The Revenue Cycle Management Technology Adoption Model (RCMTAM)

    RCMTAM offers healthcare providers a comprehensive tool to evaluate and enhance financial and technological performance through an evidence-based, five-stage maturity model.

    Learn More

    Featured Content

      FinThrive_EXEC_Revenue Management Automation Guide-svg

      Your Guide to an Autonomous Revenue Cycle
      Plot a course toward forward-thinking innovation that improves efficiency, the patient experience and your bottom line.
       

      Technology Transforming the Impact of SDOH Programs with Amit Kale

      Healthcare Rethink - Episode 12

      Seeing the social health needs at the household level is very challenging, but is where Amit Kale, Vice President at Highmark Health, believes we need to start to help members live healthier lives. Amit Kale joins the podcast to talk about the opportunities and challenges of addressing social determinants of health.

      Don’t miss a second of what’s trending in healthcare finance

      Check out our other topics.

      Show Me All Podcasts

       

      Healthcare Rethink: Hear From Leading Changemakers

      Ready for another episode?

      Show Me All Episodes 

      Brian Urban: [00:00:22]
      Here we go. This is the Health Care Rethink podcast. I'm your host, Brian Urban. And today joining us all the way from Highmark Health is Dr. Amit Kale, and he's coming with a deep background in technology coding and practicing as a medical doctor for years. He received his M.D. at Mumbai University and then went on to Cornell University to receive a masters of Health Administration. And he's joining Highmark Health to help transform their social determinants of health initiative, leading community health and provider partnerships. So amidst, thank you for joining the show.

      Amit Kale: [00:01:00]
      I'm glad to be here, Brian, and happy New Year.

      Brian Urban: [00:01:03]
      And Happy New Year. Yes. So I met with every show, we like to get our audience familiar with our guests. So we wanted to open up to just understand a little bit more about where you've come from and how you've come to now be the vice president of Community Health and Provider Partnerships for the team at Highmark Health.

      Amit Kale: [00:01:28]
      Sure, Brian. So and before we start right, I was having a discussion with my ten year old about this podcast. So one is I was surprised to to know that he knew what a podcast was and he thought it was cool. So it's good to score some cool points with my ten year old. But I've been fortunate to work in different types of organizations. I've had the privilege of having some excellent mentors who have taken the time to guide me and provide me with the right set of opportunities. So from health care technology startups, where I was working with a bunch of engineers designing products and solutions to management consulting, doing a lot of quantitative analytical work, including corporate strategy, and then moving on to clinical transformation, precision medicine, virtual care, as well as community health, which I'm most passionate about. Having gone to medical school and business school, as you mentioned, along with the experiences I've had, it has helped me look at problems from multiple angles, which I feel for the most part has been an advantage. And more and more. And I'm seeing so many talented people schooled in multiple disciplines, having a really rich, diverse work experience. And it's really exciting to see the the depth of talent entering the workforce. As you know, technology underpins a lot of the solutions, including health care delivery solutions like virtual care. And it helps to know how systems and technology work in general and more importantly, what the limitations are of using that. I've had the opportunity to work with large health care systems to build social determinant capabilities and operating models and leverage a lot of my experience and learnings to scale these solutions. I'm really excited to work at Highmark with the group of individuals who are equally, if not more passionate about addressing these needs.

      Brian Urban: [00:04:04]
      And it's excellent to hear that because it sounds like. Your family's obviously been a big influence on your career and driving your passions. And now that passion has been really laser focused on community health and what what better place to focus on that than Highmark Blue Cross Blue Shield entity that has been doing community health and as a part of the grassroots of the greater Pittsburgh area and Pennsylvania and beyond. Now that you have so, so big of a growing member population that you're serving. So just that's excellent to hear. And and also your your newer to the region of Pennsylvania but you're coming from New Jersey previously Ithaca, New York. So familiar territory for you. It's not warmer necessarily but.

      Amit Kale: [00:04:55]
      You know the the one thing, Brian, that nobody told me is how gray and cloudy Pittsburgh is. It was a surprise for me and my wife.

      Brian Urban: [00:05:08]
      It is a it's not very sunny. Yes. Yes.

      Amit Kale: [00:05:13]
      And Sun is apparently an event that you look forward to.

