Jennifer Colamonico: Welcome to HMA's vital viewpoints on healthcare, concise conversations with experts that identify practical solutions to make healthcare and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely american systems. Charged with delivering health and health care in a world that has far too much information and far too little wisdom, we'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and healthcare. Our HMA experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast, it's your window into the minds of those steering us toward a healthier future. Subscribe now and together we will explore the hard earned wisdom that could change the way you think about your professional challenges. Our guest today is R. J. Briscione. RJ is a principal with the HMA strategy and transformation practice, where he came to HMA through the focus group. Before he was at the focus group, he led social determinants of health initiatives for CVS health scaling strategy across the CVS health enterprise and previously worked in business development for Aetna. Also worked with Anthem and a stint at the Georgia House of Representatives. RJ got his degree in aeronautics from Embry Riddle Aeronautical University, which of course is where I want to start because that makes no sense. How did you make the leap from aeronautics to healthcare?
RJ Briscione: Yeah, Jennifer, thanks for having me first. It's a very long but kind of fun story. I'll try to shorten it for the interest of our listeners, but all I ever wanted to do was be a Marine Corps pilot. I was accepted to marine OCs. I had an injury that wouldn't allow me to fly, so I went the civilian route. I worked for Delta Airlines for ten years and got laid off from Delta during their bankruptcy. At that time I had been doing some campaign work on the side, so kind of just for fun and decided to go into politics full time. Worked then for the Georgia health representatives, as you mentioned, and really to reboot the career. I assumed I was going to be a lobbyist for the rest of my life. So my first role in healthcare was as a lobbyist as a government relations professional for Sentine, which I then learned Medicaid managed care on the fly. So the Medicaid managed care was new to Georgia at the time and as I got into the role at Sentine I had great leadership there. Who said you had all this experience at Delta? So Delta I did a lot of varied work actually for everything. When I first started really just loading bags and checking customers in to eventually I was the writer for the pilot manuals, light work. Then I had a lot of quality assurance, continuous improvements, six sigma. So the fine folks at Centin when I was there recognized that and said, we're going to grow you on the business side some. And one thing led to another and here I am now. So about 15 years of mainly operational experience in health plans with some PNL leadership along the way there, and made my way to HMA via the focus.
Jennifer Colamonico: That is quite a journey. It makes sense, right? You sort of that Marine Corps mentality do what needs to be done, fix what needs to be fixed, right. Which actually is probably perfect. So your kind of noted pieces around areas of food as medicine as a term that has become so common. And ten years ago I was working in healthcare market research and we started talking about food as medicine. And now it's really kind of become a reality. Your journey to kind of realizing this idea of food as medicine and sort of the concepts around that as a strategic impact in healthcare.
RJ Briscione: Yeah, well, a couple things really, so maybe go backwards and the transition to explain one of those transitions, a little transitioning from leading Medicaid business development work, which is how do we win those bids for my employer and each individual RFPs are coming out, how do we continue our business? And one of the trend that I noticed this was probably in about 2016, when the idea first sprouted, was that as plans, plans serve at the behest of the state Medicaid department. And some ask about social determinants for the first time. And one of the really big things in social determinants that seemed sort of natural to me was food. And so I just dove in headlong into that and started meeting in my business development role really with food banks to see how that would work for Medicaid members. And there was a lot of really wanting out on both sides, but nobody really what that is. The fun and exciting part of that is fast forward down the road. Here we are at HMA strategy and transformation. We're actually working, we have engagements, kind of a buddhist medicine to really help each side. I just had with a really great strategic health plan leader said, we both need to kind of in the middle of those community based organizations, really need to build a work with health plans. And then we have to loosen restrictions some. But to really know when I saw it was strategic is if you dive into especially a population or a duals population. So 20% of Medicare. So if they're food insecure, that means there's a really simple test. There are two questions of basically that are you able to put enough food for your family? And so if 20% of Medicaid members are missing basic food insecurity, the problems really kind of spiral out of control from there, going for frankly just calories. I think probably anybody listening to this or interested in this work knows that Medicaid population has disproportionate amount of diabetes and congestive heart failure and a lot of things that could be related. So I think seeing those things, the combination of some disease burden that from factor fork or can be a preventative and the level of food insecurity made us realize that not as easy, but it may be one of the easier ones to get your arms around and start doing some work on.
