Move to Value Podcast

In this episode of Move to Value, we talk with Julie Quisenberry, Director of Care Integration at Coastal Horizons. Serving 56 counties across North Carolina, Coastal Horizons delivers whole-person care by integrating primary care, behavioral health, substance use treatment, and community resources. Julie explains how her team navigates Medicaid standard plans and tailored plans, uses HEDIS metrics to improve outcomes, and works closely with partners like CHESS to keep patients’ needs front and center.

In this episode, Dr. Rob Fields and Rebecca Grandy continue their conversation and focus on data. What’s useful and what’s a waste of time? What data truly drives value and why do so many predictive tools fall flat? You’ll also hear practical strategies such as where to direct focus when resources are tight, how to build an ideal care team, and how to make your value-based programs sustainable—even in a broken fee-for-service world.

In this episode of the Move to Value Podcast, Dr. Rob Fields, EVP and Chief Clinical Officer at Beth Israel Lahey Health, joins host Rebecca Grandy, Director of Pharmacy at CHESS Health Solutions, to unpack the realities of value-based care.They explore why good intentions aren't enough, what data actually drives impact, and how to build sustainable care models with limited resources. From downside risk readiness to team-based care and chronic disease management, this conversation is full of practical insights for anyone navigating healthcare transformation.

Today we revisit an interview with Tim Gallagher, a leading voice in Medicaid transformation and value-based care. With Medicaid policy currently dominating headlines, it is important to hear from someone with firsthand experience as both a policy expert and a parent navigating the system. Tim offers sharp insight into how managed Medicaid can drive equity, improve outcomes, and create sustainable partnerships.

In this episode of the Move to Value Podcast, we take a deep dive into one of the most impactful updates in healthcare risk adjustment: the transition from CMS-HCC Version 24 to Version 28. Our guest, TaSonya Hughes, CHESS Health Solutions’ Manager of Coding and Documentation Education, explains what the shift means for providers, coding teams, and care managers—and why now is the critical time to prepare.CMS-HCC Version 28 introduces new disease classification categories, retires thousands of existing diagnosis codes, and emphasizes greater specificity in clinical documentation. TaSonya walks us through how these changes affect Medicare risk adjustment, the financial sustainability of value-based care, and ultimately, the ability to deliver accurate, coordinated care for patients with complex chronic conditions.

In this episode of The Move to Value Podcast, guests Jennifer Houlihan and Jennifer Gasperini join us for a deep and wide-ranging conversation on the evolving landscape of value-based care. We explore North Carolina’s leadership in Medicaid transformation, the critical role of provider voice, and the infrastructure needed to support long-term success.From navigating administrative burdens to anticipating federal policy shifts, we also discuss how health systems can stay nimble, build smarter data strategies, and engage patients in more meaningful ways. Whether you're a provider, policymaker, or system leader, this episode offers timely insight into where healthcare is headed—and what it will take to get there.

