Transforming Rural Health: RHTP and Value-Based Payment

Featured Speaker

Keith Mueller, Gerhard Hartman Professor of Health Management and Policy University of Iowa; Director, Rural Policy Research Institute; and Principal Investigator, Rural Health Value

Dr. Keith Mueller from Rural Health Value will provide an overview of Rural Health Transformation Program (RHTP) activities linked to value-based payment arrangements in rural communities. The session will include key considerations for the design of Value-Based Payment (VBP) models in rural, and strategies for preparing rural providers, including primary care providers and clinics, to operate successfully in value-based payment environments. Rural Health Value will also highlight relevant resources that may support states in this work.

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Transcript

Kristine Sande: Good afternoon everyone or morning depending on where you are. I'm Kristine Sande. I'm the program director of the Rural Health Information Hub and I'd like to welcome you to today's webinar, Transforming Rural Health RHTP in Value Based Payment. We're so glad you could all join us and we are delighted today to be partnering with Rural Health Value on this webinar.

Now it is my pleasure to introduce our speaker for today's webinar. Keith Mueller is the Gerhard Hartman, Professor in Health Management and Policy College of Public Health at the University of Iowa and the director of the Rural Policy Research Institute. He has served on numerous advisory committees to federal agencies, testified before congressional committees, and has published more than 300 scholarly articles and policy papers. And with that, I will turn it over to you, Dr. Mueller.

Keith Mueller: Thank you and welcome everyone to a discussion of Transforming Rural Health in the Role of Value-Based Payment in the Activities of the State Transformation Plans. Let's do a little bit of table setting or level setting as the phrase goes and just talk for a moment about the value of value-based payment. It has an intrinsic appeal as a payment design because it ends incentives of fee for service and volume driven care that have frustrated both those providing the care as well as all of us receiving the care and paying for it. It also has an appeal because it explicitly incorporates patient outcomes into design, so not just process anymore. And it has the benefit of potentially shifting health spending to other priorities.

The commitment to transition to value-based payment is not a simple thing to execute, if you will. It's not a one-time project that you're going to do in year one of a five-year work plan that is set up for the state transformation programs. It does require a longer timeline. So, for most of the states who are doing this, it's going to take until the end of five years to complete an implementation value-based payment. So, we won't really know the results until we actually get beyond even the transformation experience of those five years. And to go all in on value-based payment requires that it incorporates all payers.

Now, as we take a look at what states have written and we've identified around 23 or so for whom value-based payment is a core activity of their transformation program, there are many of those who do take an incremental approach rather than all payers and all services. Some of them are focused on one or less than a handful of service lines to implement value-based payment. In Iowa, for example, one of the efforts is a Combat Cancer hub and spoke model, obviously moving toward value-based payment for cancer treatment. Could be an incremental approach by payer. Some states are doing this only in their Medicaid programs, at least initially. Now there's language in some of those plans that they will pilot value-based payment through the Medicaid program and then work toward expanding it to all payers. How fast they can do that and get all of that done in five years I think is open for question.

Another incremental approach is using a pay for performance approach to value-based payment, which for example, we've been using in the Medicare program and prospective payment system for a long time now of withholding some money from overall payment and then paying it out based on quality metrics so you are moving toward value-based payment. There's some of that in a few of the state program narratives.

And then the ultimate approach though is to make it a major activity of the rural health transformation program that in the end draws on support not only of the payment change but of other changes being done in the state transformation. So, I'll talk a little bit in this presentation about that in the context of hub and spoke models and population help. So, it can be incremental, but to really use it in a transformative way, it's beyond incremental, but takes those five years.