      Brian Urban: [00:05:18]
      That's true. I think we average maybe about 30 or something full days of sun a year or so.

      Amit Kale: [00:05:24]
      Oh, wow.

      Brian Urban: [00:05:25]
      That's some sort of statistic. I had seen the other Pittsburgher.

      Amit Kale: [00:05:28]
      I would have liked to know that before I made the move.

      Brian Urban: [00:05:33]
      But you're doing the good work that is needed now more than than ever and really a good place for us to transition a little bit more into the identity of Highmark Health. Highmark is transformed a lot from the inside side. The acquisition of Allegheny Health Network and now Highmark, whole care, a previously gateway. So you have all lines of business and now you have a care delivery side. So the parent organization Highmark Health, can you help me understand where you are now and where you're going in terms of serving your members needs?

      Amit Kale: [00:06:14]
      Sure. So as you pointed out, Highmark is a blended health organization, which means we are an insurer as well as the provider of health care services with our Allegheny Health Network. And this really gives us access to data from a peer as well as a provider perspective, and provides us with an ability to test program designs and get quick feedback from not only patients but clinicians as well. We are headquartered in Pittsburgh, but we have customers in all 50 states, including District of Columbia, serving about 6.8 million members through our. Very talented 37,000 employees. And we have a diversified health portfolio which includes reinsurance, dental insurance, as well as technology solutions. Our mission is to create remarkable health experience, freeing people to do their best. And we do this by simplifying the member experience as it relates to coverage, care, access and engagement. And we believe in creating solutions that remove the fragmentation in health care ecosystems and meet members where they are.

      Brian Urban: [00:07:49]
      And I love that because I think you can't really achieve that type of mission without having the right processes and technologies, but really the right people that are driving this work and care about it. So it kind of makes me really want to learn a little bit more about, I guess, the people side of Highmark Health. So how would you define the culture of health at Highmark?

      Amit Kale: [00:08:15]
      That's a great question, Brian. So our approach to health is based on our living health model, which puts the patient and the clinician at the center of the care delivery ecosystem. And it's based on enabling a strong patient engagement to address medical, behavioral and social needs. So what does this mean in practice, in in the context of addressing social needs? It means that there is a process in place to identify members having social risk. It means clinicians can refer patients with any of these identified needs to support organizations. It means that when we create solutions, for example, a virtual care solution. That we are also accounting for people who may not have the right equipment to access the virtual health services. So there's a lot to be done. But we are deliberate when we think about population health that we also account for health equity. It is, it is important to develop sustainable solutions that are informed by data and analytics. And Brian, I'm going to emphasize the importance of any solution, specifically social need solutions. With the intent to be operationalized. Not all pilot programs are going to yield the required results.

      Amit Kale: [00:09:58]
      But they are great opportunities to refine the hypothesis or the model and improve on it. Another overlooked opportunity is. Usually in companies is not to leverage the experience of their employees. Right? What we actively do at Highmark is leverage that experience, including those of our social workers and community health workers who in many cases are attuned with the needs of the community. And finally, it is it is about leveraging the collective experience of our diverse workforce and always strive to achieve that remarkable experience for all. One of our key initiatives is Thrive 18, where we have community health workers reach out to community members. In order to. First and foremost, establish a relationship of trust. And we seek feedback from the community on the most pressing needs at a given point of time. And no surprise that food insecurity, economic insecurity. Help with paying electric bills. These are at the top of their list. We know that we cannot get the members to focus on addressing their underlying health conditions without first addressing some of these needs.

      Brian Urban: [00:11:41]
      Absolutely. You can't live a healthy life if you are living paycheck to paycheck or you're losing a vehicle or your potentially losing loved ones might be passing away. All these different adverse life events are in front of. Hey, get your wellness check, get your vaccination, stay adherent to your medications, buy healthier foods, not packaged processed foods or fast foods and things like that. So you bring up such a great point. Omit is you have to take in the experiences of the team around you. So hi, Mark. Colleagues and employees, their lived experiences and design a model that fits to them being able to relate to the members you serve. So building that trust is what I love you saying trust Because we live in such a heavy influencer world in health, we're not really selling things or putting putting models together through influence. We should be doing it through trust, because trust is a sustained activity over time and it creates a healthier economy and thrive. Thrive 18. I love this project. I want to talk a little bit more about that, but you had me thinking about something amiss in terms of population trends or member needs. What have you seen coming through the pandemic or trending into current state that you maybe haven't predicted yet? Anything, anything coming on the horizon that's new that you're beginning to address?

