Making the Shift Toward Value-Based Care

At our recent INVEST conference, Behavioral Health Business spoke to Cooper Zelnick from Groups Recover Together, and Matt Gagalis from Eleanor Health, to learn how they are implementing value-based care. They touched on topics like market activity, timing, and the outcomes they are using to measure the quality of care.

Transcript has been edited for clarity

[00:00:00] John Yedinak: I want to thank everybody for coming today. This has been a really special day. I know for us in our team, we just want to say thank you again, but super excited about our last panel here. I think we’ve got some innovative companies that are doing some really cool stuff in value-based care.

[00:00:13] So I’m going to change it up a little bit. I’d love for each of them to do a quick intro on who they are, just because they are doing stuff that’s so unique and interesting, and I don’t want to do it an injustice by not explaining correctly. So, Cooper, we’ll start with you.

[00:00:25] Cooper Zelnick: I’m Cooper Zelnick I’m the Chief Strategy Officer at Groups Recover Together. We are, I think the nation’s largest outpatient addiction treatment provider, exclusively focused on value-based care. we kind of grew up in rural America, building brick-and-mortar clinics to treat opiate use disorder, and we’ve since transitioned to a hybrid model. Where we build brick and mortar facilities and also offer telehealth services, and I think, you know, when we tell our own story, we think of our work as, in kind of a couple of key ways. One, we have a unique clinical model for treating opiate use disorder. Two, that clinical model drives really powerful clinical outcomes and three, those clinical outcomes directly reduce the total cost of care for health plans. so the contracting work we do and the way we think about our relationships with health plans is really about aligning incentives between plans, the individuals we serve, and us as a providers. And yeah, we’re in about 15 states now. And. That’s the story.

[00:01:25] John Yedinak: All right, Matt.

[00:01:25] Matt Gagalis: I’m Matt Gagalis. I lead business development for Eleanor health, like Groups, we are an outpatient provider organization focused on treating substance use disorder. we are live in six states across the country today. We’ll be in eight states next year. our clinical model is similar, but a little bit different than what Cooper’s doing at Groups. Really focused on a higher acuity, subset of the population. So we offer a super-comprehensive clinical model that includes MAT for treating the substance use disorder, but also full psychiatry, therapy. We also offer nurse care management to address some of the physical health comorbidities, as well as peer support, like Groups where multimodal. So we have clinics, bricks and mortar clinics in all the markets where we operate. We also deliver a hundred percent of the same services that are available in the clinic via telemedicine and then some of our services are also available in the community. So we have resources that will go out and meet with members in their homes. They’ll meet in a coffee shop or near a workplace, sort of wherever is convenient. The last piece that I would touch on is like Groups and why we’re all here is our commitment to value-based care. So, our program has really been built around a population, health management, value-based contracting sort of construct, and excited to unpack that a little bit more as we get into it.

[00:02:38] John Yedinak: Obviously one of the themes that we’ve heard, all throughout the day is value-based care. So I‘d love to get your guys’ take in terms of how big of an opportunity for behavioral health providers is value-based care? So, Cooper, we’ll start with you.

[00:02:48] Cooper Zelnick: Sure. I mean, I think it’s a massive opportunity.

[00:02:50] I think it’s also a challenge. Like the place, I would start is by defining value-based care, and I think the way that we think about value-based care internally is, reimbursement tied, not to the provision of services, but tied to the delivery of outcomes. So, you know, when I think about the opportunity for value-based care in behavioral first, it’s like, what outcomes do we care?

[00:03:14] Second, how are those outcomes achieved? And then third, like are payers and providers willing to get aligned and take risks around those outcomes, right? Like, can you build trust and can you build kind of a mutual language that allows that to happen, but, you know, we’re biased, but it’s the future I think and it’s here

[00:03:32] John Yedinak: You keep bringing up the word outcomes, which again, everybody’s talking about defining what, dive into that in a little bit, but Matt, I’d love to hear your take on, like, how big do you think the market is?

[00:03:40] Matt Gagalis: Well, I think the opportunity is huge because I don’t think there are a lot of organizations doing it yet.

[00:03:47] We’ve seen value-based care adopted in other sectors of healthcare and it hasn’t fully made its way to behavioral health yet say for a few of us that are sort of, cutting new ground here to make it happen. And I agree with everything Cooper said and would add, there are definitely multiple flavors of value-based care.

[00:04:02] If you think about it on a spectrum, you sorta have a fee for service over on one side, traditional sort of getting paid for the services that you provide and on the other hand, there’s population health management with an attributed population for whom you are responsible for the total cost of care. You know, that sort of the ACO model and that’s where we’ve focused most of our energy, but there are all kinds of flavors of value-based care that live between fee for service and population health where I see tons of opportunity.

[00:04:26] John Yedinak: Do you guys ever worry, obviously your companies were created for this specific use for value-based care, do you guys ever worry that you might be a little bit too early? There seem like a lot of operators I’ve met today. They’re willing to kind of dip their toes in, but, they seem like they think it might be a little too early.

