Rae Woods (00:02):
From Advisory Board, we are bringing you a radio advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. Last week in part two of our series on value-based care, we talked about how CenterWell, which is Humana's provider arm, is growing their value-based care strategy. And they're doing that by focusing on seniors. But as the Medicare advantage market gets bigger, gets older, frankly gets sicker, controlling spend in primary care may not be enough. Value-based care on the specialty side is actually the future. And that's why in part three of our series, I want to tell the story of Zing Health, which is an organization that focuses on specialty value-based care by focusing on specific conditions. To talk about what good specialty care in MA looks like, I've brought on TJ Ackerman, senior Vice President of Provider and network performance at Zing.

(01:01):
And later we're going to bring on one of their provider partners, Will Stokes, the Chief Strategy Officer at Strive Health, which focuses on integrated kidney care for patients with chronic kidney disease and end-stage renal disease. For now, let's welcome TJ. Welcome to Radio Advisory, TJ.

TJ Ackerman (01:19):
Thanks for having me.

Rae Woods (01:21):
I don't want to assume that our audience knows who you are or what your organization is. I'm going to be honest with you. I didn't know who Zing was before we started getting into this topic of specialty value-based care. Tell our audience a little bit more about what Zing is, what you intend to do in the market?

TJ Ackerman (01:40):
Yeah, so Zing is a minority founded regional Medicare Advantage plan. Founded in 2019 with a specific focus to address traditionally underserved populations. In just a little context, one of our founders was a physician on the south side of Chicago for a very long time and saw firsthand the populations that were inadequately addressed by most of the healthcare industry, both payer and provider side. And so that's what Zing has sought to do back in 2019, launched during COVID, and has since grown to just over 10,000 lives with a specific focus on chronic special needs plans, recognizing that there's a higher prevalence of chronic conditions in the Black and brown communities that we seek to serve.

Rae Woods (02:33):
And this is where we're going to start to get into what might actually be new territory for our listeners. If I'm honest, I feel like they often conflate value-based care has to equal primary care. I mentioned that I didn't know who Zing was before we really started getting into this topic, but I guarantee that our listeners know of folks like ChenMed, Oak Street, the primary care focused value-based care organizations. You've really taken a different approach. Tell me why did you choose to focus on specialty care?

TJ Ackerman (03:06):
If you take a step back and recognize that the Medicare Advantage landscape is extremely saturated. We hear that from every provider we talk with, every health system that we partner with. And so Zing really had to define where we fit into the health payer continuum. And chronic special needs plans or CSNPs, were an area that is very underutilized when you think about the prevalence of chronic conditions, not just in the communities that we seek to serve, but all Medicare advantage eligibles. Upwards of 50% of that cohort of individuals has some type of qualifying chronic condition. Our definition of specialty care is acutely focused on those chronic special needs plans, CHF, chronic heart failure, chronic kidney disease, diabetes, where we can design benefit plans that address the actual clinical needs of those individuals that have these conditions.

(04:09):
And so, we still partner with the PCP risk-bearing entities that you referenced, the Oak Streets of the world, et cetera. But then we've taken it a step further and built out a VBC continuum of our own and a strategy that includes both a spot for the primary care, a spot for specialty entities that focus on these chronic conditions as well as home-based entities.

Rae Woods (04:34):
You're really focused on the condition, right? You named three, you mentioned heart failure, you mentioned chronic kidney disease, you mentioned diabetes, and you're targeting those conditions through these C-SNP plans, which are a part of Medicare Advantage. What is a C-SNP and what does it allow you to do that is different than traditional MA?

TJ Ackerman (04:55):
Yeah, so C-SNP, chronic special needs plan is a Medicare Advantage benefit offering. People I think are far more familiar with D-SNP plans where you have to be dual eligible in Medicare and Medicaid. A C-SNP, the requirement is you have to have the clinical diagnosis for one of these chronic conditions. And CMS has a list of chronic conditions that you can offer a plan for. Again, Zing has focused on diabetes, CHF. We recently launched a ESRD or end-stage renal disease C-SNP offering.

Rae Woods (05:28):
Yeah.

TJ Ackerman (05:29):
But I think the real value here is these are plans that are designed, the specific benefits are designed to address the clinical needs of that population. And if you think about the clinical needs of someone with CHF versus a healthy 68, 70-year-old that is on the golf course quite frequently, are going to be very, very different.