Jennifer Colamonico: So this might be a strange question, but in your years working in this area, to what extent do you an income issue, food issue, right. We hear about food deserts versus sort of nod and cooking. I could see all components and we sort of talk about it broadly, but get to the specifics. But since you've been in the trenches kind of trying to fix the problem, I'm sure it's all of.
RJ Briscione: Yeah, so there's been some great work in coalition that I helped contribute some to that's at Tufts University, and they put together a great kind of, everybody knows about the food pyramid. There's a food as medicine period. Right? So the thing is to have some season programs, right. So that begins to create some of the access. Actually, there's probably something even before that that they mentioned in the work a lot. This phenomenon is starting to get. But a lot of providers really don't spend a lot of time on education, on food as they're seeing patients because it's not on the curriculum in med school. So there's a movement at foot to change that med school curriculum, to have stringent or some additional focus on food and nutrition. Here's one of the things that could be a lot better, and there's been some good work around, is almost to the income question. Almost universally, people who are eligible for Medicaid are likely eligible for SNAP and then the WIC and school meals programs. Right. And so there's a lot of times I'll get them wrong, but if we just got everybody who was eligible onto those programs which provide some real health boost, then the next kind of thing up that pyramid or that kind of spectrum is we've actually worked with some nonprofit clients, produce prescription to Medicaid. So before that to Medicaid health plans. Again, there's some of that. How do we connect the two things that haven't traditionally spoken to each other? And then there's medically tailored groceries, meaning we're going to give you a set of groceries available on a card, the cardboard type things that are authorized. And then there's the medically tailored meals, which I think is probably what most people think about when they traditionally think about food as medicine, that is. So if you're diabetic or if you have congestive heart failure, those are meals specifically designed for that specific condition. And then I think you probably didn't mention there, there are a good number of programs, especially for those that are food insecure. I don't want to demean them in any way, but that are just calories. And so I think there's a movement afoot to change those just calorie programs instead of quality meals. But of course that all always comes with additional expense.
Jennifer Colamonico: Well, and so that's interesting. Obviously, when you're talking about Medicaid populations, you have a confluence, and obviously it's a means tested program, but the notion of the medically tailored meals, increasing awareness of nutrients, all those things really can apply to any population, to any payer group. And so it seems to me there are lessons here that we're learning lessons from Medicaid on how to solve a problem that exists all over the place. Absolutely.
RJ Briscione: There's even a whole other level that I didn't get, tend to think experience. But we've seen a lot of work and we've talked to a lot of, well, first of all, we'll back up a little bit the whole GLP one phenomenon food can be the answer to, and maybe that's not necessarily limited to a Medicaid or Medicare or duals population. That is something across the board, major cost problem. Major a lot of discussion about who's going to approve GLP ones and what are they going to be approved for. If you take the other side of that, we see there's a lot of good solutions out there that food, diet, exercise, coaching that are a heck of a lot more cost effective, frankly, than a GLP one prescription, which when you look at it, I'm no scientist, but there's a lot of evidence of people regaining when they come off that. So it's either spend a little bit of time on that GLP one, get you down to where you want to be, and then the maintenance is a long term, it's food. And then there's some really interesting higher end solutions. I shouldn't say higher end, but there's some really interesting solution budget, but that might fit for that customer, for that employer based health plan where they want to really make a difference, but they don't want to pay forever. Right. So I think we can learn from Medicaid, especially across the spectrum. One in two, anybody across any socioeconomic is either pre diabetic or diabetic right now. Right. So that's a, that's across all populations. So I think we can learn a lot from what we've done in food is Medicine at the Medicaid, Medicare duals end to kind of anybody that wants a solution for food.
Jennifer Colamonico: So I want to ask you more about kind of the specific models that you've worked on in the past, but just in general, what is your biggest obstacle to getting these services? I guess you could speak specifically to medics generally. You're talking about public health elements. You're talking about community health. There's so many elements that are not really in the. And yet we know the biggest challenge in getting these services to people who need them.
