Episode 27: Community Health Plans Building Trust & Interoperability


This episode features special guests, Ceci Connolly, President and CEO of Alliance of Community Health Plans or ACHP and Virginia (Ginny) Whitman, Sr. Manager of Public Policy for ACHP. They join host, Pooja Babbrah, filling in for Ken Kleinberg and co-host, Jocelyn Keegan to discuss ACHP’s perspective and work on building trust between payers and providers and why that’s important, how price transparency policy is translating into real-world changes, and the cultural shift happening as more data becomes shareable.

Pooja kicked off the episode by having Jocelyn briefly introduce herself and share what she's looking forward to learning from the discussion. Jocelyn shared that she recently had the good fortune of presenting at an ACHP conference in May where she met a lot of the community members.

Jocelyn went on to share that she’s been with POCP for six years as the Payer Practice Lead and has been focused on interoperability and the convergence of sharing clinical data between payers and providers to help automate interactions like prior authorization and support value-based care.

Pooja then asked each guest to introduce themselves and share how they came to work with ACHP.

Ceci Connolly shared that she is the president and CEO of ACHP now but had a 25 year-long career in journalism before catching the healthcare bug. She recounted that she was covering healthcare and specifically that passage of the Affordable Care Act which led her to pursue a second act of her career which entailed working the McKinsey and helping them set up the Center for Health Reform before moving on to lead the Health Research Institute at PwC before landing at ACHP. She expressed how fortunate she feels to have an amazing group of members and a passionate team that’s aligned to take healthcare where she believes it needs to go.

Ginny Whitman introduced herself sharing that she’s been with ACHP for almost four years and that it was only a few months into her tenure that a dear friend and colleague pulled her into the world of health policy. She continued by saying that she’s been focused on exploring what health plans need, what their pain points are and where can they excel and do wonderful and creative things to support their communities.

Pooja then asked for Ceci to share more about ACHP, it’s mission and the work it’s been focused on most recently.

Ceci responded by saying that the ACHP member criteria is essentially also the mission. ACHP represents not-for-profit provider aligned regional health plans adding that many of those are plans that are in big integrated systems across the

She explained that many ACHP members are smaller and local in their communities with tight relationships with their provider community which often include risk arrangements which ACHP believes is a model with a bright future for healthcare.

Ceci went on to say that ACHP members are very much about access for all in their communities and focused on health as opposed to acute care. She relayed that the ACHP roadmap set by the board of directors includes setting a course to really serve the consumer, meet members where they are and improving transparency and data fluidity so consumers and providers both have the data they need to make the best decisions. Affordability is also a big focus for ACHP, they release a report each year and have taken a pledge on two chronic diseases, diabetes, and cardiovascular to start to move the needle in our members' communities on those.

Ceci expressed that she is very positive about the recent law President Biden just signed on inflation reduction that included provisions about drug pricing which is a huge pain point for ACHP members and their communities. She explained that she is also pleased about the enhanced affordable care act provisions as well.

Pooja then transitioned the conversation to focus on the theme of a recent ACHP event that highlighted the need to build and improve trust between payers and providers. Pooja asked Ceci to provide her assessment of the historic level of trust between payers and providers and why it’s important to redefine and strengthen these relationships?

Ceci responded by explaining that the recent event was Ginny’s brainchild and would like her perspective on this topic. She went on to explain that ACHP has been hearing from all directions that trust is an issue.

Ceci expressed that they were thrilled to have a keynote by Dr. Jan Berger who has written the book on the theme of trust in healthcare. There is a strong foundation to work from because ACHP members are grounded in their local communities. She explained that developments in the technology and the data arena can be positives when it comes to trust, but also pose potential risks.

Ginny added that ACHP member plans have close relationships with their provider systems and provider groups but that sometimes the technical infrastructure doesn’t support good communication. Part of the focus of the ACHP event was how to make technical level changes to improve that communication with providers ACHP members value so much.

Pooja then asked if there were any specific initiatives or programs ACHP members have employed to improve trust with providers?

Ginny explained that there are so many programs but one example she described was a vaccination campaign in Minnesota where the community health partners, using data, recognized they were missing communities of color in the vaccine effort. Stakeholders from across the community collaborated to create education and vaccination events to close those gaps. She went on to explain some other examples of partnerships and collaborations between ACHP members and their communities that help build on the foundation of trust.

Pooja asked Jocelyn to comment on payer provider trust and data exchange based on her work as the program manager of Da Vinci.

Jocelyn started her response by making the observation that there is a duality with how big nationals come into these regional markets and work hard to make themselves seem small and local. They will do things like sponsoring local teams, getting involved in local charities to make themselves seem like part of the community. The small plans, on the other hand, who are already connected to local provider system plans and the community, are spending all this effort to make themselves seem bigger and seem wider and deeper right out into the market. Jocelyn expressed that she finds this juxtaposition interesting.

Jocelyn went on to say that the reusability of the work that's emerging in the industry around things like DaVinci and other FHIR initiatives and other standards helps create a more level playing field for smaller plans to make investments in interoperability and more easily tackle regulatory challenges.

Pooja then asked what ACHP, and its members are doing around price and patient cost transparency.