      Amit Kale: [00:13:17]
      So let's let's take a step back. Right. Covid 19 has had a devastating impact globally because infected over 100 million people in the US and led to over a million deaths. Honestly, we didn't expect the pandemic to last for three years. Even now in the US, we are tracking at 10,500 deaths per week, which is a high number. And it has most certainly highlighted the glaring inequities. The COVID infection rate in the US is three times higher in predominantly black communities than white, and this has always been the case, even in previous pandemics. The impact has been disproportionately felt by the poor and the disadvantage. Post COVID symptoms, or what we call as long COVID is another condition that was not anticipated. Some of the the symptoms of this can be mild like brain fog or fatigue, but some others might be debilitating and the symptoms can last from three months to a year. And this is real implications on employment, medical expense and overall quality of life. It is important to have a multidisciplinary care approach for these patients, including. Having social workers and behavioral health workers to be part of their care delivery team. Many social needs including. Home environment homelessness. Race, ethnicity, poverty can have a measurable impact on COVID 19 outcomes. If you are if you are a smoker, if you have any preexisting conditions. Then you need to take extra precautions, starting with being up to date on vaccines. And a lot has to do with education, which again, going back to our earlier point, it starts with building a relationship of trust that has historically been a challenge. We need to continue to study the impact of socioeconomic conditions on disease, infection and life cycle. And it should be part of the public health policy as well.

      Brian Urban: [00:16:01]
      The best thing about your brain, I think, is that you can flip between being a technology leader and a physician pretty quickly. So being able to break down where we are in terms of an infectious disease in our society and the underlying component being a fractured trust, fractured relationship between medicine, community and disadvantaged vulnerable populations. And building that trust takes time and it takes those repetitions. It also takes, as you know, very good data that you need to maintain that can help you further that trust and that human to human connection. So in thinking about both the quantitative and qualitative data here to measure social needs and inform programs, what are you doing there? And use any examples of? Just really curious because I have a feeling our conversation was going to go with this direction.

      Amit Kale: [00:17:00]
      So going back to what I mentioned earlier, we Highmark is a blended health organization in that we are able to capture large amount of data not only from the payer but also from a provider perspective, which means utilization as well as outcomes data. And as you rightly said, in addition to this data, it is critical, in my view, to collect data on patient engagement and experience what is going on in people's lives. That they may be placing a higher value on than taking care of their health. It is far too common of occurrence than you may think. This may also help some of the real reasons. When we see patients having had no primary care visits in one year or. Missed behavioral health appointments or missed prescription refills. Someone may have been just recently laid off from work or maybe going through a divorce. And filling a prescription or following up on a PCP or a specialist appointment may not be the most important thing for them at that point of time. And we are not going to know about it unless we make an active effort to build that trust relationship with our members. All we end up seeing.

      Amit Kale: [00:18:43]
      With a reactive approach. Is the end result of all of these changes going on in a member's life. Everyone is unique. And we need to be careful when we design interventions. That we not only look at the prevailing data at the community or the census tract level. But we combine that with individual member level insights. We have a great partnership with our data and analytics team, along with several other departments that we have been able to jointly build capabilities where we can better test hypotheses, generate new insights, inform program design. And then evaluate those impact and build better predictive models. Brian, I can cite some specific examples which include creating a social health record as a golden source of social determinants data. And integrating that into our longitudinal record. Creating interactive assessment tools that our business leaders can use to drill down on specific market segments and subpopulations. Using predictive modeling to develop propensity score indices and social risk groupers. And then basing our proactive approach on those scores. And finally incorporating social determinants variables into all of our program evaluations to understand how these programs perform across various subgroups.

