Understanding the Power of Coordinated Care Organizations with Dr Jim Rickards, Senior Medical Director for Population Health and Delivery System Collaboration at Moda Health

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: Welcome back once again to the Outcomes Rocket podcast where we chat with today's most successful and inspiring health leaders. I thank you again for tuning in and I welcome you to go to outcomesrocket.health/reviews where you could rate and review today's podcast because I have an amazing guest and a great contributor to healthcare. His name is Dr. Jim Rickards. Dr. Jim Rickards has a wealth of experience in the healthcare sphere. Currently he serves as Senior Medical Director for Population Health and Delivery System Collaboration and he's also an author and thought leader in the space over in the great state of Oregon. He's doing some really interesting things to reshape the way healthcare policy is and really focused on strong strategic direction in what the state of Oregon is doing and so what I wanted to do is open up the microphone to Dr. Rickards to fill in any of the gaps of that introduction and give you a warm welcome to the show. Welcome, Jim.

: Yes thanks, it's great to be here. Appreciate the nice introduction. I selected just kind of highlight the fact that here in Oregon we're doing a lot in terms of healthcare reform especially in the Medicaid space and we've been pretty successful over the last five to six years in changing how we pay for Medicaid with our coordinated care model of care hope to touch on that throughout the program.

: Absolutely Jim and we definitely want to hear a little bit more about that you guys are ahead of the curve as it relates to that and what is it that got you into the medical sector to begin with?

: Well from a physician a radiologist by training so it's a physician who interprets medical imaging studies like CTs and MRIs and I was always just kind of interested in science and biology and what attracted me to radiology was just the fact that it really allowed you to kind of apply your core knowledge of anatomy and physiology and pathology without having to deal with a lot of the kind of more burdensome aspects of medicine like administrative complexities pre-authorizations which is kind of funny now because that's kind of the space I operate in now working for a health insurance plan. About seven years ago actually I kind of started moving out of the so-called dark room of radiology and into the healthcare payer space largely because I was becoming a little bit frustrated with my practice of medicine. It wasn't for the usual reasons you hear of declining reimbursements or increasing administrative burden. But I was getting frustrated because those feeling I was getting to know my patients a little bit too well. And I would say that most people are kind of taken aback and say oh you're a physician you're supposed to know your patients well and they say yeah if you're a family practice doc or an OBGyn and caring for a pregnant woman then by all means you should know everything there is to know about your patients. But as a radiologist the way I practice medicine is with high cost imaging exams which actually expose people to radiation. And so I was frustrated because we had so many so-called frequent flyers in my small town in Oregon. And I was questioning whether or not I was really delivering value to these individuals by reading you know multiple repetitive C.T. scans or MRI scans. Week after week on the same people and so I needed a way to to try to help these folks but it wasn't medical care they need. They needed help with their health. But what I started to learn was that so much of our health is determined by things other than the medical care we receive. Term by things like our behaviors or our peer group or level of education. All these so-called determinants of health. But as a physician, I didn't really have a way to impact these other areas. And so that's why I was excited in Oregon when we started to think about how we were going to change the way we paid for Medicaid and develop what was called the coordinate care model and basically it was way start looking at how can we pay for and govern all those other elements that impact an individual's health that aren't medical in nature. But think about behavioral health aspects, the dental aspects, the educational aspects. And so learning about that model what kind of attract the a healthcare administration and eventually moving on to make firm position as a medical doctor without insurance company.

: That's pretty interesting Jim and listeners if you haven't heard about it Jim wrote a book it's called Our health plan :community governed health care that works. In it, he takes you through this topic that he's just discussed with us. The coordinated care organization the CCOs. Jim, maybe we could dive into that a little bit. Widespread are the CCOs and what's that looking like ten years from now?

