Kelly Garrison, MBA, MHA – Practicing Value in Medicaid

In this episode, we have a conversation with Kelly Garrison, President and CEO of Emtiro Health, about the leap into managed Medicaid care in North Carolina and how to support providers that participate in value-based payment arrangements for Medicaid populations.

Let’s talk about Emtiro Health. Tell us about what you’ve been doing and how it’s been going lately

Great! So Emtiro Health is a population health management company based in Winston-Salem, NC with a specific focus in working with the Medicaid population there’s a lot of companies and groups out there that focus on Medicare, Medicare Advantage, other commercial insurers and where we have really found our niche is supporting providers and patients in their move towards value in the Medicaid space which is something that’s a little bit new and a little bit different. Emtiro was born by two not for profit companies with a 20 year experience in working with the Medicaid population. North Carolina specifically has for 25 or more years had an enhanced primary care case management program that was really overseen by the Department of Health and Human Services and a number of years ago now, about nine years ago, there was an emphasis on moving the state’s Medicaid Program towards managed care and after many pauses and delays and an even a suspension along the along the way, we finally have gone by with the Medicaid managed care program last July. And we are still in the fairly early phases I think everybody across the state has learned a tremendous amount including Emtiro and we are still rolling out new components of the Medicaid managed care program in North Carolina but with the change that we saw coming with what Medicaid managed care was going to bring to providers, the impact it could have on our local communities and the patients that we had served for a really long time, there was really a group that came together that said there’s a different vision that needs to be had, This is an opportunity for us to partner with and just do Healthcare differently for this population specifically. And so that’s why we decided to form Emtiro Health and really make the bridge across the bridge from the old Medicaid program to now the Medicaid managed care program.

The managed Medicaid program in North Carolina went live in July 2021. How has this start up then and how are things proceeding?

So I have to say that overall I think the program implementation has gone over incredibly well. I think, one our Department of Health and Human Services did a tremendous amount of work and looking around at other states to see kind of lessons learned. North Carolina was really the last big state to transition to Medicaid managed care so there were a lot of learnings that could have happened over the last 20 to 25 years that other states have gone through this type of transition. I think we’ve learned a tremendous amount. I think we learned the importance of data flow and that being accurate from the get-go. I think we learned some hard lessons potentially particularly around patient attribution which was it always going to be important in any value space regardless of the payer because that’s how we collect quality data and have to report out on it and ultimately payments get tied to those types of things. And so overall I think generally it went smooth. Of course, we didn’t have as many patients self-enroll as maybe we would have initially liked but we’re still, again, kind of in the early phases so we rolled out the first phase which is the standard plan we are still looking ahead now towards December 1st of 2022 who were going to be rolling out tailored plans which is a specific program that is designed for the this more severe behavioral help mentally ill patient population that is going to be served by Medicaid going forward.

So it sounds like Emtiro Health is moving into the behavioral health space?

We are. So I think one of the big emphasis that the Department of Health and Human Services had was really whole person care. The kind of adage probably many have heard is that you can’t separate the head from the body and we know that any patient that has any type of behavioral health issue even though it might be a mild to moderate depression or anxiety, that can still have a long-lasting impact on their physical health and vice versa. And so in the Medicaid managed care program the mild to moderate patients are largely incorporated into the standard plans so we’re actually holistically treating patients in the standard plans now and then after December we’re going to have tailored plans which are going to be separate essentially health plans that are going to be responsible for the management of about 160,000 patients across the state that are the more severe, so it is the IDD population it’s the traumatic brain injury what most would just kind of lump into a broad category of SPMI or severe and persistently mentally ill. And so and then those providers and those plans are responsible for not just the behavioral health component, but also the physical help component for those patients. And each of those arrangements, both standard plans and tailored plans are under capitated payment arrangements for delivering whole patient care,

I’d like to know more about how Emtiro Health interacts with patients. Can you tell us more about that engagement?