Rae Woods (05:51):
And the kind of benefit to the patient is a little bit more obvious to me. It's one of the things I want to keep talking about in of this conversation. But can we just take a moment and talk about the business side for a second? You said yourself, the Medicare Advantage market is saturated. Not only is it saturated, it's also being squeezed. It's being squeezed this year, frankly, with changes to STAR ratings, rate cuts, right? It's more difficult to be financially successful in MA. Tell me more about the benefits of the business model behind the C-SNP plans.

TJ Ackerman (06:27):
Yeah, it's a really good question. We're not immune to the pressures that I think all managed care organizations are feeling as the regulatory environment continues to change and shift. I will say that on the surface, a member that enrolls in a chronic special needs plan innately has a higher risk than your traditional Medicare Advantage member because of the chronic condition that they have to have in order to enroll in these plans. When you think about how risk adjustment ties to revenue and things of that nature on the business side of Medicare Advantage, not all members are created equal. When we partner with our primary care risk bearing entities, they can have a thousand MA lives that are at risk score X worth a thousand dollars PMPM, they could have a thousand CSN lives at a different risk score that are worth 17 $1,800 PMPM.

(07:25):
So the financials there do start to look very different in the CSN cohort versus your traditional Medicare Advantage cohort. With that said, going back to the regulatory components, there's some squeezing happening, but I think Zing is not immune, but we are able to mitigate a lot of that impact because our investment and benefits are focused on those things that truly impact the clinical needs of a member. So, we're less focused on your flex card and being able to get gas in your car and things like that. And we're more focused on $0 tiering of formulary For your most highly utilized diabetic drugs, cardiovascular drugs. We are lowering the copays associated with the specialists that you're going to see very frequently, your nephrologist, your endocrinologist, your cardiologist, your ophthalmologist.

Rae Woods (08:19):
I imagine that it is very important to have the right provider partner. Because you've said maybe five times now how important it is to manage the clinical condition of this population. How do you go about finding the right partner?

TJ Ackerman (08:35):
Recognizing our focus on chronic conditions, we needed to dive headfirst into that specialty space. And so it became an evaluation of a lot of individual companies, newer companies are out there addressing different clinical conditions, and we recognize the need for a cardiovascular partner, a diabetic partner, and a kidney care partner right from the very beginning.

Rae Woods (09:01):
And we actually have one of those partners with us on this podcast Will Stokes from Strive Health, which is a provider organization focused on value-based care for chronic kidney disease. Will, welcome to Radio Advisory.

William Stokes (09:16):
Thanks for having me. Excited to be here.

Rae Woods (09:18):
I'm going to give you the same offer that I gave to TJ. Tell us more about Strive and what you do to support patients with chronic kidney disease.

William Stokes (09:28):
Yeah, absolutely. Strive Health is a value-based kidney care company. We're delivering a complete clinical model for patients with chronic kidney disease and end-stage renal disease with the ultimate goal of improving clinical outcomes and reducing costs. And we partner with payers and providers across the country as the specialist in chronic kidney disease and end-stage renal disease. Most of our partners have a general population and we're brought in for that clinical model.

Rae Woods (09:55):
Because it's needed, right? Because you need that extra layer of care and specificity when you're talking about a set of diseases as complex as ESRD and CKD.

William Stokes (10:05):
Absolutely, these are patients in a low prevalence but high complexity condition that too often fall through the cracks of a general model. I think we're in about 35 states now, 110,000 members who we manage. In a value-based care model they account for about four billion of healthcare spend in this country. A big population of patients despite the specialized nature and a big problem for the healthcare system that we're trying to address.

Rae Woods (10:33):
And tell me more about the two of you and how you came together and I guess more specifically, one of the things that's in the back of my mind is that even though you're growing quite quickly, your two organizations represent, I mean, dare I say, kind of smaller fish in this pond of everything that's happening with value-based care, everything that's happening with Medicare Advantage. I have to imagine that you two coming together not only serves patients, not only is going to support your business model, which it has to, but I have to believe it also gives you a little bit of armor to go up against the big guys. Am I right?

William Stokes (11:09):
Absolutely.