CMS Changes and the Future of Value-Based CareJennifer Houlihan and Jennifer Gasperini of Advocate Health discuss the impact of new CMS and CMMI leadership, current challenges in value-based care, and the future of ACOs, ECQMs, and Medicare Advantage. A timely conversation for anyone navigating the evolving policy landscape.Welcome to the Move to Value Podcast, powered by CHESS Health Solutions.In this episode, we’re joined by Jennifer Houlihan, Vice President, and Jennifer Gasparini, Director of Policy, from Advocate Health’s Population Health Team. Together, we unpack the implications of the recent administration change, explore what new leadership at CMS could mean for value-based care, and hear their perspectives on the legislative priorities they hope to see take shape.Thomas Royal Jennifer Houlihan, Jennifer Gasparini, welcome to the move to Value podcast.Jennifer GasperiniThanks for having us.Jennifer Houlihan Happy to be here.Thomas Royal So you both just attended the NAACOS conference?Can you tell us what are some of the hot topics that folks were talking about?Jennifer GasperiniI can get us started.I think it's always great to see colleagues at the NAACOs conference and was also great to see Kim Brandt, who is the deputy administrator and COO at CMS, come and share some of Doctor Oz's priorities. For CMS and I think a lot of those priorities align really well with value based care. So they they really spoke a lot about tackling fraud and abuse. And as you know, ACOs are really the early identifiers of fraud.And so really was pleased to see them talking about that and also using technology and better data really for beneficiaries and providers to advance care. And I think ACOs obviously are very focused on that goal as well.Jennifer, do you have anything else to add there?Jennifer Houlihan Yeah. There, in addition, there were some really good sessions on the new team model, the transferring Episode Accountability model as well as guide and a lot of thoughtful conversation around how to integrate these models into the ACO and a clearer path for outcomes there. So I think there was a great discussion and got to give kudos to Jennifer. She was part of a really well attended and fantastic panel on how ACOs are adapting ECQMs and MIPCQMs and some of the kind of demands and multiple issues that are impacting ACOs on how to do all payer adjustments leveraging some of these requirements. So a lot of really timely topics and I think then the kind of final was Specialty Care integration, I think continued to be a recurring topic that we need to think more deeply about that and and how those get nested within cost, so hopefully we'll see more about that in the future.Thomas Royal So there is new leadership in place at HHS, CMS and CMMI.What does NAACOS think this might signal for the future of value-based care?Jennifer HoulihanSure, I I can. I can jump in on that one first, so I think you know, looking at Abe Sutton, you know, as as Jennifer mentioned, Kim Brandt was there from CMS. But we've also seen with Abe Sutton's appointment, who's been a strong supporter of value-based care. I think the mood was mostly positive, that there has been sort of a lot of statements, whether it's in some of the confirmation hearings, or direct statements that value-based care and the need to achieve savings is is one of the priorities. I think there's gonna be some different thinking about more aggressive requirements for more savings and as as as we've seen already, some of the model review that's already taking place. The ability to kind of end models early if they're not achieving the outcomes and the savings. So I think the mood in...

In this episode, Kari Curry, Medicaid Care Coordination Hub Supervisor at CHESS Health Solutions, shares how CHESS delivers high-touch, high-impact care management within a Medicaid Clinically Integrated Network (CIN).Kari walks us through a patient journey that highlights how CHESS uses real-time data from NCHIE, comprehensive social determinants of health (SDOH) screening, and structured care planning to reduce ED utilization and improve health equity. She also covers CHESS’s success with AMH Tier 3 audit readiness and payer collaboration—proving that value-based care in the Medicaid space is not only possible, but measurable.

In today’s episode we continue our conversation with  @American_Heart  Senior Advocacy Advisor of Health System Transformation Melanie Phelps, who was integral in the recently published study on the benefit of Accountable Care Organizations. The findings support that managed care provided by ACOs not only improves outcomes for the medically complex patient, but also benefits every patient, family caregiver, provider, and healthcare team member. www.heart.org/bettercareYates Lennon Melanie Phelps, welcome back to the move to Value podcast. So let's try to pick up where we where we finished last time. Melanie and I wanted to go back to really to sort of the heart of your research in the medically complex patient. So we know these folks require hard higher touch and really need coordinated, managed coordinated care. And, wanted to talk about why it's crucial for the American Heart Association to understand and advocate for better models of care for this patient population. And then we'll after that, we'll follow up on sort of how we can work together to do that.Melanie PhelpsYeah. So medically complex patients are of course more complex and more costly.They require a lot more services and the burden of navigating a fragmented fee for service system adds to their already very stressful lives and the chances of things falling through the cracks or delayed care is pretty high in a payer fee for service system, the ACO provides those extra layers of support, communication and enhanced access that really do lead to better outcomes, reduce stress on the patient and their caregivers, which is pretty important. We also believe they are more likely to get the most up to date care under these arrangements because the incentive to do better is there and that is not there in the case of fee for service. So, we all know that there is a pretty significant lag between new innovations and evidence-based solutions and adoption or implementation in reality, and we see ACOs as a vehicle for expediting adoption of those. The other piece on medically complex patients, why we wanted to focus on those is when talking to other patient and consumer advocacy organizations, which is a key target audience of this of this study, there was a lot of apathy and even skepticism about ACOs, OK. They're not involved in the advocacy. They're not steeped in the details and they are very suspicious of ACO’s of value based care. They're thinking there's a lot of stinting going on. They think that they're being, you know, medically complex patients are being denied care and being kicked out of ACO’s. And that certainly was not my experience when I worked with the ACO’s in North Carolina. So, one of the reasons we focused on medically complex patients was to be able to say, OK, you know, are they getting the care that they need? What do they have to say about it? And that's why. I mean these are the people that really need the extra care and support and the results really showed that they were getting much better care and support, which should be important to everybody.Yates LennonYes, absolutely. That's that's interesting. I never would have. I guess I never would have thought about that kind of skepticism from consumer advocacy groups around value based care, and certainly my experience has been the exact opposite is the ACO model is a ideal model to have those patients in because you have the sustainable, a sustainable path to provide these wrap around services to both, both the provider and the patient and their families. I can think of multiple instances where these like in our NextGen days and our ACO REACH nursing facility waiver as an...