[00:04:40] Cooper Zelnick: Less so now, but I think, you know, back then, we wouldn’t, we wouldn’t have said we were created for value-based care. In 2014, when we were founded, we would have said that we were created to solve a problem where a clinical model existed that could save lives and where that clinical model wasn’t deployed.

[00:04:59] So we kind of stumbled to value-based care, right? Like our goal was first and foremost to deliver a model that worked and secondarily to figure out how to get paid for that model, and in that second piece, we learned that we had to build a reimbursement model to match our clinical model because the existing fee for service reimbursement models for a whole variety of reasons didn’t work.

[00:05:19] But back then it did feel like we were too early. Right? Like we were banging our heads against walls for years and years, and I think, you know, we’ve been talking for two and a half hours in the waiting room about how hard it still is, but I think it is getting easier.

[00:05:34] Matt Gagalis: Yeah, I don’t think we’re too early like Groups. We started on a fee-for-service sort of construct, but we were specifically built. We started that way, knowing that it was all gonna be about value-based care. So achieving outcomes in a fee-for-service construct is really hard to do and it’s, it’s a losing proposition.

[00:05:51] So, we lost money for the first year getting to the point where we had the outcomes, where we could say. Yeah, what we do works, and the only way we’re going to do it for you moving forward is if we have a value-based construct to do it under

[00:06:02] John Yedinak: Cooper, I’m curious, you said that you’re not worried you’re too early. Was there a turning point, anything specific that you remember? It was like, okay, this is actually kind of work.

[00:06:09] Cooper Zelnick: Yes. I think the turning point for us, was probably about two and a half years ago where we, it was the first moment when we were able to demonstrate. A tangible reduction in the total cost of care for the population we were serving.

[00:06:24] So we had previously, you know, in the early days it was a little bit of like, here are our clinical outcomes, trust that those clinical outcomes translate into financial impact. But when you get to that place of say, Here is the tangible financial impact, and the reason that we as a provider are able to deliver that when the rest of your provider network can’t go is because we’re compensated in a different way.

[00:06:48] The incentives that have been set up for us are different and seeing, that in black and white, like seeing our ability to engage this really costly population, and not only save lives, like really, really, really save lives while also reducing the cost burden, is like, that was the moment where I think for our kind of first plan partners and also for us as an organization, the light bulb went off and it was like, oh, this is working.

[00:07:15] John Yedinak: Matt, You guys were obviously fee for service at the beginning and then made the switch. Was there a point similar to the question I asked Cooper but was there a point where you started to see certain outcomes? You’re like, this is going to work. We can take this to insurers.

[00:07:27] Matt Gagalis: Yeah. A couple of things. One, as we started to work with payers to identify a prospective target list of members. So rather than waiting for folks to come to us and ask for help with their substance use disorder, we work with payers to proactively identify based on data based on diagnoses, based on drugs that they might be taking, or prescriptions based on other patterns in their utilization that suggest they’re at high risk, we would be getting lists of thousands, you know, 5,000, 10,000 names to try to engage in care and when we realized. Oh, people are actually engaging and they’re staying with us, and then the outcomes are that we knew the outcomes would be there because we’re wrapping our arms. We’re wrapping all of these clinical services around folks in a loving and caring way, you know, in a harm reduction model, reduction of stigma, all the things that are important.

[00:08:12] But our ability to sort of get people in the door and keep them there really, that was when the light bulb went off and said, we could, we could do that much more.

[00:08:20] John Yedinak: So we keep talking about outcomes and it’s been a theme throughout the day. I’d love to hear, Matt, we’ll start with you to change it up a little bit in terms of what type of outcomes are you looking for? How are you measuring that? And I think everybody in the room would love to get some insights in terms of, what you’re tracking and how you’re tracking it.

[00:08:35] Matt Gagalis: I mean, I think about it in phases. So it starts with an engagement like I was just saying. We’ve got to get people engaged and we got to keep them engaged and retained in care over time. Can’t do anything if you haven’t been able to do that.

[00:08:45] Once they’re in, then we think about things like satisfaction. And we think about, you know, another sort of quality measures like PHQ-9 and GAD-7, and some of the other screeners that we’re doing and showing positive movement on those.

[00:09:00] Which leads to some of the more specific health outcomes around readmission prevention. Are we able to follow up when folks have been in the emergency room or in the hospital, are we able to follow up in a timely manner to get them care, post-discharge, and all of that sort of builds towards reducing the total cost of care at the end of the day? That’s the thing that we are ultimately measured on.

[00:09:21] Cooper Zelnick: I think, the reason why I love doing this work is because the outcomes that matter to the people we serve to our patients are also the outcomes that matter to the people who pay for care. So retention and treatment, which you mentioned is the key benchmark for clinical efficacy in our industry.

[00:09:37] It’s directly correlated with long-term recovery. So there, you know, those who are retained in care for six months are less likely to suffer an overdose or relapse, but it’s also directly correlated with the total cost of care.

[00:09:48] So I think for us, same deal access, getting people into care quickly. Engagement, are they attending the scheduled sessions? Are they enjoying care, satisfaction, retention, and then, all of the sorts of cost and quality metrics. But for us, I think, you know, if we have the ability to deliver like a really wonderful service to people who frankly, like don’t get wonderful service, And that service reduces costs then I think we’re doing good work.