      Brian Urban: [00:20:42]
      First of all, great list of examples. Thank you. And I love that you listed out the electronic the Longitudinal electronic health record. And just as a quick aside, for those listening to this, might be wondering what that is. It's a it's a record of member level, patient level data that stretches across their entire health care journey. And a level up from that is not just the clinical information, but also the social health information as well. So social and clinical together for a 360 view on an individual. And that's growing and I hope it grows at a very fast rate and gets stressed across our health care ecosystem quickly to really coordinate good care in the doctor's office and at home. So just love that you got me excited there. But the rest of the list there is quite unique and I love how you're saying that you're incorporating the information that's happening outside of physician's office into the patient member experience. So you can better inform physicians, you can better build programs, connect services, and do it in a timely and meaningful way. And that coincides with the whole trust component if we're helping you because we need to and we want to if you want that. So that's just such a great approach. I can see why you've been brought in to Highmark Health Amid. So I love.

      Amit Kale: [00:22:08]
      Just to add to what you mentioned, right, It is critical to get all of the information on a patient to the clinician at that point in time when the patient is in front of the clinician. Right. That is where the magic happens. So all of the infrastructure and the data that we collect. Has to be put in a way and has to be made simple that it is available to the clinician when he's making those important decisions related to patient care.

      Brian Urban: [00:22:47]
      I love that, and you can speak to that from experience. Doing this retroactive is very difficult and it's very after the fact. But if you have this information. Job loss, loss of a spouse, potential DUI, criminal record, things like that that could be discussed through a relation dialog is very helpful because then that physician is building trust directly with the patient and we're talking about life and we're solving things or trying to solve things. So I love that you said the timeliness and the application of that data is critical. I couldn't agree more. That's fantastic. So you make me think about so many different things in the innovations that are coming out of Highmark Health in your space. Matt And I think the one challenge that people from the outside perspective look at here is as they look at the value of these interventions and kind of a fun phrase here, it's the classic wrong pockets problem or who's pockets problem from an economic standpoint. So there's the various levels of of government, there's the payer, there's providers, then there's the actual individual members or patients, and they all get some level of value for these interventions. But it makes it really hard for one particular entity of those all to swallow that upfront cost in addressing these underlying barriers. So with that said, my question to you is how do we get past this?

      Amit Kale: [00:24:21]
      So that's a great question. So before I answer that, let's let's discuss some macro level data. Right. The US expenditure. In 2020 was about $4 trillion and health care accounted. Almost 20% of it. The health care expenses have been growing consistently over the past couple of decades, and this is not a sustainable trend. About. 100 million people in the US have some form of medical debt, which is about 40% of adults. And this is in spite of 90% of the population being covered by some form of insurance. So there is soon going to be a tipping point. And getting back to answering your question now, it is in everyone's interest to change this course. If you look at the upcoming therapeutics pipeline and what's projected in terms of specialty pharmacy and precision medicine, the cost of treatment is only going to increase. And this increase does not apply to only a small population. It manifests itself as an increase for everyone, whether in terms of increase in premium or additional payment for more benefits. So how do we best spend health care dollars? The logical answer is we focus on prevention and wellness. We diagnose and treat conditions early. And remove the barriers that prevent us from achieving that. Thereby, as a society we consume less of the more expensive treatment and improve overall population health. And now we all know that. There are factors outside of the traditional care delivery systems that impact health. The key is to identify those needs that have a measurable impact on outcomes. If you look at.

      Amit Kale: [00:26:49]
      The investments over the past several years in special needs programs. We are averaging at about $1,000,000,000 per year and increasing. Cms is looking at different payment mechanisms for social programs. Social determinant capabilities as stable states for many state Medicaid bids. So we do need to invest in social determinants. But. Also be cognizant of measuring the impact of those investments. And as you know. One major challenge. Traditionally has always been the measurement of ROI. Roi for social determinant interventions tends to be over a longer period of time. Because a lot of these interventions are upstream. So organizations will need to consider other measures of value and quantify them. For example, value placed on productivity loss, improve patient experience, improve provider experience. These levers are traditionally not used in measuring ROI, and that will eventually need to change. Payers and providers need to move upstream, as I mentioned, and invest in our communities before patients show up in the doctor's office or an emergency room. And the government also has a critical role to play with many people moving into government health programs like Medicare and Medicaid. So really taxpayers should view. Health care transformation as a social, a moral and an economic imperative. And government leaders can work with health insurers and providers to. Better understand what programs and initiatives move the needle in terms of health care outcomes and costs. And we need to take calculated risk and use evidence and evaluation to decide what works. We can then build models based on shared investment for shared returns.