Today we hear from Melanie Phelps, Senior Advocacy Advisor of Health System Transformation for the American Heart Association, who shares with CHESS President, Dr. Yates Lennon, the motivation and detailed findings of a new study conducted by the AHA which found that ACOs provide better care and outcomes for patients and a better practice experience for members of the health care team than traditional fee for service. www.heart.org/bettercare Yates Lennon Melanie Phelps, welcome to the move to Value podcast.Glad to have you with us today.Melanie Phelps Glad to be here.Thanks for having me.Yates Lennon Sure, of course.So Melanie, recently the American Heart Association, released a study called Understanding Patient Family Caregiver and Health Care team member ACO experiences. Can you talk to us a little bit about what motivated the American Heart Association to conduct this research?Melanie Phelps Happy to. So the idea for the study arose out of a desire to be able to talk about ACOs in a more relatable manner to people who are not steeped in the technical jargon around ACO and value based care generally.We thought the best way to do this was to hear directly from patients, their family, caregivers and healthcare team members who receive or who provide care through ACOs.So from those who are on the ground receiving and providing care, and our hope is to use this information to better explain the benefits of ACOs in a way that's more understandable to more people.Yates Lennon Yes, certainly that, that sounds good.I know. ACO is an acronym that I think everyone of our listeners would be familiar with but when you get outside of the healthcare team member and even within in some settings, it's something people don't understand. Well, the study compares patient experiences in ACOs to the more traditional fee for service models.What were some of the key differences that stood out in terms of patient's experience first?Melanie Phelps Well, the results showed that.The care that's provided through these ACO models is just better in terms of quality and access, because there's a usual source of care through a primary care provider, whether that's a MD or an advanced practice provider.And there's usually a dedicated care manager as well as a team of people to ensure that all their needs, physical, mental, emotional and health related social needs are addressed.So essentially their experience is that they receive better, more timely and coordinated care with added supports that they wouldn't get in a pure fee for service arrangement.And I heard more than a few times that it's better than what we had before.And I also heard that my friends don't get the same level of care, and even some of the healthcare team members who lamented the fact that they can't provide this level of care to all their patients, especially those who are not assigned to an ACO, so.Yates Lennon Yeah. And I can echo that experience.I think some of our care team providers share with us stories of patients they interact with and we certainly hear that same story and even I have family in a different part of the state than the triad. And I can say from personal experience, I wish they were in these models.The American Heart Association conducted interviews like you said, just talked about among patients, caregivers and these healthcare team members.What were the what were their common themes?You just mentioned some common themes among patients, but if you expand that, what were some of the key findings or common themes across all three of those groups, patient, caregiver, and healthcare team...

