Fred Goldstein  00:06

The first thing I would think about is, what is it you’re trying to impact? Is it your whole practice? Is it a subset? And then what do you need to do? From a data perspective, from a systems perspective, from a people perspective, from an analytics perspective, to try to make that happen, set something up, run it, score it, see if you made a difference and if you didn’t change it

Gregg Masters  00:33

PopHealth Week is brought to you by Health Innovation Media. Health Innovation Media brings your brand narrative alive via original or value-added digitally curated content for omnichannel distribution and engagement. Connect with us at www.popupstudio.productions. And welcome everyone. I’m Gregg Masters, Managing Director of Health Innovation Media and the producer co-host of PopHealth Week. Joining me in the virtual studio is my partner colleague and lead co-host Fred Goldstein, President of Accountable Health, LLC, today’s show is a special edition if you will of PopHealth Week worthy aforementioned. Fred Goldstein is the subject matter expert in the box. And it is my privilege and opportunity to extract key insights from his considerable range, depth, and experience in the space.  We’ve been producing Fred and I’ve been producing this podcast series now for over six years. We kicked it up in 2015. And we’ve generated a tremendous amount of content and our relationship with our syndication partner HealthcareNOW Radio has been great amplifying that message. And we’re coming at it from a point of view of population health Fred’s usually the lead guy in this conversation with our guests. And we’ve talked to plenty top-level people in the space over these years from Dean’s of colleges and medical school to entrepreneurs launching companies to nameplates in the health system and health plan world. we’ve pretty much covered the bases in population health. But what many of you may not know if in case you’re not paying very close attention to some of Fred’s narrative, Fred’s healthcare subject matter expert in population health? So, Fred, we don’t generally dive into that. But why don’t you give our audience a sense of your career trajectory, where you launched, and then ultimately, how you found your way into what was then the disease management industry that’s now been retooled, and hopefully upgraded to what we’re calling population health management. So tell us a little bit about that history. And that glide path?