RJ Briscione: Yeah. The biggest challenge, apart from we could separate the logistics out a little bit, there's been innovation on that. The biggest challenge is this is the challenge we work a lot with in strategy and transformation practice, when we have clients who have great solutions for payers or for the system in general. And what are they paying for an improvement? Are they paying for a pure ROI? Are they paying for an improvement in quality in one of their heatist measures, in some of their customer satisfaction numbers, which, again, could be something really attractive to employer based? There's some movement on that. I'll do that a little bit, because we've been really in the weeds on this issue right now. The probably most difficult thing in trying to fit in what most people think medicine landscape to a Medicaid, to a Medicare plan, is that most social, and this is even broader. For a lot of social determinants, work is most of anything in the realm, can't fit in the medical box in that MLR calculation for health plans. And that leaves a really tough decision. As a former health plan PNL leader, you're looking at, in a Medicaid plan, you're looking at usually somewhere between a one and 3% margin. So do you want that on a food program? To complicate that even further, the typical Medicaid member health plan for nine months. So you don't even get a full twelve mile kind of cost out on that. So there's some great movement on that. Right. So as people begin to see, I think the opportunity of true ROI for health related social needs, we're seeing some movement on that. So the 1115 demonstrations, I've been coached, 1115s, everybody always calls them the waivers. They're actually 1115 demonstrations, but they're commonly known as waivers. The New York one has all of these health related social needs in the medical line. New, hasn't even started or operationalized yet, but that's really exciting. We've seen a lot of work. We've worked with clients in Cal and the CalAIM program. Calam has carved out a Medicaid, but Calam has 14 different services, non health that are reimbursable. Right. And so we've been working with clients on how do they bring their especially food but other social need work to that program. Because there's, so that's sort of a hybrid. It's not actually saying it's in the medical line, but there's a specific reimbursement path for it beginnings. And we counsel clients for states that may not have an 1115 on the docket. We all know Medicaid is very, well politically charged. There's an opportunity in lieu of services work at the state level where you could say, hey, we're going to do a food. We'll start it with just a smaller, maybe we'll start it with, I always counsel people to say we don't know where to begin and pick and go and study it and see what you come up with. A kind of no brainer is people who are food insecure and have higher uncontrolled a one c just like we talked about, get around and study that. So maybe you do that as your first in lieu of services population and start from there. So there's a path towards becoming a little more mainstream and being able to be being paid for by payers or the public programs, but still a long way to go. And then friend people have to make the decisions. Do they want to include that in benefit design? Did they want to include that as included as part of an incentive program? We haven't talked about yet is there is a really interesting model for food as medicine where it's food as engagement, meaning there's food companies that specialize in this food as engagement work with health plans. Health plan has goals around hedis or member satisfaction or something like that, where the member gets a box of food or box of produce tied to measures. So postpartum visits, illness checks, any of your tied to heat. And it's a really nice thing to be able to do. And it's really demonstrable in that you can show these specific heatis measures that we were working on that we gave people food for showed up. So that's something that I think wasn't originally as, hey, we got to go attack a disease state. But what if we just want, everybody wants Medicaid and Medicare members to be more engaged, food to be able to do that is a really great path to do so.
Jennifer Colamonico: So I think if I'm hearing you, you're talking, there's ROI in terms of kind of financial ROI, and then there's measures, quality measures, Roi, if you will. Right. You're getting a return on your quality measures by doing this kind of work.
RJ Briscione: Definitely.
Jennifer Colamonico: Chris, what you think about is this maybe a little provocative question, but is this the best way to spend my problem? Healthcare. We know that one person's waste is another person's income. And as long as I've been in this business and we've been talking about SDOH, an interesting, not a criticism, but sort of isn't this just anti poverty, right? Isn't this something that government should just be doing through anti poverty programs? And now payers and health are putting the bill. Is there some sort of just like shifting onto these entities, making money in the healthcare system to kind of give it back or pay it forward? Would this be more efficiently spent in government? I'm just curious your thoughts on this. You've been kind of worked around all sides of the issue.
RJ Briscione: Yeah. I don't know if anything's more efficient in government, but that aside, I think we get closer to being able to get our arms around the true ROI. I think there's more. So true ROI is loaded answer. So I'll decouple that a bit. You can have a traditional, what I call traditional. My former boss, when I was doing a lot of this work at CBS, was chief medical officer. Right. And used to that real, like, if I'm going to put then to our operations, it's going to get me back. And again, I sort of acted as an internal consultant in that role. I had to sell some of this to those leaders who are the PNL leaders. That's the thing that I'd like to counsel a lot of our clients about, is you are not selling to a larger system. You're selling to individual health plans who have their own individual PNL and it has to work for them. So for it to have to work for them, you have to bite size it down. That example I gave is a real world example. We started with dual eligible members who were both food insecure and an uncontrolled A1C in South Florida in partnership to give them full credit. Feeding South Florida, feeding America. And it encompassed all of the things that you would need to make it work, meaning there was a dietitian on site to help walk the members through what they should be looking for for themselves, introducing some new foods, new fruits, new vegetables, how to cook those things, by the way, learned that the hard way on some other stuff earlier on, that you can't solve one social need in isolation. But we got real results relatively quickly reducing those members a one cs, and that can easily translate. You can translate a reduce inside a health plan. So does it have to be health plans paying for Medicare, Medicaid paying for it? Maybe not, but I think the more of those that come back and the more evidence that's seen, the more they'll want to, or the more that that could become a part of a base offering, especially for specific disease, for members who have, again, one of the best, I think, innovations in social determinants since I've been working on this has been that there's almost. I don't want to say there is universal, because nothing's universal, but CMS has done a really good job of putting their money where their mouth is and requiring social needs screening, both at the hospital. So basically every hospital in the country now has screened for social needs, as do most plans. Right. So now that we know, we're starting to know better what those members individual needs are and matching it with that. There's a lot of data and ability to learn from that data and get a better sense of ROI from that, how that can and how that works for your health plan on an individual member basis.
