As healthcare organizations reach COVID-19 peaks and leaders begin to look at post-pandemic healthcare protocol, it becomes clear that the healthcare scene post-COVID will be very different than it was before the pandemic.
Join Collective Medical’s Head of External Affairs, Kat McDavitt, and Community Based Coordination Solutions’ CEO and Founder, Dr. Enrique Enguidanos, in this inaugural podcast as they interview Dr. Joanne Roberts, Senior Vice President and Chief Value Officer at Providence St. Joseph Health System, and Deborah Kozick, Associate Director of Delivery System Reform at the Center for Health Care Strategies to see what changes we can expect to see moving forward, and how this will impact our nation’s most vulnerable patients.
- Challenges faced with an influx of inpatient care
- Employee retention during recession and pandemic
- Positive “lessons learned” as a result of COVID-19
- Forward-moving initiatives to address patients with behavioral health, social determinants of health, and other vulnerable populations
Enrique: What are some of the gaps in healthcare you’ve noticed with COVID, and what are some of the early successes you’ve been able to identify?
Joanne: Providence is a primarily West-coast healthcare delivery system serving seven states and one of our hospitals was the index hospital with the first COVID patient in the US. That patient came to us in late January. Pretty quickly, we started learning lessons because the ramp-up from that first patient to what ended up being 140 patients per day at that hospital was pretty traumatic.
Testing was the first big challenge because we couldn’t get folks diagnosed. We got the first patient diagnosed within a day through the CDC. For subsequent patients, it would take us 1-2 weeks to get results back. The second challenge was personal protective equipment. Within a month of that first patient, that hospital was down to about eight hours of personal protective equipment. The third challenge was the absolute explosion of home monitoring and virtual care that we’re seeing. We went from seeing about 300 patients a week virtually across our system to seeing upwards of 20,000 patients per week.
Deborah: One of the core challenges is keeping providers afloat given the changes in revenues, particularly those for whom revenues are tied directly to in-person encounters which has, for some years, been a topic of conversation and one we’ve tried to help facilitate the shift to value-based payment for this exact reason. The pandemic is a stark reminder of how much the health system and the whole Medicaid ecosystem really needs to evolve in order to thrive. This crisis also has left more vulnerable communities exposed, highlighting these long-standing disparities in access to care. And that’s something we’ve been focused on.
Enrique: I imagine there have been some unanticipated or unique partnerships that have evolved, particularly with cross-sectional collaboratives. Can you both speak to that?
Deborah: I think one theme is tapping into existing infrastructure and partnerships that were perhaps less formal or in the pipeline and thinking about how to scale those further. Some of the on-the-ground partnerships have been really creative. For example, Medicaid beneficiaries that access food banks and other social needs typically rely on in-person visits and we’re figuring out ways to leverage community-based organizations and care team members like community health workers who can support food delivery alongside medication delivery.
There’s also been an effort in the digital health space to address the digital divide. The increase in telehealth and understanding its importance makes us aware that many Medicaid beneficiaries don’t have internet access. Some Medicaid and state agencies have been partnering to support getting folks access to computers, internet, and the technology they need to access the virtual care that’s now being offered.
Joanne: To touch on virtual care, we’ve known for a couple of years that the lack of access to Wi-Fi is significant. However, the lack of devices is not. While not everyone has a device, it’s almost ubiquitous to have one these days. We think virtual care will be a substantial advantage for vulnerable populations once we get the connectivity improved.
Historically, our biggest barrier to driving virtual care for populations has been physician workflow and hesitancy. COVID allowed us to present virtual care as a way our physicians could offer care and they jumped on it. And I don’t think we’re going back. Payment for virtual care has been opened up and I think it will be hard to close it back down. Additionally, what we’re finding in patient surveys is that they like virtual care more.
Kat: I know there’s been talk that some of the support systems propping up virtual care might not be sustainable. Are you seeing any concern or is there a plan being put forward by either of your organizations to make sure virtual care is a sustainable part of your care delivery?
Deborah: In terms of reimbursement, there’s parody to some degree with the virtual care perspective. But that’s not true across the board. With more sensitive services related to behavioral health, there’s a preference for telephone rather than video. So at the end of the day, it’s about promoting flexibility and meeting the beneficiary where they are in the terms of the type of care they want. Ultimately, the patient needs to be comfortable in receiving that care and that doesn’t go away based on modality.
In regard to sustainability, most states have explored 1135 waivers to increase flexibility around different types of services. This pandemic has highlighted opportunities to streamline care even more.
Joanne: It’s going to be uncertain month by month as we go through this next year. What we’re talking about on the delivery side is getting back to business as we get over this first wave, yet we wonder what business is going to look like. What is the care model going to look like? Personally, I think the coming recession is going to force a lot of rethinking about our care delivery models and structure. It’s an uncertain future, but I’m optimistic that the system is going to look a lot better once we get through it.
Enrique: We’re going to have to share information across systems and communities in ways we haven’t before. Any thoughts about how those dialogues and information will be shared?
Joanne: We have been sharing information with a few other large health systems. But, in this crisis, most of our data has been internal. I do think that’s an area we’re going to have to look at soon in regard to how we’ll collaborate more broadly. Even getting data to public health agencies is often a challenge right now.
Deborah: We’re hearing a fair amount about exploring more sophisticated risk-stratification models, particularly at the provider and plan level to better target the most vulnerable—particularly in the context of COVID—who need support and may not have access to it. Certainly, many of these tools have existed for a while now—but I think revisiting them with the lens of COVID is important to see what the needs are.