Fred Goldstein  02:41

Yeah. Well, thanks, Greg, for that introduction, obviously, and you and I, you got 30 plus years in healthcare, too. And I think that’s what’s made this show dynamic because as many people may not know, we communicate on the backside as we talk with our various guests on the show. And I get input from you on what we should be talking about and where to take the conversation. And it’s really made it a dynamic duo. In terms of my background, I originally did not plan to go into healthcare, although I grew up in the industry. My father was a professor of medicine at UC Davis and KU  and I used to work in his lab actually in high school doing air pollution research. But I didn’t want to be a physician, I wanted to study sharks. So I went into that field and got a zoology degree. But I spent a summer at the shark research lab, the United States, which was fantastic lived on a boat at the dock here in Florida and found that there were no careers. The the head of the lab actually pulled me aside at the end of the internship and said, Fred, you need to find something else. There’s no money left anymore for research, the Navy is pulled out, and you should find something else. So I did. And I decided to ultimately go into healthcare, thinking I could take my science background into that and help with better decision making with new technologies and things like that, and got a Masters in healthcare administration and went right into the hospital business, running general Med/Surg hospitals for a company back in the day called Republic. And not only did I run some hospitals for them in California and in Texas, but I also helped install the first DRG management systems and work for the regional VP of finance doing analytics on hospitals. I ultimately left Republic and went to Charter Medical and that was really an interesting career choice for me because although moving to behavioral health was definitely in the healthcare system considered a step back from being a Med/Surg hospital administrator, it introduced me to the entire behavioral health field. And I began to realize just how important that was and was able to then integrate that expertise later. I then left the business to run a startup it was a Medicaid plan, which was really another fascinating change, and learned about managed care. We then got a commercial license at that health plan. We got a Medicare demonstration project, the health plan rated the highest quality health plan in the state of Florida. And ultimately, that health plan was acquired by Coventry about 15 months after I joined and I stayed on with Coventry for about another 18 months. And I then had this wild idea of founding an HIV HMO for Medicaid patients. My father was an HIV physician, very active in that since the disease first began out on the West Coast or was identified. And I thought, wow, I’m seeing people who could be doing better. Why is that? And so I approached the state of Florida to do an HIV HMO by first really pushing this in politics. And they wanted to do it, which just blew my mind. So they actually introduced legislation in 1997 to do a Medicaid HMO here in Florida. for HIV patients, they pulled that legislation and introduced disease management and said to me, Fred, go set up a disease management company. So I said, Sure, I can do that. And pivoted again, we had done an asthma and maternity program at the HMO, which were early on in the mid-90s. And so I set up an approach reading a lot of people’s stuff on how to build a disease management company from scratch. Essentially, we were awarded the HIV project with a group out of California called AHF and they continue on with that project. Now, then added to the to that work, I built programs for another nine conditions and ended do ended up doing 10 state Medicaid programs for disease management. And we use a community-based model without a call center. And I also partnered with McKesson, and their big Health Solutions division. And we did eight of those 10 states with McKesson, where they had the call center and I had the on the ground staff, we ventured into some new areas, we did the first program for persons with Schizophrenia. In Medicaid, we also did a program for high-risk maternity in the Mississippi Delta. And also that taught me all about social determinants of health, which I didn’t know what they were, until a few years ago, when the term really got out. I used to say people can’t focus on their health because their life gets in the way. So let’s focus on their life. And we would have our nurses and our community resource coordinators or promotoras, focused on transportation, getting a bassinet, so a mother could, wouldn’t sleep with their baby, helping them get their prescriptions, who’s going to watch the kids, all of those issues? How do you get food to these folks, and we worked on all of those. And it was really a great experience. So I spent 15 years with a company I founded called specialty disease management services, 10 years as that company, and then merged it into an employee health improvement company called US Preventive Medicine. So it’s been a windy road, but it’s crossed a lot of different sides of the healthcare system, which is you recognize gives us different lenses into the problem. And, and been involved in population health, as you talked about now for really, you know, over two decades if you consider the disease management experience, and so that’s really allowed me to look at these problems and say, how do we go about trying to solve them in an efficient and effective way understanding the health plans role, the hospital’s role, the physician’s role, the pharmaceutical manufacturers role, all of those pieces

Gregg Masters  07:42

Great, so, general acute care hospital administrator for a proprietary hospital company, to behavioral health administrator for again, a proprietary hospital company charter medical, to them focusing on AIDS into Medicaid population, which then sort of transitioned you into what then became essentially disease management 1.0. Is that correct?

Fred Goldstein  08:09

Yeah, pretty much. And so essentially, I, I developed a framework back then to do the programs and some software, and then just applied the different conditions and pushed, not pushed them, but brought them into that framework. So we could say, okay, we did asthma. Now, how do we do diabetes? How do we do persons with schizophrenia, etc. And, and that was really the key to then rolling those out very successfully. The other advantage as a learning experience, in terms of it was if you do Medicaid, it’s a whole lot easier to do commercial, you know, we had employer contracts with the city of Tempe or Orlando county libraries as well doing disease management, but that was very similar. But again, people are people. And it doesn’t matter if it’s a Medicaid beneficiary or a commercial health plan, all people struggle with similar issues. And the question is, how do you solve those for them?

Gregg Masters  09:02

So let me clarify. So you’re saying if you develop chops, if you will, in Medicaid, then you had essentially portfolio to leverage into commercial or is it just an easier population at the commercial level than it is in Medicaid?

Fred Goldstein  09:15

I think overall, it’s probably a little bit easier, because because obviously with it with the Medicaid population, you’re dealing with deeper levels of social determinants of health that are impacting these individuals, although I will say this, if you consider an employer group, and for example, one of our clients was a big resort. They have gardeners, housekeepers, cooks. All of those individuals also live within a lower socio economic grouping, and suffer from similar issues that are barriers that they’re trying to overcome. Whether it was we have one car, but somebody needs to be somewhere else, how do I get my prescription or get to the doctor? All of those things go on as well. So there’s there’s certainly more overlap than many people who serve the commercial Market recognize.

