Host Aparna Higgins, LAN Senior Advisor and a Senior Policy Fellow at the Duke-Margolis Center for Health Policy, interviews Frederick Isasi, Executive Director at Families USA, one of the nation’s leading nonpartisan nonprofit health care advocacy organizations. In this episode, Aparna and Frederick take a deep dive into health equity and discuss creating solutions to reduce disparities in the U.S. health care system through APMs and value-based payments.

Frederick Isasi, Families USA (02:45): Terrific question. Thanks so much Aparna. So, as you mentioned, Families USA, we've been around for over 40 years and our mission really is to ensure the very best health and healthcare equally accessible and affordable to every living soul in our country. And these are three of the key pillars that we work in. So, the first - as you mentioned, was, is healthcare value. And for us at the heart of what value is really about is first and foremost, making sure that the healthcare system, all of the resources that we have in this country directed towards healthcare really do result in improved health for all. So, it really is at its heart about reorienting the system all the way towards health, not just simply units of healthcare, and then making sure that in seeking care, and, and trying to take care of oneself, one's family, it really is affordable, that it's something that isn’t creating economic instability for families, and that's allowing families to really thrive and live to their full potential in our society. When it comes to health equity, it's really acknowledgment that we have some very deep and pervasive inequities in our health, in our society and in our healthcare system that resulted in some pretty terrible outcomes, for different populations of country, folks who live in rural America, but in particular for communities of color. And so, a lot of our work is focused on trying to surface where those inequities look like. You know, things like for example, that in this country right now, the African American babies who are being born are twice as likely to die during childbirth, then their white counterparts, right? That's this is a country that was really built on the premise of fairness. There's something so fundamentally unfair about that. So, it’s about surfacing those kinds of inequities and then developing solutions that really can drive the entire system to allow for the, for these populations to thrive, alongside of their, say white or, or urban dwelling counterparts. And then the last area you said, you mentioned was consumer experience. That's really important to us. You know, we are at our heart, we are trying to bring forward the interest of all families in this country and in particular, some of the most vulnerable and what we've learned through our experiences, we are constantly working with policy makers, either in the U S Congress or in the federal administration. And then we also do a lot of work in state capitals around the country and with governors and in all of that work, what we've learned is that some of these issues can become incredibly partisan, incredibly politicized. There's nothing at all that can cut through all of that rhetoric, all of that partisanship better than the experiences of individuals and families trying to seek help, right. When those, when we can bring people forward and they can talk about, for example, you know, a history in their family of, right now we know in this country that if you're, African American, you're 50% more likely to die prematurely from cardiovascular disease, right. Just another example of kind of inequities we have in this country. And, when somebody comes forward actually tells that story, what it's like in their family to watch the older folks in their family dying early, that cuts through a lot of the rhetoric, a lot of the partisanship, and really speaks to our values as a nation where we really believe every single family, every person should have a shot at their best life possible.

Aparna Higgins (6:08): Great. Well thank you for that great overview. Obviously, there's a lot of work that you're involved with. So, I want to, you know, sort of even zero in further on the health equity issue, and you gave some examples of the stark differences between communities of color and the white population and mentioned some of the solutions you think that could help address that issue. So, could you talk a little bit more about Family USA's efforts to help advance health equity and reduce disparities in this country?

Frederick Isasi, Families USA (11:13): Well, I'm really proud of where the LAN has been going on this issue and how hard they're working towards raising both on the importance of APMs and the importance of addressing health equity. I think it's really powerful work and it's been a… it's been a real honor to be a part of it. I think a couple of really important concepts. First, I think that as we've talked about, the idea that LAN is trying to make health equity central in the transformational enterprise is really important for the very reasons we just talked about, because if we don't, it's not just that we won't make them better, we're going to make them worse. But the other thing, I think one thing that's most exciting is at its foundation, some of the most bold alternative payment models, APMs out there are really about collecting the resources in a community in a state, that are provided for healthcare, right. That could be through federal Medicaid dollars. It could be through Medicare dollars, it could be through private insurance, state employees, right, collecting those resources, building a community table, which includes insurers, hospitals, physician groups, but it also includes social service agencies, housing supports. We’ve seen for example, mental health services, behavioral health services, all at that table, right. And they look at their data for that community. What's really going on here? What, where do we really see the opportunity and the real problems for, for achieving health in this country or in this community? And then they really start to set targets for themselves about how they can change, the way in which the resources are being utilized to achieve the goal of health, not just simply units of healthcare. That's a really, really powerful idea. It's a really transformative idea. And when that happens, you see really tremendous reforms that are very innovative happening. Things like addressing unmet behavioral health needs, addressing housing insecurity, addressing, violence in communities, the impact of systemic racism, things like that can be really powerful. So, I think at its heart APMs and the work the LAN, and the LAN is really pushing hard to say, we have to go much further in reallocating, these resources, nutrition and other parlance by developing much stronger risk-based models. Right. That is really exciting to us and Families, I think is the key, one of the most important keys to addressing health inequities. Aparna Higgins (13:41): Okay. So, you talked earlier about, you know, the work that you're doing through the Center in terms of being intentional, intentionally designing, ways in which to address health equity. And as you think about the intersection between APMs and health equity, could you share your perspective on what it means to intentionally address health equity in the context of an APM?

Aparna Higgins (16:05): Okay, great. Well, that almost sounds like a nice playbook for people to follow in terms of some of these goals. So, we’ve talked a lot about health equity, the intersection of health equity and APMs, and the importance of having these alternative ways of paying for health and healthcare, as you said. So, I was curious if you could actually elaborate, you know, even more on efforts that you're undertaking to advance APMs, you know, Families USA, obviously you focus a lot on consumer experience and some of the other pillars you talked about, but could you talk more about your efforts to advance these kinds of alternative payment models?