As I said, we've identified at least 23 states that specifically chose the activity of value-based payment. You'll read occasionally about, well, almost everybody's doing something related to value-based. That's if you do a word search through all of their activities and see if they've mentioned it. To say that it's one of the core activities though is a level that exceeds that of just saying we're going to do some of those things as part of another initiative. It redesigns the healthcare delivery system to achieve better outcomes at the same or lower cost. That's the core of what do we mean by value-based payment. Many of them use technology to support the delivery of local services that improve patient outcomes through enhanced access. And addressing workforce becomes part of what you want to do with value-based payment and value-based care that leads to value-based payment because a comprehensive approach to this requires occupations such as community health workers that address all the circumstances that affect health outcomes, including things that happen prior to interaction with a clinical care team. Sometimes we refer to those as upstream drivers of health and those that happen after the initial clinical care when you're managing someone's chronic condition or a post-discharge plan and you need to do more than just monitor the clinical part of that, you need to understand the dynamics that occur when people aren't back in their home environment. So when you move all activities related to value-based payment, you are including technology, system delivery change, workforce change.

Now, what are the value-based care initiatives that we see in state rural health transformation plans? I've given a few examples on this screen at a high level. Nevada has a rural value acceleration network they're creating that will reward healthcare providers for improved outcomes and administrative efficiency. Colorado is exploring the feasibility of using shared savings and bundled payments to reward prevention and finalizing contracts doing that by the end of year five. New Hampshire is starting with a first cohort in 2027 and a second in 2028 that will work through the Medicaid program on value-based payment models that prepare rural providers to accept two-sided risk. So, as they reach the end of the five years, the idea is to get to the point where rural providers can accept two-sided risk. Montana is exploring value-based payment for dual eligible and special needs plans and also through the PACE model and looking at value-based care for nursing facilities. So not quite a specific service line, but in this case, addressing service to particular populations that are sometimes a challenge and who would benefit from value-based care and value-based payment.

Doing a little deeper dive into a few states, I'll start with Kansas. Kansas is moving to operate a state accountable care organization that would be statewide in partnership with a national ACO management company. I believe they're doing that through the request for proposal process. It'll be open to rural providers who are not already participating in Medicare Shared Savings Program or ACO REACH. They'll create incentive payments to rural providers to participate in the ACO and develop new Medicaid managed care organization contract requirements to tie payment incentives to care coordination services. Their goals are that by 2031, all providers will achieve improvements in paid for performance measures identified as foundational to clinical integration and that all providers will participate in clinically integrated networks.

Another state example is Louisiana where they're focusing on risk sharing value-based payment arrangements that look at the needs of high need populations, providing quality incentives to improve care for those populations. It evolves into a statewide value-based payment by starting with pilots and innovative care models and utilizes community partnerships to serve hard to reach populations, including putting mobile units in healthcare deserts, providing care in correctional facilities, and meeting the needs of rural hospitals and rural pharmacy access. I chose this example because it's intriguing that there's so much emphasis on hard-to-reach populations, which clearly has a key component for rural.

Their timeline is to start with a needs assessment that identifies priority innovations. Interventions, excuse me, for innovative pilots, do some preparatory work to create some of those partnerships that were mentioned in the previous slide. And by December of 2027, launch initial pilots working on metrics to monitor care coordination, then do evaluation and prepare to spread those pilots to the point of reaching full implementation in 2031.

Another example is South Dakota. South Dakota is looking to use value-based transformation through Medicaid reform to align financial incentives. So, this is one of those states with a focus on Medicaid. They aim to provide predictable revenue that rewards quality and incentivize preventive care. They're doing this in stages, first define goals and identify the needs, note the similarity with at least one other state that talks about doing needs assessment, finalize roles and establish some infrastructure funding, then select vendors and create model quality reporting and bridge payments for federally qualified health centers and rural health clinics. Then the third step is to staff the project fully developed quality metrics and pay our alignment incentives. The fourth step is with those quality metrics, now define the outcomes you're going to hold everybody accountable to and launch a model. And then the fifth step is to analyze the quality and utilization and use the results to inform ongoing budget and legislative considerations.

So, drawing from those overviews of some states and a little deeper dive into a few others, I'm pulling out some general themes. One is in the early stages, lay the groundwork. That included needs assessment. It included metric development. It included engaging providers either through Medicaid or for all payers. Sometimes that can be accelerated if you already have something in place. Missouri is an example of that. Their program which we profiled in Rural Health Value, so you can read that off of our website. They had already developed a network approach with hubs and spokes both in rural areas through a Medicaid demonstration. Their plan for the transformation program is to extend that now statewide through regions within the state, developing that same notion of a core hospital or facility in a rural place, then partnering with spokes also in rural. Models are often the first step in these proposals, unless again, as in the case of Missouri, you already have the model and now you're replicating. And the scale varies from targeting providers or service lines to being more comprehensive.