TJ Ackerman (11:10):
Yes. I agree that, I'll speak on behalf of Zing. I think we understand exactly where we fit in the small Fish big pond that is Medicare Advantage, but this partnership with Strive, I think has been mutually beneficial in the evolution of both of our organizations and the growth of both of our organizations.

William Stokes (11:30):
And I would say interestingly, both of our companies are entering categories with very large, mature established players in the space, large dialysis organizations in the kidney care space, very large Medicare Advantage plans, and as TJ mentioned, very consolidated space.

TJ Ackerman (11:49):
I think, Will, you hit on something earlier too of we are both focused on a smaller subset or smaller cohort of the larger Medicare advantage population, but one that requires an extremely high level of touch and a high level of engagement, a high level of utilization, which is ripe for efficiencies in management to help them manage through their chronic conditions.

Rae Woods (12:14):
I want to acknowledge the fact that most of the folks that listen to this podcast are business leaders in healthcare, right? They're healthcare executives, they're maybe VPs, they're directors, right? We're talking to the business folks. I want you to define for us what does success actually look like when your organizations come together. And what is it that you need from each other in order to get to that definition of success?

TJ Ackerman (12:39):
If Strive is not successful managing our CKD ESRD population, then Zing is not successful. It's not a good situation for the member either. And so what we're looking for is financial and clinical success. If we set full-risk targets, we want to empower Strive as much as possible, them sitting first chair driving the clinical model, but Zing as the health plan, providing all the supplemental support necessary to effectively manage that population below the MLR target set in our agreement, leading to lower cost of care, which is important for the whole healthcare system. Obviously, there's financial gains to be had for Strive and ultimately Zing benefits from effective management of that membership cohort.

William Stokes (13:29):
At its root, and getting down to brass tacks on the math, we have to find a way to manage this population at an MLR, at a medical loss ratio, at a healthcare cost level, that is profitable and sustainable for both organizations. Historically, some of these members were pushed off of Medicare Advantage plans. Because they were seen as just an inevitable loss leading population-

Rae Woods (13:57):
Too expensive.

William Stokes (13:57):
Dialysis patients, they're too expensive, they're never going to be profitable for the average health plan. That was sort of the old school of thought. As we come into this, we know, both organizations know that if managed well, if taken care of proactively, if we deliver preventative care, keep patients out of the hospital, these are members who can do really well clinically with this specialized model, but can do very well financially if managed appropriately through this model. And so when we look at our financial alignment, we have a real opportunity to truly create a win-win contract whereby Zing is able to make money sustainably on this population, grow that membership and seek to grow that membership. Not very many health plans are out there trying to grow their ESRD membership.

Rae Woods (14:46):
No.

William Stokes (14:46):
Zing is. Strive needs to find a way in a contract with Zing where they're getting value. But we're also able to manage a profitable population as well within our own model. And we think we've found that structure in our partnership, and that's fairly unique.

Rae Woods (15:02):
This is really interesting for me, because the big experiment with value-based care, and really the big experiment with Medicare Advantage is, can we actually at least uphold outcomes while reducing costs? And when it comes to that experiment, there are actually very few folks that are doing that well, if at all, what practically speaking do you need in your own businesses and in your partnership in order to actually get to, "We're going to improve or at least uphold outcomes and we're actually going to lower costs?"

William Stokes (15:36):
That case for value-based care is a challenging one to build. It requires large populations and a lot of time managing a population to truly prove that you've done it, you've done what you've described. For us in our partnership, it's early on, it's early days, and the path there is more members and more time managing those members together to show and be able to demonstrate to ourselves and externally that we've achieved that value-based care aim. I will say that the leading indicators are very, very positive. Good enrollment and engagement of patients, patients who are actually utilizing the services that we think are going to improve outcomes. We're seeing impact on reduced hospitalizations for patients engaged in a program. We're seeing good, clinical outcomes around the specialty itself, patients transitioning smoothly to dialysis, getting more transplants, things of that nature. But it's early days and those are leading indicators to that ultimate goal of population level, improved MLR and lowered costs.

TJ Ackerman (16:37):
And so what have we put in place at Zing through our call center customer service onboarding to make every single member aware, "Hey, you have CKD, you signed up with Zing. This is our partner. This is who you should be engaging with. They're going to address your clinical needs." Instead of just having it be an offering that sits on our website, "This is a proactive, you chose this plan because you have a chronic condition. These are the partners we use to help manage those chronic conditions and we get them engaged with you."

