Regional Partners in Innovation: My Site Visit to the South Central United States

July 31, 2017

Program:  Multi-Payer Primary Care Transformation

It’s rare to have the opportunity to observe collaboration in action firsthand. But that’s what happened when I recently traveled to Arkansas and Oklahoma to see how public and private insurers in Comprehensive Primary Care Plus (CPC+) markets do their regional work.

As I set off walking from downtown Little Rock to my first meeting, I wondered if it was just me (an acknowledged heat wimp from Vermont) or if it was really as hot as it seemed. Characteristically, everyone I interacted with reassured me that it was terribly hot and humid and gently teased me for visiting in the summer. A small detail, but one that reflects the graciousness, good humor, and ease of my hosts and those in their hometowns.

I met in person with representatives of 9 of the 11 public and private insurers currently participating in CPC+ in Arkansas and Oklahoma. Within their home states, these insurance companies meet regularly with other partners to hammer out the myriad complexities of CPC+ while serving populations of varying size and complexity. Seeing many of their administrative offices gave me a flavor of several parts of these cities, which are centers for front line health care innovation. It was notable that in both states, the project partners, often direct competitors in their markets, came together to dine with me and engage in lively conversation about the challenges and rewards of being part of CPC+.  Alicia Berkemeyer of Arkansas BlueCross BlueShield (ARBCBS), who serves as a Multi-State Collaborative Steering Group member and de facto convener noted, “Improving health care is not a competitive issue. We must align and work together to be successful in our goal of improving health care for all Arkansans. The payers collaborate extremely well and that carries over.”

A little background. Arkansas and the Tulsa metropolitan area of Oklahoma were in the first wave of the Comprehensive Primary Care (CPC) initiative, which ended in December 2016. When CPC+ began in January 2017, the two programs—which now serve vastly expanded geographic areas and population sizes—were joined by nearby Kansas City. When they met at a national CPC+ meeting, several leaders of the three regions realized that they had a lot in common, including geographic proximity and similar concerns, such as providing health care in rural areas. These three regions, hours away from each other by car but drawn to each other culturally, took the initiative to craft their own tri-region working group, and now meet quarterly in person. At these gatherings, regional payer representatives share best practices and discuss topics relating to reporting, audits, internal marketing and education materials, and alignment of quality measures for practices enrolled in Track 2 of the CPC+ model. “We can work with each other [on the same kind of issues], take that back to our individual states, and learn and grow from it,” said Peter Aran of Blue Cross and Blue Shield of Oklahoma (BCBSOK). “CPC changed the game because it got competing systems talking to each other and really made us focus on relationship building.”

Several important themes emerged during my brief visit.

1. There was an easily-ascertained culture of collaboration that had evolved into “business as usual.” Examples of this include:

  • ARBCBS funds a multi-disciplinary practice facilitation team, including nursing, nutrition, respiratory therapy, and social work professionals who interact regularly with the over 150 CPC+ participating primary care practices. This means one or more members of the team visit every office several times a year, many of which are in far-flung and rural corners of the state. The team members spoke of these practices with familiarity and empathy.
  • The Oklahoma Field Services Team plans collective ongoing educational and quality improvement action opportunities with representation by every participating regional payer. When I attended their monthly meeting, they were puzzling through the development of the next learning session curriculum with the regional learning network faculty, who are locally based subcontractors to the Centers for Medicare and Medicaid Services (CMS). The quality of the learning opportunity will be greatly enhanced by leveraging the payers’ firsthand knowledge of the practices’ capacity and interests.
  • As with any skill, learning to function as an effective and respectful interdisciplinary multi-stakeholder team member needs to start when health professionals are still in school. The University of Arkansas for Medical Sciences (AUMS) Interprofessional Education (IPE) curriculum represents a state-level commitment to team-based care, starting “way upstream” in undergraduate and graduate education. Students in all schools at the AUMS are required to complete courses in IPE prior to graduation.

MMF intern Catarina Abreu asked some of the CPC+ regional leaders via email why they literally go the extra mile to meet in person. Qiana Thomason of Blue Cross Blue Shield of Kansas City (BCBSKC) answered, “There was a need for learning and collaboration. We want our CPC+ markets to operate with strength, and there’s value in collaboration.”

2. Payers and practices agree on the benefits of collaborating across regions (as well as within them). Arkansas and Oklahoma both face challenges in supporting smaller independent rural practices that don’t have the same access to resources as those in larger health systems. “We’re all about establishing relationships with practices, talking to them about aims and establishing common goals. Everyone involved wants to improve [patients’] health regardless of their enrolled plan,” said BCBSOK’s Elaine Olzawski. Added Aran, “When you’re in your own state you can have blinders on. [All three regions have] had state mandates and regulations and done a lot of work in learning how to solve pitfalls and barriers. [The working group] has benefitted all of us.”

3. The professionalism and dedication of the wide variety of health care and health care-related professionals is striking. Despite formidable challenges related to the allocation of scare resources in all communities, everyone I spoke to indicated their intent to continue with CPC+.  I left with the feeling that commitment to the process and goals—and, of course, to the local patients and families in the three regions—was firmly in place.