[00:10:15] John Yedinak: So let’s talk a little bit about the relationship with payers. I’m curious. I know there are people in this room that I’m sure would love to hear how you approach them with those outcomes. What are some strategies you would recommend? Somebody that’s obviously has a relationship with the payer, but they’d like to move towards a more value-based care model.

[00:10:29] How would you suggest that they go about doing that?

[00:10:36] Matt Gagalis: Yeah, that is a tough one because payers are notoriously hard to work with, and they’re slow and they’re not super innovative generally and that this is the first time I’ve worked on the provider side in such a, such a like provider-centric way.

[00:10:48] I sort of always assumed that it was the providers that were reticent to go into value-based or sort of accountable care kind of contracts with payers. I now believe it to be the opposite payers are very reticent and it’s, I hear more often than not. Why don’t we just start fee for service and then we’ll see where we go from there.

[00:11:06] That often comes from the folks on the network contracting side, who I think have a playbook for how they contract with, and they don’t have a lot of leeways to go outside of that. So the key really for us has been identifying someone within the plan and they, from my experience, live in lots of different roles within the plan, but we need to find someone who is willing to be innovative, willing to sort of drive something different and understands that it will probably take us a while. Six eight, maybe 12 months to put together a structure that is going to work. I guess they’ve never done it before.

[00:11:40] John Yedinak: I’m curious if they come back to you and they say, let’s start fee for service. Will you guys take that?

[00:11:43] Matt Gagalis: Generally we’re saying no.

[00:11:46] Cooper Zelnick: We do not do that anymore either.

[00:11:47] I completely agree. Like, I think. Plans often say let’s start fee for service. I think that a strategy that we’ve really spent time working on and developing is within the construct of a value-based model that aligns with incentives. How do we meet the health plan, where they are? Right. And I think like a lot of early-stage companies, you tend to say, well, okay, give us a flat claims file and refer members directly to us and we don’t want to submit claims or encounters, and we want you to pay us. You know, X on every single member and it just, it doesn’t work.

[00:12:20] I think, Matt’s point is about finding the appropriate place along the spectrum of value. We’ve spent a lot of time saying, okay, here is how we can successfully serve your members and also, we understand the limitations of your claims system and we can work within it. Right. And, especially given the competing priorities that health funds have. Being able to meet them where they are while also pushing towards this outcomes-oriented work is really important.

[00:12:46] John Yedinak: I’m curious with everything obviously going on with COVID mental health, being more front and center and the addiction just in general, has it made those conversations more of a top priority, like when you’re having them with insurers or if you notice a difference, I guess since you know, COVID hit and as we try and work our way through this.

[00:13:01] Matt Gagalis: They’re definitely more aware of it.

[00:13:02] I mean, they’ve been aware of it for a while. You know, prior to COVID, there was probably some sense that, yes, this is a big problem, but in the grand scheme of my problems at the health plan, it’s still pretty small. This is not diabetes or heart disease. I think with the reduction in the stigma and the increased awareness of these problems on the behavioral health side and substance use side, they are more aware of it and, you know, I think I’ve started to hear even contracting teams say we are now being incentivized in our own comp structures to figure out innovative structures with providers like you guys. So it’s coming along and interesting.

[00:13:42] Cooper Zelnick: Yeah and I think the other thing I saw I’ve seen over the last two years, and I’d be curious to see if you’ve seen it as well.

[00:13:47] Pre COVID the push towards fee for service was stronger because there was a relatively more robust network of legacy brick and mortar addiction, treatment providers. Amidst COVID, we were empowered to shift to virtual very easily because of the nature of our contracts, right? By contrast, the majority of the folks in our industry earn most of their revenue from lab testing, basically, lab-based urine testing and that is the only activity that can not be done over telehealth. so suddenly the ways in which fee for service contracting is adequate were shown, in stark contrast. We had the ability to say this model actually allows us to flex and serve your members virtually in person in a hybrid way and I think that helped us move more quickly, as it became more top of mind for folks.

[00:14:39] John Yedinak: So you guys can be more nimble than the traditional behavioral service.

[00:14:42] Cooper Zelnick: I mean, if you’re less focused on services and more focused on outcomes you can kind of by definition, be nimble as it relates to the service delivery.

[00:14:49] John Yedinak: So not to put you guys on the spot here, but I guess should the more traditional operators kind of see you guys as a threat, somebody that they would want to work with and are they at a disadvantage, I guess to you, you guys, and what you’ve built, would you say.

[00:15:01] Matt Gagalis: But we’ve talked about this. We were up here together. We spent the last two hours talking and sharing notes. We don’t see ourselves as a threat to one another. We were talking about how can we work together.

[00:15:11] I’m sitting out there. And I think that same sentiment would be true for the traditional operators as well. Yeah, this is a much bigger problem, than either of our two organizations can address on our own.

