Alicia Berkemeyer
I still have practices in Arkansas that are on paper charts. And at what point do we leave them so far behind they can’t catch up? That concerns me. That worries me. Thinking about those value-based care and payments, it really can’t happen in a paper environment. So how do we meet them where they’re at and how do we bring them to the point where we can get them into that value-based care, is something that’s on my mind every day.
Narrator
That was Alicia Berkemeyer talking about just one of the major challenges facing payers and providers as they try to address gaps in rural healthcare. Berkemeyer is spearheading innovative solutions that not only increase access to care in rural communities, but reimagine what care delivery means. Berkemeyer, who serves as Executive Vice President and Chief Health Management Officer at Arkansas Blue Cross Blue Shield, thinks creatively when it comes to such things as value-based contracts. One example includes helping a rural primary care practice install a washer and dryer that’s enabled care teams to have more direct contact with families about health issues when they come in to do their clothes. She explores that type of problem solving as well as the power of data in this podcast with Oliver Wyman’s Rohith Banerjee.
The Oliver Wyman Health Podcast is brought to you by the global management consulting firm Oliver Wyman. For more insights on the business of transforming healthcare, visit our online publication, health.oliverwyman.com.
We pick things up with Berkemeyer detailing some of the lessons learned from the COVID- 19 pandemic in terms of reaching rural communities.
Alicia
COVID has put a spotlight on the gaps and the challenges in rural healthcare. We’ve seen some opportunities that we knew were there with health inequities, but the spotlight that COVID put in place really put us into action. And so we’ve been working with partnerships across our state with the health department, with minority organizations such as fraternities and sororities. We’ve worked with some African American mayors trying to understand where are the gaps, because a big part of understanding this is where are the gaps and how do we help support them? One of the lessons learned, certainly, has been you’ve got to be careful of who the messenger is. You cannot take a message out to a population that is not like them. We learned that early on. And so finding the person in the community, some may be the pastor in that area, some may be a grandmother in that area that just everyone goes to for the insight, so learning the community by listening, learning, asking questions, and then matching up the resources and the needs.
Rohith Banerjee
It’s a really interesting takeaway. I think a lot of Blues across the industry rely a lot on the brand, and a lot of their members have trust in the brand. Have you felt that that was the same way as you started to engage the communities, that these members, these individuals have a natural trust in Arkansas Blue Cross Blue Shield just by holding the medical insurance, or are there other tactics that you have to go above and beyond that to really build that trust?
Alicia
It varies by community. And we are proud to be Arkansas Blue Cross and Blue Shield, and we partnered and did a media campaign around Vaccinate the Natural State, bringing in that multitude of stakeholders. And we campaigned and educated about the COVID vaccine. So locking arms, aligning in that method, and trying to work together has been very beneficial, because some communities, it was going to be Blue Cross would be the lead and we’d take turns. And so it wasn’t a prideful situation. It was a partnership and understanding who was the best messenger at that time. So it’s certainly lessons learned. You’ve got to match up to that, what the need is.
Rohith
And how have you seen that vary even community by community? Arkansas is not just one rural area. It’s also highly segmented. How applicable have the learnings been community by community or rural area by rural area?
Alicia
I’ll give an example. Certainly, up in northwest Arkansas, there’s a lot of Marshallese population. And one of the things that we worked in that community with the Marshallese was that the families that lived together, we were learning very quickly as COVID was spreading that the whole family spread within that home. So we ended up, when we were around to the vaccines and the education, we came to the point of we donated a van and partnered with community health workers to go out into those homes to educate in those homes, to deliver those vaccines into the people there, because sometimes you just don’t understand with a different culture what the requirements or the understandings or expectations are. Not everyone sees healthcare the same way.
Rohith
And was that tough culturally also within Arkansas Blue Cross Blue Shield? Just drawing from some of my experiences working across Blues and payers, I think a lot of executives still don’t look at the data on a geographic basis or there still is a bias to think about, “What’s the standardized way in which you can roll out solutions to our community?” So how did you even think about the cultural aspect internally and thinking and challenging yourself to do things in a different way?
Alicia
We looked at it through three lenses basically. But you have to make partnerships within the community, and that’s very important to work together. You have to have a leadership standpoint, which important in leadership is listening to understand the problem and then be the leader to help come with the solution. And data’s the third element of that. And we partnered closely with Arkansas Health Department around the COVID cases and then around the COVID vaccine. We were on a weekly call with them to deploy the vaccines as they were being received into our state and what areas needed it to ensure that the populations were equitable. And we were trying to increase those vaccinated for the minorities just as everyone else. And so data plays a huge part for us.
