Jeff Brandes is president and CEO of Azara Healthcare of Burlington, MA.
Tell me about yourself and the company.
I am a serial entrepreneur who has dabbled in all sorts of areas of technology. About 10 years ago, I came upon an opportunity in healthcare. At the time, I truly didn’t know the difference between Medicare and Medicaid, but I was heavily schooled by our initial partners as we started Azara. Here we are 12 years later and I can speak the lingo and I actually think I might even have a bit of credibility. Azara provides population health, primarily to safety net clinics, Federally Qualified Health Centers, and others who are serving the underserved.
The argument could be made that value-based care is the superior healthcare delivery model, yet patients are usually part of a federally supported program who are seen as underserved or disadvantaged. What are we learning about value-based care that can change the healthcare system?
The Federally Qualified Health Centers in general, depending of course on the state that they reside in, have mostly been fee-for-service with some shared savings and some upside. But because they are held accountable for quality metrics and improvements to maintain their status with HRSA, they have started to place an infrastructure that looks just like what is needed for value-based care into place. Looking at quality. Looking at high-cost events like readmissions. With both the cost aspect in mind, but clearly if someone’s going back to the hospital, they need more care or they need different kinds of care and it’s all in the effort of improving the patient’s health.
How is technology being used to identify those patients who need the most specific care?
We have learned a lot over the past few years. We started by automating things that we were doing already, in particular, billing. US-based EHRs are all centered around billing for services. But through that, we have collected a vast amount of data on our patients and are now just starting to find ways to unlock that data and make sense of it.
But as we do it, what we are learning is that it doesn’t matter how good the reports are and how good the information on the reports is if you can’t get that information to the right point in the workflow of the clinician or the provider where it’s easy for them to see and digest. You can’t make an impact on the patient. What we are starting to see, and what we will see in the years going forward, is more and more emphasis into how to get the right information that we already have to the right place at the right time.
There’s a significant amount of patient responsibility involved in participating in these programs since they need to be engaged, receptive, and perhaps educated about the concept. Does technology help in that way as well?
Technology helps us identify which patients are complying and are engaging a lot sooner potentially than waiting until they come in their next visit and they’ve gained 10 pounds and say they only take their meds once in a while. Using technology, we can at least identify some of those things. If they’re not picking up their prescriptions, it’s unlikely that they’re taking them. We can use things like that to get a bit ahead of the problem instead of waiting six months or a year, or for an emergency room visit, to realize that the patient is not engaging the way we had hoped or the way we had talked to them about.
They may be skipping doses because they can’t afford the prescription. How do you draw a line around delivering value-based care versus the social services that may be required for the patient to do what they need to do?
There are technology aspects and programmatic aspects of it. Of course, there’s just being in tune with it. The vast majority of our clients, the ones who are in the safety net, are very in tune with the patient’s social needs, screening for those and finding their patients affordable means to get the medications and other services that they need. First is identifying the need and then having access to the programs that can fulfill that need. Definitely medications is an obvious example, and there are programs to get medications in the hands of those who can’t afford it.
But when you start to expand the scope of those needs around housing and access to quality food in caring for patients, all of a sudden you need programs like Medicaid and Medicare to be a little more flexible in how those benefits can be delivered. Because it may not be a drug they need, but enough money to buy high-quality fruits and vegetables instead of processed food. Definitely we are hearing and we are seeing our clients look more and more for that flexibility in caring for the total patient in order to address their medical needs.
Capturing social determinants of health is becoming common, but what is the role of providers to help address them?