Jennifer Colamonico: So. Right. The need to establish that ROI is really, I mean, that's business speak, but really what we're talking about is getting to out. Right. You can give people food, but if they don't know how to cook it or they don't eat it or an outcome. So by tying it to outcomes measures, you're kind of ensuring that it's being effectively distributed.
RJ Briscione: Exactly. Right. Yeah. And I've done a full 180 on the engagement issue that I mentioned before, because when I originally. Well, that's not aimed at real numbers, but it can be aimed at real numbers for things like I mentioned previously, for hideous results for customer satisfaction. Imagine the uptick in customer satisfaction if you're sending your members on a regular basis or a semi regular basis.
Jennifer Colamonico: So you talked about, use my words, but I think you talked about bridging the gap between organizations that are kind of set up to do this kind of work and the plan leaders, the business leaders they're selling into. So what is your advice? Obviously there's so many entities, not for profits or startups that want to be helpful, but many of them don't work in the healthcare space. So how do you advise them in kind of making their pitch salient to the buyer here?
RJ Briscione: Yeah, well, fun. Perfect. Great question. And strategy and transformation group, we're doing exactly that right now and we love to do that work. So there's a couple of things. One is there are always blocking and tackling capabilities that the health plans are goal to data to them to pass their IT security and those kind of things. Now again, I just talked to the plan leader called just before this, which was fantastic timing, who said, hey, we got to work on loosening that up a little bit and making it a little bit easier. But community based organizations have to do, there's a couple of paths that they could go. One, they can make a decent size investment mainly in it type work so that there's data, there's enough data. These were this health plans members. We know we got this to them, we got it, they're receiving this. We're kind of a senior management piece for them. Enough technical capability to be able to do that confidently to bring that to plans. And you've really got to know. I think the main thing that you really got to know is what those members needs actually are and fill those needs. So not every member, not any member is going to have the exact same needs. So can a feeding America food bank, for example, no. To those can they other social needs and let the plans know about that and then understand what that ROI is for that member, if that member is then going to the ER less because they're having needs fulfilled outside of the traditional healthcare system. But you have to have the data to be able to know that and you want to get the data back and forth to be able to do that and know which members were on which plans and then is contract with health plan. Right. So health plans I think are doing a good job of finding easier and to contract with community based organizations. There's a lot to go there. I think one of the things I've seen is that there's some provider incentives for closing the gap on social needs. Now, some plans are doing that. So there's a great way to plug in there. It doesn't have to be directly to the plan. It can be with a provider organization, meaning a hospital, health system, large provider organization. They're still going to run into some of those same pieces, but it's another opportunity. And then you see is the tech enablement I worked with. Find out. There's Unidaut, who I worked with in my former work at CBS, that are creating the technical enablement for organizations to be able to say who they're serving, where they're serving them, how they're doing that. And I think some of the larger ones, some of the larger national organizations are thinking about how do we do this on our own, if you will, that we can bring to health plans, that we can bring to health systems to do that. So some of that work here at strategy and transformation, which is really exciting, that all of the work that's been building up over the six to seven years I've been super closely tuned into this is starting to be able to happen and to be real, so that places like a food bank can get biohealth bears for not about earlier, but for making real differences in lives of those members.
Jennifer Colamonico: So in essence, a lot of these organizations that are used to serving populations, really what they have to do is to be able to tie their, to individualize their work. How public health and CBOs think. They kind of think in aggregate, but it seems to me that's because specifics individuals. Right. And so tying the aggregate to the.