Now, what you discover is or where you start working on these solutions is, there’s more challenges where that comes into place, because how reliable is the data? How accurate is the data? Is everyone tracking it appropriately and entering into the same fields that can be pulled from? So we just started that and really as a state with Arkansas Medicaid and with other payers in our state, trying to get some consistency and understanding of our data. So again, I go back to the theme that seems to be that spotlight that COVID brought for us. That was another area that data accuracy and collecting the data is so critically important so we can break it out by the geographic and the special populations.
Rohith
Yeah. It’s a really interesting insight, because if you think about the data that most health insurers have, it’s very structured, very timely. It all flows through claims. How was it dealing with those other organizations where the data may not be timely, you may not have trust in it? How does it even change your view on the different types of data sets you may need to be collecting in the future that you never even thought you needed, even five years ago?
Alicia
I will tell you, certainly we were fortunate starting in the value-based work back in 2012 with CPC Classic. We had really put a lot of emphasis on getting all the payers to align in our health information exchange. And so starting with that health information exchange and having the large connection with the hospitals within our state, they played a key role in having consistent data and being able to push and pull that COVID data and information. And so we really started very quickly. And even into the medical homes, we were pushing how many positive cases you have and how many are vaccinated or not vaccinated and all sharing that information.
Rohith
We’ve talked a lot today about the importance of building trust in these communities in rural areas. It’s almost sometimes foreign to them, the type of work that a health insurer may do. Talk to me a little bit about how you’ve been able to supplement that with new technology and new resources to think about access and delivery in a different way.
Alicia
There are several different things that we’ve been working on through either telehealth, tele visits, and we’ve recently been piloting a program on eConsults with the CMMI, the Centers for Medicare and Medicaid Innovation, around our CPC plus population. And in that case, it’s actually supporting the primary care practices in that area to help people local. You look at opportunities of, if you can keep some mother that’s having a pregnancy and they’re not having to travel in two hours to go get care, what are the areas that we can keep them in the local area and the local community and support them with the needs?
But it also is an opportunity, honestly, to upskill the current practice in that area as well. And so what you find is there’s that confidence with that consultation with the specialist. And then those truly that are being referred are the ones that really need to go for those referrals, and that assists with the specialist scheduling as well.
Rohith
Yeah, that’s really helpful. And I guess that the natural question that I would have is, when you think about the technology that you’ve been able to deploy in a very rapid basis over the last two or three years, how do you see that evolving? I think a lot of the technology across many health insurers was very reactive to COVID. And now, there’s an opportunity to think about much more proactive technology, think about strategically what we need. And every health plan needed much stronger telemedicine, which we now have. But now, I think each health plan is going to be looking at their tech stack a little bit differently going forward, given the unique needs of their population. How are you thinking about new technology that you don’t have today that is going to be important over the next five, 10 years, especially in the rural communities you serve?
Alicia
With the pandemic, we had really received a lot of pushback from many providers about doing telehealth or tele visits. And even ourselves, we were a little bit hesitant on it, about the quality of care, how do you credential telehealth, and other things. But once we moved into it so quickly, we found the providers to be so creative. They were looking at opportunities and ways to do things. Some of the clinics, because of the broadband being so poor in those rural areas, they would have the people drive to their clinic but keep them outside and give them an iPad. And so they would receive their care or treatment in the parking lot in the iPad, but yet keeping the environment a little bit safer.
We saw the uptake of both medical and behavioral health skyrocket during COVID. Medical began coming down. Behavioral health has remained high. So as we have a behavioral health crisis in our country today, I am very hopeful that we have maybe found a new avenue for behavioral health if people are more comfortable with behavioral health via tele. And that way, we can receive the treatment that’s maybe needed. And it also helps with the limited resources we have around behavioral health. There was a therapist that shared with me that she really was struggling with no show rates in her clinic. Since she’s gone tele visits, they show up all the time. It doesn’t matter if they’re in front of a restaurant or wherever. They’re comfortable. Her question is, “Do you feel like you’re in a safe place?” They say yes and then she begins therapy. But they show up for those. And so if we’ve found a new avenue to get better behavioral healthcare to our members, to the people in Arkansas and across the country, I’m really excited about that.