Now that's focusing just within that identified activity of value-based payment. I'm going to spend a few minutes pointing out that to move in a transformational way to value-based payment, you need to have value-based care with those quality metrics. You need some system design to get you to that point. You need some population health effort, you need some workforce effort. So let me take some of that statement and lay that out as related initiatives. One of those is establishing hub and spoke models. This is using facilities or other building blocks to move toward network development. So in a hub and spoke model, as an example, in the Missouri model in one region in Southeast Missouri, they have a core hub actually they are using in that particular region, a hub that's located in Springfield, Missouri that already had spokes and add more spokes to that system.

You could take another example I'm familiar with in Iowa when I mentioned Combat Cancer. That's actually being based on the Centers of Excellence model the state already had in place from internal care around the state where both the hubs and the spokes are located in rural communities. So the hub calls itself a center. In this case, in the Combat Cancer Initiative, it'll be a cancer center, not a comprehensive cancer center, but a cancer center that might take on, for example, infusion therapy for the region and have patients coming in who are connected to spoke facilities. And that could be a hospital in a rural community, it could be a clinic in a rural community. And you get into relationships as this unfolds of the dynamics of moving patients back and forth to the most appropriate site of care, keeping it as local as possible. So that's a building block toward advanced care management and the ability to accept risk because now you've got full control over the total expenditure.

Population health initiatives can pave the way for reducing utilization and uses of technology can improve effectiveness and efficiency. I've mentioned the Missouri TORCH example as well as the Iowa example of the hub and spoke model and what that might mean. We're working now to create a database, if you will, of the states that are moving toward hub and spoke so we can get some comparison about who's doing what with that model.

North Carolina is another example in hub and spoke established what they're calling North Carolina Roots Hubs. These will be six locally governed networks that coordinate medical behavioral and social services tailoring projects to regional needs. Each of the hubs, again, they're based in rural areas must address prenatal care, chronic disease prevention, cancer, and physical fitness. Ohio is using rural health innovation hubs to establish clinically integrated networks and regional centers of excellence. Their mission is to address rural residents needs to close healthcare gaps. So all of these hub and spoke models are ways of changing the delivery system that moves you closer to being able to develop value-based care and then accept downside and upside risk to move to a value-based payment model.

Population health initiatives are another closely related set of activities to moving toward value-based payment because these are the ones that can directly affect utilization of services through more appropriate access and use of population health services. So examples from the states include screening activities, including wellness visits, preventive services, primary to prevent the onset, secondary to prevent moving beyond the maintenance needs of someone like myself with chronic asthma. Tertiary when there is an episode, how do you handle that so that it doesn't exacerbate? Addressing living conditions, any of the upstream factors that affect health. So what is the housing like? What is the interior of the house like? If I have a chronic condition where I need access, how are we dealing with that with housing transportation and other living condition? Colorado ... Just some state examples, now has a specific focus on population health outcomes. Florida has a focus on health and lifestyle. Georgia is addressing transportation needs.

Technology plays a role in moving toward value-based care and value-based payment. One step is to modernize health information exchanges, being done in Indiana as an example. Investments in telehealth that provides access to services not otherwise available locally and that can support local services. Remote patient monitoring is an activity in Louisiana. I would point out with activities like that to really move toward ultimately transformational change into integrate remote patient monitoring with what you're doing in delivery system reform with what you're doing in payment reform. And then Kansas has a defined activity around population health management.

In workforce composition some of the activities we see from the states are pipeline development. So pipeline programs. Many, many states ... I don't have the number in front of me, have included this as an initiative. Several states have included community health workers. I made that point earlier in the role of community health workers as part of the team that can provide comprehensive services that contribute to value-based care. Some have included training in emergency medical services, Oregon being an example. And then every state's doing something in recruitment and retention initiatives.