Today we continue our ACO REACH conversation with Kim Williams, who discusses how this model facilitates enhanced care for the patient. She also shares insights on measuring success, engaging providers, and the broader impact of ACO REACH on healthcare equity and value-based careThomas Royal Kim Williams, welcome back. Thanks for sticking around so we could continue our conversation here today.Kim Williams Thank you, Thomas.I'm happy to be back and ready to continue our conversation.Thomas Royal So last time you know, we discussed a lot of the nuts and bolts of ACO reach.You know what it is, how it helps us, the various entities that are involved.One of the things that I want to talk about a little bit is the is the patient.So we, you know, previously you mentioned a HealthEquity plans sdoh screenings.What beyond that and including that specific advantages, does ACO reach offer to the patient compared to traditional fee for service models?Kim Williams Yes. So, in ACO reach the advantages for patients are actually quite substantial.Especially in care delivery through waivers or what they call benefit enhancements and incentives. So, for example, with the public health emergency coming to an end, a lot of the telehealth flexibilities that existed during the pandemic are no longer an option after March of this year. So if you were if you are an ACO reach, this is still an option through the telehealth waiver, which removes geographic restrictions and allow patients to get care from their provider regardless of where they are. So you know they can be in their living room doing a check in visit. It is so beneficial for rural communities and patients with mobility issues. I've had site visits with providers that really stress the importance of telehealth because they are in a more rural setting where it's not, you know, good for the patient with mobility issues to go back and forth to the offices. So I think that's definitely a huge plus for those types of population. There is also a financial benefit play that patients can take advantage of, and that's through the cost sharing for Part B services. Now this one allows reach ACOs to reduce or eliminate cost sharing for Part B services and remove financial barriers for things like a primary care visit or your chronic care management, even preventative services. So for instance, CHESS has it set up right now to where we can waive chronic care management co-pays. And so the hope is that. If we're able to waive those co-pays, patients will be more willing to seek intervention. And really participate in chronic care management programs when you know they're not too worried about those co-pays. Chronic care management is just super important in this model, alongside of transition of care management because it focus on preventions. And so I think again this is a win win situation for both providers and patients and also ACOs alike.Thomas Royal Well, that's fascinating.I so I I know that when we talk about there's options of care and financial efficiency for the patient, how does the program ensure patient receives more coordinated and personalized care?Kim Williams Yes, so care coordination plays a huge role in ACO reach. And you heard me mention earlier that implementing the HealthEquity plan requires coordination from everyone. But I want to specifically highlight the great work that care coordination teams put into personalizing the care for our traditional Medicare patients in this population, right? So first the the outreach to the patients are beyond the normal amounts and I'm I'm using our HealthEquity plan as an example here because our care management teams spend more time on the phone with patients, really to better understand why. Why are they not getting their cancer screenings, for example? And...

In this episode we hear from Kim Williams, Senior Manager of Government Programs at CHESS Health Solutions about the value of ACO REACH. She shares her expertise on what it is, why it was created, and how it benefits the patient and provider by being a care collaboration model that improves quality while incentivizing health equity.Kim Williams, welcome to the Move to Value podcast.Kim Williams Yeah. Thank you so much for having me.It's really a pleasure to be here.Thomas Royal So Kim, today I want to explore some of your knowledge that you have and your expertise.So let's talk about ACO reach first.Can you explain what ACO reach stands for and how it differs from the other ACO models?Kim Williams Sure, I'm happy to.ACO REACH stands for realizing equity access and community health.And really, the differentiator of this model is in the name itself.It's looking at HealthEquity and getting patients access to care in a timely fashion, but it's also looking at social needs and also working with community health providers to have a more coordinated approach in the patient's care journey. And so a lot of the programs requirements that we seeare centered around those core principles.And this is a huge shift away from your traditional fee for service model, where everything is based on quantity of services to now looking at value.Now we are looking at not just at the bigger picture. We're looking at the entire picture.We're looking under the rugs and we're addressing root causes in this ACO reach model, also part of what makes this model unique is in the innovative payment structure and that is what I call a capitation-like model.So this means that CMS will give us a prospective payment upfront and providers have the flexibility to structure that payment however they want to do that in a multitude of different ways.So one option is that a provider can elect to do a fee-for-service pass through where you are paid 100% of what you Bill to Medicare. Or you can elect to get 90% of what Medicare pays you.With an option to earn back bonus payments.Or if you don't want any of those options, you can also say, hey, just pay me a per member per month payment upfront.So that's called pmpm.Pay me that amount monthly or however they want to structure that arrangement with the ACO.So there's a multitude of different ways that you can go about this, and really the idea is that if the provider knows how much they're receiving up front to care for their beneficiaries, then they will be motivated to stay under that threshold and that benchmark.And that's really where the shared savings comes in.So I think the ability to select these payment options based on what you're comfortable with is not something you typically would see in other models outside of ACO reach.Thomas Royal Oh, that does sound pretty unique.Kim Williams Yeah.Thomas Royal So he touched on this a little bit, but I'd like to dig a little bit deeper and and if you could tell me what are the core goals of ACO reach and how does it align with the broader shift towards value based care and how does this model prioritize Health Equity and patient centered care in its design?Kim Williams Yeah. So, earlier you heard me mention that the goals of this model are centered around Health Equity access and community health.And so I want to camp on certain components of those levers.So I want to expand on why that matters and talk about the Health Equity for example. So as we're moving away from again the traditional fee for service and moving towards value based care, you see more and more payers prioritizing patient, HealthEquity and social determinants of...

