In this episode we hear the second half of the conversation with Franklin County Public Health Director, Scott LaVigne, in which he shares his views on the role of properly addressing behavioral health, providing a positive patient experience, and the importance of partnerships, and how these elements, and others, work together in order for his team to provide holistic care for patients.

I want to go back a little bit to something you mentioned earlier. So we talked, you talked about the needs-based care, what I call the contextualized care and Medicaid is very focused on serving the whole patient, right, which includes some of those social determinants of health. And, and we've talked about access and access to behavioral health is really important. How's Franklin County Health Partner Department partnering or attempting to partner with other agencies to address these needs?

Well, one of the things that when I first came down here that that I just said we really needed to do was get our medical staff. And by that I mean everyone from the person that greets somebody when they walk in the door and checks them in to the person that works through everything with their, their claims and submitting and all the financial pieces of all that interaction from start to finish and everything in between that we had a trauma informed and, and with a focus on integrating behavioral health and, and behavioral health is a broad term. I should probably break that down because it's used a lot in different contexts. I don't look at it as a way of, of sanitizing mental health. So I look at it as a collection of mental health and substance use disorder and, and really what we wanted to focus on here and it and it goes to the social or social determinants of health. We wanted to focus on the whole patient, not just one aspect of that patient. I know I don't think I've ever heard of patients say that they felt their life was better because they met all their HEDIS metrics.

Me either, by the way.

But what, what we did and what I, I did do almost immediately was we purchased an outcome measurement tool because I knew that one of the things that we want to do is we didn't want somebody to have all their screenings done, you know, meet all those metrics like that on the healthcare side, but have housing insecurity and be living in domestic violence and to have substance abuse and mental health problems. Because I know as a mental health provider and a substance abuse provider in my background history that most of the people that show up in emergency rooms with preventable emergency room presentations are people that have mental health and substance use disorders and other things on board or have experience childhood trauma. So we knew that if we didn't look at that whole picture and integrate that in, we were going to have a hard time doing that. So we pulled an outcome measurement tool from behavioral health. It's called the DLA 20 and it, it focuses on 20 areas of a human's existence. And we wanted to make sure that if somebody experienced a good positive health outcomes, that translated into all these other areas as well. And that became our outcome measurement tool. So that was a big piece of what we focused on. Let's see. The other thing I mentioned already was we wanted to do more screening. We, you know, we do screenings routinely as a health department. We have to spend more time with patients because of our funding than providers in the community do. That is a blessing because we have budgeted time to take into account all of what we need to do, and that fits very nicely with a more holistic approach. So it really wasn't causing us to suffer a lot in the volume department. And we focused all our efforts. And I told everybody here, you know, one of the things we want to focus on is the equation of value. And yeah, you got to have a certain amount of volume to make that equation...

Today we hear an important conversation about the role of local government in population health and wellness. Scott LaVigne, Public Health Director of the Franklin County Health Department in North Carolina, talks with CHESS vice president, Josh Vire, about the broad scope of work his team is responsible for and how they are successfully tackling numerous initiatives, including managed Medicaid, to be a safety net provider for community health needs.

Scott LaVigne, welcome to the Move to Value podcast.

Oh, it's great to be here.

We're we're really excited and looking forward to the conversation. Scott, as a public health director, you're responsible for all aspects of the Franklin County Health department from the clinical to environmental services and you balance state mandated services. So for the audience that things like vaccines, basic health screenings, environmental services, and with the expectations of Franklin County government, all while dealing with the critical workforce shortages. Health departments are considered safety net providers in most of North Carolina's counties. Can you share how your team is addressing the specific healthcare needs of the Medicaid population in the county?

Sure. Well, after hearing all that, I'm, I'm getting tired. Yeah. That that is a we have a lot on our plate here at the health department and a lot of they're, they're not very often competing interests. But you know, I think what we look at when we talk about healthcare services in general and the overall health of the county, we don't break it up into per SE Medicaid population, although we do focus on that as part of the work that we do. But we, we have 2 broad missions and one is obviously population health and that it cuts across all payers and everyone in the community. And then the other role, which you correctly identified as we're a safety net provider. So in addition to putting out a lot of population health initiatives, we're also a provider and we're involved in a lot of the initiatives that all the providers in the community are involved in. So, you know, that gives us a unique position and we get to tailor some of our initiatives as a healthcare provider based on what we know the community health needs are. So it's, it's, I'm going to be honest, it's not very easy to do all of that. I would say we, as I said, we don't just focus on the Medicaid population, but we do have a lot of initiatives that cut across all of that.

