June 23, 2023
A good read, whether you agree or disagree with the various solutions being proposed.
National Affairs – Summer 23
Interesting article discussing service line replication from OpenMinds:
Geography As Growth Strategy
June 22, 2023 | Monica E. Oss
“All health care is local” is an adage I’ve heard throughout my career. But while face-to-face health care services have historically been delivered locally, more health and human services organizations are taking a decentralized approach, expanding to multiple locations as a growth strategy.
The U.S. health care delivery system has experienced a surge in geographic service line replication. CVS Health now has 9,500 pharmacies, 1,123 Minute Clinics, 966 health hub locations, and 100+ Oak Street Health primary care offices. WalMart recently announced major expansions in two additional states (see Walmart Health Nearly Doubles in Size With Launch Into Two New States in 2024).
Even traditional brands are expanding their geographic footprints, with some going global. The Mayo Clinic now has five health centers in three countries and 50 additional satellite service locations. The Cleveland Clinic has 22 hospitals and 275 outpatient facilities in three countries. And many specialty provider organizations are developing a national presence. For example, LifeStance Health has 600 centers in 34 states and Hazelden has 17 treatment locations in 8 states.
replication and standardization from cohen veteran network
The question for many executive teams is whether geographic expansion should be part of their growth strategy. And, if so, what are the management and marketing best practices for adding physical centers and service locations in new zip codes? This was the focus of the 2022 OPEN MINDS Management Best Practices Institute session, Scaling Up: Best Practices In Replicating A Program In New Geographies & New Markets, featuring Anthony M. Hassan, President and Chief Executive Officer of Cohen Veterans Network (CVN). CVN serves post-9/11 veterans and their families through a nationwide system of mental health clinics.
Over the past seven years, CVN has demonstrated the effectiveness of their replication strategies, with 24 currently operational clinics and another one on the horizon. This accomplishment reflects their vision of establishing 25 clinics within a relatively short time frame while maintaining excellence in both clinical and operational aspects. “When a military family member or community member raises their hand to get help, they get help. That’s our mission,” says Mr. Hassan. He notes that the situation is such that even the active duty can’t service their own members, leading them to off base for their care. Mr. Hassan points to causes rooted in the current staffing crisis. “The clinician workforce is a pain point. We try to pay people more and offer a better environment. Nevertheless, it’s still challenging.”
By which framework has CVN garnered the success of its expansion? It consists of selecting good partners, suitable locations, and achieving positive outcomes. He believes that their success lies in their specialization and working with a specific population. This approach can be applied to any population, as evidenced by inquiries from organizations such as LeBron James’ group, who sought to replicate CVN’s community-based success.
Recreate, and stay in your niche The replication plan starts with strategic decision making about geographic locations and potential partners. CVN opens locations near those they serve—military bases. The central tenants: good partners, good locations, and good outcomes, according to Mr. Hassan. “We’re very specific about who we see, and I think this is part of our success. We’re good at what we do, but we only work with a certain population—that makes us even better.”
Ultimately, an organization cannot remain sustainable while serving every population. Thus, as Mr. Hassan says, “think neighborhoods, not counties.” “Otherwise, you’ll be like everyone else: long wait lists, low quality services. There’s just not enough time and resources.”
Mr. Hassan explained that the model for each location is standardized, including hiring an executive director, a case manager and community outreach worker in every clinic. “Most would cut these staff in mild to moderate mental health. We invest in community recruitment and outreach and case management because it’s critical in meeting the needs as a community. We view the community as a stakeholder, especially with our military-based communities.” Mr. Hassan touts that the organization sees its patients for initial care within 2 weeks. This is a point of pride for the non-profit, noting that they don’t create boundaries for patients seeking their services.
For more complex cases, CVN relies on its 14 clinical partners to offer an array of services beyond the scope of the non-profit organization’s niche, such as Centerstone and the U.S. Department of Veterans Affairs. “How can we rise all boats with what we do and be collaborative with 14 CEOs?,” explains Mr. Hassan, noting that CVN has been fortunate with success in leveraging the partner network of as collaborators rather than organizational adversaries.
Build, then launch Speaking to their operating model, Mr. Hassan draws comparison to popular restaurant chains such as Chick-fil-A, with an emphasis on their franchise models. CVN owns the physical space, the office furniture and equipment. And, CVN negotiates all the relationships with the state and takes care of legal and IT, onboarding, and training. CVN also handles brand awareness and loyalty.