Rohith
Yeah. I think that’s so critical in these rural areas, because I think almost the first, second, and third problem sometimes is access. And you have a very unique role at Arkansas Blue Cross Blue Shield. You also think about the many aspects of total cost of care, including provider contracting. How do you view the provider world in Arkansas? How concerned are you about issues around access, issues around economic stability for these providers, given that so many of these rural communities are maybe so dependent on one or two physicians or one hospital system? How big of a problem is it?
Alicia
It concerns me greatly. The hospitals today are struggling like they’ve never struggled before. We certainly have been having some discussions in our state. We need to collaborate, again, that partnership. How do we look at services? How do we support them as a whole? Because we don’t need service units that shut down that create even worse rural challenges than we have today. And so we’ve got to look outside the box at additional solutions. And I think that the technology that we’re facing and looking at, I think the tele opportunities, and then also the value-based care and payments, moving away from that fee-for-service and stop that payment just for every time we do something, to giving that money to be used as it needs to be within that community, makes a big difference.
Rohith
You shared a story with me earlier about how the creativity around value-based payments is almost at an all-time high with providers in rural areas, sharing a story about how you wouldn’t think about it, but a provider used value-based care dollars to invest in a washing machine and a dryer. Can you share that story with us?
Alicia
Absolutely. In some of the value-based payments, the clinic has the opportunity to use it as they need within their community. And there was an independent primary care practice that was in very rural south Arkansas. And one of the things that they decided they needed to invest in was that washer and dryer, because many of their patients didn’t have access to a washer and dryer. Well, their creativity within that is it really gave hope to those children, those families. It’s important to feel good about yourself, to have clean clothes, and to present yourself well. And so when the patients would come in or the families would come in to wash and dry their clothes, those care coordinators, those nurses, or others, knew those patients, and that gave them face time with those patients. So as those clothes were being washed and dried, the care coordinator would talk about their diets or their diabetes or their asthma, and then that gave them the time.
And so I was so complimentary of that practice to think outside the box and think of ways that they could connect with those patients to make a difference. This similar practice also, too, they were looking at the next goal was going to be potentially offering some type of gym equipment. And then could those care managers then go intermingle with them and encourage that community to exercise? And so thinking creatively on those rural areas of, what are the resources and the gaps, what is the care that’s needed, and how do we get to them, speaking their language and meeting them where they’re at?
Rohith
That washer dryer story is incredible, because healthcare organizations, I feel, sometimes are known for not being anywhere near that creative. How do you take and harness that thinking, that creativity, in ways to look at the problem differently and spread it not just across your geography in Arkansas, but how do you take that thinking across other payers and providers across the country?
Alicia
We certainly are big in stakeholder collaboration and coordination, and my staff would laugh and tell you that I’m a white boarding queen, because I like to white board everything out. One of the things that we have done is a multi-stakeholder collaboration on a quarterly basis. And I think through that, we work together to identify and line out what are the key priorities and then how do we support them. And so with that, I think it’s enabled all of us to think a little differently outside the box.
For our first year, we really focused on some of the behavioral health issues. One of the concerns, the problems was... It basically says... We started out with a white boarding session, “What’s going well in the market today? What’s going well in Arkansas today around healthcare?” and then you start thinking positive. And then what’s the most broken thing? And then we focus, and then everybody votes on what the opportunities are. And so certainly it was around the burden of administration, the behavioral health challenges, the information and technology. And we start narrowing some of those things down, and it offers us an opportunity to think differently.
And so in that value funding, when we pay value dollars, we encourage those participating in that, which is certainly the providers and other payers in that community that are thinking differently, to use the money what you’re needed in your area. There are no limitations when they receive their value dollars of what they can spend it on in their community.
Another thing I’m very proud about through that brainstorming process and through that white boarding, is a not-for-profit, nonprofit behavioral health, integrated behavioral health company was developed, Arkansas Behavioral Health Integrated Network. For the last few years, they’ve been working on training individuals within primary care to address and treat behavioral health. And so that’s something just out of a little thinking outside the box, thinking differently, just coming together as a multi-stakeholder group to ask what are our problems? And now, they’re making a big difference throughout the state. And really, they’ve even done some training outside of our state as well to make a difference. So it’s important to think outside that box.
Rohith
I think there’s a very macro lesson in there, in fact, that we all need to really think outside the box if we’re going to address rural healthcare.
Alicia
Absolutely.
Rohith
One of the questions that we’ve heard a lot is, it’s been difficult to move rural healthcare providers to value-based care. They rely so much on the fee-for-service medicine dollar. They’re a lower scale. They have less resources and technology to make the shift. Is that the experience that you’ve seen as well, or do you think we are now past the tipping point and value-based care can be successful in rural areas?