Rae Woods (17:08):
I see. I see.

William Stokes (17:09):
One element of that we haven't really mentioned that I think extends and I think is common in specialty value-based care at large, Strive has partnered with about 750 nephrologists out in the community and growing. And a big part of specialty value-based care is not just entities like Strive, but really bringing the specialty and specialist network online in the value-based care, and Strive is doing that in nephrology. That's great from a clinical standpoint, you have to have those physicians engaged and involved to be successful in these populations. It's not just primary care in our category. Nephrologists also, maybe even more so has to be activated and aligned to the clinical goals we're trying to achieve.

(17:55):
But that's also an under penetrated Medicare advantage market. ESRD, especially CKD. It's a population that hasn't been a focus. It's a specialty category that hasn't been as focused for Medicare Advantage plans historically. And there's a lot of members out there on traditional Medicaid or otherwise that don't know about Zing, don't know that an ESRD C-SNP is an option for them. And we have an opportunity to connect with those patients and present them with an offering in a much more hands-on focused way through that network and through that connectivity to the community and to the patients in the community.

Rae Woods (20:16):
We happen to be talking mostly about kidney conditions, chronic kidney disease, end-stage renal disease because of your partnership. But I have to ask, maybe TJ, this is more for you. Do the structures that you've put in place with partners like Strive, which are very deep structures, will they scale and apply to other conditions, either the ones that you're already focused on or even conditions beyond just heart failure and diabetes? Or is there really enough differentiation conditions and between C-SNP plans that you've got to have fundamentally different partners, different options for each group you're focused on?

TJ Ackerman (20:57):
The surface, there's definitely a blend, right? There's so many comorbidities in the CKD population or the CHF population. It's less likely you'll have an individual that only has CHF. And so what we've found is, we're partnering with other entities that can handle their primary focus, if you will, where Strive is CKD, ESRD or kidney Care. To make it very simple, we've identified others that their primary focus is diabetes. Primary focus is cardiovascular disease. I think that the job we have to do at the health plan is making sure that Strive understands who they are accountable for managing, and these other entities understand who they are accountable for managing.

(21:40):
You hear attribution is a big struggle within, I think specialty value-based care. Because with PCP, it's very easy. If I select Rae as my primary care physician, I'm holding Rae accountable as the health plan for management of TJ's total cost of care, quality of care, et cetera. But when you go into the specialty space, how do you delineate between kidney care and CHF and diabetes?

Rae Woods (22:05):
Especially when patients have to pick one special needs plan, right? Even if they fall into that category, which to your point, many of them do where they have multiple chronic conditions, they can't have multiple C-SNPs, correct?

TJ Ackerman (22:16):
They can't have multiple C-SNPs. But to clarify, the C-SNP offering that we have in place at Zing is for multi conditions.

Rae Woods (22:25):
I see, okay.

TJ Ackerman (22:27):
This goes back to some of the regulatory requirements of CMS. You can have a diabetes-only C-SNP, a CHF only C-SNP, or you can have a combination.

Rae Woods (22:35):
And that probably also speaks to why you have then specific provider partners who are going to have the specificity to focus on that special population.

TJ Ackerman (22:43):
Yes, exactly. And so, what we've been focused on over the past 12 months is we've onboarded Strive and some of these other partners is the overlap between them. And so we've worked with our clinicians internally, as well as our partners like Strive and others to say, "Look, if this individual has kidney care needs and they are utilizing a Strive nephrologist, then Strive is accountable for the full management of that member, even if that member has diabetes along with their CKD." Because we've had these conversations with Will and his team of, "Yeah, their primary focus is the kidney care population, but their clinical model contemplates holistic care for that member, not just the acute nephrology and dialysis needs of that population."

Rae Woods (23:30):
I do want to acknowledge the fact that you two are really representing something that is a bit unique in healthcare, which is that you are focused on specific populations and most of our listeners are seeing or working with general populations. I'm curious, what advice do you have for them when it comes to what good specialty care would look like for an organization that is trying to move forward in value-based care, they're trying to serve the needs of specific populations, but they don't necessarily have the same kind of benefit that you all have, structural benefit that you all have of just focusing on select groups?