Great. What are the specific issues that that I think you have a lot of experience in close to 30 years of behavioral health experience with much of that coming in New York. Can you describe the changes in public health that you see in your career and maybe also for the audience contrast the differences between the public health in New York and North Carolina. What are the differences you've seen?

Sure. Well, when I was in New York, I was a a mental hygiene director for a county and, and when I came to North Carolina, I became a public health director. But we were actually in the same building in New York with our public health programs and we had a very close relationship with that program. But there are some significant differences, but a lot of similarities. You know, the some of the big differences though relate to some of what we're talking about. Medicaid managed care being a big one in New York. Medicaid managed care started first with medical care and then they brought behavioral health and IDD into the picture. In North Carolina, they did it the exact opposite. And so that that was a, a big difference. When I came down here, we had a mental hygiene system that had already made the conversion and was and, and medical care, which is what I was now in, we had to make that shift. So, I would say that was a, a big difference. But in New York, most of the public health agencies had gotten out of...

In this episode, we hear the second half of the conversation between Kris Shepard, Senior Vice President at Advocate Health, and CHESS President Dr. Yates Lennon, as they discuss how physician networks and primary care services are the backbone of the value movement in healthcare.

So Chris, welcome back to the Chess Move to Value podcast. Look, look forward to continuing our earlier conversation.

Awesome. Well, had a good time so far and I'm expecting nothing less for the second, second-half.

OK, great. Well, let's start out the second-half here. Just let's talk a little bit about some of some business development goals, both from the lens of the MSOVSO and from Advocate perhaps as well as if I'm an independent physician in the market, whether that's the Carolinas, Georgia, Wisconsin, Illinois, what should I be thinking about? So come at it from both sides.

It's a great, great question. The, the starting point for me is really an acknowledgement that the healthcare industry is changing. And you know, we've, we've talked about change and transformation in healthcare for a long time. So this is I think part of that broad continuum in the future, I expect that there will be increasing, it would be increasingly important for the ambulatory enterprise to take on more of the care delivery then perhaps we have historically it's more and more expensive to build hospitals. I think you, you know, you see a lot of commentators talking about hospitals becoming more focused on kind of higher acuity, higher complexity things. And so you know, they're always going to be here. And we're, you know, we are building broadly in facilities across the advocate enterprise and investing in, in improvements in the facilities. And at the same time, it's going to be increasingly important for the ambulatory enterprise to take to take on more and more. Some of that is is is has a regulatory dimension to it. So for example, CON laws being loosened or removed in in South Carolina, North Carolina, perhaps other places. I think those those kinds of regulatory changes, reimbursement changes that that encourage certain certain types of procedures and certain care to move out of facilities into the ambulatory setting. All those I think point us toward a future where to for a health system we are going to need to be successful in that ambulatory space as well as as as with our facilities. So what does that mean from a physician you know, or a clinical enterprise development lens, a physician partnership lens? I think those relationships become even more important and and in some ways more challenging because there there are a lot of organizations, whether they're payer backed organizations or private equity backed organizations or public companies like an Amazon who are moving into that ambulatory space. There's almost nobody going into the facility areas, you know, not a lot of new money or new entrants, if you will, into in building hospitals, but they're definitely a lot of new entrants rolling up ambulatory practices. So, you know, from a strategic lens advocate can either, you know, choose to focus on, on the facilities or, you know, alternatively, what we've done is, is really geared toward building a significant ambulatory presence. And you know, we, we already have thousands of physicians employed, you know, hundreds and hundreds of clinic sites. We, we have a significant ambulatory presence already. But it's going to it's going to be increasingly important going forward to do that. And I think, you know, some of the some of the discussion we've already had about what's the right relationship within it with a given group and a given specialty is those, those questions become more significant when you think about how the industry is, is trending.

Yeah, Yeah. Let's let's head toward, I mean MSOs/VSOs are networks in and of themselves. But let's talk a little bit about physician...

Today hear from Kris Shepard, Senior Vice President of Clinical Enterprise Development and Core Market Growth and Physician Partnerships at Advocate Health. In a conversation with CHESS President, Dr. Yates Lennon, Kris talks of how Management Services Organizations benefit patients and creates opportunities for practice growth and professional development for providers.

OK, Well, good morning, Chris. Glad to have you on the chess Move to Value podcast. Look forward to our conversation today.

Good morning. Yeah, great to be here.

Good. So Chris, I'm looking at your title clinic, SVP, clinical enterprise development and core market growth physician partnerships. Tell us what you do.