: Yes. So usually when I start talking about the CCOs I'd like to take a step back and just remind folks that in the U.S. basically there's three ways we pay for health care. There are all types of health insurance but in general there's three types of health insurance one there's commercial health insurance which individuals receivers employee benefit through there from their employer or they may purchase it on the exchange as an individual plan. So that's one type. The second type health insurance is Medicare that's health insurance available to individuals 65 years of age and over just by virtue factor 65, the cost associate of Medicare paid for by the federal government gets a little bit complicated and that there's parts ABCD of Medicare but I don't think we need to get into that. Then the third main type of health insurance is Medicaid and that's health insurance for economically disadvantaged individuals. If you're in one of the so-called expansion states and you earn up to 138 percent of the federal poverty level which is around 13 to 14000 that are here for an individual and you qualify for Medicaid benefits and the delivery of Medicaid benefits is largely up to the states. Now the federal government helped pay a significant amount of the costs associated with Medicaid but the states are in large part responsible for administering the benefits. Well in Oregon back in 2009 - 2010 we were having some challenges with our Medicaid program. We were facing about a 2 billion dollar budget deficit, the state budget deficit largely driven by cost associate with Medicaid the quality outcomes associate with our Medicaid program we're now what we wanted and Medicaid members were having difficulty finding access to care. So we knew we needed to change the way we delivered Medicaid benefits. We've had some managed care entities delivering benefits across the state but the system was pretty fragmented. There was really no coordination of various benefit providers from medical to be here to help the dental and a large number of the recipients also receive benefits directly from the state and the so-called fee for service system. And so while there were payments being made for Medicaid services again the payments weren't coordinated. There wasn't one single mission and vision for what it meant to have a healthy community of Medicaid members. There were no common. There was no common set of metrics to see how we were doing in delivering benefits. There was no one global budget for a community to try to manage to try to control spending around Medicaid benefits and there was certainly no way for Medicaid members or providers to give input or to have governance over Medicaid benefits. So the system was very fragmented care was siloed and it was really kind of inefficient. And so we decided and Oregon was that we were going to revamp the way we deliver Medicaid benefits and the state passed some legislation. We work with CMS to get an Olympic team waiver and we created what was called the coordinated care model and basically the foundation of the coordinated care model was the development of a new type of organization called coordinated care organization or CCO seashells or similar to organizations that probably most folks are familiar with hold ACOs or accountable care organizations. Now they're different in the fact that they go further in that they don't just pay for and deliver medical benefits but also behavioral health and dental benefits under one global budget. And they're also governed by the local communities that they serve. And so my story was I helped start one of these CCOs and the community I lived and being an actively practicing physician and seeing the need and the benefits of such an organization.

: Jim, supercool that you did that above and beyond your call of duty but it's something that you took on as a mission and that's what the leaders listening to this podcast do. And just like our guest just like Jim here and in our previous guest right you do more than your calling to create those solutions for the folks that need it most. And you had some success in creating that. And what would you say today has been some of the benefits that have been derived from the community through this CCO?

: Well so now across Oregon about 90 percent of all Medicaid members receive their benefits through with the CCO. So we have 50...

: Wow.

: Across the state care. Yeah. So it's huge like the model has really transformed the way that we pay for and deliver Medicaid benefits that are arguably the most challenging population there is. And so some of the big benefits have been for one the CCOs was our community governed. So now there's much more active participation in the development and delivery of Medicaid benefits than ever before. So each CCO has a governing board the governing board composition is actually laid out in state legislation. It has to have individuals on the board such as local elected officials local hospital administrators and actively practicing behavioral health provider and actively practicing primary care physician. So these organizations really have true broad based community input which again it's a little bit different than an ACO in charge or mainly governed by health care systems and medically focused is the CCO model goes much further by including those other individuals from the various parts of the health care system that aren't necessarily medical in nature. So I think one key success is very foundational in how these organizations are governed and organized and the fact that we've been able to stand up 15 of these organizations you know looking at some numbers or some more kind of quantitative or objective measures of their success. I think a big one is this number of 3.4 percent and basically that means that for every year these CCOs have been in existence they've been able to keep their annual trend rate increase at 3.4% or less so in other words the health care spending increases for the Medicaid population annually it's only been three point four percent for the five years the CCOs have been in existence which is really tremendous. I mean if you think about it. Yeah that the most challenging arguably most expensive members of our population we're able to control the health care cost increases associated these numbers by simply delivering care in a different fashion through the CCO. And I know that the ability to maintain that the cost increases has not come at the expense of quality but it's actually come about as a result of increasing quality. And one of the main reasons or ways we've increased quality is to dramatically increase the number of Medicaid members who are enrolled in medical homes. So in Oregon we have a really robust medical home recognition program called the PCPCH or patient centered primary care home program. Essentially the Oregon Health Authority which is a division of state government recognizes primary care clinics for being medical homes. We now have more than 90% of all Medicaid members enrolled in a medical home where they receive their primary care. So that's really been key to helping control costs while increasing the quality of care delivered for our Medicaid members. You know before the CCOs were around we had very few medical members that could even get access to a primary care physician. And now we think about it more than 90% are enrolled with a high functioning recognized medical home has resulted in better outcomes in lower costs.