      Brian Urban: [00:29:25]
      And probably interventions make the basis of those models, whether it's food, transportation, medication, etc. But I took away from your comments there as investing into social determinants of health models is the next generation of preventative health medicine because it really encapsulates a person's life that you are addressing and being aware of and having a dialog with, and then providing that data in a timely way to ensure that you have improved provider relations across your network. You'll retain more members, you'll have better experience from that perspective. And I agree with you. It's not just the zip codes that we have already established. There's no incentive. There's no there's no will to do it yet. But it is a gold mine of being able to share critical data in a universal way to in network and out of network, urgent, emergent, ambulatory. Anyone can see it. And that that needs to happen. And I just love how you said a change has to happen. We're coming to a tipping point in this way as well. From the economic standpoint, spend part of our GDP. It's 20% plus. It has to change and it's a new path. It's a new model. So with new models usually comes more revenue, more improved experiences, more technology, easier simplified access. It's it's the next jump on that curve of innovation. It has to start with investing in Sdoh. So again, got me really excited there and I hope I was capturing your your thoughts well there on that. So. I want to look a little bit in the future here. I want to take a journey to the next 24, 36 months, a couple of years, a couple of years and a half from now. What do you think is going to be the biggest impact Highmark Health will have on your members and the lives that you serve looking into the future?

      Amit Kale: [00:31:35]
      So from the context of social needs programs and social capabilities, we are focused broadly on four key areas. And the first is to continue to build the evidence base related to addressable social needs, including getting insights from our members and providers and identifying interventions that move the needle in terms of costs and outcomes. Secondly, we want to leverage our learnings with Allegheny Health Network and continue to work with our provider partners to innovate and design new capabilities, including being. Prepared with any mandate requirements. Third is to build a strong collaboration with community based organizations. And if I may, I'd like to mention a specific example here. Where we stood up a high performing social care network. That was launched in western Pennsylvania with 20 community based organizations who are incentivized in a VR arrangement to close the loop on patients who are referred to them by the clinicians. This work is funded by the Richard K Mellon Foundation. And we are looking at this and similar models to partner with like minded organizations in order to ensure our members get the required support that they need in order to address their social needs. We are seeing some really encouraging early results with 72% closed loop referral rate amongst participating CBOs, compared with only 10% amongst those that did not participate. We also want to work collaboratively with our provider partners, technology companies, governmental agencies in order to design and execute programs. And lastly. I'd say transportation, housing, workforce development, social isolation and health literacy are all priority areas for us and are on our solution roadmap.

      Brian Urban: [00:34:13]
      That is quite a social determinants of health portfolio really. That's a huge undertaking and obviously you're prioritizing and doing things in the fastest way to market to help the lives that you serve in the best way. So I love what we talked about investing in the Sdoh as the next preventative medicine model, leveraging your culture and your workforce to come up with creative ways to engage with your members, partnering with your providers and your communities to be able to build the right trust. And knowing what's happening outside the doctor's office is so critical. And I think that's what's always made Highmark Health a really strong community partner in health. So it's great that that legacy is continuing. So happy for you in the role that you've come into with Highmark and the work that you're leading with an amazing team. And just thank you so much for joining our little show today. This was wonderful.

      Amit Kale: [00:35:14]
      Thank you, Brian. It was it was I enjoyed our discussion.

      Brian Urban: [00:35:18]
      And for more insights and excerpts for our episode here today, please visit finthrive.com.

      Naval Flight Surgeon to Family Doc...The Journey of Dr. Otten!

      Healthcare Rethink - Episode 100

      In the latest episode of Healthcare Rethink, host Brian Urban explores the unique journey of Dr. Todd Otten, a...

      Read More

      Boston Medical Center is Leading the Way in Social Impact

      Healthcare Rethink - Episode 99

      In this episode of the "Healthcare Rethink" podcast, host Brian Urban sits down with Sheila Phicil, a Social...

      Read More

      How a Futurist Sees Healthcare Being Delivered!

      Healthcare Rethink - Episode 98

      In a recent episode of the “Healthcare Rethink” podcast by FinThrive, host Brian Urban explored the future of...

      Read More