So that was a pretty rapid run through. I'm going to be allowing plenty of time for questions. I think that's a more appropriate way of doing even deeper dives. So let me move toward summarization here. Transformational change is written into, well, almost by statute, every state's application. But then as you do a deeper dive and read through the applications themselves and as they begin to implement that, what they're posting on their websites for their implementation activities, you can see that every state has multiple initiatives. I think the minimum, if I'm remembering right, from the NOFO is at least three. Most states have around five or six major initiatives. I've made the point here, even if the state narrative did not make the point that those initiatives interact. And so there's a dynamic effect here toward transformational change from multiple initiatives. Some of the initiatives include ... And I'll concede this, include one-time efforts. So for example, several states have already rolled out spending and committed dollars for capital investment. There's a cap on that within the program, but that's something where, for example, hospitals have begun purchasing some of the da Vinci robots for surgery in rural hospitals. It's an example that it appears to be a one-off. On the other hand, we can link it back to system change because it enables them to provide a service line more cost effectively that can be tied back to eventually moving toward value-based payment.

The timeline is across five years and I made it the point of emphasis in the beginning that to get to the point of transition from volume-based payment to value-based payment takes an extensive period of time. So in the states that are doing this, they're even being ambitious to say we can get there in five years if they don't have a headstart, as Missouri did, Vermont has a headstart. A couple of other states that were already making some transitions can probably get there by the end of those five years. Some of the states can get all the building blocks, and I mentioned that in a couple of those examples. All the building blocks done, some pilot testing done, and then move to full implementation toward the end of the five-year timeframe. That means you need to have consistent efforts to build toward sustainability. Sustainability ultimately is going to depend on what is the steady revenue stream that supports the transformed system, which is why the transformation to value-based payment becomes important. However, you design that value-based payment elements of capitation, elements of global budgeting, elements of pay for performance. However, you've designed it, you have to keep in mind that the role is to sustain all those success stories you may have reached through some of the delivery system reform, use of technology, et cetera.

Sustainability requires, this is the summary statement, building the change into the ongoing financing of healthcare services. This is a presentation from Rural Health Value and so including in here some of the tools that you can access through our website. We have a virtual summit on designing value-based payment for the future that was just put out on the website a few months ago. There's a payer perspective on value-based care so you understand the kinds of conversations you need to have with payers about moving to the redesign. There's a value-based care assessment tool that we're getting great feedback on being very useful. There's a rural community engagement resource guide that can help you as you move into particularly in some of those population health initiatives where you need to engage a lot more than just the clinical provider team. Document on serving high need, high cost patients in the emergency department. An introduction to rural clinically integrated networks. We've got some tools and resources for you on the site. One of those resources is looking at what other people have done. So the example is up here of some innovative profiles that we've done on the Missouri program, the Colorado Program on Hospital Transformation, Iowa's health centers and how they've transitioned or are transitioning to value-based care and payment and another summit proceeding on driving value through community-based partnerships.

Going beyond what's available to you off the Rural Health Value website for other information that is relevant to this presentation, I've put up some of the RUPRI sites, the Center for Rural Health Policy Analysis, the health panel, and Rural Health Value appears there again. And then my own contact information, if you want to send me an email with particular questions or follow up, please go ahead and do so. Or you can send things in to the Rural Health Value site and we will all then as a team reply to that.

Kristine Sande: So, we do have one question already. And Joshua writes, "Thank you for your presentation. Do you have any thoughts on what metrics the state ought or ought not use to set goals and measure the success of the state's rural value-based payments section of an RHTP initiative? Also, any measures that ought to carry incentives?"

Keith Mueller: Hey, I'll take a stab at that. Joining me in this conversation is Karla Weng also from the Rural Health Value Team, and she may have additional comments particularly around metrics. The metrics ought to be at least a couple of categories. One category should be quality outcome metrics for the population being served, and I would divide that one into two buckets. One, those needs assessments that I mentioned that everyone will want to do to set all of this up. We'll identify in the typical needs assessment, what are the high leading causes of mortality and morbidity? What is the experience of our healthcare system in terms of what's most frequently coming into us and then how do we measure that over time? So can we reduce the mortality rate for certain cancers? Can we reduce time to full recovery at the individual patient level for some of those conditions? One is population-based bucket, the other is a patient-based bucket around some of those needs.

