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