006, more Medicare beneficiaries have selected Medicare Advantage than traditional Medicare. There might be some reasons related to the fact that the value-based models have worked more on that side of the business, and the expanded benefits like dental or others that are more flexible on the Medicare Advantage side. Can we have a more focused effort on identifying what might be some of those drivers of why beneficiaries are choosing Medicare Advantage over traditional Medicare, and then can we work together to create a more sustainable long-term program in these ACO models that you're putting out in CMMI and CMS? Are there things that we could be doing within those models to make it a more competitive or long-standing program? Because I want to see traditional Medicare around for the long term.