The partner organizations manage the service delivery. Partners need to build their own team, meet their quality standards, and get involved in the community—something that Mr. Hassan notes is important to CVN, especially given the hesitancy from their patient population.
replication and standardization from cohen veteran network
Optimize “It’s about having great teams and processes and learning as you go,” explains Mr. Hassan. “We still have a great amount of learning to do.”
Continuous optimization is a core principle at CVN. Dr. Hassan emphasizes the importance of having great teams and processes while learning from experiences along the way. CVN has learned to reduce its physical footprint and optimize its space without compromising the quality of its services. Adaptability is another key attribute demonstrated by CVN, as the organization transitioned from 16% to 100% telehealth overnight during the pandemic. Currently, they maintain a hybrid model with 60% in-person and 40% telehealth appointments.
Data plays a crucial role in CVN’s operations. Dr. Hassan highlights the significance of partners in gathering data on clinical outcomes, utilization, and costs. Power BI dashboards are readily available to Dr. Hassan via his cell phone, and all data is collected in a centralized data lake. Each clinic has its own dashboard, and CVN employs a dedicated data team to leverage data so CVN can operate as a learning mental health system. Some of the key performance indicators (KPIs) and performance requirements include service levels, clinical hours and processes, risk and acuity, and overall patient access to care services. Success in these metrics serves as an entry point for expansion into other markets at scale. CVN utilizes artificial intelligence (AI) to predict patient dropouts and actively engage with them to ensure continued participation in care.
CVN initially provided free services and later introduced billed services, resulting in a doubling of their billing revenue in just three years. However, this billing revenue is still comparatively low in relation to their costs. To support fundraising efforts, CVN has established a full team of strategists in philanthropy, as well as partnerships with state, federal, and county sectors to sustain the clinic network. This multi-pronged strategy is crucial for long-term sustainability.
Every executive team needs a growth strategy to keep pace with the current changes in the field. For those that choose geographic expansion as part of that strategy, it is important to develop a replicable model for that replication to increase the likelihood of success.
And finally, from today’s Albany Times Union, a harsh reminderand call to action re: the inequities associated with access to high quality healthcare:
Closure of St. Peter’s dental clinic also deals blow to medically underserved
In New York, Medicaid guidelines and a scarcity of dental providers mean the disadvantaged face even more hurdles to get care
Rachel Silberstein, June 23, 2023
ALBANY — Christine Mitchell has a stack of rejection letters in her living room.
All of her molars needed new crowns, but Fidelis — a managed care plan that contracts with Medicaid — denied coverage for each procedure. Her dentist at the St. Peter’s Hospital Dental Center in Albany told Mitchell the teeth would need to be extracted. Eventually, Mitchell was told, she’d lose all her teeth and require dentures.
“It’s very shameful to me to have a situation where I can’t pay for my teeth,” the Guilderland resident said. “People just think you are a crazy person without teeth. I try not to smile. My face has gotten sunken. All of the lines that were faint lines are getting worse, because my face is caving in.”
Mitchell, 65, is among millions of New Yorkers on public health insurance who lack access to what many perceive as basic oral care.
A scarcity of dental providers that serve the adult Medicaid population, combined with state Medicaid coverage policies that require unnecessary extractions, leave many toothless — or worse.
Mitchell’s immediate challenge is finding a dentist who can extract her remaining teeth before she develops an infection. Citing staff shortages and financial pressures, St. Peter’s last month announced that it would close its dental clinic — which treats about 4,000 patients annually — by next Friday, June 30.
The impending closure puts even more pressure on federally qualified health clinics that provide dental care to low-income and uninsured residents, which are also dealing with staff shortages in the wake of the COVID-19 pandemic.
In the Capital Region, the dental clinics will be down to Whitney M. Young, Jr. Health Center in Albany and Hometown Health in Schenectady, but they can’t absorb all of St. Peter’s clients and maintain the same level of care for their existing patients, according to Kathryn Rothas, dental director at Whitney Young.
“Even if we were open 24 hours a day, we’d still be behind,” Rothas said. “Our mission is to provide equitable care to our community and we are doing everything we possibly can do, but I think the whole community needs to come together and come up with a solution.”
A spokesman for St. Peters said it was a difficult decision to close the clinic, but despite years of optimization and improvement efforts, “the center continued to face annual financial losses, as Medicaid reimbursement rates for these services are significantly lower than the cost to provide them.”
