In today’s episode we continue our conversation with @American_Heart Senior Advocacy Advisor of Health System Transformation Melanie Phelps, who was integral in the recently published study on the benefit of Accountable Care Organizations. The findings support that managed care provided by ACOs not only improves outcomes for the medically complex patient, but also benefits every patient, family caregiver, provider, and healthcare team member. www.heart.org/bettercare
Yates Lennon
Melanie Phelps, welcome back to the move to Value podcast. So let’s try to pick up where we where we finished last time. Melanie and I wanted to go back to really to sort of the heart of your research in the medically complex patient. So we know these folks require hard higher touch and really need coordinated, managed coordinated care. And, wanted to talk about why it’s crucial for the American Heart Association to understand and advocate for better models of care for this patient population. And then we’ll after that, we’ll follow up on sort of how we can work together to do that.
Melanie Phelps
Yeah. So medically complex patients are of course more complex and more costly.
They require a lot more services and the burden of navigating a fragmented fee for service system adds to their already very stressful lives and the chances of things falling through the cracks or delayed care is pretty high in a payer fee for service system, the ACO provides those extra layers of support, communication and enhanced access that really do lead to better outcomes, reduce stress on the patient and their caregivers, which is pretty important. We also believe they are more likely to get the most up to date care under these arrangements because the incentive to do better is there and that is not there in the case of fee for service. So, we all know that there is a pretty significant lag between new innovations and evidence-based solutions and adoption or implementation in reality, and we see ACOs as a vehicle for expediting adoption of those. The other piece on medically complex patients, why we wanted to focus on those is when talking to other patient and consumer advocacy organizations, which is a key target audience of this of this study, there was a lot of apathy and even skepticism about ACOs, OK. They’re not involved in the advocacy. They’re not steeped in the details and they are very suspicious of ACO’s of value based care. They’re thinking there’s a lot of stinting going on. They think that they’re being, you know, medically complex patients are being denied care and being kicked out of ACO’s. And that certainly was not my experience when I worked with the ACO’s in North Carolina. So, one of the reasons we focused on medically complex patients was to be able to say, OK, you know, are they getting the care that they need? What do they have to say about it? And that’s why. I mean these are the people that really need the extra care and support and the results really showed that they were getting much better care and support, which should be important to everybody.
Yates Lennon
Yes, absolutely. That’s that’s interesting. I never would have. I guess I never would have thought about that kind of skepticism from consumer advocacy groups around value based care, and certainly my experience has been the exact opposite is the ACO model is a ideal model to have those patients in because you have the sustainable, a sustainable path to provide these wrap around services to both, both the provider and the patient and their families. I can think of multiple instances where these like in our NextGen days and our ACO REACH nursing facility waiver as an example. And while that is great for patients, I think we’ve had more comments from caregivers and family members about the benefits of that program than we have from patients themselves. It’s really interesting that it’s another layer of skepticism that we need to breakthrough. So, going a little bit further then, so how can ACO’s, provider groups working with inside ACO’s, how do we get past that skepticism barrier, so to speak? How can we work together with organizations like the American Heart Association to promote ACO’s and the benefits for patients, families and care helping providers?
Melanie Phelps
So one of our challenges and it was a pretty significant challenge was the fact that to recruit study participants, particularly the patient and caregivers, how do you do that when somebody doesn’t even know what an ACO is or that they’re assigned to an ACO? I mean you know there are a lot of regulatory requirements around that, and they’re not particularly helpful to meaningful communication and meaningful understanding. So how can patient and consumer advocacy organizations help communicating the benefits, communicate the benefits of these this model and similar models? And it’s through research like this that comes from, you know, a neutral patient advocacy group that folks can give or use to help communicate the benefits of in a way that is relatable to folks. You know so often we talk about ACOs from the provider perspective, well, providers get paid differently to do that and you know that’s not what’s going to resonate with patients or their caregivers or their advocates. What does it mean for them? And until we really do a better job of doing that, I don’t think we’re gonna have a huge cry from patients and consumers and community advocates. And it’s a shame because people should be demanding this kind of care, right? Not running from it or not ignoring it. We should be working together to improve a very good and solid model. So that’s, that’s where we would like to go with that.
Yates Lennon
Yeah. No, I think you’re right. We want to create a Stampede almost for patients demanding access to these kinds of programs. But you’re right, folks don’t know what they are, and they don’t know unfortunately, they don’t know when they’re in one. They don’t know when they’re not in one, it’s just not obvious. And the communication options sometimes are onerous and restrictive and don’t allow sort of the free flow of information back and forth between the providers that are in these models and the patient. So that that’s a real challenge.
Melanie Phelps
You guys are restricted in what you can communicate. We’re not.
Yates Lennon
Right. You’re not. You’re right.
Melanie Phelps
So so we are a huge untapped resource and we being the patient and community and consumer advocacy community. But most of us, you know, there’s only a handful of us that are engaging in these policy discussions. And so we really need to grow that that table.
Yates Lennon
So Melanie, given the American Heart Association’s clear role in guiding heart health recommendations, does this study suggest that ACOs are a model that should be used to promote these preventive health recommendations more widely for all patients, first of all, but then, particularly as it relates to those who have cardiovascular disease?
Melanie Phelps
Yeah, simple answer is yes. I think we’d say all patients, including those with CVD or cerebrovascular conditions, should reap the benefits of ACO and similar models. So, but it shouldn’t just be patients with CVD or cerebrovascular issues. All patients, especially those medically complex patients, will reap the benefits of these models.