Gregg Masters  10:02

So maybe higher acuity type casemix,

Fred Goldstein  10:05

you’ll certainly see higher acuity sometimes, obviously, later access to care further along in the disease progression, less access to resources. And there’s some clear examples that we had of how some of these social determinants impact individuals. So for example, in the persons with schizophrenia program in the state of Colorado, the state recognized it was a major problem back in the day that the the non-emergency transportation companies were typically the taxis or stuff like that. And they were taking states to the cleaners by, for example, picking somebody up and taking a super long route to get there. So you began to see other players come in like Logisticare that capitated the , they the transportation for a state, but the state of Colorado didn’t have that. And they noticed this fraud, and they said, we’re gonna just do this, we’re gonna require every patient who needs transport to get that by their doctor approved by their doctor and the doctor has to order it. Well, we recognize that for our population of persons with schizophrenia, that was probably less likely to happen. Sure enough, within two months of the state implementing that, we saw a huge increase in visits to the ER, missed appointments. And we quickly took that data back to the state, and they exempted the population from that transportation requirement so that these people could then get to their appointments and not suffer from that change in policy,

Gregg Masters  11:31

clearly a measurable outcome by way of benefit of the program. So let’s, I want to talk about what’s happening now. But let before we transition to that give me a sense of what’s the basic chassis of pre-population health industry, as disease management, what’s that chassis stripped down, and then let’s bring it forward into maybe iterations one and two of the current state of the art in population health?

Fred Goldstein  11:59

Yes, if you think about early on, it was, okay, we’re going to identify these individuals with some sort of claims process looking for ICD codes or something like that, ICD nine the day now, ICD 10, or the use of certain pharmaceuticals, or a physician referral, or maybe a self-referral, and then we’re going to use some at that time fairly limited assessment tools, you know, they may risk stratify based on cost, or if you had one admission, or two ER visits in the last 12 months, we’re gonna say you’re a high-risk patient, which actually is not a very good way to go about doing this. It was very simplistic approaches, but they were a start. And then obviously, your interventions were mostly telephonic, you know, we although we did face to face and quite a bit of it, that obviously requires a higher ratio of staff. And, and we also coordinated a lot broader services in the typical program that may say, Well, I’m going to remind them to get a flu shot, and they will go to their appointment. We were doing much broader stuff when we didn’t just send a packet and then call them in three months.

Gregg Masters  13:06

And where these typically are in case managers are,

Fred Goldstein  13:09

yeah, we typically used registered nurses. And then we had what we called community resource coordinators, who did a lot of the setup of the appointments, they would go out and see how people were doing, they could arrange for some of the non-clinical kinds of things. And we actually were proud to say we hired the first certified promotoras in the state of Texas, where we were doing Texas Medicaid, and and those individuals, obviously, lay health workers that can go out into the community and are well recognized and received by their communities they live in. So yeah, it was mostly a clinical staff combined with these community resource coordinators, we did not run a big call center. But on the projects, the big ones we do with McKesson, they had a large call center. And we would take the higher-risk patients.

Gregg Masters  13:50

And if you’re just tuning in to PopHealth Week, my guest is industry veteran colleague, partner, and friend, Fred Goldstein, President of Accountable Health LLC and the co-host of PopHealth Week, and where you typically accepting a sub capitation, or what was the funding mechanism,

Fred Goldstein  14:07

the funding mechanisms, originally were per member per month fees. And you know, they could vary quite a bit depending on which disease state, you know, if you’re doing a program for, say, persons with schizophrenia, your ratios of staff to patients are much higher. So obviously, you’d have a higher per member per month fee than, say, a program for persons living with asthma, or diabetes,

Gregg Masters  14:31

and just not maybe necessarily unique to your experience. But let’s say back then what was the typical, shall we say, discounting of disease management 1.0 in terms of its impact and contribution to better care at lower cost?