TJ Ackerman (24:04):
My thought as a health plan is, when I have conversations with integrated health systems or community-based providers, my value proposition and pitch for Zing is, if you have a patient of yours that has one of these chronic conditions, then I would challenge you to defend why you're not promoting them to enroll in one of these C-SNP offerings. And selfishly, I'd love for it to be Zing, but it doesn't have to be. There are other entities out there that are offering a C-SNP, but when you think about a diabetic member or a diabetic patient who's not adherent to their medication, maybe it's because they can't afford it, then why are they in a plan that has a great flex card and all these other flashy benefits, but not one that has $0 formulary for the drugs they need to be taking to help manage their condition?

(24:57):
And so, recognizing that they're dealing with a general population, my ask is, Zing can fit into your general population by helping remove the financial barriers for your patients that have these chronic conditions. It's not going to be a plan for everyone, right? Like we said at the top of the call, a healthy 70-year-old may be perfectly fine in their general enrollment HMO plan. They don't need all these other benefits that we have tailored to chronic heart failure. But if you have a patient who does, let us do the hard work for you by structuring the benefits that inevitably will lead them or we hope will lead them to be more compliant with the clinical care plan that you as a physician or you as the health system are prescribing.

William Stokes (25:44):
And then I think from the provider side, it's similar themes that applied to providing care. One, take a data-driven intellectually honest approach to where the generalized model is leaving gaps. Where are patients? Where are the outcomes underperforming? Which patients are less engaged? And really identify where those gaps are and then proactively identify and close those and those populations. And then second, there has to be connectivity to the specialist community that goes beyond referral management that was built in the fee for service paradigm. There has to be real communication, real data sharing, real clinical collaboration around patients. And that's hard work that takes integration, sometimes technology integration, but it takes an effort to really look at those specialists as partners, not just referral relationships. And looking for ways to collaborate with those physicians who are really going to be a primary caregiver in the care for that specialist condition.

Rae Woods (26:48):
Well, I appreciate both of you coming on Radio Advisory. I have one more question for you. This conversation is happening as we're talking about value-based care in this industry more broadly. My question for you is, what does the future of specialty value-based care actually look like?

TJ Ackerman (27:04):
We're starting to see this now in specialty value-based care is there's a proliferation of disease-specific provider entities, so Will can speak in more detail to the kidney care space. You see it in cardiovascular, you see it in orthopedics, you see it in oncology, you see it in diabetes. I equate it in a way to the cable streaming conundrum that we've dealt with. Everyone got sick of paying for their local cable and they were felt locked in. And so they went this à la carte route. And so I do think I would caution the industry of getting to à la carte with the different specialties

(27:46):
Because as you start to carve things up, we talked about it a number of times during today's discussion. There's so many comorbidities that how do you effectively decide that an individual needs to be prioritized with this clinical condition over this one?

(28:01):
Now, physicians can make that call and we can look at total cost of care and the clinical outcomes that are required. But I do think that's a fine line that we're going to have to navigate, both on the provider side and the plan side of not having so many options that you're losing sight of the holistic management of an individual that has one of these conditions.

William Stokes (28:27):
And I think from the provider side, especially value-based care is new as Rae called out early in this discussion, primary care has gotten all the attention in value-based care and specialist physicians have largely been left out of that trend. I think this space can reach a sustainable place when those physicians, those provider practices have a meaningful component of their business and their practices in a value-based care model. There's a lot of details to figure out structure around how attribution works, the specifics of the payment model, but ultimately, for standard of care to change, for this to reach sort of scale across the country, physicians and caregivers in the community have to be operating with a value-based care mindset and have to be incentivized to outcomes.

Rae Woods (29:19):
Well, Will, TJ, I'm so excited to see what your organizations do next. Thank you so much for coming on Radio Advisory.

William Stokes (29:26):
Thanks for having us.

TJ Ackerman (29:26):
Thanks for having me.

Rae Woods (29:32):
There's a lot that all of us can learn from understanding what different populations need in primary care. Today we focused on seniors, but the bigger takeaway for me is the recognition that one-size-fits-all primary care doesn't work for anyone. And there's a lot that all of you can do to make care better for the senior population specifically. And remember, as always, we're here to help.

(30:21):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Kristin Myers, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston and Erin Collins. We'll see you next week.