In today’s episode, we revisit our episode with Josh Vire, Vice President of Value-based Operations at CHESS Health Solutions, where he discussed what has been learned during the move to managed Medicaid in North Carolina and what CHESS brings to the table with its all-patient solution.Josh Vire, welcome to the Move to Value podcast.Thank you, Thomas. Thanks for having me. Pleasure to be here.So, Josh, let's talk about managed Medicaid. First, can you tell me what is managed Medicaid?Sure. It may be easiest to start by sort of describing how traditional Medicaid works. In traditional Medicaid, typically this operates under what's called a fee for service payment model. This model is going to reimburse providers directly for every service that they provide to Medicaid beneficiaries. And generally the upside to this model is that it's going to allow for the flexibility and provider choice for the beneficiaries. But what we often see is that this leads to fragmented care and ultimately the incentives in this fee for service type model really incentivizes the volume of services over outcomes. So, in contrast to that, Managed Medicaid utilizes alternative payment models including capitation and what are called value-based payments. And the way that the capitation works is that a managed care organization or a MCO as they're referred to will receive a fixed monthly payment per Medicare beneficiary that's going to cover all their health care needs. And then that fixed payments are paid regardless the amount of services that are provided. And then those MCOs are going to use those funds to incentivize providers to be more cost effective in their care as well as incentivize sort of tighter coordination of the care. And then what they can layer on to those, as I mentioned, is the value-based care payments which are intended to reward providers based on the quality and outcomes of care rather than just the quantity of services provided. And so in theory, right, this would encourage more efficient, high-quality delivery of care. In addition, managed Medicaid may employ other payment models that are along that continuum of value based care payments, which could be like pay for performance or bundle payments. But really the goal there is to align the incentives to focus on driving down total cost of care as well as improving health outcomes for beneficiaries.Well last December North Carolina made the transition to managed Medicaid and Chess spent the year prior to that establish establishing the infrastructure and beginning to make preparations to offer this service. Can you tell me why this decision was made and a little bit of the story about how Chess built this service line.Absolutely. CHESS has a decades plus long history of working with providers to transform care delivery to value based care. And historically our focus has been on traditional Medicare, Medicare Advantage and commercial contracts. But as we went through our engagements with our value partners and then as we began to have discussions with providers across the state, we heard consistently that one of their pain points was the need to work with of having to work with multiple enablement companies to serve all their patients. So some enablement companies only work with MA or maybe the traditional Medicare options or commercial. But no one was really acting as sort of a one stop shop in in serving the entire patient population for these providers. So our decision to expand our services to include Medicaid was really driven by our desire to be what we call an all-patient solution, which essentially just means we want to be able to align incentives across the provider's entire patient population. And really that's because we believe this is how true transformation can and will occur, not in certain segments, but by treating all patients with an...

