When we look at Medicaid members, they seek help in places that might not be the best places for them to seek help.”
Q&A: Alliance for Better Health CEO Jacob Reider on achieving interoperability
One of the top issues at HIMSS19 this month was the need to rethink and broaden services provided to patients. Jacob Reider, former federal deputy national coordinator of health IT, has thoughts on how to do that. As CEO of the Alliance for Better Health, Reider has gathered a network of social service not-for-profits, connected them by technology, and is contracting with managed-care organizations to handle all of the social determinants of health related to their Medicaid members in upstate New York. He spoke with Modern Healthcare Editor Aurora Aguilar shortly after the federal government's announcement on rules to improve interoperability. The following is an edited transcript.
MH: What's your reaction to the proposed rules released by the CMS and ONC?
Reider: The part of the CMS regulation that says payers have to share clinical data with consumers might reduce payer enthusiasm in acquiring clinical data. Historically, payers don't capture much clinical data. They haven't adopted the standards used in the health information technology of health systems. Some companies have bought health IT firms to capture and analyze this data. Optum is the best example. Centene and Humana also recently bought companies to do this.
As the industry figures out how to better manage clinical data, we might see that health systems, as they take on more risk, are going to maintain that type of clinical analytics capability and the payers might do less of it. Payers might say, “Well gosh never mind. We don't want that data because then we're going to have to figure out how to share it with that consumer. Just leave the data in the health system and give them the risk.”
MH: But shouldn't insurers want that data to track outcomes and cost?
Reider: This is the question, right? How do we measure outcomes and if the payer has shifted risk to the care providers, maybe the billing data is all they need? So if Mr. Jones goes to the hospital because of a congestive heart failure exacerbation, that's an outcome the payer knows about because they just paid for it.
I don't know that it's as clear as some people think it is. It's possible the health systems might manage the clinical data long term. The question is, should payers spend the hundreds of millions of dollars that it's going to take to evolve their information systems? Or should they let the information systems that were built to manage and maintain clinical data do what they do and do it well?
MH: Are the proposed rules the approach you would use to fix interoperability?
Reider: You need to think about the four A's. The first step is acquiring information. And if you acquire gobbledygook then you have to clean it up. So you must acquire information in a way that makes sense. After you acquire it, you aggregate it. After you aggregate it, you analyze it. Then you act on it, creating new data, and that gets acquired.
It's a cycle. How do we solve the problem? Well, we have to capture data that's valuable and rich. If we capture DoctorSpeak or free text, and I'm not saying free text is bad, but it's much harder to extract the meaning of what somebody was talking about if it's free text. I think with EHRs we went too far in the checkboxes and drop-downs and all of that, and then we put all this massive burden on the highest-paid person in the room.
I would solve the problem by creating systems that capture the semantics, the richness of the information, meaningfully at the start. You've probably by now used Google's new email tool that auto-completes your sentence. That's natural language processing. It's real-time processing that takes into account context and then we can interpret what someone's going to say. We're starting to see this sort of tool in health information technology—notice I didn't say electronic health records—HIT that starts to anticipate our needs and guide us to the right place.
So my nirvana is capturing data well and making sense of it from the start. I think we're probably another five to 10 years away from really doing that. HIT now is the maturation of these billing systems that we built 30 years ago. I worked at Allscripts for many years. I'm not saying anybody was bad, we did the best with the tools that we've had.
MH: Let's talk about the Alliance, which works specifically with Medicaid patients. What's it changing?
Reider: When we look at Medicaid members, they seek help in places that may not be the best places for them to seek help. This program's goal is to help people stay healthy. And the consequence is that we spend less money caring for this population because they aren't going to the emergency room for a sore throat.
We're taking government money and investing it where we can actually help these folks make better decisions for themselves. The key is what do they want to achieve? And how do we help them achieve it?
Historically, we've conflated social care and medical care. And what this work has allowed us to do is make more investments in social care and (therefore) fewer investments in medical care. And we're seeing healthier people and lower costs. We've been tracking this for 4½ years now. We've reduced preventable ER use by about 10%. Our goal is 25%.
MH: What are you learning that could be useful to other providers?
Reider: Our communities are so varied. Super rural places you won't see a house for miles to urban areas where people are really stuck together. So their needs are highly variable, and that's part of why we have to listen first and speak second. We learn about the reasons people utilize a hospital when perhaps they shouldn't. They might not have a primary-care provider or they can't get there because of timing or weather. Maybe they don't have money for the co-pay.
There are all kinds of reasons, so we have to ask those questions and then meet those needs. One thing we did is pay for Lyft or Uber rides for any Medicaid member for any reason. They can get a medi-cab paid for to see a doctor. But it turns out that going to the pharmacy to get their medications isn't covered. Going to the food pantry or supermarket isn't paid for. And you need food to be healthy.
So we've said, “Look, you have Medicaid. We'll pay for Lyft or Uber and we're not going to ask questions. You want to go to the library because maybe that's where you use the internet and maybe that's how you learn about things or you connect with your family and you feel less lonely.”
We asked folks in the ER who didn't say they need to socialize and get good food, but they might say, “Hey this is a really nice place with nice people and there's good food. And they met my needs fast and they did a blood test and an X-ray. Why wouldn't I do this?”
We say, well, what if you could have a video phone call? It turns out 85% of our members have smartphones. So could you do a video call with a clinician?
There are all kinds of things that, what if you did X or what if you did Y instead? And then when they say, “Oh yeah, that would be great.” We're learning every day and for me that's so exciting, to be back connecting with real people and learning about how we can work together to meet their needs.
MH: The CMS wants to pay for housing but has no specifics yet on how to do it. How would you advise them?
Reider: This would be a question for HHS Secretary Alex Azar's lawyers because I suspect that he's having issues of where HHS is supposed to spend money. Remember Flint, Mich., and lead pipes? Who paid to fix that? HHS. Because Michigan refused to pay and the city didn't have enough money. The government is explicitly told by Congress what to pay for, you do this and nothing else.
HUD is where the dollars for housing are currently flowing. So the big question is how is that money going to flow? We have been spending money on housing. Previously sick Medicaid members who were discharged from the hospital and who were homeless had nowhere to go because the shelters couldn't take on the liability of taking care of these fairly sick people, but they weren't sick enough to still be in the hospital. They would actually end up on the street and then bounce right back to the hospital.
We funded a program that took an empty floor of a former hospital, staffed it with a nurse and a bunch of social workers, so these members go there for a week or two and get a little bit better. Then they're placed in permanent housing, skipping the homeless shelter entirely. This is the kind of thing that's led to a tangible improvement in the health of this community. It wasn't hundreds and hundreds of people, but tens of people every month who were being helped.
My advice to HHS would be have your lawyers work with HUD. Don't replicate HUD's funds flow, but what's interesting is that HUD hasn't been on the hook for medical outcomes. Maybe they should start working together and maybe some of HUD's funds can flow into programs where the housing folks are accountable for medical improvements.
In order to make sure there's accountability, we're using Unite Us, which is a closed-loop referral technology platform. And we have people watching, sort of like air traffic control. Here's somebody with food needs in this ZIP code. OK, where do we refer them and how do we get them there? We're taking care of that connection piece and I think that's what's most important, is making that connection.
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