[00:15:20] John Yedinak: I would say I’m relatively new to this space, but I think that’s one of the things I’ve really loved about the spaces that it seems kind of like a communal effort everybody’s figuring out together and everybody’s pretty willing to share.

[00:15:28] Cooper Zelnick: Yeah. And, and our opportunity, I think that as both of our opportunities is to raise the bar as it relates to quality for the whole industry. Right. Like nothing. Our organization is happier than if the value-based structures we developed were put to use with other providers. Right?

[00:15:46] Like if we’re, if we are getting paid to deliver really high-quality outcomes and that works for others. Great. Like that, that’s the best possible case here.

[00:15:56] Matt Gagalis: I would add to that. To that point, as we think about who do we want to work without there in terms of other providers, whether they’re in our space or sort of tangential spaces, they do need to be like-minded.

[00:16:07] We are focused on value-based care. We’re taking the risk on total costs. We want folks that maybe they’re not in similar contracts, but they need to be thinking about quality improvement, the same way that we do.

[00:16:17] John Yedinak: Yeah. So, Cooper, you had talked about how you guys were able to be nimble with stuff like telehealth and things like that, is that going to be a part of your business going forward or do you think you’ll go back to kind of more the traditional way, how you guys were originally set up?

[00:16:29] Cooper Zelnick: No, it’s definitely going to be part of our business going forward. I think, you know, we spent seven years serving people, brick and mortar, and we’ve just spent a lot exclusively.

[00:16:40] We’ve just spent the last two serving people digitally, exclusively. The first thing we did was understand whether our outcomes held up, right? Can we deliver the same level of quality in this new modality? And we can, and it gives us confidence. Not that the future is digital, but that the future is hybrid. So we think there will be some people who really want to get back to the offices and see one another in person.

[00:17:01] There’ll be some people for whom telehealth in perpetuity is great and there’ll be people who want to mix and like we’re excited to deliver all of them.

[00:17:08] John Yedinak: So do you see different outcomes based on the telehealth versus the in-group?

[00:17:11] Cooper Zelnick: We didn’t, no. And that was the most important thing to us, right.

[00:17:14] Because if we had seen, if we had seen a degradation in outcomes. We wouldn’t have felt like it was worth it. Right. But, and, and this is also one of the things that I think is true of your organization too. Like, we are very, very data-driven and the question was like, all right, Vic, you know, in-person cohorts, comorbidity matched. How do they perform against the tele-cohorts?

[00:17:35] John Yedinak: Were you surprised when he got the data and it was the same?

[00:17:37] Cooper Zelnick: Yes, I think we honestly, we were heavily, heavily Medicaid, and we had some walking around assumptions around technology barriers, and the ability to engage virtually within that population that were proved totally wrong.

[00:17:49] John Yedinak: So were they just doing it on their phone?

[00:17:51] Cooper Zelnick: Yeah, lot of mobile. Of course, bandwidth constraints and issues, especially in rural communities. But we found that the reduction of the removal of transportation barriers more than outweighed that.

[00:18:03] John Yedinak: So, Matt, I’m curious to get your take. Obviously, COVID changed things. People had to adapt more to technology. Has that changed your business and I guess going forward, do you think, are you going to revert back to how things were before, or how do you view it?

[00:18:14] Matt Gagalis: So when we started, the plan was always multimodal, technology, bricks, and mortar in the community, like all three channels were a part of the plan.

[00:18:22] When COVID hit, I think we were probably doing 75 or 80% in person. So the technology was sort of support. when COVID hit though, like Groups, we were prepared immediately to pivot. We went in one or two weeks to 90% virtual with all of our care delivery, and I think our payer partners appreciated that our community members definitely appreciated that like Groups, we did not see a difference in outcomes, but what we did realize is, in a purely virtual care delivery environment. We have to do more touchpoints. Like we had to try harder to achieve the same outcomes, which was what surprised us.

[00:18:58] John Yedinak: Interesting. So you brought up Medicaid. I’d love to touch on that. I guess a lot of people in the room, obviously, some things that were said, people are saying the reimbursements to on Medicaid to make a real business out of it.

[00:19:08] You’ve obviously found it to be a little bit different. I’d love to if you could tell people a little bit about how you’re working with Medicaid and your model.

[00:19:14] Cooper Zelnick: So we are 70 plus percent Medicaid as, as a proportion of our census. it’s hard for all of the reasons we all know, right.

[00:19:23] Reimbursement is so starkly lower, regulations are more onerous. It varies entirely from state to state. The reason that it’s critical for us is that it’s where our people are. Like we grew up serving rural Medicaid beneficiaries. It is a key part of our mission. It’s where, you know, the largest, it’s where the highest prevalence is for opiate use disorder.

[00:19:45] And we’ve actually found that Medicaid plans can be really forward-thinking. Again, if you can get out of, sort of the fee-for-service contract, the network trap, you can go and engage with these folks who, frankly, aren’t getting like a lot of love from innovative companies, right? Like most of the like behavioral and mental health startups in the US are very employer-focused or commercial focused or coastal-focused.