Fred Goldstein  14:47

So a lot of the programs back then, and particularly, you know, Medicare did a big demo project back in the mid 2000s. And had these huge launch and none of their programs actually worked. It turns out as you look at this, one measurement used back in the day was probably not appropriate. And there’s still questions about measurement today, people like our Lewis talk about that all the time. And that’s why you have things like the validation Institute. And also, it’s a whole lot easier to move process measures and to move indicators, then it is to save money. So you can get more people to get their flu shots or their annual eye exam or a colonoscopy, or a foot exam for a person with diabetes than it is to actually lower the cost of care. And that’s where it got tricky. So for example, we did a program that program for persons with schizophrenia in the state of Colorado, actually reduced ER visits 54% reduced hospitalizations 2%, but we made a fundamental error, the drugs at that time, the atypical antipsychotics had just come out, they were really expensive, maybe $400 a month, they were the number one cost for Medicaid. And we were able to increase the adherence rates from 23 or 24, day fill rates per month, to 29. So essentially, early on, they were missing three prescriptions a year, about 84 days a year of fill of their of these medications, we increase that to 29 days. And so the increased costs of the pharmaceuticals, appropriate utilization, which resulted in the decreased utilization actually offset the savings. And the program didn’t save any money net. And so, you know, the state was looking for one thing, which was did it save us money? And it didn’t, it improved the health of these patients, considerably in the members. But but that program actually was cancelled because it didn’t save money.

Gregg Masters  16:40

Right? So okay, so let’s say that’s a sort of a generic limit of the v1 model, per se. Yeah. So now, from that point, today, we’re we’re I don’t know how many iterations in population health, we can be considered to be technology-wise, chassis wise, impact, outcome wise, but between then and now, it seems to me I think, correct me if I’m wrong, Affordable Care Act gets passed, ACOs get introduced lots of conversation about population-level accountability, from an ACO perspective, and so on and so forth. That kind of gave rise to then was it Kindig, who popularized the idea of population, but at some point, there was this bridge, talk about that.

Fred Goldstein  17:28

Yeah. So as you mentioned, Dr. Kindig, actually wrote the seminal paper with a co author, and I’m blanking on his name, my apologies. That said, you know, here is, this is my definition of population health. And it really was, you know, a fairly broad definition that it’s the health of population, and the status within the group and the change of that status over time. So are they getting healthier? Are they getting sicker, those kinds of things. And as disease management came into place, and the others did, suddenly, population health became the thing you know, it’s part of the Triple Aim. And it’s actually one of the legs of the triple aim to improve the health of populations. And I think there’s an important reason to understand while everybody talks about precision medicine and precision medicine is critical. But precision medicine is nothing more than the appropriate survey or information needed to know what that patient as an individual needs. But if you don’t improve the overall group’s health, but you’ve improved one patient, you really haven’t made a difference, because three others may have gotten worse. So that’s why you want to look at it in an overall basis while recognizing you change population, one person at a time. And, and as you said, we’ve added a lot of technology, we’ve added a lot of things to it. But it’s still the same fundamental steps, select your population, survey them or gather the data on it specify where they are in that risk levels, then you really need to in this scenario I talked about a bit that I think people don’t look at the same way quite is you need to sell this program to people. Healthcare now is really being to recognize we need to sell mean pharma’s on TV, you’re seeing hospitals on TV, everybody’s selling, but we don’t talk about it, we talked about we want to engage them, we want to get this and that it’s really about selling that selling get is what gets done. We know companies and a lot of them sell stuff, we need to get that into healthcare to get them to buy or to do these products, then solve their problems, score it, straighten them out and start again, it’s these series of steps that are still the same. And it’s really about execution at the end of the day. And so today we have all this stuff out there, but it may not be executed against right and I think that’s one of the fundamental issues