I would also develop metrics that are specific to the clinical side and in there I'm a little reluctant to say those myself because we have experts that deal with that. Then finally, metrics related to payment, related to the total expenditures. So that would be, can we do things that reduce utilization in a way that generates savings? And I would refer you to the kinds of metrics that are used in shared savings programs. So those are readily available off of sites like CMS's site and some private program sites. Karla, anything you'd like to add to that?

Karla Weng: No. I think the clinical measures would be dependent and aligned with whatever focus area you're looking at. So there is a set of what CMS has called universal measures that they're building into a lot of programs that are broader. So looking at cancer screenings and control for diabetes, control for hypertension, readmissions, those types of things are good places to start as well. But if you're going to focus on cancer, then your measures are going to be cancer. If you're going to focus on chronic care management, then it's going to be focused around that. So I know I think it's actually Iowa's focusing on skin cancer. Well, those measures are going to look a little bit different. So you may end up with some state specific metrics depending on where they're focusing the efforts.

Keith Mueller: And part of your question was also on the incentive side. So that would be the organization bringing that measurement down to the level of individual clinicians or maybe at the one level above that level of each of the clinics that are participating in a clinically integrated network and they'll compare those across each other and even that is an incentive to perform better even if it's not tied directly to payment.

Kristine Sande: All right. Thank you so much. The next question is where do these smaller hospital administrators go if they just have no idea where to get started? Is the rural community engagement guide the best place to start? Thoughts?

Keith Mueller: I think that's a good place to start. There's one on our site about clinically integrated networks. Which even if you're not going to do a CIN, just looking at what it takes to get there gives you some awareness of what's going on in the value-based payment arena. Looking at the value-based payment assessment guide is another place where, again, even if you're not ready, it starts giving you some notions of what are the terms being used, what are people talking about. Then I would also encourage networking in your own peer groups. So, looking to other hospital administrators within the state initially first so they're addressing some of the same issues. So, going through your state hospital association and your state rural health association to get to those peers that are already somewhere down the road to see what do I need to be aware of? What do I need to be thinking about?

Karla Weng: The only thing I would add there is just that there are, I believe all 50 states have a state website for their RHTP plan. I think RHIhub, you have links to those. I know the National Rural Health Association has information there so depends on where you're trying to get at. If you're trying to understand what's happening in your state, then that's where I would start. And then as Keith mentioned, connect in with local partners, State Hospital Association, State Rural Health Association, State Office of Rural Health. And then for tools and resources, I agree with him with the ones they listed.

Kristine Sande: All right. So up next is a long question, maybe several questions embedded there. Do you know how involved payers will be in these value-based initiatives? Are the states providing resources to help rural health organizations gain the expertise to manage value-based care programs such as understanding payment models, risk adjustment, member management, data setups, et cetera? Do you know what the nature of the payment models are such as shared savings models, capitated payments, quality incentive payments, and annual wellness visits? Are those states looking into good infrastructure for data support? An issue we have is that the data is almost a year late and is not accurate. How transparent are the models to participating organizations? We also have an issue where a lot of key information is proprietary and the payments are severely delayed, some as much as three years. So, I'll let you comment on all of that.

Keith Mueller: Well, the easy answer is there is no direct answer to any of the questions that covers all 50 states because they are doing things differently across the states, but that's just the glib general answer. Let me take the questions one at a time.

How involved are payers? And again, that core answer does remain though. It's quite variable across the states. In some states, as I mentioned, it's just the Medicaid program initially and then trying to attract payers to whatever the pilots are that come out of what they're able to do with Medicaid. In other states, they may be farther along and have other payers already engaged with them. States like Vermont where they've done that with an all payer accountable care organization approach. At one point, Pennsylvania had all the payers involved in their rural model approach. I don't know where they are now with all of the payers. So, it will vary considerably across the states. I've made the argument in the presentation that to sustain change beyond the five years, you really are going to need to involve the entire revenue stream. So that's all payers. But best guess would be we'd be doing well if half the states got to that point by the end of year five.