I do a few different things. And as that title probably implies, sometimes I'm working on your plain vanilla physician practice acquisitions. Sometimes I'm working on acquisitions that are not so plain vanilla in a more complicated in a larger scenarios, something particularly unique. And then I work on a range of other physician partnership transactions, professional services arrangements, as well as working on management services opportunities that we see with groups. And we really view that clinical enterprise development as, you know, broadly designed to look at our physician networks across the Advocate enterprise and and pursue what we think will work in a given market, a given specialty. And so that's why it's a fun job to have. I get to be creative and yeah, engage with people in a very different settings and try to put together things that that are appropriate in the right context.

Yeah, never a moment of boredom, I would imagine with that much variety. Well, you, you, you touched on managed services. You know, there's a lot going on today with various managed services organizations as well as what you might call value services organizations. Talk to me a little bit about sort of at a high level, what do you think the opportunity is in the MSO slash VSO either or both market today?

Yeah. I think I'll, I'll come at it from the perspective of physician groups that we talked to pretty regularly And you know, different groups have different needs. But one of the realities that seems to be hitting a lot of, you know, physician owned practices is that they don't necessarily have the scale to keep up with whether it's, you know, physician practice infrastructure needs or, or it's and, or the value-based care capabilities that they need to be successful. And so, it's, you know, two different buckets that are that can be addressed through management services and value services arrangements. But that's the reality. I think practices used to be able to kind of, you know may do just fine on their own. I think there are a variety of factors playing in to the challenges on independent practices now, payer relationships and kind of reimbursement challenges that exist, the cost pressures that are hitting every everybody, especially in the healthcare industry, kind of inflationary factors. And then there are things like, you know, EMRs are expensive. It's expensive to fend off cyber-attacks, to have the right cyber security frameworks in place, to make sure that you can you can continue in operations, to have the best revenue cycle, the best supply chain options. All those are things that are I think increasingly challenging even for the larger physician practices out there. So there's a, there's a scale factor there, same kind of themes with respect to value services. I think it, it takes a lot. There's analytics platforms, there's teams of people to support, to support a practice in, in delivering care the right way and then being able to record that and have that be a parent in quality metrics that get reported and cost metrics and, and everything else. So I just think, I think it's this moment. And from a, you know, I work for Advocate health for the health...

In this episode, we hear the second half of the conversation between CHESS Vice President of Value-based Operations, Josh Vire, and Wilson Gabbard, Advocate Health Vice President of Quality and Condition Management, who discuss the importance of partnerships with payers and implementing value based care practices with all patients, even if they aren’t in a value-based arrangement.

Wilson, thank you so much for being willing to stick around and continue this conversation. I really appreciate it. Wilson, you had just talked about on our last episode, you, you talked about clinician engagement, that relationship management and that activation. And, and this is something that I think you guys have been leaders in for a while in the Midwest. You your team not only supports the Medical Group of Advocate, but also support a large CIN that includes a significant number of aligned independent physicians in the area. Can you talk a little bit about the challenges of supporting aligned physicians versus the Advocate Medical Group?

Well, absolutely. And thanks again, Josh for inviting me to participate in this forum. So, I think, you know, we certainly don't have all of this figured out. I'd be lying if I said we did, but I think many of our listeners will probably appreciate the challenge that it is to operate in both of these worlds. And in our space, especially here in Illinois, it's especially pronounced. I think we have over 830 aligned clinics that participate in our clinically integrated network. And so the challenge that we talked a little bit about last time or about the data exchange and data exchange barriers is incredible, especially at that scale. But I think true clinical integration is really hard to accomplish without strong data and handoffs. And so I think we've leaned into this space of trying to bridge that gap with data exchange efforts. Again, time back to some of the work we're doing in ECQM reporting to kind of bridge the gap between those aligned DMRS and our data warehouses so that our reporting is as accurate and as timely as possible. That we are reaching out to patients for Medicare Wellness visits, annual Wellness visits. But when we can go in and see in an electronic means that they're already scheduled for those Wellness visits that we aren't, that we build off of care plans when we're doing care coordination activities that their PCT and their instances of EMRs have already documented. And so that is very hard work. And again, we're not completely there yet. If anyone listening has figured it all out, please add me on LinkedIn and give me a call because I'd be happy to hear from CIN who has figured it all out from the provider-based space. But anyway, it's certainly a challenge, but I think that it has applications across what we do in quality or condition management or utilization management. And I think that all of the principles about clinician activation that we talked about last time and kind of building out those teams and points of contacts are critically important to translate those messages that we do. I call it internally, I call it we have one strategy with different flavors, right. We have a flavor that is applicable to our internal clinicians on their instance of their EMR. And we have a different flavor that is applicable to the clinicians who maybe are on dozens of different EMRs.