Gregg Masters  19:42

Segment the population so that that you know segment them assess risk stratify and then design around the care needs from a continuum of care point of view. So you know, the first cut at population health could be the health plan. You know, that General membership in the health plan, or it could be a subset of the general membership based on the disease commonality, and so forth. And then the orientation needs to be okay, given that population, given the risk, given this continuum of care here, what here’s what the intervention looks like, you know, from acute subacute to ultimately exiting the program, because they don’t need it anymore. Is that what we’re seeing now in terms of population health management? Or is this aspirational?

Fred Goldstein  20:31

Well, I think some places do it. And and, and also, another point to be made is, there’s some people that you exit out of the program, that tends to be more of a case management approach, you case manage them during that condition, and then that condition is over, they’ve had their surgery and out they go, whereas other people, it’s for their life, it’s a chronic illness. It’s a, you know, it’s diabetes, or something where you’re going to be managing or assisting them throughout their life, even if they get low level, you want to still have some sort of an ability to understand what’s going on with a low risk individual and potentially impact it so they don’t move up. They don’t become major or high risk, because you left them alone.

 

Gregg Masters  21:14

So here’s where I would assume the tools of today, digital apps, so forth, platforms are the value adds to what was available back during the disease management days. So is that correct? Is this tech-enabled? Is it workflow optimization and outcomes achievement?

Fred Goldstein  21:33

It’s, it’s, it’s all of that, which is a great way to look at it, Greg, because you’ve got all of this tech out there, which I think about when I was doing my programs, we had this face to face stuff with a cell phone, although we did some the first in home monitoring in Medicaid back in 2003. This, but this Tech has got to be integrated. It’s a problem we’ve talked about forever, is how do you integrate this stuff? integrate the tech? How do you integrate the program into your health plan, to the doctors to the hospital, to the Home Health company? And how do you create that, so you actually have a system that functions and executes like you would hope?

Gregg Masters  22:15

And that’s what I remember when I toured the digital health pavilion at the CES. Early on, can’t remember the year, but it was the rollout of MDLive, Optum had their everyone had their sort of row of intellectual property that makes this stuff work. And I kept saying, I remember posing this question to Randy Parker, who was then the CEO and MDLive, and I said, Well, we’re a virtual health plan. And I said, What and do you nest with or integrate to the health plans of the world are you sort of the separate parallel universe, and at the time, it was a separate parallel universe, but today, 2021, now we’re hearing about, for instance, Headspace, just IPO’d. Headspace is now coming out, and they’re fully integrating with, you know, bricks and sticks of mental health care. So the tech and the workflow of the professionals is now meshing in a way that was theoretical, you know, at CES 2011. And now we’re seeing more and more of that. So can you speak to that from a population health perspective?

Fred Goldstein  23:23

Yeah, I think the idea is you talk about and this integration is critical. And what you point out is interesting, because there’s always this hype cycle. And, and we saw it, you probably remember to when we walked around HIMSS and every single booth that we do population health, you know, well, you do a piece of population health, you know, MDLive is a piece of a health system. Right? And so that really is the holy grail is how do we, how do we integrate, we’re still struggling to integrate behavioral and medical, right, we’re still struggling to integrate, this EMR  with that EMR,

Gregg Masters  23:58

your your PHA forum in 2014. was, was the guy from the Kennedy Foundation, talking about the Mental Health Parity, and it was like right in sight, and we’re gonna finally have elevation of mental health with general acute care. And we’re still struggling today.