Absolutely. So we have kind of an interesting business model. So the state actually put out this Clinically Integrated Network or other support provider and we really fall into that other support provider space and so we work directly with providers to help them in their negotiations with the pre-paid health plan. We don’t actually negotiate the contract on their behalf. And we support the operationalizing of that contract in a number different way. So we have one model where we work directly with patients. We provide care management services from the prevention and wellness component all the way up through transitions of care to the most complex care management that can be provided that is NCQA recognized and that kind of thing. And then we work with providers who a lot of I think that we can see is that a lot of providers have had some experience delivering chronic care management or transitional care management especially for the Medicare population because those codes have been out there for a while. So they had a little bit of practice. And so we say you know care management that is delivered locally at the provider level is where care management is most effective. And so we support other providers in that realm where they’re delivering that prevention and wellness, care gap closure, some care coordination functions but they’re not quite ready for the true complex care management what we’re talking about spending you know 45 minutes on a conference of health assessment and developing a patient-centered care plan. And so we have a hybrid model where we support them with those more complex and transitional care patients. And then the final kind of model that we and how we work with providers and patients is really supporting them through all of the data and technology requirements. So for the first time really in North Carolina, Medicaid providers are responsible for data that’s a very different space than they’ve been in. So if a provider were wanting to be Advanced Medical Home Tier 3 practice under this Medicaid managed care arrangement, they’re responsibility for data aggregation and claims processing or accepting claims files and beneficiary attribution files pharmacy lock in files and others from now potentially 5 different health plans. They’re responsible for risk stratifying their patient population and they’re responsible for all of the quality reporting, both in terms of hedis measures but also care management productivity. And they have to report that back to the plans. And so since that is such a new space and it’s just incredibly complex, Emtiro works with providers to provide that technology solutions, so if they are ready and equipped to deliver all aspects of care management on their own, we can come alongside them to support them with the data and technology platform that they need in order to be able to ultimately manage their patient population and document all of the care management and care coordination activities and be able to report those back to the plans.

So how does the data flow? How would one visualize the movement of that patient data?

Absolutely! So this is where you know we should probably have a whiteboard and lots of different colors of markers, but so ultimately the plans house the data. Providers are billing the plans the they have a partnership with the state in which they get the beneficiary attribution files. And so patients self-select into a prepaid health plan or they are auto assigned to one of the pre-paid health plans here in North Carolina. Those files come to Emtiro and in some cases they are also mapped over to our provider partners. Ultimately we believe that the providers own the data, we are the housekeeper of the data and the ones that can help them make sense of it. And so ultimately our goal is to accept all of this data standardize it, normalize it into a digestible format which is populated in our information system ultimately we’re doing all their quality reporting and care management documentation and then give that back to the payors in the formatting that they need it. But the probably the most complex part of it is being able to, one, pull all of that data in, standardize it, normalize it, marry it up with the real-time clinical information that we pull out of the provider’s EHR so that care management can be done most effectively. I think a lot of times what we have seen is that we get claims files, which is great because it’s a little bit of a map of where the patient has gone, but if a patient was seen, for example, in the emergency room and they had high blood pressure and we know that they followed up with their PCP it would be nice to know what the high blood pressure is. But because we are pulling that real-time clinical information directly from the providers EHR, we’re able to have all of that information in one spot for the care manager, for the provider, for anybody who is on that care team to see and ultimately be able to manage the patient.

So to provide so background, can you explain to us how a prepaid help plan works?

Absolutely. So it’s funny the best thing that I know to do is to really talk about what were the goals. So obviously the Medicaid Program is kind of a dually funded program. They’re – part of the funding for Medicaid comes from the federal government and part of it comes from the state. But the state puts in about two-thirds of the total funding. So the states actually have a pretty good amount of discretion as to how the Medicaid Program operated in their state. And so I like to say that there used to be an old commercial here in the Triad and they would say you know I’m the Father of the Bride I write checks. And ultimately that is what our general assembly wanted they wanted budget predictability around the Medicaid Program and the way to do that was to ultimately roll it over to prepaid health plans. So is just kind of a North Carolina term for managed care company or an insurance provider. So we’ve seen organizations like Blue Cross Blue Shield and United and others that are very familiar to anybody in North Carolina that have rolled out now a Medicaid plan. And so the state provides funding to each plans based on what their population is and then they are responsible for paying providers, both for claims but then also a couple of additional payments that providers are eligible for. So one, just by seeing Medicaid patients, they have an enhanced per member per month for having attributed Medicaid patients on their panel. The second bucket of payment on top of their fee-for-service that providers are eligible for is that they can attest to and act as an advanced medical home tier 3 practice, which basically says that we have the capability or can partner with somebody to bring the capabilities to the table, like Emtiro, to provide the care management at the practice level, do all of the quality reporting and meet quality measures and they negotiate an additional per member per month payment for those for their patient population. And the final that we are moving into now, that we’re six months in is based on quality. So we’re seeing performance incentives based on kind of core standard hedis quality measures, trying to move the needle along. So North Carolina has four statewide health plans – United Healthcare, Blue Cross Blue Shield Healthy Blue, AmeriHealth Caritas and WellCare and then we have a local, what they call a provider-led entity or PLE, you often will hear it called and that is based on a couple of different regions so in North Carolina that is Carolina Complete Health and Carolina Complete Health is a provider-led entity with the backing of Centene, which is a nationally known Medicaid plan but it was actually a joint venture that was formed by providers and is led by providers here in North Carolina and their operating in three of the six North Carolina Medicaid regions.