Ginny responded by saying that many ACHP members had price estimator or cost estimator tools prior to any regulations coming out which put everyone in a very good place when regulations did drop. Most plans had either already met the requirements or only needed to make small adjustments to do so. She explained that the challenge now is how to incentivize the providers and patients to use these tools.

Ginny expressed some concern around some future regulations particularly with some of the overlap of the No Surprises Act and the transparency and coverage rule.

I'm not that worried about it, but I will say that I, I do have some hesitations and reserves when it comes to future regulations that we are expecting, um, particularly some of the overlap that was in the no surprises act part of the consolidated appropriations act and what's in the transparency and coverage rule.

Ceci added that some ACHP plans are further along in this journey and are incorporating quality information for instance which starts to get at value. She expressed that healthcare is a funny world where transparency is currently defined with price. She explained that if you look at travel and are looking for a hotel, one might look at the cheapest hotel or the cheapest flight but maybe location or a comfortable bed is more important to you.

It's the same in healthcare. Some consumers are going to be looking for that value package. Ceci added that some ACHP members have gotten very sophisticated and developed tools that are so easy to use but consumer uptake is still very small and slow.

To make her point, Ceci highlighted a health plan in Michigan that developed a super slick tool that’s extremely easy to use. The tool shows where plan members are in their deductible, what the co-pay is and where services are located. This plan put in financial incentives, and they have seen some uptick in the utilization, but it's going to take a long time and a big, big effort. In the meantime, there are all these machine-readable files out there creating an insurmountable mound of data that is challenging for payers to sift through.

Jocelyn responded by expressing the important role of standardization in helping solve many of these issues. She explained that so many stakeholders are so focused on using standards to meet regulatory requirements they lose sight of the real-world problems that need solving like how to get patient important cost and value information so they can make better decisions about where they get their healthcare.

Jocelyn continued to explain that here is a huge investment related to many of these transparency projects and when there is so little uptake, it can be discouraging but that the more we normalize the data using standards we can reduce the overhead cost.

Jocelyn explained that it’s important to get the right information to the patient at the right point in time. She went on to use an analogy of when someone is in Target shopping, they may look at their Amazon app to see if they can find the item cheaper but sometimes, if a person is on their way to a birthday party and hasn’t shopped for a present yet, convenience may be more important in that moment than price.

Jocelyn added that the question is how we can create information parody so the provider team and the patient have equal information about the patient's benefits so they can discuss a treatment, procedure or test and where or even when a patient may want to go to get maximum coverage.

Ceci jumped in to provide an example of how a mid-Atlantic plan not only provides patients with where they can get a colonoscopy but will mail plan members a home test kit with all the pertinent information about risk factors. This helps make patients more health literate while also allowing them to take more control of their health in the convenience of their own home on their schedule. She added that it's about data, communication, and trust. If your health plan and provider sends information about a colonoscopy and home kit saying this would be good for you to do, you’re probably going to do it. So, it’s a win, win.

Ceci explained that using data in this way to support the patient in a transparent way, it goes a long way in repairing trust in the healthcare system. Adding that if a patient is surprised by an astronomical bill, that's not going to repair their trust, but when data can be used to support conversations leading to a strategic care and financial plan, progress can be made.

Pooja then zoomed out the conversation to focus on how interoperability projects are making more data flow and changing how businesses operate. Pooja asked Ceci and Ginny to describe how ACHP is counseling their members on how to approach making this cultural shift.

Ceci shared that they emphasize that this is going to be hard work. She pointed back to the early days of electronic health record adoption which took about a decade. Change is hard, especially when it's something personal, like healthcare. Ceci and Ginny both expressed that they just continually beat on the drum to remind their member plans to not give up and make sure the interoperability and serving patients the best way possible through the best use of data must be a top priority, but it will take a long time.

Jocelyn agreed that the cultural shift for both big and small plans is still in the early days but that there are some early adopters starting to make more substantial changes. She added that of course there are still organizations that are still checking the regulatory box versus making real, systemic changes but as CMS and ONC continue this unprecedented alignment and increased communication with the industry about their priorities, it may make it easier for stakeholders to make the changes needed. Ultimately leaders need to keep evangelizing and painting the picture of the future and what it looks like from a roadmap perspective.

So really laying out where things are headed from a regulatory perspective, [00:34:00] it does still surprise me that folks are taking the checkup, check the box approach. But I wholeheartedly agree with CC and Jenny, I think that this is about evangelizing and painting that picture forward, helping people understand what the roadmap work is and that it includes APIs and a patient-centered approach. Some will lead and some will follow.

In closing, Pooja asked the guests if there were any final messages or calls to action, they wanted to put out to the industry.

Ceci responded by saying that she thinks this is an incredibly exciting and a bit unnerving time and that she wanted to share the mantra all ACHP members get on a laminated card which is “think big, start small, act fast”

Pooja closed out the episode by thanking guests, Ceci and Ginny before reminding listeners that they can find and subscribe to The Dish on Health IT podcast on Apple podcast, Spotify, or whatever platform you use to pick up podcasts and that videos of episodes can be found on the POCP YouTube Channel.

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