[00:20:10] And if you want to go talk to like the CEO or CMO of a Medicaid plan in Iowa, like those are folks who want to talk. And, we also, we deliver a service that, we deliver a service that Medicaid beneficiaries sadly often don’t get. Right and it’s, it’s really important for us to do it.

[00:20:25] Matt Gagalis: Same thing. Yeah. the approach we’re taking and having some success in Medicaid, and today it’s a smaller percentage of our population.

[00:20:33] Probably closer to 20% of our population has Medicaid today. But by the end of this year, it’ll be probably closer to a third of our population. We’ve had a lot of success with population health models, with Medicaid plans that are about to launch, where Medicaid plans are saying, yeah, we’re going to, we’re going to find 5,000 of our highest risk members and we’re going to give them to you and you are now responsible for.

[00:21:09] I didn’t like that in as many commercial plans or Medicare plans. So to your point, yeah, I think they’re, they’re dying to try something new.

[00:21:17] John Yedinak: Are you surprised that you don’t get as much engagement from the commercial plans? I guess that you’re getting more from the Medicaid plans versus the commercial?

[00:21:23] Matt Gagalis: No, I mean, I think it probably speaks to the prevalence, as Cooper said, and I think it also speaks to like probably a legacy to some extent of, abuse or misuse in Medicaid as well, not on there, on their membership side, but on the provider side, overuse of urine drug screenings, you know, some things that they just, you know, there’s, we hear a lot from medical directors that Medicaid plans that say there’s not enough quality care being provided to our members. And so we just, we’re dying to have partners that are doing things the right way.

[00:21:55] John Yedinak: So one of the words you brought up, which I just want to make sure everybody in the room, including myself, totally understands. So you had brought up that you’re willing to take risks, help, help us understand that. What do you mean by risk?

[00:22:06] Matt Gagalis: So give you an example of the types of risk contracts that we’re doing. I’ve talked a couple of times about these attributed lives or these managed populations that we’re taking. So a plan might identify 5,000 members that are high risk. We get paid a PMPM fee, a per member per month fee on those 5,000 members. Regardless of how many of those members we actually provide care for the fee that we’re being paid is a prospective payment basically, and that fee is going to be at risk tied to one engagement rate. So we’ll set some targets and we might have to give some of that money back if we don’t hit certain targets.

[00:22:42] Similarly with quality measures, we might agree to three or five or seven quality measures in these contracts and same thing thresholds to hit along the way, and if we don’t hit those thresholds, we might have to give some money back. Then ultimately, The most risk is around the total cost of care, so we’re going to set a baseline cost of care for those 5,000 people for the 12 months prior. then we’re going to measure that same cost of care at the end of the next 12 months, and if there’s a difference, we either have to give money back to make up that difference, or we get to share in the upside some of the savings that are generated.

[00:23:14] John Yedinak: What about you? How do you, how do you view risk?

[00:23:16] Cooper Zelnick: Yeah, I think we view it similarly. That is, as you said like that is the end of the spectrum. One of the things we’ve spent a lot of time on is thinking about how to align incentives and take risks for plans who aren’t there yet. Right. And that could be as simple as, you know, quality bonuses. It could be one of the structures we’ve used a lot that we really like is we will get a sort of bundled payment per engaged member per month, but we only actually get a portion of that. We get about 50% of that upfront, and then the other 50% of it, we earn based on the achievement of specific clinical milestones or financial outcomes, right.

[00:23:55] Reduction in ED utilization, retention, increase in PCP and. But, I think the end of the road for us and where we like to be as well as the total cost of care. Fascinatingly, there are a few ways to look at it, right? One way is 12 months, pre 12 months post, another way is to think about folks who are entering our treatment modality versus folks who are entering other lower quality or higher cost modalities and doing sort of an AB comparison. But ultimately like the promise of, you know, for opiate use disorder, the promise of medication-assisted treatment and for substance use disorder, the promise of evidence-based medicine, is that it is like cost efficacious and that’s what we’re trying to demonstrate, and that’s what we’re setting up our contracts around.

[00:24:39] John Yedinak: So do you see a lot of differences in terms of the risk agreements that you sign up for with different insurers? Whether it’s this insurer could be comfortable with this, does that make your business more difficult? If you’re having do different things for different people.

[00:24:51] Matt Gagalis: We see huge differences in the contracts like Cooper said, you know, the pop health contract that I described is on one end of the spectrum. There’s a lot of layers in between whether it’s bundled payments or pay for performance incentives, tied to hidden quality measures, those sorts of things.

[00:25:04] So there’s huge variability in the structure of the contract, but there’s less variability in the goals of the contract, and so that’s what makes it easy from an operator’s perspective. Almost all of the contracts are, aiming towards the same. 10 quality measures or a subset of the same 10 quality measures.

[00:25:21] Cooper Zelnick: The way that we articulated is historically we have been militant about our clinical model and very flexible about our reimbursement methodology. But the other thing we were talking about, outside. We’re our organizations, both. I think this is true of Groups and Eleanor are getting to the place where we can actually be more prescriptive with health plans and say, this is a model that works, and our goal is to standardize. Not because it makes it easier for us to operate, but rather because it allows us to create programs. , that can scale across health plans and can scale across providers and as a result, broaden our impact.