So as you are well aware, at CHESS we often refer to the seven pillars of value-based care. What are these pillars and how does each impact fee-for-value? So, we’ve tended to use these pillars, if you will, to think about the process. Really, it follows our implementation process in many ways. So, I would start with practice transformation. So, that involves ensuring that physicians, advanced practice providers, office staff from CMA to nurses to even front desk staff, has some awareness of value-based care, understand why it is important, and then are engaged in the process of transforming that practice to a infrastructure that supports the delivery of the value-based care models and success in those models, both clinically, which is ultimately what this is really all about, and financially.From there, you can begin to layer on other services or pillars if you will. These don’t necessarily have to happen in this order, but we often start with thinking about quality. Most organizations today have some quality efforts already in place just due to primarily to the fact that CMS and other payors are pushing those. And most people have at least some pay-for-performance type of arrangements, where they’re paid for closing quality care gaps. But quality goes beyond just thinking about closing quality care gaps. For our quality team, we’re thinking about optimizing the annual wellness visit so that the template within the EMR is just capturing data points and discrete fields. That makes reporting easier back to CMS as well as to the private insurance companies, Medicare Advantage, as well as commercial.We think about Care Coordination and as we define care coordination, that includes, for our teams, nurses and CMAs. They work together to assist also in quality. So, the CMAs help close quality care gaps throughout the year. They schedule annual wellness visits, that’s a big emphasis in the first half of the year. If you can already tell, that annual wellness visit is a key component of value-based care because it touches on so many different elements of value. The other role for Care Coordination would be moving with that patient, tracking that patient, outreaching the patient between transitions of care. So, patient is admitted to the hospital, discharged to the skilled nursing facility, then discharged home. Our Care Coordination teams are monitoring that patient as they transition through those different sites of service and ensuring that each transition is as safe as possible. We all know that medication errors, in particular, are a massive problem through transitions of care. So, ensuring that patients know what medications they’re taking, or supposed to be taking, and that they can afford those medications. If they can’t, then connecting them with the resources to be able to provide those medicines for them.They also perform Chronic Care Management. So, that’s identifying. So, we can go back to population health, identifying a group of patients who are either at high risk or rising risk of a complication or with a certain disease state. Identifying those patients, and then on a regular basis, setting up telephonic or even telehealth outreach to those patients, so that between those four office visits a year, that a chronic patient might have with a provider in the office, someone is touching base with them throughout the year. As a clinician, I always think that way. That for an average chronic care patient, I might have an hour or two hours a year of face time with a chronic care patient. Whether that’s diabetes, hypertension, the combination of the two. That’s really not very much time over the course of the year. And so, when you think about the Care Coordination team being able to touch those patients in between those visits, you really are improving the patient’s experience of care. You’re extending the provider’s reach and ability to impact the patient in between those...

Let’s start at the very beginning. What is value-based care and why does it matter?So, what is value-based care. I tend to think about population health and value-based care side by side. And, in some ways, it’s value-based care is population health plus a payment structure that you find in value-based care models to create sustainability for those pop health efforts. So, when you think about population health, you’re thinking about groups of patients, whether that’s groups of patients by demographics, by disease state, by recent hospitalization. They’re all ways you can slice populations. And you’re thinking about caring for that group of patients. Now at the end of the day, population health is delivered one patient at a time, generally speaking, in my mind anyway. But, when you add value-based care to it, you’re creating an incentive structure that creates sustainability so that you can deliver the services you need to care for those populations of patients as they move through the continuum of care. So, from the outpatient setting, to inpatient, to home, to skill nursing facility, back home. That’s a very broad definition, but when you dive a little bit deeper into value-based care as a clinician, I’m thinking about value-based care as a way to support resources that will assist me in caring for those patients. So, it’s not all falling on the physician or the advanced practice provider at the point of care in the office.What is the triple aim and how does practicing value-based care help to achieve that?So, the triple aim was coined back in 2008 and it really aims to do, as you might guess, three things. One, is to improve the patient experience of care. The second is to lower the cost of care. And then the third would be to improve quality or improve the health of populations. Value-based care, and as we discussed already, is perfectly suited to solve these. So, if I start with improve the patient experience, or patient satisfaction. The fact that a patient is able to access a care team larger than just the provider and the nurse, I think, moves us in that direction. The other aspects of care when you think about, I think about my parents, so, and their encounters with the health care system. And how it’s been traditionally very disjointed. Still is. They live in a part of the state where value-based care is not really penetrated very well. And it’s very disjointed. My Mom gets information from her providers and her payors, and she’s confused. She doesn’t know what’s real, what she should respond to, you know, is this a scam, just all kinds of questions. So being able to reach into a care team on a consistent basis is very important. And especially for that generation. They don’t want to bother their physicians. We could have a discussion about whether that’s the right thing to do or not. But, that’s just the way she thinks. I don’t want to bother anyone. So having a care team whose proactively reaching out to a patient, especially following an important transition, goes a long ways towards bringing comfort and to that patient. And when I hear the stories from our Care Coordination team, including our social worker, the impact their having on patient’s lives is profound. They are addressing things that I as a clinician would never get into in an office visit. In part sometimes because I was afraid to ask the question because I didn’t have any resources to deal with what I figured the answer would be. To improve the quality or improve the health of populations, so we’re focused on quality, closing care gaps. We’re focused on an Annual Wellness Visit, which is designed to allow a provider to look at a patient’s whole picture. So, where are they receiving care, do they know who their providers are, do they know who their durable and medical equipment providers are. Are they up to date on screening procedures and are they up to date on any...