My perspective is a little biased because I believe that my customers in the safety net are a good bit ahead on this, but it doesn’t just affect patients at Federally Qualified Health Centers. My first experience with how being in tune with social factors and social determinants of health was an interesting one. In talking to a clinician, they talked about having a flag to tell them that the patient had unstable housing or was homeless. The patient presents themself with a run of the mill tonsillitis or some type of infection that requires antibiotics. Just by knowing and recognizing that that patient is homeless, you’re going to look at the available meds, antibiotics in this case, that you could prescribe. If you know they are homeless, you’re going to choose the one that doesn’t require refrigeration. Even though the refrigerated one may be the best one, you’re going to choose one that you know the patient is capable of hanging onto and taking effectively to cure that infection, versus something if it required refrigeration would get thrown away or likely not provide the intended effect. That was my first experience at how recognizing these factors and working with them could really change the way the clinician and the care team delivered their care to be more effective.
What are the constraints in recommending and arranging those services?
The majority of our customers are in the safety net. They are community health centers, and many of them function in the true nature of the word “community,” where they provide the medical care, but they have long established relationships with food banks, shelters, and social service agencies that can help fill these gaps. Do new challenges present themselves every day? Of course, they do. But I think they’re pretty adept at handling it.
I think what they’re optimistic about is that now that the broader world is recognizing the social factors and some of the disparities and starting to put funding and services in that direction, they are well positioned to be able to align their patients to take advantage of those services better today than they were yesterday.
What is the role of text messaging?
In our experience and with our clients, text messaging is extremely effective in the populations that our clients are serving. I’ll speak for myself. Getting text messages for my doctor is quite effective, and in some cases, maybe a little too effective, where I want to turn them off because there’s so many of them. But when I go back to the kind of programs we run and with our clients using texting, there are a lot of ways you can configure a texting campaign, especially around childhood well visits, immunizations, and cancer screenings that you’re automatically due for when you hit a certain age.
We wanted to work with our partners and our customers to make these things really, really simple to execute. From our perspective as a population health company, we know magically when you turn 45 and you’re due for a colorectal cancer screen. We don’t need someone to generate that list. We can build that list every week of who turned 45 and is due. We can see the record. We can kick off that campaign to message them to schedule an appointment. A week later, we can look and see if they’ve taken that action. If they’ve not, we can send them a second, gentle reminder. In fact, a week later, we can send them a third reminder and ask them if they care to schedule an appointment or if they are going to ignore this, etc. We can get some feedback through texting.
All of this runs in the background. No human has to go pull these lists every week look at who took the action and who didn’t. Every new week there’s a new group of patients that turn 45 and are due. It’s combining the text messaging with effective patient identification and automation to make this stuff just happen in the background so that no one at the practice has to handle it day in and day out.
What impact did the pandemic have on your clients?
I think the number one thing they walked away with, besides the confidence that they know how to treat patients even under some of the worst circumstances and keep things moving forward, is the importance of data and information. We had been in this business long before the pandemic hit, but all of a sudden that need for accurate data and the accuracy of it just bubbled up to the executive suite fast and loudly. We had clients for years whose quality staff and operational staff were engaged with Azara and all all of a sudden we were hearing from executive directors.
We were watching a lot of the disparities that we’ve read about in the pandemic, or as the pandemic unfolded. We were watching it in real data how it disproportionally affected those that were black and brown, and how that compared to the population within the practices that we were already serving. As these practices rolled out telehealth, we saw who had access to telehealth, who took advantage of it, and what those disparities were. It’s one thing to go with anecdotes, whether it’s to the state house, the Feds, or to your payers. It’s another thing to go with real numbers and fact. To come back to your question, it heightened the need for accurate and easily available information.
What will be important to the company over the next few years?
To us, the most important thing is to support our clients on their journey to value-based care. They are in different states and in different spots along that journey. Everyone is concerned about improving quality and making the patient better, and we should never forget that there’s a patient behind every number. No matter how good the data is, if there’s not someone out there to take action with it, it doesn’t make an impact. But getting the data, making it available for that journey, whether it’s quality, cost, or risk utilization. All of them play a part. More and more, the requirements are going to be how to get it to the right place at the right time in the workflow so it’s very easy for that provider to know what to do when they’re with the patient, whatever type of provider it is.