For example, we can use zip codes to figure out how vulnerable someone is to social isolation or how far they are from a supermarket. We’re also seeing more community referral resource platforms that facilitate cross-sector partnerships, give more transparency about capacity of social services, and support communication about the needs of a particular individual.
Enrique: In the road ahead, what practices are going to be permanently changed?
Joanne: Up to this point, healthcare has not considered patients as much as we should have. So, virtual care will be a cornerstone and will be a primary entry point for most patients.
The second area is that I think we’re going to see a shrinkage of high subspeciality care. I think some areas of care in the elective space won’t recover fully. People will have discovered they didn’t need that elective care because they’ve lived without it for six months. People will also be without insurance as the economy sinks and will be avoiding any kind of care they don’t have to have.
Third, I think top-of-license practice and team-based care is going to be higher. I think we’re going to be seeing more patients in their homes, even patients that aren’t truly homebound. To do that, we’ll see more generalists among physicians, more use of nurse practitioners and physician assistants, and even nurses and non-licensed professionals doing care directly.
Deborah: In addition to what Joanne said, in terms of virtual care, we’ve been thinking about how to leverage technology to support improving and increasing provider bandwidth and capacity. Frankly, that will be another issue in terms of shortages and the pandemic exacerbating those gaps.
A project we’ve been working on is allowing providers to remotely train teams in underserved areas. Telementoring and virtual collaborative learning is something that may become more of a trend now to keep up with the demand for services. Virtual care and access for vulnerable populations will continue to be a challenge. A lot of community-based organizations have pivoted to focus on facilitating those connections for populations without internet access or older populations that are less comfortable with technology.
Kat: How can we improve care for homeless populations and others that are being disproportionately affected by the pandemic?
Joanne: I hate to say this, but I think we haven’t paid the attention that we would during normal times to vulnerable populations. For example, we’ve seen some groups suffering worse mortality rates. We’re planning that behavioral health is going to have to be a much bigger part of our organization than it has been in the past.
Deborah: I would echo Joanne’s comments on the behavioral health front. We’re currently pursuing projects focused on the health of individuals experiencing homelessness amid COVID-19. Efforts until now have focused on temporary things like increasing shelter capacity and halting evictions. So, the question of how to sustain that and address deep-rooted issues are still major concerns.
We’ve certainly started to see data showing that vulnerable populations based on race, ethnicity, and socioeconomic factors are being hit harder. It’s definitely a cause for concern, even if no one’s figured out a solution yet.
Enrique: Do you have any suggestions for success for organizations moving forward. What do we need to do to survive or even excel in the new environment going forward?
Joanne: What I see on the delivery side, in 2020, the care model will change. In 2021, I think we’ll see a wave of consolidation across the delivery system. I don’t know how the last of the independent medical groups will survive this economic crisis.
Deborah: We’ve been keeping an eye toward what state Medicaid agencies can support and where there seems to be opportunity to do so. Areas like care delivery, collaborating closely with public health departments, providing additional guidance around identifying high-risk patients, and technical implementation support.
On the social needs front, we’ve seen states looking to provide more guidance to health plans on how to cover services that fall into buckets of value-added services or in lieu of services, where there’s some additional funding—including things like in-home care and food delivery.
In light of COVID, some states are thinking about providing more funding to allow health plans and providers to experiment with various ways to connect beneficiaries to the range of services they need. So, there’s certainly a reimbursement and provider-financing piece to all of this. But also, providing more flexibility in existing programs and value-based payment arrangements.
On the workforce piece, there are areas where folks are trying to think beyond traditional care teams in terms of who else can support the care that needs to be supported. For example, looking to train and pay family caregivers to deliver home-based services to patients.
And finally, looking for ways to convene stakeholders together on a regular basis to learn from each other and spread the innovative practices we’re all learning about.
About the Speakers
Dr. Joanne Roberts is the Senior Vice President and Chief Value Officer at Providence St. Joseph Health System. She has over thirty years of experience in the healthcare industry, working with clinical leaders to build improvement and leadership skills to deliver the best care at the lowest costs. Dr. Roberts has practiced in academic, primary care internal, emergency and hospital, long-term care, hospice and palliative medicine, and has served in local, regional, and system physician leadership physicians.
Deborah Kozick is the Associate Director of Delivery System Reform at the Center for Health Care Strategies. As a senior health care leader with over 15 years of experience designing and implementing innovative care delivery programs related to digital community resource platforms, provider network-building, and value-based payment initiatives, Deborah leads the CHCS’ technical assistance content development for the Center for Medicare and Medicaid Innovation’s Accountable Health Communities Model participants. She also advises on several projects related to delivery and payment reform with a focus on addressing social determinants of health through Medicaid managed care.
About the Podcast
The Collective Conscious is a monthly podcast aimed at addressing gaps in healthcare for some of our nation’s most vulnerable patients. Each month, we’ll meet with healthcare leaders to discuss what care teams, communities, and government agencies are doing to better support individuals with unique care needs—this includes mental and behavioral diagnoses, substance use disorder, homelessness and social determinants of health, and other complexities of care.
About the Hosts
Enrique Enguidanos, MD, MBA has been a practicing emergency physician for 20 years. He’s the CEO and founder of Community Based Coordination Solutions (CBCS), an organization that works to find better solutions and improved care for vulnerable individuals—while ideally improving cost of care.
Kat McDavitt is the Chief Medical Officer and Head of External Affairs at Collective Medical, which has worked with CBCS for over a decade. Kat has spent over a decade working in the healthcare technology sector and has worked with more than 70 healthcare technology companies during her time in marketing consulting.