Phoenix-based Equality Health has added a home-based component to its value-based care solution dedicated to serving independent primary care practices in closing gaps in care. Mark Stephan, M.D., M.B.A., chief medical officer for Equality Health, recently spoke with Healthcare Innovation about the company’s ‘Medicaid-first” business model and lessons learned piloting the new home-based effort.
Prior to joining Equality Health, Stephan served as the vice president of clinical integration for physician integration at Dignity Health, where he was responsible for the development and expansion of clinically integrated networks across the enterprise. Previously he was the CMO for Arizona Care Network (ACN), the Dignity Health-Tenet ACO.
HCI: Did your role as CMO of the Arizona Care Network prepare you well for your role with Equality Health?
Stephan: It did. That was my real first foray into population health work. But honestly, a lot of what prepared me for Equality Health was just being in the trenches. I practiced for 17 years and always with underserved populations. There are a lot of elements that I bring to bear every single day around understanding everything that the providers face in trying to do value-based contracting and manage patient panels and the challenge of working with Medicaid populations. It's a very diverse, challenged population in many ways.
HCI: Could you describe the basic business model of Equality health? Does it focus specifically on Medicaid contracts or is it broader than that?
Stephan: We describe ourselves as ‘Medicaid first.’ Those tend to be the first contracts we bring to the provider network. The way we enter markets is in the Medicaid space, but we also have Medicare Advantage contracts and we're in ACO REACH. It’s important to bring a portfolio of value-based agreements to a practice. It helps with mindshare and behavior change and practice transformation when you have a significant part of your panel in a value-based agreement. We're not in commercial at this time, but we may be in the future.
HCI: As the company looks to expand, are there big differences between Medicaid programs that could make one state more attractive than another to enter?
Stephan: There are elements that make states more attractive, but the saying goes: if you've seen one state Medicaid program, you've seen one state Medicaid program, right? They're all different. There are some commonalities that help us prioritize state markets to enter and a principal one is the state agency appetite for APMs and moving along. Because if the expectation isn't set, then it's not always a first priority for an MCO, as you can imagine.
HCI: You started in Arizona. What other states are you working so far?
Stephan: We're in Texas and Tennessee today, and the plan is that we'll be in two more states in 2024.
HCI: How do you recruit the practices themselves? Are they ones that have an interest in value-based care, but perhaps don't know where to start?
Stephan: Part of the pitch is around that Medicaid-first idea. No one's really knocking on their door to talk about helping them with their Medicaid patient population. So it's relatively easy to start a conversation. They're all over the spectrum. Some have a lot of experience in value-based contracting and panel management, but most do not. Or they're in arrangements but they're not successful. So it's been 2, 3, or 5 years and they haven't received a check. It makes it a little bit easier to start a conversation because of the way that we engage them, and the way that we pay incentives, the way that we bring tech and services at no charge to them. It's not a hard conversation to start.
HCI: So is the business model that you guys get paid when they do well in these programs?
Stephan: Yes, we are the risk-bearing entity if you will. The benefit to a plan is that we're aggregating dozens or hundreds of PCP practices from the smallest solo practitioner all the way up to an underperforming large group of different flavors. And we're able tie that into one value-based agreement where we can progress to taking downside risk, whereas that typically isn't something that a practice is going to take on. Or if they have struggled, it is a value to the practice because they can tie their raft to something bigger. They don't have to make the investment in technology or additional resources. They've got a reliable revenue stream to help them as they progress in their practice transformation with us.
HCI: Do some Federally Qualified Health Centers participate?
Stephan: Many do participate with us. In every market, we have FQHC participants because the value proposition provides benefit to their patients fits in terms of underserved SDOH needs. Attribution methodologies are always a struggle, especially for a safety net provider. The odds are that they haven't been super successful. And that is a common theme, not because the clinicians aren't doing good work, but because being responsible for a population is really a different animal to manage.
HCI: Is one of the things Equality Health brings to the table the technology to do predictive analytics to help providers identify where to deploy the resources and where the gaps are?