Yates Lennon
Yeah, I think what we have to be mindful of, I’ve been thinking about this a lot lately myself is that we need to make sure that the value based care movement, if you will, doesn’t get mired down in becoming a chronic disease management solution, only right how do we leverage the infrastructure and the data, the tools, the technology we have to prevent chronic disease, right? We just, I think the fee for service world has just turned into a sick care system, not a healthcare system. And we need to be mindful that we don’t allow the value-based care movement to get to become that same to be captured by that same mindset, if you will. Well, as we as we start to round home here, what do you hope that health systems, policymakers and other patient advocacy organizations which you’ve mentioned take away from this research and how can the association help drive change based on your findings in this study?
Melanie Phelps
So I hope that all the groups that you mentioned will have a better understanding of what ACOs do, what they are, what they mean to those on the front lines of receiving and providing care. That’s the patients, their family, caregivers and all the members of the health care team and how it improves the care they receive, their quality of life. How it saves money by catching things early and avoiding costly trips to the ED and duplicative services. And, of course, its focus on prevention. And finally, you know, again, we really need to see more people, patients, caregivers and healthcare team members in these arrangements.
Yates Lennon
Yeah. So, what are your next steps for the American Heart Association? More research? Further explanation, I mean, I’m sorry exploration of how ACOs can impact cardiovascular and other health outcomes. Where do you see the Heart Association going next?
Melanie Phelps
Yeah. So we don’t currently have plans to explore the impact of cardiovascular outcomes, at least not to my knowledge. That would be a different section of AHA.
That doesn’t mean we won’t. It just means that I don’t think it’s been discussed or has not been shared with me. And So, what else is there? Well, there’s an outline of a heart failure model that we published in as part of our value in healthcare.
Initiative back in 2020 with Duke Margolis. I’ve heard that there’s some interest by the current administration in that, but you know, we haven’t been contacted directly about that. We do have a huge food as medicine initiative. It’s called healthcare by food, we’re putting millions of dollars into research on food is medicine. And there’s I think we might be exploring how food is medicine can be utilized in this these models. How successfully it can be utilized in these models. And then regarding this research, we do hope to further engage and educate other patient and consumer advocacy groups and then work with them and other stakeholders on elevating the patient consumer voice in these models so that they can truly be person centered, right? I mean, we talk a lot about person centered care, but really the patient hasn’t been part of those discussions. How do we make that more integral at all levels of decision making on value-based care.
Yates Lennon
Yeah, absolutely. So that’s interesting. Food as medicine. There is a lot of interest I know today around what’s called functional medicine and a big emphasis on healthy foods, and it’s just so important. And I know from my own my own lifestyle, it’s just it’s challenging to sometimes know what to eat or how to prepare what to eat. But that’s really good to hear that you’re working on that. You know the last question I’ll ask you, Melanie, is one. I usually come to at the end of any interview and that is we’ve talked about a lot today, but is there anything that we’ve not covered today or I’ve not asked you that will be relevant to this conversation that you’d like to share with our audience?
Melanie Phelps
I can think of two things. First of all, I think your listeners would be really interested to know that we conducted 29 semi structured qualitative interviews with 31 individuals and that means that two of the interviews included the patient and their caregiver spouse. That’s how we got to 31, but we only were able to include in the data analysis, 27. So two interviews with the patient, with individual patients, had to be discarded because there was something was wrong with some of their responses that made me think they were not in an ACO. So after the conclusion of the interview, I was able to go and trace back through their PCP and their PCP practice, whether they were in an ACO or even some other primary care arrangement. And they were not, OK. So how did that happen? And well, first of all, the giveaway why I suspected they weren’t in. Well, there were two reasons. The first one, neither one was managed right? And so all the other medically complex patients that I had interviewed, they were managed and these two weren’t. They also happened to be sisters, and they were also cousins of the care manager who is helping with recruitment, right? So we had to change. We had a lot of trouble getting patient and caregiver study participants and so we had to change our research protocol. So instead of the healthcare organization getting a HIPAA authorization to give us contact information, we gave them a flyer that they could hand out to appropriate patients to call and you know, on their own, asked to be part of the study and there was $100 visa gift card that was assigned to it anyway. So we had a little this overzealous care manager was giving them out to friends and family. So yeah, so we had to regroup and you know, change again, but it was very interesting that I could tell that they weren’t in an ACO that I mean, I would not have expected that. The other issue that I think was really interesting is that you know, at the end of the each interview we asked, you know, if they had any suggestions for improvement?
And so the patients for the most part didn’t have anything that was particularly helpful. We had one patient that said that they didn’t like their primary care had inadequate parking. Another one didn’t like their primary care provider, but knew they needed to change. And then the only other suggestion for improvement was from the patients was that external providers who were not in the ACO, there was a little bit more difficulty communicating. No big surprise there, right? So that that was all we got from the patients. So then, but then you go to the healthcare team members and what was really remarkable is there was a cry for more education and communication about the benefits of these models. Not only for their peers, but for patients as well. And they wanted more patients in these models. And one even lamented not being able to provide the same services to patients not assigned to that the ACO. And then we did hear challenges with data sharing with external providers. I mean, not a surprise there, right? There was also calls for multipayer alignment because of all the different contracts and rules and oversights and concerns about the ratchet effect over time of the benchmarks, right?
That’s being a problem. And then finally. Enhanced payment for primary care services was mentioned, and that didn’t even come from the primary care docs. And I probably should let you let you know that on the as far as the care team members are concerned, I did I interviewed four primary care physicians, a specialty physician, a nurse practitioner, four care managers, nurse care managers, two community health workers, two social workers, and a pharmacist. So I had a pretty good diverse make up of. Yeah sample so that’s that was pretty interesting, I thought that was pretty interesting to capture that information.
Yates Lennon
Yes it is. Well, Melanie, thank you so much for joining us today. It’s been an intriguing conversation. I look forward to hearing more from you and thank you for joining us.
Melanie Phelps
Thank you for having me.