Yeah, that's, that's great. It's I will accept your modesty, but also toot your horn a little bit. That why you guys may not have it figured out. You, you guys just evidence here in this conversation are pretty good at it and are probably more advanced than a lot of the other folks. And, and really impressed every time I talk with you guys about how you approach and work with your line providers. It's not an easy thing to do. We've been at this for a long time as well at CHESS and, and, and I think you highlighted accurately some of those challenges. So I appreciate...

In this episode, CHESS Vice President of Value-based Operations, Josh Vire, talks with Wilson Gabbard, Vice President of Quality and Condition Management at Advocate Health, about how to gather and present meaningful data to providers in an easy and accessible way which enhances their delivery of better patient care.

Well, Wilson Gabbard, thank you for joining us on the Move to Value podcast.

Thanks, Josh. Thanks for having me. It's good to be here.

Great. Wilson, I know you have a wealth of knowledge, both population health and value based care. Can you just start by giving our audits an overview, a little bit about you, your background, where you've been, what you've been, what you're up to today, and your responsibilities at Advocate Health?

Yeah, absolutely. Well, again, Josh, good to be here. You know, value our friends and colleagues at CHESS and have long followed all the great work that you all have done. And so, it's a privilege to be here. Again, you know, by way of background, I'm a former practice operator, used to lead clinic operations in Eastern North Carolina and had the privilege of kind of pivoting into a population health focused role back in 2013. So, over a decade ago now helping build out some of this work in a prior life. And you know, over the years it's been really interesting to see the evolution of value and how we've gone to taking on more risk and building out more sophisticated programs and blending together Medicare Advantage and MSSP or different value-based programs together to ultimately really just better serve the patients and clinicians that were really just privileged to be able to serve on a daily basis. So, you know, today what I'm up to is here at Advocate Health, I have the pleasure of leading quality and condition management efforts as part of our enterprise population health structure. You know, we think about value-based work and kind of the formulaic equation that is driven based on three main components, which are quality, utilization and premium and lives. And how we do that, how we operationalize that is really around the two functions that I again have the privilege of kind of serving in or related to the quality and condition management work and have the again opportunity to do that along a really amazing physician dyad, who I feel very privileged to work alongside as we implement some of these programs.

That's great, Wilson, thanks for that background and I'm glad to share that with the audience. You mentioned you've been you've been at this for a while, you're very well versed on what drives and improves contracts in value-based care. So really excited about again having you here and could you go a little bit layer deeper in what is condition management and documentation? What does that mean specifically at Advocate and a little bit about what your how your role plays in supporting value-based care efforts.

Yeah, great question. I think that our approach to value and again I think value-based care is you know the corollary or antithesis maybe is the wrong word, but to fee for service, right. As we move from fee for service to value, we think about the premium and lives component that I mentioned earlier about ensuring that we are receiving the appropriate reimbursement for the patients that we're caring for. And the way that CMS, our government programs have implemented that financial model and value is through a risk adjusted payment mechanism. But at the end of the day, the way that we think about risk adjustment here at Advocate is that risk adjustment really at its core is just a population health fundamental that ensures that it's really, it's all about ensuring that patients and their conditions are not lost to care. In value-based care, I love that the focus is not about on widget counting, but rather on caring for conditions, ensuring that those...

In this episode we finish our conversation with Rebecca Grandy, Director of Pharmacy at CHESS, and learn how pharmacists can overcome barriers to issues in patient care through tools such as prior authorizations. We also talk about how CMS doesn’t consider pharmacists care providers and how resolving that will lead to greater efficiency and better outcomes.

So Rebecca Grandy, welcome back to the Move to Value podcast. Glad you could stick around and continue this conversation about pharmacy services with us.

Thank you.

Rebecca, last time we were talking about all kinds of great things and how a pharmacist is such an integral part of the care team and we talked about collaboration with clinical providers and other healthcare professionals. One of the things I wanted to talk about is prior authorization because that's prior authorization for medication is crucial in value-based care. Can you explain to us a little bit about the process and any, I don't know, administrative burdens that might be there and how do we address these to make sure that our patients are getting timely care?

