After a pandemic exposed inefficiencies the healthcare system has faced for decades, the trend toward value-based payment models for in-home care and accounting for social determinants of health is more important than ever, according to Eric Galvin.
Mr. Galvin is CEO of Franklin, Tenn.-based PopHealthCare and its value-based medical group Emcara Health. PopHealthCare is a subsidiary of GuideWell and provides in-home care solutions, while Emcara provides in-home medical, behavioral and social care across 15 states.
Mr. Galvin sat down with Becker's to discuss insights from his 25 years in executive leadership roles across the insurance industry at EmblemHealth, Blue Cross Blue Shield of South Carolina and Cigna.
Question: Why are we seeing payers invest so much in in-home care?
Eric Galvin: If there was a silver lining to the pandemic, it's that it really forced the ecosystem to find alternative ways of delivering care. People started to say, "I don't have to be fully virtual, but I also don't necessarily want to go into a building that has sick people." The better solution is to have someone come to my home.
The additional factor is that people have challenges with social determinants like transportation, so this is an important solution to some of those problems. Why are payers investing in those kinds of assets? Because friction between the payer and the delivery system exists, so in a lot of scenarios there's potential to eliminate and have someone who has the ability to provide that primary care without it becoming a contentious relationship.
Our philosophy is slightly different in action and is different from simply enabling our parent company that happens to be a payer. Whether it be a specialist office, a lab or a chronic condition management program, we want to be a bridge. As an Emcara organization, we want to be that organization that can navigate across all of the health needs, including mental health.
Q: Some payers are now exploring ways to incentivize or even reimburse Medicare Advantage members who have family members come and act as caregivers. Do you believe that's a viable solution to help health plans get better care outcomes among their older members?
EG: Having caregivers directly engaged makes a lot of sense. We find that there are better results and better outcomes when you're not just engaging with the patient, but you're engaging with the patient's family. Perhaps that's a spouse, child or sibling, because then there's accountability beyond just the provider-patient relationship.
In terms of incentivizing people to do that, I think CMS is going to have to make a call as to whether or not they see that as being a good use of Medicare funds. What we tend to find is that the only incentive family members need is to be invited to the conversation. That may change, and if it does we're more than happy to find a creative way to incentivize with a monetary approach, but today we're just not seeing that.
Q: You believe value-based payment models are the future when it comes to in-home care. Why is that?
EG: I come from a long career on the payer side, and it's an interesting journey going from payer to provider and then trying to take some of those lessons learned and reapply that within a new orientation. If you go back to the early days of value-based, providers just didn't have the skills or the talent within their organization. We're going to be hiring our own actuaries because that's a skill set you need the deeper and more sophisticated you get into value-based arrangements. If you rewind five or 10 years, those skill sets didn't exist in the provider space. A provider or a hospital system would be very risk averse and say, "What do I know about insurance at all and do I want to be on the hook for potentially unlimited dollars?" That's the first reason.
The second reason is that if you think about what has happened in the last 10 years, there has been a lot of capacity consolidation in the delivery space. As delivery systems have become more and more comfortable with how much specialty care you end up consuming as a patient, the more it becomes forecasting.
The final point is that the dollars are more scarce. While there are more dollars in the whole pool of spending on healthcare, the way in which we have dollars that are available to any one entity are harder and harder to grab and recycle those into programs that care for the patient. Those three things really incentivize people to want to work together to get the right outcome.
Q: What do you believe still needs to happen for widespread adoption of alternative payment methods?
EG: First and foremost is data and sharing that information. I can't tell you how many conversations I've had as a payer and talking with providers about the amount of data that they wanted on the patient and the interactions that patient had with caregivers outside of their system. Mental health is one of the key areas. But we need to get to a better spot with data interoperability, and there are a bunch of steps being taken.
The second is finding new ways to simplify the conversation with a patient and the caregiver. Here's an industry where you have a provider that bills an amount that they never expect to receive. And then there's this whole back and forth about "did you pay me?" How the heck would we ever expect a patient to understand the care that they were receiving and be a steward not only of their health, but of their economics, in that kind of environment?
Q: What do you think are the key components for delivering care outcomes that account for social determinants of health?
EG: With SDOH challenges, I think that they're going to continue to get worse. Just take this inflationary environment for instance. If you're having to make a decision between buying food or buying medicine, or you're having to make a decision about the type of housing that you're going to live in — those become real issues for folks who are on a fixed income. So I think the social determinant challenges are going to be evermore important tomorrow as they are today.
What we find is that those determinants have such a pronounced impact on someone's ability to keep themselves healthy and out of acute care settings. If you don't have to worry about where you're going to sleep or where your next meal is coming from, you're more likely to adhere to your medication. As a result, you may have less emergency room visits, which ultimately improves health outcomes and lowers the cost of care.
Social determinants in a lot of scenarios might be an add on, but I'd actually put it right at the front. It's one of the things that our care teams do when they come into the home. The first thing they're doing is looking around, looking at that environment and taking a mental scan of what's in place in his home so that this individual can live their healthiest and best life.
Q: What's your plan to scale Emcara and PopHealthcare?
EG: Most, if not all carriers want a substantial amount of value-based payments for their insurance population. Being a part of a payer portal certainly gives us credibility with government payers, and more and more we're finding that the interest is coming from the delivery systems.
The capacity in primary care is just under such massive constraints, and this is going to be a generational problem. It's similar to mental health, where reimbursement levels for mental health professionals have not been very attractive to draw people into that profession. We have a five- to 10-year cycle to get out of that, though if everyone were to move in unison, it would be something to the tune of between five and seven years.
With primary care, we're very sensitive to physician burnout issues, we have different levels of clinicians that we bring to the table and we're extremely efficient in our delivery of healthcare. It's an attractive model for clinicians to go into because it doesn't necessarily have the same pressure of productivity in a traditional sense. Our growth is really fueled by helping payers achieve their objectives, playing an important part in the delivery systems out there and providing a really interesting and attractive employment opportunity for not just physicians, but for clinicians too.
Q: Final thoughts?
EG: There is just an absolute shortage of talent. I wish that I had foreseen the mental health challenge that we're seeing right now, with constraints on the supply of clinicians and the massive increase in demand.
There's plenty of specialty capacity to meet the demand of an aging population. I don't think it's perfect, but I don't think it's lagging in the same way as primary care and mental health. There are a whole series of clinical professions that we just haven't been able to draw the interest for people to get into. I worry not only for my own family and friends and the community that I live in with regards to there being enough care, but I also worry about my children's generation and hope we can do something now to stem the tide. As they get older, I hope we've returned to a much more robust and whole-person care environment. If you romanticize the time when the doctor did a house visit, they really were worried about the whole person. That's what is attractive to me about being here and the mission that we have to serve others.