[00:25:57] John Yedinak: All right, so we’re starting to get some questions then. Thank you. keep them coming. But the first one here, for Matt. So you had mentioned that, providing pop health to 5,000 high-risk members, do you provide any services to those that don’t get treatment from you?

[00:26:11] Matt Gagalis: That’s a great question. So the one thing that we will do for all of those attributed members is outreach and engagement.

[00:26:18] So we’re going to try to engage everybody. We’re going to reach out to where say the spin a hard year. You got a lot on your mind, whether it’s, your mental health or your physical health or your substance use like we’re going to reach out and try to get everybody to engage, and I think even just surfacing the question, are you interested in this kind of help? Will help some people. But not everyone’s going to choose to engage. People, don’t associate with substance use disorder, even though they might have one. they might be getting treatment somewhere else. Uh, and, and those things, those are okay. We ultimately still have the risk for those people that don’t engage. We’re always trying to get everybody into the program.

[00:26:58] John Yedinak: Well, that changes things for you because if you can’t get access to them and they’re using someone else’s treatment, that’s going to screw up how you guys do business.

[00:27:02] Matt Gagalis: Absolutely. Yeah. We build the financial models around an assumption that as long as we can get at least 10% of the population engaged, really able to reduce their costs so much that we can impact the entire population.

[00:27:16] John Yedinak: What about you? Do you guys provide services to people that aren’t getting treatment from you?

[00:27:17] Cooper Zelnick: We do so, so for us where it starts is I think similarly like we try to engage people, we also have a 24-hour crisis line, um, that is available to everyone. So that’s, you know, for us, I think our, our view of the world really is there are people who we serve and there are people who need our help, who may not need our modality.

[00:27:41] So we do care coordination for anyone who calls that line. We open our physical spaces to the communities we serve. We do recovery meetings that are. You know, unrelated to our modality and that are open to the public. We do family nights and things like that, and I think again, like part of this part of treating the disease of addiction is bringing together communities and reducing stigma, and we do that by making our treatment, not sort of a black box. But rather this open system that anyone can participate in and even a small way.

[00:28:12] John Yedinak: How do you recommend getting visibility into your population’s total cost of care without entering into agreements with payers and sharing data?

[00:28:22] Matt Gagalis: Yeah, that’s a great question, and it’s actually, we were talking about this outside. Not every payer is giving us the data that we need to actually be able to monitor our own progress within these contracts. So we’ve found other ways to do it by proxy. One, we know the data about our own members.

[00:28:40] Like we, we generally have a sense if one of our members goes to the hospital, we generally have a sense for the types of things that we’re doing to support our members. We also partner with some companies like PatientPing, and there are a few other companies like PatientPing that provide real-time ADT data.

[00:28:55] So basically, they’re like an HIE they’ve collected real-time data feeds from all the hospitals in a given, and we can upload to PatientPing a list of our members, and anytime one of those members lands in a hospital, we know it. So we use that data as a pretty good proxy for whether or not the population has been in the hospital, which is a proxy for sort of the biggest driver of the cost of care.

[00:29:20] Cooper Zelnick: All of that. Plus we actually rely pretty heavily on member self-report data. There’ve been some interesting studies that show that in substance use disorder treatment. The disparity between actual outcomes and members of report outcomes is quite small. So we do massive surveys of our members around things like utilization, et cetera.

[00:29:41] But I think that, yeah, the broader point. Not all health plans are there. And as often as they are giving us their data, we are giving them their data. Right.

[00:29:53] John Yedinak: So how do you guys work with residential providers to facilitate care transitions for handoff to residential outpatient? Are you doing anything there?

[00:30:01] Matt Gagalis We do. Yeah. We, we partner with all kinds of different providers in the communities where we’re providing services, residential treatment, acute and sort of other post acute providers as well, primary care providers, other specialists in the community, and like we talked about. Our goal is really to identify those partners that are like-minded in their approach.

[00:30:19] So, you know, we are making referrals to those residential providers when a step up in care is required, and similarly, we’re looking for those warm handoffs back when folks are ready to go back into the community.

[00:30:31] Cooper Zelnick: Yeah, we think of ourselves not as the full continuum of care, but as like a valuable piece of that.

[00:30:36] So same goes making referrals back and forth. I think to Matt’s point about like-minded providers, you know, for inpatient providers who are focused on helping people get to long-term recovery, we are a wonderful partner because it’s 30 days, it’s often in a place that you don’t live and being able to transition back home and have like a high-quality provider in your community is valuable.

[00:31:04] For residential providers who view their economic model as like a recurring revenue business, we are not a good partner. I think there, sadly like some, unethical players in our space, our space has been really stigmatized for that. That’s a challenge.

[00:31:16] John Yedinak: Do you guys think you could get into other areas of the continuum to start to help your clients more? Is that part of your growth roadmap?

[00:31:24] Matt Gagalis: Yeah, absolutely. I think if we were going to head in any direction next, it would probably be closer to primary care. I could see us right now, that PMPM payment that I talked about is really sort of a sub cap payment. We get paid a PMPM that’s relatively small, that is intended to cover the services that we provide.

