Date:
Monday, June 22, 2026
Duration: approximately
60
minutes
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.
From This Webinar
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.