Are the states providing resources? The answer is yes. That's why they're getting anywhere from $140 to $280 million in year one, and they'll continue to get that level of payment for four more years. So, they're using that to help rural organizations gain some expertise. Exactly what they're doing, again, highly variable, but all the states are spending at least some portion of the dollars to help people understand where they're going with the transformation.

Nature of the payment models, I think right now the most dominant one is the shared savings approach, but some states are moving a little bit more rapidly toward some combination of capitation and global budgeting. That's how the AHEAD model in the world of Medicare demonstration projects, that's where the AHEAD program is. There are a couple of states. Georgia as an example has said, we want to move toward the AHEAD model, which is capitated primary care and global budgets for hospitals. Other states are taking much more modest steps of quality incentive payments along the way.

Are they looking into infrastructure for data support? Yes, within the constraints of how much money can be spent on capital investment and how much can go directly to data support, but that technology bucket is the one that they're using. So, as you look at states and like your own, look at their description of what they're doing in technology.

And then in terms of how accurate the data is and how timely it is, you're absolutely right that there are all kinds of challenges with that. States and programs that are able to get all the payers to the table are the ones with the highest likelihood of dealing with timeliness and comprehensiveness of the data. The closer you can get to an all payer system based off of payment, the closer you're getting to comprehensive in real time. I don't have an example of anyone who's gotten all the way there yet in being able to do that. There are some states that have all payer databases, so they're getting a little closer, a little quicker. Minnesota being one of the examples of those.

And I don't know what to do about payment delay other than trying to put that into contract negotiation, but you're right, that's always an issue.

Karla Weng: The other thing I would add is that if you have any influence over the folks who are talking about this and designing this in your state, point them to the resources that are available. We have a couple briefs on our site that basically say, "Here's the things we've learned over the last several years about what works in terms of value-based payment models in rural settings." So, there are some guiding frameworks and documents out there to help them be thinking through that because it is different than it will be in an urban setting. So, it depends on who's making those decisions and what kind of understanding they have about rural. So, the more that we can help people understand what it looks like in a rural environment and what's successful in a rural environment, the more likely we are to be to get these programs to actually work well.

Kristine Sande: Great. Thanks. That was a lot of information there. We have one more question and so if anybody else has a question, now would be a great time to enter it. And this question, you did touch on it some in the previous answer, but if you have anything else you'd like to mention about it, how do you anticipate the involvement, participation, and cooperation of commercial insurance providers?

Keith Mueller: Well, I hate to fall back on what I characterize as a glib answer, but it's true that there's going to be a lot of variation across the states on this. I think the way to approach it, if you're engaged in this and want to achieve the outcome of value-based care and value-based payment and make that transition, there are a couple of recommendations. One is one of the documents on our site is what is the payer perspective? I'd look at that, understand what their motivations are and what would interest them in value-based payment. In one of my early slides, I talked about that and what is appealing about value-based payment. What's appealing to the people providing the care would be a stream of revenue that enables me to do what I see I need to do for patient health, not for a specific encounter, but for overall patient health and make that a dependable source of revenue.

From the payer's perspective, okay, if we're going to make it a dependable source of revenue, I need to make it a predictable expenditure that I can have my actuaries built into a different model than what they've been doing, which has been a model based on use of specific services. So we need a new actuarial model, but the payers are going to need to understand what that is and they're going to need to be satisfied that it at least is a predictable payment. So that's what enables them to do things, like I said, premiums, copayments, deductibles, everything else they do as insurance companies. So that's not a direct answer in terms of what I anticipate the involvement to be. I'll confess personally, I'm an optimist. I see glasses as half full. I see a lot of reasons for commercial insurance providers to want to do this, but I also see a lot of problems in the details and a lot of challenges in getting both them and the healthcare organizations to settle in on what's the right path to follow.

Kristine Sande: All right. Another question is how do you see the health information exchanges participating in these various payment models?