: That's outstanding. And kudos to you and your team Jim for having put this together. I mean healthcare is tough enough but you went even further you knew impacted policy and implemented what you guys set out to do and just want to offer you and the team that you work with. A big congratulations.

: Yeah thanks. It's really been the effort of course of hundreds of people across the state all over different communities and you know really what the CCR model did was it finally gave so many of our communities and so many of our health care leaders and our providers permission to work together in a different way. You know before the CCL model was around as I was saying before payment for health care services was siloed and fragmented. But now with the Speciosa we currently have 15 of these CEOs and essentially each CCO receives a global budget for the number of members it serve or in other words it receives a Per per month payment for each individual responsible for covering. And then the CCO takes this global budget really PM PM from the state. And then it uses those dollars and as I risk for those dollars possible managing those dollars and providing medical behavioral health and dental care services. But before the CCO model before those dollars flowed the community before we had this board structure that was inclusive of all members of the health care system there wasn't that framework, there wasn't that permission for communities to do things like we've been able to do here in Oregon. So I think that's really been crucial in allowing us to be successful.

: That's outstanding and an inspirational story. Now it wasn't always easy, it wasn't always a success. Jim maybe you could walk us through a setback but you had that maybe other people trying to influence health policy can learn from.

: Yes so when we started the CCO model a lot of the different parts of the delivery system that were being pushed to work together really had had never worked together so public health departments it never really worked closely with primary care physicians radiologists such as myself and never really worked closely together with dental delivery providers. And so with that it was challenging to learn how to develop relationships. But part of structure of the CCO really supports the development of relationships among these various types of health care providers that didn't really work together previous to the CCO model and one of the ways we're one of the parts of the CCO structure that allow that to happen was development of what was called the Clinical advisory panel or CAP so most CCOs have a clinical advisory panel that's a governing arm made up of the various providers in the community and in the CCO that I was involved with the anthill CCO when we started the CAP or the clinical if as you panel one of the first things we did was we asked our providers you know what were some of the challenges they had and in terms of delivering care to the Medicaid members and rural Yamhill County where I was practicing we had challenges with access to specialty care we just didn't have a lot of various specialists in the county. One type of specialty in particular we were limited with was dermatology. So physicians who deal with skin issues we only had one dermatologist in the county and who was nearing retirement and didn't see a lot of Medicaid members and our primary care physicians told us you know we need to have more specialty dermatology care. And so one option would be Welkin the CCO work to recruit a dermatologist. Well there's not a lot of dermatologists out there fewer than 400 come out of training every year. So that's you know almost one for every million Americans. The ability to recruit run to rural Yamhill County was not very likely. Typically dermatologists like to go to more.

: Urban city.