Stephan: This gets at the fundamental difference for us. Yes, we have predictive analytics, but we don't bring analytics to the practice. We bring actionable, bite-sized pieces of information, and help them then with work lists that are prioritized by who needs to be in your office and get this bit of work done today and tie it to workflows. Workflow is king in a primary care practice. It is the key to success. We don't just push data to them. It's really about actionable information, tied to workflows and specific role types in the office, so that the clinician can be a clinician. Really what we bring to them is practice transformation, and it benefits their entire panel, even though we're only a portion of their value-base book of business.
HCI: Let's talk about the new Equality Health at Home offering. Does it involve insurers paying specifically for home-based care or is it that in a capitated setting, this is the most effective place to spend the money — going into people's homes?
Stephan: It's the latter. It really is part of our value-based agreement. There are patients, because of SDOH, language and health literacy barriers, who are not connected to a PCP. And they've been to hospital too much and they've got 10 specialists and 20 medications, but no one's really managing their care. They are falling into the emergency department on a regular basis. So it's that subset of the population that we prioritize. We say to the PCP: you do your work on the ones where we know you have an established relationship. We'll start at the other end of the work list with those who haven't seen anybody from a primary care perspective, and we'll meet in the middle. It is a short-term program to bridge them back, to repatriate them to a primary care setting. But as you can imagine, a lot of the people we're engaging are older and sicker, so about a third of them probably are eligible for palliative care. That is our current experience, so we also facilitate those discussions. We call it complex care. The average engagement is around 12 weeks.
HCI: For this effort, you're building teams of providers in each market. Who is on those teams?
Stephan: The foundation of all of our high-risk management is the community health worker. They live in the community. They're field-based. They're very effective at finding these individuals and engaging them because they develop rapport quickly. If Spanish is your first language, it's going to be the community health worker’s first language as well. Trust is key. They address the social determinants of health. They address social isolation. Then they bring in the nurse practitioner. We don't lead with the medical stuff, even though it needs to be addressed. But that's not the driver of why the wheels came off. It's all those other elements, so we have to address that first. That's our philosophy, and that's our operation. Then the nurse practitioner comes in and helps you manage your diabetes and medication management and referrals or wound care — all these sorts of things that need to be stabilized and organized. We take the reins of care delivery in that sense. We stabilize them and repatriate them to a usual source of care. The third person on the team is the chaplain. They are very skilled at having leading discussions around family meetings and what's Dad's prognosis and palliative care. Behavioral health is another big factor. There's plenty of shame and guilt and misunderstanding about what a behavioral health diagnosis is, so the chaplains are facilitators, and they're advocates for people.
HCI: Was there anything that that you saw or learned in the pilot that made you make adjustments to the program went live with it?
Stephan: Number one is we lead the engagement with the community health worker. Cold-calling people and saying, ‘I'm here to help you and I'd like to enter your home’ is a tough sales pitch. The community health worker is for us much more effective and the engagement rate is higher. The trust is established early. And that's been a big learning. The other is we pivoted away from more traditional care management with licensed nurses and social workers. Because we found we had a lot of efficiency and effectiveness with the community health workers. They obviously cannot do everything that a nurse or a social worker can do, but the main barrier is not disease education as much as problem-solving, getting you needed resources. Programmatically we make referrals to the health plans’ care management, because they have care management for cancer, and high-risk pregnancy programs. We don't want to reproduce what health plans already do. We've decided our role is to stay close to the care delivery and the network and we find that that's where we're most effective and can drive better outcomes.
HCI: What kind of impact is the Medicaid redetermination issue having?
Stephan: It is a challenge. And I don't think all of the repercussions have fully played out by any means, but we're managing.
HCI: Is there anything else you'd like to see CMS do differently?
Stephan: Regarding the APM movement, there are many challenges there for sure, but what I guess I would say if the government called me is, ‘Don't blink. Keep moving.’ It's hard. There's no doubt about it. It's not a magic wand. It's not going to be overnight, but it really allows an opportunity for primary care providers, who are the low end of the totem pole in a fee-for-service paradigm. This is one of their key opportunities to actually keep their practice alive, to be honest, because fee for service isn't bringing more clinicians into primary care.