[00:31:42] But we could see actually like broadening that a little bit and getting a bigger capitated payment and sort of being the full quarterback of all the care that our members receive as one primary care. The other would be like severe mental illness. All of our members have multiple behavioral health conditions in addition to their substance use disorder and we’ve got the expertise in-house to support that. So that’s another sort of specialty area that we debate going into as well.

[00:32:07] John Yedinak: When you talk about primary care, are you talking about direct contracting?

[00:32:10] Matt Gagalis: Direct contracting with payers pay or something. Yeah.

[00:32:16] Cooper Zelnick: I mean, I think we think about it similarly, the way that the questions we would ask are, what are the high-cost needs of our patients, where they feel we have a right to serve them.

[00:32:29] So I think the entire substance use disorder continuum, for sure. We’re not ever going to be residential, right. But we want to be able to serve folks. We want to really stretch the bounds of outpatient. But then I think there are really interesting, you know, non-primary care, pieces of, of healthcare that we’re focused on.

[00:32:47] So could we directly treat Hepatitis C rather than just screening for it? Could we do more work around family planning? Could we think about things that aren’t necessarily substance use disorders, better adjacent behavioral stuff, gambling, sex, nicotine? You know, I think, there are a lot of, uh, areas where we can be of service and we’ve actually, we just surveyed our members on this too.

[00:33:16] John Yedinak: So, the performance metrics that measure value-based care success. Can you speak to those a little bit and kind of define what you’re talking about there?

[00:33:27] Matt Gagalis: Yeah. So there’s a bunch of Hedis measures that generally flow into the contracts that payers are accountable for, which then they pass down that accountability to us. Follow-up after an ED or inpatient admission, there’s some timeliness, so if there’s been an admission for a substance use-related issue, you need to have demonstrated a follow-up visit within seven days, and then within 30 days, same as true for behavioral health related admission, seven and 30-day follow-up. So those four measures right there. Lots of talk these days with payers about medication adherence, both to the MAT medications as well as other behavioral health medications.

[00:34:05] Cooper Zelnick: yeah. All of that rapid access is another.

[00:34:08] I think just rates of ED and inpatient utilization are big for us. In one of our contracts, which is pretty fascinating, held accountable for an increase in dental visits. So if you think about like, especially stimulant use disorder, there are people who haven’t been to a dentist in five years, it’s a massive driver of costs.

[00:34:30] So we’re, we’re actually pretty excited about working with plans and saying like, show us areas where if we close a gap, we will benefit you and benefit a member. And that’s like such a fun example of one.

[00:34:42] John Yedinak: So are they willing to have those conversations and learn more about that kind of stuff? The payers.

[00:34:45] Cooper Zelnick: The payers definitely are.

[00:34:47] Yeah. And I think that the question for us too, And this is maybe a question for a lot of providers, right? For a provider who is only giving medication to a member, the ability to get that member to a dentist is limited for us. As the backbone of our work is community. We, these are folks who maybe haven’t been to primary care in five years and we see them every single week.

[00:35:10] So like by building that engagement and by getting that right first. We end up being able to have an outsized impact. I think that’s how Eleanor would view the world too. Like that’s, what’s different about our organizations. It’s the way we engage with members that empowers us to engage with payers in this way.

[00:35:26] Matt Gagalis: The majority of community members that come to us do not have an active primary care relationship, 80 to 90%. That’s step one, we need to get you in to see a primary care doctor.

[00:35:34] John Yedinak: So do you have a list of primary care doctors that you typically work with?

[00:35:37] Matt Gagalis: We do. Yeah. I mean, we’d want to keep them in-network for the payer.

[00:35:40] The payer sometimes has a narrow network, you know, so we work with the payer to figure that out as well, but let’s get you in and let’s get you seen and let’s coordinate care. Let’s share our care plan with the primary care doc and vice versa

[00:35:51] John Yedinak: At some point, you said it would make sense for you guys to potentially get into primary care further down the road.

[00:35:56] Matt Gagalis: Potentially. Yeah, because just like the majority of our members have multiple behavioral health issues, they all have multiple physical co-morbidities as well. Because we build that trust just like Cooper was talking about, we’re able to just address those issues while you’re here and really understand why the substance use and behavioral health issues are driving those physical health issues. I think it’s a holistic treatment approach that needs to be, sort of better incorporated. Primary care is not addressing these issues.

[00:36:23] John Yedinak: Well, it’s like you see all the primary care companies that have raised all this money or gone public. You’ve got Oak street, stuff like that. I feel like if somebody that’s, I like to consider myself a little bit of an outsider at this point, but looking at that kinda like why hasn’t that been introduced more to the behavioral health space, I guess? Are you guys surprised?.

[00:36:41] Cooper Zelnick: I think, I mean, I think it’s sort of what Matt said.

[00:36:44] Like these, these organizations are really good at what they do, but substance use disorder has not been treated well in primary care. I think many primary care physicians don’t see it as their responsibility. So the question I would pose is. You know, does this all become one thing, right? Do we become primary care?