: Affluent areas and where they can do various cosmetic services if needed. And so we had this challenge. Well we really need a dermatologist. We probably weren't going to attract them here. They are very expensive also to hire. So what we did was we decided we would leverage technology to get access for our Medicaid member to Dermatology. This kind of came about as a result of my familiarity with the way medicine be practiced. You know I've been practicing teleradiology essentially my whole career. Really what that means is I'm able to sit at a computer anywhere any time and look at an image. It might be a CT or MRI and I can apply my knowledge and skills as a physician and interpret that image to come up with a diagnosis and treatment. While I knew that the practice of Dermatology was very similar to radiology and that most dermatologists about 90 to 95% of the time to make a diagnosis just on visual inspection or by looking at a lesion and they don't really need to do a history of physical. And with that they could even just look at a picture on a computer. So the idea was how can we imply employ a Teledermatology solution to help our Medicaid members. And so we look for a national teledermatology provider we are able to find one we contracted with them and we had a some grant money and we were able to buy refurbished iPad Minis and we placed those iPad's in 15 of our primary care clinics. And so now if a Medicaid member has a skin problem and the primary care physician needs dermatology counsel they can just simply pick up the iPad or have someone in their office pick it up take a picture log into the teledermatology company secure Website send their picture to them and then within 24 hours get a diagnosis and treatment back. So literally within six months we were able to go from no dermatology access to having essentially 15 dermatologists with these eye pads and our primary care clinics. But this all came about.

: That's awesome.

: The challenge of not having specialty care in a rural environment but then you know using the community's voice to identify that problem and then get their help in implementing a solution.

: What a great story Jim and kudos to you and your team for that. I mean listeners you either have solutions or you have excuses and you can't have both. And you know a doctor records here and his team are able to do was think outside the box and they found a great solution with some iPad Mini's and an organization that could do it virtually. What a great story. And now the community that you guys serve has access to dermatology because you are creative and thoughtful in your approach. Can you share with us an example of maybe a project that's exciting right now for you.

: So since helping start the anthill CCO I've moved on and I now work from Voda Health which is a large regional health insurer in Oregon. And most of my work is focused on a value based care. So value based care is this notion we want to pay for quality and outcomes and not just the volume of services delivered so a lot of my work is geared at helping the provider community or provider networks understand what we're looking for. Help them understand various new payment methodologies we're developing. So we're currently in the process of this monumental shift in health care payment moving from fee for service to the value based care. There's a lot of different types of ways we can pay for value. Several of the key ways in which we pay for value have value based your models in place. One we use so-called performance based payments so we have a number of quality metrics that we build in the contracts in the providers are able to meet certain targets associated with quality metrics they can receive bonus payments. Most of these quality metrics are becoming more standardized. One of the things I typically hear from providers is they're just faced with meeting the needs of so many different payers and have so many different metrics in place. In Oregon we had some legislation passed Senate bill 440 which is working on developing a standard set of quality metrics in the state. We've really tried to align our quality metrics around existing metrics and with that you know a lot of our purchasers now build into the contracts they have with us certain quality metrics so our purchasers want to see colorectal cancer screening or immunization at certain percentages so we then take those targets and those metrics and build them into our contract with our providers. And then if they're able to meet the targets and pay them you know another way we pay for value as we use so-called care management fees. So we realize that there's a lot of work performed especially in primary care clinics that it doesn't necessarily come with the CPT code a lot of chronic disease management, care management behavioral health services. And so what we do is we build in the contract so-called care management fees. We give clinics the cash flow they need to hire staff such as behavioral health therapists or panel managers or social workers to help deliver increased value and disease management and care management capabilities to their members knowing that they can't necessarily build for a lot of those services. So my work is in going out to the providers and helping them understand those models helping them understand what their needs are and then making sure that they were meeting their needs.

: Jim outstanding. You're always a couple of steps ahead of what's going on in health care. And it's super cool to hear that you're now tackling the value based care initiative. I know with the mind like yours and your previous success. I'm pretty sure you guys are going to do a great job over there.

: Thanks. Yeah and it's a long road. It's funny a lot of this value based care work. It's very easy to see and conceptualize the solution or where we want to go. But being able to implement that across a population of hundreds and thousands of people and thousands of providers trying to get everyone to understand what we're trying to do is take a lot of time.

: It does. But you know what you did it before and I know you'll do it again. So it'll be exciting to maybe chat with you a year from now to see the progress that you guys have made.

: Yeah.

: So Jim getting close to the end here. Let's pretend you and I are building our medical leadership course on what it takes to be successful in medicine. The 101 of Dr. Jim Rickards. And so these four questions that I'm going to ask you are more lightning round style so I'll ask them give me some quick answers and then we finish up with a book that you recommend to the listeners.