Aparna Higgins (19:23): Okay. So maybe building on the theme of connecting, you know, the providers of care with the people that they're serving, would be interested if you could talk more about, how do we ensure going forward that as we design APMs, they truly embrace the consumer or the beneficiary. We all talk a lot about person-centered care, right. But how do we ensure that we're truly placing the beneficiary or the consumer at the center of design and, and meeting their needs? So we'd be interested in hearing your perspective on that.

Aparna Higgins (22:51): Okay. So, speaking of, you know, bringing solutions that have maybe worked in, in one community to another community, could you talk a little bit about, and we hear a lot in healthcare about, success stories, right. And those are very important. But I'd be interested in getting your perspective in terms of how do we scale those success stories, because as you talked about, you know, bringing learning from one community to another, you know, what is your perspective and what efforts are you taking to help sort of scale some of these successes?

Frederick Isasi, Families USA (26:22): Absolutely. And, you know, that's, I think, you know, going back to our earlier conversation, that really is focused on allowing for the resources, the dollars flung into a community to become together, and to be examined as, as sort of one resource available for the whole community. One of the best models that I've seen in that is the Oregon Coordinated Care Organization model, a CCO model where literally the healthcare dollars flowing in for Medicaid are provided to this community table, right? Both hospitals, providers, but all of the other social service agencies and with data, they can figure out what are the social determinants that are being unmet, and then they can start allocating healthcare dollars towards those social determinants, in a way that really truly they're measuring impact and can say, you know, we have reduced overall costs and our outcomes are, are getting better and better. So that fundamental model that CCO accountable care accountable community model is really powerful. I think the most important social determinant interventions that we're seeing are things that are aimed at unmet behavioral health needs. There's no question we have a crisis in this country, you know, we know for example that, right now, if you're African American this country, you're 50% less likely and, and, and you have mental health illness, you're 50% less likely to get it than your white counterparts, right. It's an example of, it's very hard for all people to get access to behavioral health in this country, but then when you’re African American and, and if you're a person of color living in rural America, it's even worse, right. So, unmet behavioral health needs are really, really important. Housing insecurity really, really important, a lot of issues around substance use disorder that could, that we could do a lot better with. And then I think that there's even deeper questions about environment, things like, the impact of clean air and clear water, the impact of systemic racism and violence, and then go all the way as we were talking about earlier to the very first experiences of little children, of little babies as they're born the world they come into, the amount of care they have in just the first couple of years can be transformative, right. So, these are all examples of the ways in which if we can reallocate resources to address social determinants, we can really change the life trajectory of an individual.

Frederick Isasi, Families USA (29:24): Sure. I'd say the first one is one I know that the LAN has been working on very hard, which is underneath all of this, what we have to recognize is that economic incentives drive the, the behavior of providers. There's no way around it. And we have to be really honest with ourselves about that. And I've worked a lot and, with hospital CEOs and CFOs and Chief Medical Officers and, behind the curtain, no one's confused, right? Everybody knows that this is a volume game for high-cost or high-margin procedures, and that's what we're going for. Right. And so underneath all of this, the number one thing I would say is policy makers have got to understand that honestly, policy makers created the incentives inadvertently for fee-for-service, sort of treadmill economics and policy makers have got to unwind those, and really drive towards a model that aligns the financial interests of people with the providers that are serving. Cause I would say right now that in many instances, providers are trying to do their best, despite the way we pay them. Right. We pay them one way and they're just working really hard to try to do what's right for their patients, even though they could be losing money by doing that. So it's a, we've got to align those two things that's most important. And to get there, we have got to give providers a much larger percentage of their book of business, focused on the APM. It's got to be 80% or more of their book of business and real risk-based payments because when you, when you get into that kind of environment, you see unbelievable change. And one of the things that really inspires me about that is when you talk to the individual providers in these health systems or physician groups and this, health centers, they are incredibly excited about this. This is why they went into the practice of medicine they want to do what's right for their patients. They're tired of that treadmill, you know, patient, patient, patient, procedure, procedure procedure. So, there's a lot of within the community of providers is a huge, I think, there’s excitement and there's a lot of enthusiasm for this, that's one. Two, I would say that, remember that as we talked about earlier, inequity will not be addressed by passively just improving the system for all. We really have to be intentional about equity and understand what are the interventions that are going to most affect the vulnerable communities of color that are being left behind right now. And the third thing I would say is, and to me, this is a really helpful thing. I have done this work in the most rural states, the most urban states, the bluest of states, and the reddest of states. And the truth is so much of this work is really about reallocating resources to meet the needs of a community and to empower a community, to come forward and identify and work on their needs. That is wildly popular in all of these different environments. You know, like we did this work in Wyoming, we did this work in California. It was wildly popular in both because at the end of the day, when you devolve to a community level, it resonates with people from all kinds of different perspectives. So I think there's also a real political future here. This could really happen because it isn't partisan. It isn't, you know, it isn't about, you know, where your starting point, if you're Democrat or Republican, it really is about, I want my community's needs to be met, which is a very, very powerful, very American kind of perspective.

Frederick Isasi, Families USA (32:57): Thank you so much, Aparna. It's been an honor to be here and to you and to the LAN, thanks for all the hard work to all the folks who are watching this. You guys are out there working really hard with a vision and we at Families USA are there to support you.