RJ Briscione: Individual, and that's hard. Bar. That's not easy. It's easy for them to serve members who they know are Medicaid recipients, but it's harder for them to break it up into the individual payers and say, we serve this member to this payer, there's work to be done there to make that actually work.
Jennifer Colamonico: So if you had a magic wand and you could apply it, what one thing would you fix in this arena to kind of have the ripple effects, to create momentum in this space?
RJ Briscione: Yeah, well, I'm going to cheat, and there's not one thing, but I think some of the momentum, we talked about it. I'm focusing mainly on Medicaid, but maybe I'll pull another one. Well, we'll see where I go here. So there's a couple of things, a couple of magic wands. One is really that provider education, even though the basis of social determinants is that that happens outside of the clinical setting, the clinical setting is still super important. When you look at all the work on who do you trust most? The people trust their individual doctor. Those conversations about food and nutrition need to happen. There something that I mentioned earlier that's really frankly an easy fix and there's people doing great work on it, is maximizing all of the benefits. So if you are Medicaid eligible, you should be fully maximized on Snap and WIC and any food and nutrition programs that are state based. And then the one thing that I just talked about with the self plan leader, that would be a fantastic fix. That is a perpetual policy wish list for people in Medicaid is to have twelve month minimum continuous enrollment on the single Medicaid health plan. We talked about how difficult it is to demonstrate that ROI for individual members because the average tenure on a Medicaid plan is about nine months. So if you knew you were going to have a person for a whole year, and even better, if that was on some specific calendar year, that would be even better so that you know that you can invest for that member. I think that goes a long way. And then I would say on the upper end, I don't know what the magic wand is. I really think food has a very important role to play in this GLP one cost debate. Those are not going to be cheaper anytime soon until they come off patent. There's a world of difference to be made with the combination of diet, exercise, coaching and actual food getting to that person that will help them with the specific condition. That's a bunch of magic wands.
Jennifer Colamonico: Yeah. Okay. I didn't give you three, I gave you one, but okay. No, I appreciate that. It's interesting. The GLP one issue is interesting. I wonder if that will be kind of a gateway to a different way of paying for prevention. I mean, it's acute here because of the cost of the GLP ones, but there's so much, even when you're talking about back surgeries and knee surgery, there's so much physical kind of orthopedic work that one could argue is preventable with exercise and mobility, all these sorts of things. You sort of wonder if this, because this is going to force the issue on cost, does this create new algorithms for paying for prevention in a way that maybe we haven't been willing to do in the past?
RJ Briscione: Definitely. And I think we've seen that, we've seen some of the MSK solutions are thinking about that. Like how do we incorporate social determinants broadly into our work for all of the measures that they're sort of on the hook for, or that they want to be on the hook for. How quickly are we getting folks back into the workforce or back into full mobility? And how can any of the social needs play a role in that? But food would be a great one, right? Food is a great, yeah.
Jennifer Colamonico: So we talk about social determinants of health, and I think we've been conditioned to think of that as sort of poverty related, but really it's not. It's sort of. Right. It's the external factors.
RJ Briscione: Yeah.
Jennifer Colamonico: What makes you optimistic? Last question. What makes you optimistic here?
RJ Briscione: There's lots that makes me optimistic. Right. There's a lot of focus on food in particular since we've been talking a lot about that. I will say the optimistic is that the screening has come a long way since I've been paying attention to this, so that we start to know what people need and things like these 1115 demonstrations, things like North Carolina has had a very successful healthy opportunities pilot that they're going to expand into their 1115 where there's real dollars going to real social needs. So I think the momentum is going forward. The calam is another specific, really lot of dollars going into that. So I think there's plenty of optimism in that. And then there's a lot of optimism in nutrition in general from people really wanting to get away from this. We're only treating disease and that we want to treat it preventatively.
Jennifer Colamonico: That's exciting. That does give us hope. All right. Thank you so much for being with us today and sharing your insights and for the work that you're doing. It really is impactful. So thank you so much.
RJ Briscione: Thank you. It's been very fun. Enjoyed it.
Jennifer Colamonico: This episode of Vital Viewpoints on Healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid. From the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars and state by state overviews, HMaIs has all the information you'll need to power your initiatives to success. Visit hmais healthmanagement.com for more details. Thank you for tuning in to another enlightening episode of HMA's vital viewpoints on healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit healthmanagement.com forward slash podcast until next time, stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape. This podcast was produced by myself Jennifer Colamonico, along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