: Okay.

: Ready?

: Yeah.

: All right. What's the best way to improve healthcare outcomes?

: The best way to improve healthcare outcomes is really to monitor and track them. You know I think one thing I experienced in my practice of radiology is you know I would literally dictate thousands of just x-rays every year but very few times throughout the course of a year what I actually receive feedback from referring providers are in other ways to see no was my diagnosis and just a heart failure correct or was the right call to say there was pneumonia there as opposed to like this. And so I think having a way to track outcomes and getting feedback to the providers is key and that's something that's still largely missing in our healthcare system. But you know back to our value based care work in trying to track delivery and performance of our delivery system with metrics and targets is one where we're doing that.

: That's great. What's the biggest mistake or pitfall to avoid?

: That's a good question. I think thinking that you can do it all. I mean healthcare really is a team sport especially as a radiologist for so long I felt like a lot of the burden of delivering and doing all types of aspects of care delivery fell on my shoulders. But with healthcare becoming increasingly complex and with our knowledge of medicine and science growing we really have to acknowledge that it's a team sport and so not being willing to work closely with other folks in delivery of healthcare is a pitfall. So you really have to learn how to be part of the team.

: How do you stay relevant as a healthcare organization despite all the change?

: Well I think you have to be the organization coming up with the ideas and you have to be willing to fail. You know in general healthcare it's very conservative. You know there is some people say it takes 17 years or something from the time it's discovered to actually be implemented so that maybe a new therapy or medication. But I think you have to be willing to come up with the ideas and implement them and realize that they're not all going to work but you have to hopefully fail in a way that will make you more successful in the future. So learn from those lessons and keep willing to be creative.

: I love that gem fail forward guys and what's one area of focus that should drive everything in a health organization?

: We all going back to my current work of pay for value or fee for service system was not really set up to pay for value it was set up to help manage transactions and facilitate billing of procedural codes. But I think we really need to focus on value and realize that we're still in the infancy of value based care and it's going to be a long road until we completely move away from fee for service if that ever happened.

: That's awesome Jim. Now what book and what podcast would you recommend to the listeners as part of the syllabus.

: As far as podcasts I like conversations on healthcare forgetting right now who the folks are that do that but conversations on healthcare is a great one. And then in terms of a book probably recommended Porter's Redefining Health Care from Harvard Business Review. It's a pretty lengthy book but I think it gets into talking about value based care and it has really been the foundation for a lot of my ideas and thinking around healthcare transformation.

: Outstanding. listeners don't worry about writing any of that stuff down. Just go to outcomesrocket.health/rickards. That's Jim's last name, R.I.C.K.A.R.D.S. and you're going to be able to find all the show notes, the transcript, links to his work, links to his book, our health plan as well as all the details that we discussed here on the podcast. Jim this has been a ton of fun. We're here to the end and I'd love if you could just share a closing thought and the best place where the listeners can get a hold of you.

: Closing thought is I think now in health care there's more opportunity than ever. This was largely driven by the Affordable Care Act. I think things have kind of been in flux now with the new presidential administration. But I think we're well on the road to developing value based care initiatives and ensuring that as many Americans as possible will have access to high quality, affordable health care. So we just say folks involved in this space just keep up your good work it's going to be a long road and there's going to be plenty of work ahead. And then in terms of getting a hold of me I have my own Website. jimrickardsmd.com. You can log on to that or Google that and you can find me and that has links to contact me.

: Outstanding listeners again we'll provide that to you in the show notes. And Jim just want to take an extra minute to say thank you so much for carving out the time to be with us today. And we're excited to stay in touch with you.

: Great. Thanks a lot.

Thanks for tuning into the outcomes rocket podcast. If you want the show notes, inspiration, transcripts and everything that we talked about on this episode, just go to outcomesrocket.health. And again don't forget to check out the amazing healthcare thinkathon where we can get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is "implementation is innovation". Just go to outcomesrocket.health/conference that's outcomesrocket.health/conference. Be one of the 200 that will participate. Looking forward to seeing you there.

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