Fred Goldstein  24:15

We’re still struggling. And Patrick Kennedy, as you point out with the Kennedy Forum, talked about it back then, well, we’ve got the Mental Health Parity Act, you’ve got to treat it the same. And we’re still struggling with that. It’s really a massive problem. And so when people think, Oh, it’s easy to do a population health program, it really does require a fair amount of expertise. Because, yeah, you need data. You need the right data, but data isn’t the solution. You need behavior change, you need staffing ratios, you need the expertise, you need to figure out how you’re going to integrate, which problems are impactful? What can you actually do something about, it doesn’t do any good to go grab a bunch of data about Social Determinants of Health, if you’re not going to do anything about it. You’re just going to load extra work on your staff are they are going to say, God, this is stressing me out. I know that person needs that, but I don’t have any place to send them. And so you see some of that going on

Gregg Masters  25:07

and according to our friend and colleague, David Nash, he’s saying there’s an industry that has now burgeoned out called the social determinants of health industry. So let let’s sort of wind down here. And I want to ask you this, for those whose grappling with the strategy, whether it’s a health plan, health system, Medical Group, physician network, or even a tech aspirant, what would be your guidance on how to boot this? What what are maybe steps one, three, or whatever they are? What would you be recommending that they think about first? And I know you’re a fan of execution, talk about that glide path?

Fred Goldstein  25:42

The first thing I would think about is, what is it you’re trying to impact? Is it your whole practice? Is it a subset? And then what do you need to do, from a data perspective, from a systems perspective, from a people perspective, from an analytics perspective, to try to make that happen? set something up, run it, score it, see if you made a difference. And if you didn’t change it, do something else. One of the biggest problems I see is, I remember talking to an ACO that said, we have a diabetes program. So it really tell me about it. Well, we have about 8000 people identified, well, that’s fantastic, how many care managers do you have, we have one! You’re not gonna move a five-pound brick with four pounds of force, it just ain’t gonna happen. And and I see that a lot, it is something that or another place that went to where the CMO honestly said, I really need 35 more care managers if we want to solve this problem. And and that’s, that’s gonna take some time to work through. So I would really look at it and say, What is it you want to do? What is it you actually can do? And look at it that way?

Gregg Masters  26:50

And speaking of can do I mean, what are the typical challenges getting your arms around the social determinants of health?

Fred Goldstein  26:58

From my perspective, the biggest issue is that the health care system and the health plans need to consider is, am I really the right one to try to solve this? Should it be me, at the end of the day, as we’ve talked about, somebody needs to be accountable. And if you don’t have somebody accountable, it’s not going to it’s just not gonna it’s gonna flounder? So it’s really about if I’m going to tackle social determinants of health, what’s my role? Am I just going to pay for that service? Or am I going to try to manage that service, provide that service, and that’s where I think it gets tricky. It really needs to be the funds need to go to those organizations that really know how to do this, versus the healthcare system that should really be focusing on the triple aim of the cost, quality outcomes, you know, and satisfaction.

Gregg Masters  27:47

And to your knowledge, who’s hitting all three of those.

Fred Goldstein  27:52

Today, I have not seen cost dropping. So I used to always like talk about the two-legged stool because the third leg does not seem to be a major focus at this time.

Gregg Masters  28:03

And that is the last word for today’s broadcast. I want to thank my partner and lead co-host for his time and insights today. For more information on Fred’s work, go to www. accountablehealthllc.com and follow him on Twitter via @fsgoldstein. And if you’re enjoying our work here at PopHealth Week, please subscribe to our channel on the podcast platform of your choice and follow us on Twitter via @PopHealthWeek. And finally, if you’re in the market for private label thought leadership branded podcasts or video content whether streaming or on-demand that amplifies your company organization or enterprise value proposition do ping me via Gregg that’s gregg@healthinnovationmedia.com  and consider following me on Twitter via @greggmastersMPH. Check out the recent launch of the Academy of Managed Care Pharmacy or AMCP podcast series powered by PopHealth we get www.AMCP.org/podcast with an introduction by Susan Cantrell, its Chief Executive Officer. Bye now