Sure. You know, I think if you were to ask some of our physician or provider colleagues, they would probably say prior authorization is a four-letter word, right? However, I do believe that as we think about value based care and we think about cost effectiveness, we have to have some sort of process or I'm blanking out here Thomas, we have to have, we have to have some sort of process or way to guarantee that the medicines we're using are going to be cost effective. So, when you think about prior authorization, that's really the intent, right? Usually they're for expensive medicines or they're for medicines that can potentially have lots of side effects or that have very specific clinical niches, if you will. And so I do think they're necessary. However, more and more medicines are needing prior authorizations now, and that's really created an administrative burden for our providers and provider offices That has gotten to the point actually where Congress is sort of intervening at this point. And there's lots of legislation over the next few years, you should see that process get better. So for example, if I'm a physician and I want my patient to have a very specific diabetes medicine, so there's some diabetes medicines that need prior authorizations, I send the prescription. And for most of our providers, they're not even going to know it needs a prior authorization until the pharmacy sends either a fax or an electronic prior authorization back to that office. So I may not even know. So my patient has already left the office. I tried to send in their prescription. Now I get kicked back from the pharmacy saying, OK, this needs a prior authorization. So you can already see in this example, you sort of set yourself up for some dissatisfied patients and some for dissatisfied providers. And so once I get that prior authorization paperwork, someone has to complete it. And in my experience, I've actually had experience doing prior authorizations. If you don't dot every I and cross every T, you're not going to get it approved and you're going to get a denial. You may not know about it, you know, for several days or even several weeks, depending on the insurance and depending on the priority. And so now you have a patient that's sort of left in the dark because they don't know why they can't get their medicine from the pharmacy. The pharmacy's saying why I sent the paperwork to your provider. They need a prior authorization. The physician offices has no idea where it is in the insurance queue. And so you take that and you compound it with the fact that every insurance has a slightly different process, every medicine is a slightly different process. You have to log into external portals which are not part of the day-to-day workflow. And so the administrative burden, again, it's just a...

Today we continue the discussion between Yates Lennon and community health expert Randy Jordan, about how good health is typically achieved through a good clinical home, which has always been an insurance discussion but now should shift to a discussion about the uninsured who need the knowledge about where to go when sick, to increase savings in the cost of caring for the entire population.

OK, All right, Randy, thank you for sticking around. Our first conversation was fascinating. Looking forward to continuing that. I think you've touched a little bit on the next question I have for you, but we'll maybe expand a little bit more. Tell us about you talked about the health, the safety net and being that term being used pretty widely and you I think listed out free and charitable clinics, FQHCS, rural health clinics as sort of the network. I think I might have left one out. So fill, fill that in for me. But why is it so important? Why? Why is the health safety net so important? And to one of my earlier questions in the first session, why does it not get more attention than it does?

Well, I think added to the list Yates would be public health units and school-based health centers.

There you go.

You know it. It's a fascinating question that you're asking because I think to those who work in the space, it gets all the attention in the world. It's built around mission minded folks who want to see this issue of the uninsured being taken care of. If, if we just pause for a moment and look at all the energy that was brought to North Carolina recently about Medicaid expansion, it brought all kinds of groups together. But it was in that case, it was for the intention of getting a health insurance card in the hand of people in need. That same passion though, exists for those that are in the business of trying to, to provide healthcare services to uninsured patients. And so at one level there's a lot of attention to it, but at another level, there's, a real absence of attention. I don't think it's because people don't care. I think it's because we've not informed them well enough. And it's one of the things I appreciate, appreciate about the chance to be on your podcast today is when the message gets out, people are good hearted, they'll respond in the right way. But we do need to get the the message out. We need to get it out to policy makers. We need to find ways for that voice to be united. And that's, you know, those are some things that I'm also working on in my spare time.

Awesome. So you, you mentioned in the first session the hospital in Jacksonville that worked with the free and charitable clinic. Can you talk to us a little bit about how the Medicaid, the the health safety net can be strengthened? What, what, what needs to happen? What are some ideas and needs for strengthening that safety net?

Well, we mentioned a number of times Medicaid already today. One of the strong ideas that came out of Medicaid transformation was a recognition that social determinants of health are important for good health. And so we're talking about housing, food insecurity, transportation, and basically protections against family violence and other forms of interpersonal violence. So the Healthy Opportunities pilots that have sprung up across the state, three of them now have identified and brought together sort of the safety net of social services. It's a wonderful thing and we celebrate it. But it because it applies only to Medicaid, that access to that network is not organized in a way to also apply to the uninsured. And I think that that's one challenge that that lays ahead for us is finding a way to leverage what's being built in the Medicaid system and apply it to the uninsured. Now here's an interesting thing. If you look at the demographic of, of most Medicaid patients, it's very, very similar if not identical to uninsured patients. The it's all income