MH: Hello, I’m Matthew Weinstock, managing editor of Modern Healthcare. Thank you for coming back for another edition of the Check Up.
Healthcare, as we know, for years has been inching away from the fee-for-service payment model that it’s been mired in for so long to alternative payment models. And now many industry leaders believe that the COVID-19 pandemic has really accelerated the need for the industry to make that transition to more of a value based payment model environment. The questions really still remain over how fast the industry can move and how best to get there.
I’m really pleased today to be joined by Brandon Fryar. He’s president of Presbyterian Health Plan, which is part of Presbyterian Healthcare Services, a large integrated provider insurer network in New Mexico. We’re going to talk about how their plan has embraced this transition, not just with Presbyterian, but with other providers throughout the New Mexico region. Brandon, thank you so much for being with us.
Fryar: Thanks for having me, Matt. Really appreciate it.
MH: So, as I mentioned at the outset, Presbyterian Health Plan is part of Presbyterian Healthcare Services, a large integrated delivery system there in New Mexico. But maybe for our readers and viewers who aren’t totally familiar with the New Mexico market you can give us a little snapshot of Presbyterian Health Plan and the larger integrated delivery service you’re a part of.
Fryar: Sure. So Presbyterian Health Plan, we serve roughly 600,000 members, a little north of that. I would say New Mexico … It’s important to understand the dynamics we’re facing in New Mexico in terms of the government penetration across the insurance side. So we’re probably the lowest in the country in terms of commercial insurance and among the very highest in Medicaid insurance.
And if you look at our population across New Mexico and the aging of our demographics, we’re projecting by 2030 roughly a doubling of our residents who are over 65, so you’ve got some macro trends that are really influencing I think this value based conversation in New Mexico. As more and more are seeking coverage on government programs, Medicaid has been really important to New Mexico and certainly during the pandemic has been a real stabilizing force to New Mexico through the pandemic.
MH: And certainly I do want to talk about how you guys have shifted and grown those government Medicare managed care, Medicaid managed care, sorry, and Medicare Advantage. But as we think about Presbyterian Health Plan in total, if I’m right about 65 to 70% of your plan is capitated, is that accurate?
Fryar: That’s right. About 65% of our payments to providers are under capitated arrangements, yeah. And it depends according to line of business. I think you see more of that probably in the government programs, just by virtue of what those government programs are driving to. They’re pushing for value, they’re pushing for clinical quality and measures, and we can align those value-based programs to the desires of CMS and the Human Services Department of New Mexico.
MH: And so as you think about that large of a percentage of your members, of your enrollees being in a capitated environment, what are some of the lessons learned as you’ve grown that share of the market? What have been some of the pitfalls? What have been some of the opportunities that you think others need to learn from?
Fryar: Yeah. We haven’t reached the mountain top, so I wouldn’t say we’re there. We’re constantly learning. You learn all the time and you add to your repertoire all the time.
I would say a few fundamentals that really stick out to me. One is alignment and really where are providers in the value journey? I mean, it’s almost a heart issue, right? Do they believe they can influence care or not? And if they don’t, you probably need to back up and not go to first base.
But once you get past that first gate of, look, they want to pursue value, they believe in value, and they believe they can impact value, it’s probably, we start with trust would be probably ingredient number one in establishing trust and partnership.
And then secondly, transparency. I would say that’s huge really. And by that, I mean, true transparency and alignment of incentive. And transparency in terms of here’s what we’re trying to achieve, here’s how it aligns with what you’re trying to achieve, and here’s our collective results, if we both meet our objectives. And it’s sort of and. It’s not we. It’s not an or. It’s both have to be successful or not.
MH: Sure. And on that term value, right? I imagine when you’re working within the Presbyterian network, you’re aligned, but talk to me a little bit about working with providers outside of Presbyterian. How are you defining value with those organizations and how are you reaching compromise on metrics and measures that you’re going to utilize?
Fryar: Well, first I’d say, Matt, it’s not one size fits all. So we’re very intentional and you learn this very early on. You’ve seen one provider, you’ve seen one provider, so where are they at in that journey? It’s really important that you titrate whatever model you have to their experience and where they’re at in the value continuum.
So I would say one of the core concepts, we’ll go out, we’ll describe to our providers that we can do very simple value based arrangements, upside only value based, all the way to double-side risk sharing, all the way to the end result being capitation. And you don’t necessarily have to graduate at a certain pace. If this is where you want to play, we have a program for you. So it’s really not one size fits all.
I think it’s sort of like a training wheels concept. Analogous to learning to ride a bike, right? You want to get them on the bike. You want to give them the protections, the safeguards that they feel comfortable with, and then learn together from there what works for them and not. I’ve learned don’t push too hard. Get where they’re really comfortable and usually what happens is they’re coming back and asking for the next iteration of that.
MH: And so if we think about where we are a year and a couple months into the pandemic, there has been, as I’m sure you’re hearing and having these conversations, a lot of talk about providers that were in either capitated or global payment or some sort of alternative payment model did fairly well during the pandemic as they saw volumes drop because they were in that kind of an arrangement. What are your thoughts about how as we come out of the pandemic, what that’s going to mean towards the push towards more of these types of models away from fee for service? Is it really going to accelerate it or are we still going to sort of inch our way across to these things?
Fryar: I would like to believe, Matt, that it’s going to accelerate it, but honestly, I really don’t know. It gets back to, again, that message, where are the providers in their journey? And they’ve got to be convinced that they’re better off winning in a value-based world than a volume-based world. And so I think time will tell. I always try to take the glass is half full approach on this, but the jury’s out on it.