So given your relationship with providers, how have you gone about fostering good working relationships with payors?

So I think, early on we realized just how important having good close relationships with the payors is for a number of different reasons. So the first reason being that the plans for practices that are not attesting to tier 3 that Emitro are supporting, the plans are actually taking on the responsibility of managing the Medicaid population. But the Medicaid population in particular is fairly transient. So they move and they may move providers and so all of a sudden we’re having to transition patients from their care management being provided by the health plan to now the care management needing to be provided Emtiro. And so facilitating warm handoffs at the patient level was going to be of utmost importance, The second way is really an understanding how Emtiro works with providers because I think at the end of the day, we’re all trying to drive quality and value forward both the plan, the provider, Emtiro, and ultimately so that we’re getting the best outcomes for patients and doing it in a way that is as easy and as seamless as possible for providers. And so, one, I think we have worked really hard and diligently to foster relationships with the plans, one so that we can align on quality. What we didn’t want to do especially is to really chop up the population anymore. So just because now we’ve gone from the single Medicaid payor to five Medicaid payors, we wanted some standardization of quality across those. We’ve had to develop incredible strong relationships with the plans as it relates to data flow because they do own and house the data a lot of times and we needed to have good understanding of how the data was flowing, at the frequency at which it was going to be coming to us, any data quality management issues that we’ve had, we had to have really good close working relationships with them. And finally is understanding Emtiro’s role in this population health and Medicaid managed-care space, and really quite frankly, what our business model is because there are providers across the state and even broader than just North Carolina alone now that are trying to find how they move on the value continuum. And I think we often seen providers asking themselves the question of what does it take in order to move this value continuum? What does it take specifically in the Medicaid space and how do I do that? And really saying yes we can provide care management and then move along the continuum to where you’re doing some of this work and ultimately driving care management delivery that is local and facilitating that and really teaching providers how to provide local community-based care management for the Medicaid population in particular where we’re dealing with a lot of social determinants of health issues and other disparities that are just so local that it can be hard to provide it in another way. And so we’ve been able to work successfully with providers and understanding that model so as providers are willing to take on more risk for their Medicaid population, they now have resources that they can refer to to facilitate that because the state is trying to drive providers and plans toward risk and so they’re kind of pushing the plans to push it down to providers but the plans can’t do that unless they’re comfortable with the providers that are that are providing that support to these patients. And so a couple of key areas there where we work really closely and developing those relationships with the plans as a referral mechanism for providers that are seeking solutions.

Where does a provider begin the journey to be an effective giver of care who is not only going to have the best possible outcomes for the patient but also most effective in the system and for themselves so we can optimize healthcare in the US? What can a provider start doing right now?

That’s a great question and there’s a couple of things that really jump out at me when you when you asked that. I would say the first thing it’s commit to the move to value. This is not really a space where you can sit on the fence but for so long because the move towards value even in the Medicaid space is happening very quickly. Most states, if we look at Medicaid in particular have had 20 to 25 years of managed care experience before we’re just starting to see states like Washington State and others move towards having providers owning some risk in the Medicaid space. In North Carolina we’re not going to get a 20-to-25-year runway. We really are looking at just a couple of years before that expectation is going to come even so much North Carolina is one of four states that is participating in a state transformation collaborative that’s kind of under the umbrella of the HCP LAN or health care payment learning in action network. So I think we can expect that move towards risk is going to come really quickly and it takes a commitment on behalf of the providers and really anybody that is in their practice because I think that what we believe is that value is driven and you can begin to move toward accepting risk when everybody is involved in the process and has a clear vision of what the outcome should be. So having everybody from the front desk person onboard to the nurse that is responsible for rooming the patient all the way through the referral coordinator that might be the last person seeing the patient at the end of the door or out the door. I think the second thing is understanding the help her ecosystem that surrounds them so all of the people that are touching their patients. So whether that is providers in the inpatient and outpatient setting understanding the hospital-based transitions that take place and what’s happening there. Building out community-based relationships that are specifically in the Medicaid space and I know there’s a lot of conversation happening just globally around addressing social determinants of health, but specifically in Medicaid there are different resources a lot of times that are available to patients that are on Medicaid or even uninsured and so understanding that ecosystem and who is interfacing with your patients. Because again goal alignment, to the extent possible, I think is going to be critical. And ultimately the final thing is probably those relationships with the plans. Ultimately having good collaborative relationships with the payors with the plans to drive things forward in a manner that is both sensible and reasonable but yet helps meet the objectives of all the parties involved I think is going to be critical. So understanding what is the plans long-term vision, what does their runway look like, how does that compare to that of the provider, and then building out the infrastructure that’s needed in order to do that efficiently and effectively as we move forward.