Clay Holderman

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Timing is everything. In midst of launching an Inclusion, Diversity, Equity and Accessibility (IDEA) effort within Presbyterian Healthcare Services , a federal order makes it a political hot potato. The memo casts all unconscious bias training or racial sensitivity training as “anti-white” and “un-American”. So what to do? Delay implementation until the political context dies down? Or continue forward and begin the self-examination, the data collection, and the conversations that will propel us forward?

“Integrity is choosing courage over comfort; it’s choosing what’s right over what’s fun, fast or easy, and it’s practicing your values, not just professing them,” Professor Brene Brown has said.

Having integrity about IDEA starts with collecting and believing data. Assuming yours is like ours, it is filled with uncomfortable oxymorons. Many have high engagement but low resilience. We want to hear everyone’s voice, but understand not many feel safe enough to speak up. We have a workforce that reflects the diversity of our community, and a leadership team that doesn’t come close. This data compels us to move forward, to start the conversation, and to begin to make change.

The issues of bias and racism are not theoretical. They play out in micro-aggressions towards our workforce on a daily basis. We recently convened several hundred caregivers to talk about the issue. We were shocked to hear physicians of color share that they are subjected to racist comments or requests for a different provider "up to three times per shift." If this is occurring in our workplace, to the most educated among us, who are in positions of prestige and actively working to help others, what must the experience be for those at the bottom of the social ladder?

The research is clear on the benefits of inclusion. The more we build an environment that is inclusive, diverse and equitable, the better our results. Innovation increases. The sense of belonging and psychological safety improves. The racial incidents and misunderstandings with caregivers decrease. The capability to have a courageous conversation expands and allows every person to grow.

As a leader, I know where I fall on the issue. As Federal agencies are “directed to begin to identify all contracts or other agency spending related to any training on ‘white privilege,’ I will lean into the issue. I will seek to understand why our health outcomes and leadership ranks are so unequal across race.I will stand for those that are under-represented and practice my values.

I take a firm stand in valuing every human being’s unique talents, celebrating their differences, hearing their ideas, and practicing cultural humility. I will practice leading with courage and having courageous conversations in the midst of our country’s divisiveness. I will advocate that we continue to provide enterprise-wide implicit bias training as a catalyst for disrupting bias and addressing our decision-making practices. I will give our workforce more language to talk about these issues from many different points of view, not less.

Silence is not acceptable. Action is required. Today, choose courage over comfort. Let your organization know where you stand and that you stand with them. Remind them of your values and your commitment to practice them every day. As Elaine Dalton put it, “If you desire to make a difference in the world, you must be different from the world.”

Clay Holderman is the executive vice president and COO for Presbyterian Healthcare Services in Albuquerque, New Mexico, a not-for-profit integrated system of hospitals, clinics, a medical group and one of the nation’s largest provider-led health plans.

Articles

Battling racial bias in the workplace. How implementing an inclusion, diversity, equity and accessibility training initiative can lead to better results in racial disparities within healthcare and beyond. 

Stand Firm: Lean Into Bias Training

We continue to see health systems throughout the United States merge to build economies of scale and skill as the health care landscape that is shifting from volume to value. While health systems have the clinical experience and aptitude to drive care that makes patients healthier, many struggle with keeping that care affordable.

And, this struggle is not going away. Government programs like Medicare, where reimbursements are historically below costs for most providers, are predicted to drive 65% of all insured patient growth in the next ten years. As reimbursement decreases, health systems already struggling for financial sustainability will experience further stress to drive down costs.

How to Successfully Transition to Value-Based Care

To succeed now and in the future, health systems must capture and manage more of the total premium dollar. Specifically for Medicare, it requires a system-wide movement away from fee-for-service toward full-risk or capitation. Health systems can succeed in a full-risk arrangement by segmenting and managing care with targeted interventions for specific patient-level cohorts and expanding their reach into the healthcare value chain to mitigate some of the greatest non-hospital cost drivers today.

Drive value by cohort development, not by payer reimbursement

Health systems have tremendous value savings sitting in the data trove of electronic medical records. Determine how to slice the data to create patient-member cohorts with similar risk profiles, diagnoses, or utilization patterns and design care models accordingly.

 At Presbyterian, we found that 5% of our Medicare Advantage population was driving 50% of care costs due to frequent emergency department (ED) visits and higher-acuity conditions. Through further analysis, we found that interventions at home were highly successful with this cohort. We created a program where a specialized care team-including social workers, pharmacists, and physicians-provides intensive services for this population in the patient’s home. Many of these interventions would not be billable under fee-for-service Medicare, but through our capitated arrangements with our Medicare Advantage plan, we can pursue effective interventions funded out of the full premium pool. Through this program we have seen costs drop dramatically while also providing a better patient experience and avoiding frequent ED visits.  

We could have managed each patient in this population in our clinics visit-by-visit, but by viewing them as a cohort with similar needs, we were able to develop a care model that drove up value and decreased costs to both the Medicare Advantage health plan, our delivery system and the patient-member.

Expand your reach into the healthcare value chain

Facility and professional fees account for just about half of health claims nationally. This leaves nearly half of every premium dollar open to greater influence from the health system. Often systems ignore the potential value of pursuing opportunities to influence care outside of a hospital room-yet with more programs transitioning to a value-based model, they are going to be held accountable for that care and subsequent patient outcomes.

 As pharmaceutical costs soar, the opportunities to capture and manage more of these costs also increase. 

 show that when health systems fully engage in specialty pharmacy, it can drive down costs as well as result in better clinical outcomes for patients. Presbyterian’s in-house specialty pharmacy has helped decrease drug spend and increase patients’ medication adherence while also generating additional revenue.  

 As reimbursement is increasingly tied to outcomes, managing post-acute care is a critical step to achieving clinical results that lead to higher incentive payments. But, managing post-acute care can be difficult for traditional hospital-based health systems. By partnering with community providers, as well as our own medical group, Presbyterian was able to perform in the top 4% for total reimbursement across all hospitals and 6% among hospitals that achieved an “excellent” rating for CMS’ Comprehensive Joint Replacement model. This required an intensified focus on care coordination and managing the highest-risk patients in post-acute settings where hospital systems have very limited experience or control.

As those closest to the care, health systems should be the primary drivers of health care in a value-based system. Through initiatives centered on the development of new cohort models and finding new ways to influence costs downstream, health systems can start to experience greater clinical and financial outcomes.

Clay Holderman is executive vice president and chief operating officer at Presbyterian Healthcare Services.

Why health systems need to move toward full-risk or capitation models.

Clay Holderman

Articles

Stand Firm: Lean Into Bias Training

Driving Value-Based Care as a Health System