Alicia
Yeah. Interestingly enough, early on, we started a pilot around medical homes in 2010 and then in 2012. What we found, interestingly enough, is some of the independents were much quicker to move into the value than the owned practices. One of the particular practices that I worked with was an independent practice. Her husband was our IT guy. So if you can get your husband to fix your system to make that work, they were very effective. So ironically, that was one of the lessons learned, that sometimes the people working within the systems had to get on a waiting list for their IT changes, because, back to the data, you got to have the data.
And then the other challenge that we learned very quickly, EHRs were really meant for data entry, not pulling data out. And so how do you get consistent data to be able to pull it out in a meaningful manner? It’s a mix. Certainly, there are some systems that have really bought into the value and have purchased systems and processes and done a really good job around value. But you’d be surprised some of the superstars that are also independents that are out there doing really good things.
Rohith
Why is it, do you think, that some of the owned systems may still lag behind? Do you think it’s similar to the challenges in urban areas around culture and incentives, or do you think there’s a different mix in rural areas for why there may be slower adoption?
Alicia
Yeah. It’s easy for us to sit and say, “Oh, it’s all the providers. They’re having trouble moving away.” But health plans are built on fee-for-service. The whole communities are built on fee-for-service. So this is different for all of us. It’s something new and something different. And on the CMMI programs we’ve participated with quite a bit, that’s been one of my fears. My concerns are, we are up to in Arkansas, we’ve got 410 practices from a primary care standpoint in value-based care payments. I still have practices in Arkansas that are on paper charts. And at what point do we leave them so far behind they can’t catch up? That concerns me. That worries me. Thinking about those value-based care and payments, it really can’t happen in a paper environment. So how do we meet them where they’re at, and how do we bring them to the point where we can get them into that value-based care, is something that’s on my mind every day.
Rohith
It really rethinks the role of the health insurer as a partner in the provider ecosystem, when these providers are at essentially many different places along the spectrum of technology, of will and skill. It really underscores the fact that rural healthcare and advancing, it can’t be one size fits all. It’s unique to the community, it’s unique to the underlying population, and now it’s even unique to the providers. There’s a lot of permutations that you have to solve for.
We’ve talked a lot about the economic model on the provider side. I’m curious, though, about the economic model on the payer side. So as a non-profit Blue, Arkansas Blue Cross Blue Shield isn’t in this to … The goal, I would assume, is not to optimize MLR. That being said, the common refrain is, “No margin, no mission.” We have to find a way to make this somewhat financially viable long term to be able to invest the right level of resources and the technology of investment in the communities. All of that is not cheap. How are you guys thinking about the financial equation of improving rural health?
Alicia
Yeah. So you’re certainly right. It has to be margin and mission. We are a very mission organization, and we work hard to service our communities, our customers. I can tell you, I’ve been very fortunate for the last 10 years through the multi-payer initiatives, that I don’t just represent Arkansas Blue Cross. I’ve been able to represent our state. Early in 2012, when we started the CPC and the first time I got to go to Washington, QualChoice, one of our competitors, they’re locally... He’s like, “OK, Alicia, when you go to Washington, you’re not just Blue Cross. You’re us, too. You’re QualChoice, too, because I can’t go.” And so we’ve really had a collaborative effort to make healthcare better. And I’m a big believer that you bring community leaders together. There are areas of competition, and then there are areas of collaboration. And focusing on those areas of collaboration is what brings success. And so how do we find those things that we want to move forward, we need to move forward for Arkansans and for our customers across the country? And that’s what we focus and work on together.
Rohith
Yeah. Maybe let’s end on that theme of moving forward. What’s one piece of actionable advice that the healthcare executives out there listening can take and start to enact at their organization if they want to take a more serious stance on improving the health of their rural communities?
Alicia
I would challenge them to really take a leadership role in rural healthcare, in health equity, and in behavioral health. Then listen as a leader to the problems and partner on solutions.
Rohith
We all need to do a lot more listening and understanding, especially after the last few years. Thank you, Alicia, very much. I really enjoyed the conversation and I’m looking forward to more conversations.
Alicia
It’s been my pleasure. Thank you.
Narrator
The Oliver Wyman Health Podcast is brought to you by the global management consulting firm Oliver Wyman. For more insights on the business of transforming healthcare, visit our online publication, health.oliverwyman.com.
This transcript has been edited for clarity.