Building the Foundation
Voices From the Field
Art Jones, M.D.
Dr. Art Jones has 27 years of experience as a primary care physician and chief executive officer at a Chicago area community health center. The health center was an early adopter of managed care, successfully operating under a partial capitation payment system for all ambulatory and emergency room services and shared savings for inpatient services since the early 1990s. He was the architect for the first capitated federally qualified health center (FQHC) alternative payment methodology in the country in 2001.
Q: What do you think community health centers should focus on as they consider the business case for primary care transformation?
A: Move off the fee-for-service chassis. Capitation gives you the flexibility to optimize the full care team, and really optimize providing options to access care in a way that is most timely and convenient for patients. Once you take the handcuffs off your providers and care teams, they can be really creative, but they are so used to hearing, “No, we can’t do that. That’s not financially sustainable.”
We didn’t have the luxury to start dreaming about the ideal care team. We didn’t have an offset investment. We just focused on how we can take our existing staff and redeploy them in new ways. We figured out how to use the community health workers, do home visits, really think outside of the fee-for-service box. It can be done. You can’t go in with the assumption that any of this is an add-on; it’s got to be a total redesign. You can’t expand and do everything, you have to really think about what can be done differently.
Q: As organizations move to capitated payment and consider going even further with value-based payment arrangements, what kind of care transformation opportunities do you see?
A: The best leverage for capitated payment is in the context of total cost of care. I am the chief medical officer of Medical Home Network in Illinois, a clinically integrated network and accountable care organization with 180,000 Medicaid lives. We started in 2014 and got certified by the National Committee for Quality Assurance (NCQA) for care management, started with shared savings arrangements, created an agreement to move to shared risk in three years, and are now in global risk contracts. Our care managers are employed and geographically situated within the community health centers so that they can really function as a core part of the care team, and have succeeded in generating over $100 million in savings since 2014.
We were able to make investments in nonmedical services, such as a fitness center, a preschool, housing, post-prison transitions, and an urban farm that raises tilapia and healthy greens.
We are also using community health workers to support our patients who have hypertension, diabetes and depression, and we are really thinking about how they change access to care. We were having trouble with staff recruitment and retention for medical assistants. So, we took a look at the MA work experience: call people from the waiting room, gather chief complaints and vital signs, and repeat all day long. What if, instead, we say, you’ve built a relationship with these patients and I will give you half a day a week where you are going to be the community health worker supporting the patients who are self-monitoring for hypertension. You are going to teach them about taking their blood pressure, talk about medication, self-management, etc. Then we are going to have a hypertension clinic once a week, where we see six patients in an hour instead of three in partnership with their community health workers. You can even do it by telehealth, and if you are capitated, then you don’t need to see the patients every month, you can just see the ones who aren’t well controlled and you don’t have to worry about video and audio requirements because you are capitated.
We can have the patients come sit in our waiting room at a time that is convenient for us and not for them, and keep getting the same results. Or, we can actually take a step back and see how we can do things differently.
Q: What do you find particularly exciting relating to payment reform for advancing health equity right now?
A: Care management of high risk individuals is a health equity issue. The way to address health equity is to recognize that we can’t treat everyone the same; we have to determine who is high-risk, and go beyond looking at disease burden, demographic and claims data. We have to look at the social conditions and enabling services that can interfere with any health improvement efforts. We have a health-related social needs screener who we have been using since 2014. Now, we have a lot of rich information in our data warehouse, and use artificial intelligence to identify who can most benefit from high risk care management. In other words, not just focusing on the people on dialysis or chemotherapy.
Hiring is also critical to equity. We were having trouble hiring community health workers and said, “Where’s our workforce? They are out in the waiting room.” We created an initial training where we paid $500 for a week of training and then we bring those people into the hiring pipeline. We just started doing this in the last year because we had people who had been laid off during the pandemic, and when we tried to bring them back, they said they prefer to work at Amazon. What does that say about the quality of their employment conditions? So, we are really looking at how to hire differently and become a better and more equitable employer.
Q: When you look on the horizon to the future of payment reform, where payment arrangements may account for activities beyond the walls of the clinic, what interesting things do you see happening with payment reform and community partnerships?
A: This is really hard. It’s hard to tease out the impact of interventions on reductions to total costs. It’s easy to do PCP attribution; a good next step would be to include behavioral health, and then take a similar approach to community-based organizations. If we track the data of where patients are going, we can think about incentivizing the community-based organizations to make sure kids come in for well child visits, and adults are coming in for cancer screenings and diabetic visits. But we have to start by learning how to do this well with behavioral health.