Keith Mueller: Well, if the HIE or Health Information Exchange is achieving everything that a lot of us hoped it would when they were set up initially, and part of my background is I actually chaired the committee in Nebraska when I was there for a few years around trying to develop a statewide health information exchange. If you were able to really do that, so the challenge of interoperability across information systems is met. Then it could play a critical role in the payment model because you'd have full information about every person as you come into contact with them in the system. And that's really what you need to help individuals better manage their own care and what you need to help systems better manage patient care. So, the HIEs I think could play a critical role and there are multiple states that wrote that into their program that they would strengthen the HIE and particularly addressing the issue around interoperability across systems, across information platforms.

Kristine Sande: All right. And one more question. Is there a trend that you're seeing in how payers or health systems are targeting social determinants of health and/or what are the challenges to address the population? Are there value-based payment or incentive towards that specific population?

Keith Mueller: Well, fortunately here, the answer is yes. One of the examples I gave that I do find intriguing was Louisiana that specifically is targeting hard to reach populations and specifically building in population health kinds of programs with their ... It's more than just a mobile clinic. It's a mobile source of care, if you will, that includes addressing some of the social determinants of health. There are others who have built that in specifically. It's actually one of the benefits of the incentives they have to address the elements of the Make America Healthy Again platform of HHS because that really is addressing ... If you're doing that well, you are addressing a lot of the upstream factors to change the [inaudible]. In a lot of states picked up on that, they were given an extra incentive in the scoring system to do that. So yes, they are trying to address those challenges.

How do you get payers and health systems to do that? I think the initial leverage, if you will, is twofold. One is addressing the needs of high need populations. So, if you took by analysis of the expenditure data and you identified a set of conditions, some of those cancer-related conditions that are incredibly expensive but have the potential to be less expensive if you introduce better management like screening early. So, you get early stage detection and cancer is a good example. You get early stage detection, you can deal with it at that stage rather than suddenly having a stage four as a patient. So you realize that so you target patients based on condition or you target patients based on the results of an analysis of their own health to say that while you have some of the pre-condition indicators, so we're going to help you address that by including you in a group that we've created to address those particular needs. I'm trying to be careful with language here and not say it's top down, you will do this as a patient. No, it's a building up, but it's finding those needs.

One point of leverage is that, another point of leverage is as you advance more toward value-based payment, you really start incorporating more community-wide population-based measures because you don't know, especially in an all payer system when that patient may be one of your insured patients and when there's somebody else's, but there's an incentive for all of you to address the community population measures. I'd say that leverage is out there, but the reality is the primary leverage is the one of: It's going to have an impact on utilization, which is going to have an impact on my ability to get positive rewards from the incentives of value-based payments. I am going to address high-need populations as a high priority when I'm looking at what am I doing in upstream drivers or social determinants, whatever the terminology might be. Karla, anything to add to that?

Karla Weng: Yeah. I would just echo a few points. If you think about incentives, oftentimes we're looking at potentially avoidable utilization. So whether that's readmissions, whether or not that's admissions, I'm in the emergency department that could potentially have been avoided. A lot of times if you're tracing those back, it might be related to some of those social needs factors. So they have the food that they need. If you have a kid with asthma and you're sending them home to somewhere that has mold and no air conditioning, and then they end up triggering back around. Are there things that we're doing to help address individuals social needs that are going to help address their overall health and make them healthier? So we do see that even now I think tied into not necessarily specific around addressing that, but if you're going to do a good job addressing some of those potentially avoidable utilization factors, you have to be looking at those health related social needs.

Kristine Sande: All right. And then we have a follow-up question about HIEs. It says, "Regional HIEs are providing the interoperability for many of these models, namely steps toward real-time data being available in rural settings. Are there states that are including or considering regional HIEs for monetary incentives to build and maintain interoperability and sustainability?"

Keith Mueller: My direct answer is I'm not sure because I haven't had the time and opportunity yet to dig that deep into that part of their applications. And obviously we started digging into the value-based payment and care because that was a top interest to us. However, having read some of what's in the hub and spoke models and some of what's in the technology, I would confidently say yes, that there are states that are including or at least considering regional HIEs and helping to provide incentives to strengthen the HIEs. I just do not at this point have the specifics.

Kristine Sande: I'll take this opportunity to thank you, Keith and Karla, for the great information that you have shared today. The slides for today's webinar are currently available at www.ruralhealthinfo.org/webinars. Thanks so much for joining us and have a great day.