During the pandemic, I will tell you, we really continue to have those conversations. Even knowing where we stood, we were putting ourselves out there in terms of we’re willing to enter a value based deal today with you. And all in the spirit of gaining that trust, right? Because it’s one thing to go to that.
A lot of times with that trust factor, you’re going to a provider and there might be the perception, well, you want to drive down utilization, et cetera. What’s in it for us? But it’s a different story when you can go out in a pandemic and utilization’s really low and you’re basing your value-based payment on something that’s post pandemic. So they really saw the value there. So we approached it both ways.
MH: As part of that conversation, because I imagine people still … There’s still this view that the insurers are really the ones who benefit from some of these arrangements. Providers maybe not be seeing it as much. I imagine you still have to get past some of that hurdle in messaging, right?
Fryar: You absolutely do. And that’s the fun part of this. I was just on within the last day with one of our value-based non-affiliated provider partners. By non-affiliated, I really mean non Presbyterian provider partners. And it’s a large FQHC in the state of New Mexico and talking about what this meant for them during the pandemic.
Now we had gone to a value-based capitated deal with them in the first part of 2019, so it was well in advance of the pandemic. And to see what this did for them, but it’s really aligned us, right? Instead of them talking about things like how to cut back workforce, how to manage through this trying time, they were instead focused on how to advance quality, how to advance our partnership with Presbyterian, how to better manage the population. We were having a lot of exciting conversations during the pandemic with them, and they just had the assurance that everything’s going to be fine.
MH: And as you think about post pandemic going into maybe the 2022 plan years or plan year, excuse me, do you have to rejigger some of the metrics you’ve had with some of these providers because they’re numbers may have been thrown off during the pandemic because of utilization?
Fryar: Yeah, absolutely. We really have to be sensitive to that, where the numbers are at, where are the quality metrics? As we all know, in particular, a lot of those quality programs are what really suffered as people were foregoing necessary care treatments and tests, et cetera. So we’ve really felt it here and we’ve got an uphill battle ahead of us.
MH: One of the other things that we’ve talked to a number of folks about is the growth, obviously, of telehealth during the pandemic and where we’re going to be with that. Obviously, we had the pendulum swing in terms of payment during the main surges of the pandemic. We’re starting to certain to see some of that payment revert back to sort of pre pandemic days. I’m curious from your perspective how you think we get to an equilibrium where telehealth payment is right for the insurer, right for the provider, and ultimately right for the patient at the other end of it.
Fryar: Well, I’ll tell you New Mexico has mandated equilibrium with face-to-face and telehealth payments. So there’s so much you can do. But even in advance of that mandate, we thought it is good to incentivize that telehealth, that more convenient care, and focused on the more preventative care that required tests and treatment that individuals need. So we were all in on incentivizing our providers around that.
Now, certainly when you’re under a capitated deal it’s built in incentives, right? They can do that at a lower cost point and benefit from a value perspective there. So it’s just something that we’ve pushed. We’re behind the telehealth journey. It’s been very instrumental for our providers across New Mexico, in particular, given the rural nature of New Mexico. It has been a really important component of how providers have been able to withstand this. Even if they weren’t in a value-based deal, a lot really leveraged the telehealth component and we want to be there to support them through that.
MH: Got it. Brandon, I also wanted to talk to you a little about some of the innovative programs Presbyterians put in place. The Complete care for Medicare Advantage program you’ve got, right? That’s something I was curious about. You’re targeting a small percentage of patients, but they account for what 50%, 60% of the costs, is that right?
Fryar: That’s right. Complete Care is a targeted program mostly in our Medicare Advantage program for those individuals that otherwise would be seeking hospital care, hospital level, acute care. And these are chronically ill individuals that have a lot of emergency room utilization and a lot of really acute needs and being able to manage them at home. And we’ve seen really dramatic, great, great results.
Of course, it’s a really targeted program to your point, Matt, at those that really have heavy unmanaged utilization. This is a way to really manage their health and it really changes their lives. I’ve talked to those members and their spouses and their loved ones and being able to be cared for at home is a big deal. So programs like that I think is where we’ve got to get to, right? More hospital at home, more complete care, more virtual options, convenient options, all those things that we’re all talking about.
MH: And obviously that program started well before the pandemic. It was a number of years ago. But as you think about how do we start to spur some of that innovation now that we’re starting to see the light at the end of the tunnel here are you guys having conversations at Presbyterian about some new ideas that you can bring to the marketplace?
Fryar: We are. We’re having a lot of those ideas. You think about where technology has gone from a home monitoring perspective and what can you do with the new technologies around home monitoring? That’s one example. I see us launching some programs, some targeted programs to high need members or members maybe even less about need and more about convenience or more about access. Rural New Mexico, it’s hard. You don’t want to travel 300 miles to see a specialist in Albuquerque. We can do it better. And there’s technologies that allow us to do it better. So we’re exploring all of that.
MH: That idea of reaching the patient sort of where they are no matter what, right?
Fryar: That’s right. We’ve got an innovation hub that’s doing a lot a great work around this, and I’m glad to be partnering with them.
MH: Well, great. Brandon, we appreciate your time talking through some of the innovations you’re working on there at Presbyterian. We’d love to check back in with you periodically to see how some of these things are evolving, but we definitely appreciate your time and sharing some of your expertise with our audience today.
Fryar: Thank you, Matt. I really appreciate it. Take care.
MH: Thank you. I’m Matthew Weinstock with Modern Healthcare. Be sure to come back next Monday for another edition of the Check Up.