This comes as St. Peter’s confirmed last week it is seeking state approval to close the Burdett Birth Center at Samaritan Hospital; officials also cited staffing and financial pressures post-pandemic for shuttering Rensselaer County’s only maternity unit. Burdett’s closure, which advocates and officials have pledged to fight, would also greatly impact women of color and the disadvantaged.
And while the hospital says it is seeking other community partnerships to take on its dental patients, Whitney Young is currently the only provider on the list.
The eight-point rule
For decades, eight teeth have separated rich and poor in New York when it comes to oral health.
Federal law requires states to provide dental benefits to children, but covering oral health for adult Medicaid recipients is voluntary.
New York’s Medicaid program, which includes one of the more generous dental plans, has long denied coverage for tooth-saving procedures like crowns or root canals for adults who have eight back teeth — or four sets of molars — that touch.
That could soon change with the settlement of a federal class-action lawsuit against the state Department of Health, which charged that the state’s policies denied people medically necessary services. When approved by the court, the settlement is projected to impact an estimated 5 million New Yorkers.
The three-year case, brought by the Legal Aid Society and firms Willkie Farr & Gallagher and Freshfields Bruckhaus Deringer, was settled in May, compelling the state’s Medicaid program to include coverage of things like root canals, regular denture replacements and medically necessary implants.
According to Wesley Powell, partner at Willkie Farr & Gallagher, the state’s standards were out of line with modern dentistry practices.
“By the time you’ve lost that many teeth, and as you grow older, it impairs the integrity of your jaw line. It basically guarantees that you will lose all of your teeth,” Powell said.
The settlement is a win for plaintiff Matthew Adinolfi, a retired New York City cab driver who lives near Plattsburgh, who has been living with an ill-fitting top denture for over a decade.
Adinolfi, 65, lost all but three bottom teeth in 2010 after contracting an infection that doctors feared could spread to the rest of his organs.
The settlement entitles him to bone restorative surgery and implants, which he says will enable him to feel more confident in his dating life and restore his ability to chew and taste food.
“I’m a full-blooded Italian, so food is on the top of the list,” Adinolfi told the Times Union.
The settlement is subject to court approval and it could take more than a year before the new coverage rules go into effect.
More coverage, fewer options
Even with the expanded oral health benefits, having insurance does not get someone into a dental chair, notes Belkys Garcia, an attorney with the Legal Aid Society, which filed the suit.
Adinolfi has not been able to find a provider within driving distance who will do the multi-step dental restoration. St. Peter’s Hospital agreed to take on the case last fall, but his appointment was canceled when the clinic began scaling down services.
According to Garcia, Adinolfi is the only lawsuit plaintiff who has been unable to find a provider.
“For my clients upstate, it’s just getting to the dentist,” Garcia said. “They just do not have anyone to see and they are traveling very far.”
Finding a dentist outside New York City that participates with Medicaid plans was always challenging — but the COVID-19 pandemic has made the situation worse.
Private dentists cite Medicaid’s low reimbursement rates and extra administrative headaches created by managed care plans for declining to participate.
But lack of access to dental care leads to greater health problems that are more expensive to treat, placing a burden on emergency departments, according to Dr. James Galati, a Clifton Park dentist and former president of the New York State Dental Association.
“Usually people who don’t have a dental home, what they tend to do is wait for a major problem — abscess or swelling — and all they really get is a script to go see a dentist, which they don’t have,” Galati said.
According to Rothas, Whitney Young’s dental director, federally qualified health clinics cannot be the only providers for the Medicaid population.
Whitney Young, which closed a dental center it had in Troy during the pandemic, has the space, equipment and funding to expand, but has struggled to hire and keep dentists since the COVID-19 health crisis, Rothas said.
Rothas had recently completed her dental residency when she was hired as a staff dentist at Whitney Young in August of 2021. She was soon the clinic’s only dentist and was asked to take on the additional role of dental director.
Whitney Young has since hired three more dentists, but the clinic does not have the staff to operate at full capacity. The clinic is also short dental assistants, receptionists and dental hygienists, Rothas said.
St. Peter’s was able to recruit dentists through its dental residency program, which will also close this month. Whitney Young has received a U.S. Health Resources and Services Administration grant to create its own dental residency program, which is expected to launch in July 2025.
While expanded Medicaid coverage is a good first step, more must be done to ensure that claims are being honored and that patients can access these services, Garcia said.
“I think (the) settlement will result in a huge expansion of dental coverage,” Garcia said. “What it does is it changes the Medicaid coverage rules … Once we get that, we are in this land of where yes, on paper it’s covered, but we need to make sure people actually have the access.”