[00:37:02] Does Oak street become an expert in treating addiction or is it about coordinated care and bringing together really powerful partnerships? And I don’t think, I think it’s a false dichotomy. It’s not one or the other, but there’s a really interesting question about it. Where does our responsibility to render services end and our responsibility to get members where they need to go begin?

[00:37:23] John Yedinak: All right. So where does it end?

[00:37:25] Cooper Zelnick: I think for us, it’s probably a little bit shy of primary care. We think about it all the time. What we would love to be able to do is build amazing partnerships. The thing that would force us to become primary care would be looking around at, our office, our office in like Callous, Maine, or Machai Maine communities, two and 3000 people in saying there actually aren’t high-quality providers here. So we have to become those providers too.

[00:37:52] Matt Gagalis: Yeah. I don’t know. I don’t know where we draw that line. I think it’s probably a little north of primary care because that’s sort of where we’re heading already. We’ve sort of embraced this medical home model, ACO model, whatever you want to call it, where we’re, we’re wrapping so many services around folks, I think to add a little bit more and just continue to coordinate within our ecosystem. Not that we’re being protective of it, but because we already have you there, I think we can do so much more with you while we have you.

[00:38:20] John Yedinak: So what types of value-based care arrangements, do you think have the most potential for behavioral health?

[00:38:32] Matt Gagalis: Any of them. Really, I mean, I think to be able to say we are doing value-based care in behavioral health is a huge step right now. There’s not enough of it. So I think anything that we can do to start to move in that direction, let’s have a fee-for-service contract that pays us a small bonus. If we achieve quality measures within the population that we serve, that’s huge because there’s not enough of that. I think every step in that direction helps sort of bring everybody just along in the right way.

[00:39:02] Cooper Zelnick: I agree with that. I think the only, the only question I have as it relates to fee-for-service is like, how much does a qual, like a bump on quality really get you, right? Because there are so many providers, I think who are faced with this adverse incentive, they can either do what’s right or do what pays. And I wonder if you don’t need to get freed from that. But I agree like anything that gets you away from the way healthcare has been paid for forever and towards payments for quality is a really good thing.

[00:39:29] John Yedinak: So you’re saying, meaning the bump might not be big enough to justify…

[00:39:35] Cooper Zelnick: Our industry substance use disorder treatment, the two things, if you look at a fee schedule to pay are like urine testing and one-on-one ENM visits with physicians, it’s changing, right? Like that’s changing slowly. But things like group therapy or ill compensated things like pure recovery coaching are often non-reimbursable, there are so many incredible services that, you know, for a provider and a fee-for-service relationship with the payer, it just doesn’t make any sense to render, and the question I would pose is like, how do you incentivize the delivery of services that really work.

[00:40:10] John Yedinak: Where would you like value-based care and behavioral health to go in 2022?

[00:40:20] Like what, what would make you happy at the end of the year? The progress?

[00:40:25] Matt Gagalis: I think what would make me happy is for more providers to sort of be willing to do this and for more payers to continue to sort of refine and develop and refine models for value-based care contracting.

[00:40:40] Some payers are starting to do that. I think they have. In the primary care space. I think for, for health systems, they have models that say, we’re the payer, we’re coming to you with a, with a program for value-based care. Do you guys want to opt into this? We are going to payers today and saying, Hey, this is how we think we’d like to do this, what do you think want to build it? So I think to the extent that payers start to adopt this and say, yep, this is the future. We’re going to start investing in building out the model and we’re going to build the infrastructure internally to support those models would be huge. I think in order to get them, I don’t know, you know, it’s a chicken or egg question.

[00:41:17] I don’t know what comes first. Like the payers doing that or more providers sort of go into the payers being willing to adopt those models.

[00:41:26] Cooper Zelnick: I think, I think similarly, like for me, it’s about scalability and transparency. Right. I would love to live in a world where, you know, we’re going into a state where Eleanor has built like an incredible model.

[00:41:38] We see what that model is, and we’re given an opportunity, to use it. I’d love to be in a world where the models we’ve spent like years, pioneering and Maine and New Hampshire are available to every provider there. Then I think selfishly and for the industry as a whole, uh, I’d like the end of 2022 to be a moment where claims data is freely available.

[00:42:00] And we can actually like, there’s real sharing of that data. So that we can understand like our impact and for us, you know, with that data allows us to do is not necessarily like sign better deals, but rather better impact those we serve. Right? Like we can actually see in real-time where we’re doing a great job and where we need to do more.

[00:42:22] John Yedinak: So why can’t you see that now? Help me understand.

[00:42:24] Cooper Zelnick: Because well, the health plans don’t want to show it to us. You know, they don’t wanna show it to us, and I was very gratified to learn in the last couple of hours that we’re not alone. This is the best providers in the country are struggling with this

[00:42:41] John Yedinak: Are any of them showing you though?

[00:42:41] Cooper Zelnick: Yeah. Yeah, but it’s very, it’s hard. It’s early days. It’s not standard. There’s a number of data issues that we could spend two hours talking about.