Dawn Alley, Carebridge, on scaling value-based payment models at CMMI and beyond

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Dawn Alley, President of Decision Support at Carebridge

In this episode, I sat down with Dawn Alley, President of Decision Support at Carebridge, a company that works with health plans and states to care for individuals receiving long-term support services. Prior to joining Carebridge, Dawn spent about a decade working in the federal government as Chief Strategy Officer at the Centers for Medicare and Medicaid Innovation (CMMI), and before that as Deputy Senior Advisor for Value-based Transformation at HHS.

Dawn and I discuss:

• The main initiatives she worked on at CMMI including the Accountable Health Communities Model and Medicare Diabetes Prevention Program
• Lessons learned during her tenure about implementing and delivering healthcare models at scale
• Why Dawn is excited about the future of long-term care services and why she believes in Carebridge’s model

Beginning — 10:35: Dawn’s entry into healthcare

• Early career aspirations: Dawn’s response to my usual icebreaker question, “when you were a kid, what did you want to be when you grew up?,” made it clear that she’s always had an interest in patient-centric care. She described how a Reader’s Digest story about a young girl with cancer inspired her desire to be a pediatric oncologist, mostly because she couldn’t imagine losing her hair at such a young age.
• Studying gerontology: In college, Dawn majored in gerontology, the study of aging, put simply. Her upbringing led to her interest in the field, having spent part of her childhood in rural Indiana, where she lived with her grandmother who was the manager of a public senior living option. Because of this, Dawn spent a lot of time with older adults. In college at USC, she was struck by the difference between how much a person’s unique experiences and circumstances impacted their health. Specifically, she witnessed how some people entered their golden years healthy and thriving while others required really significant support often due to major inequalities that played out over their lives.
• Career decisions: Dawn has done a number of interesting things in her career. She has a PhD, and worked in research, in the public sector on policy issues, and is now in the private sector. This variety of experiences has taught her three main lessons about what matters to her: she wants to be learning, have an impact, and love the people she’s working with. If an opportunity meets these criteria, the part of the healthcare ecosystem she’s working in matters less.
• Career advice: I also enjoyed hearing from Dawn about the career advice she’s picked up over time and carried with her. It includes:

1. If the reason you’re taking a job is to get to the next job, don’t take that job. Instead, Dawn has chosen to go where she’ll be happy and have an impact, and it’s served her well.
2. Think about whose day you want more than where do you want to be in five years. While Dawn didn’t find many people whose days she wanted when working in academia, she found many at CMS. She emphasized that this question can be especially useful for people from marginalized backgrounds who might have a harder time seeing themselves in leadership or high-powered roles.
3. Find opportunities to shadow, even if just for a day, the people whose role you want. Dawn was able to do this with an ACO executive, which she found incredibly helpful.

Dawn wrapped up her advice with a phrase she heard from Annie Lamont, Co-Founder & Managing Partner of OAK HC/FT: “repotting yourself.” It means taking yourself out of one place and putting yourself somewhere else to gain a broader perspective, a concept Dawn has tried to follow in her career.

10:35–21:26: Working at CMMI

• Priorities at CMMI: Dawn initially joined CMMI to work on the Accountable Health Communities (AHC) model, which attempted to more closely integrate community services into the traditional healthcare ecosystem. She shared how cool it’s been to see the concept of health-related social needs play a more mainstream role in the healthcare industry over the years. In addition to AHC, she worked on expanding the Medicare Diabetes Prevention Program, Maryland All-Payer Model, Integrated Care for Kids Model, Maternal Opioid Misuse Model, and Geographic Direct Contracting Model. Across these, there was a strong interplay between population health, catalyzing stronger relationships between healthcare delivery and public health organizations, and more closely integrating with community-based resources.
• How CMMI develops models: I asked Dawn about CMMI’s approach to moving from an idea about a model to phases of implementation and beyond. She shared that in her experience, a model would often start from the administration’s interest in a certain part of healthcare like SDoH or the opioid crisis. From here, a concepting process took place, which involved looking at the literature, and what was happening and working with health plans and providers at the time. For the AHC model, for example, they assessed the market by looking at what was happening in Hennepin County, interesting Medicaid MCOs that were developing community-based collaborations, what Health Leads was doing, hub models, and the role of community health workers. Then teams work closely with CMS’ Office of the Actuary to develop a hypothesis around the model’s likelihood of improving quality or being cost neutral or lower cost. Finally, she’d engaged with a variety of stakeholders to determine the likelihood that target entities would participate in the model if it were voluntary.

Editor’s note: Since speaking with Dawn, she and some of her colleagues from CMMI published a piece in Health Affairs on the impacts of the AHC model on ED utilization and more.

• Scaling the Medicare Diabetes Prevention Program: Dawn spent a lot of time working on the Medicare Diabetes Prevention Program (DPP), which tries to prevent the onset of diabetes in people with pre-diabetes. The model started as an NIH trial, then became a large CDC program, and then CMMI tested it through its healthcare innovation award, finding it very successful at improving quality and cost in the Medicare population.

However, a major challenge arose when thinking about implementing it at scale. The CMMI team wanted organizations like the YMCA, which had already been successful in delivering this model, to participate, but there’s no fee schedule for CBOs. To solve this, they created a new Medicare provider type in hopes that this would offer a sustainable way to pay CBOs and move away from a grant-based model. In reality, this proved a steep hill to climb. The requirements put in place to support Medicare program integrity, among other things, made the program extremely challenging to enroll in. Moreover, it remains challenging for CBOs to enroll and bill Medicare and Medicaid for services since they lack advanced claims infrastructure and face legal fees to get enrolled. As a result of these challenges, fewer people received the DPP under Medicare than they had in the original Healthcare Innovation Award. In summary, Dawn used the DPP implementation to illustrate how good policy without a great operational plan can fail to get a program to the people who need it.

21:26–32:03: Building healthcare solutions in other environments

• Scaling in the private sector: I asked Dawn about some of the unique elements of scaling models in the private sector, and she described how Medicaid models are particularly well-suited for the venture-based environment. She shared the old joke that if you’ve seen one Medicaid program, you’ve seen one Medicaid program, but added a correction that if you’ve seen one, you’ve probably seen about 20 programs since states have separate packages for different populations. In fact, there are 267 Home and Community Based Services waivers in Medicaid, meaning that each state has more than five. This is to say that the amount of that work goes into just figuring out what services are covered by a program is enormous, which presents an opportunity for learning and the creation of new tools required to operate in these different environments.
• Working in Medicaid: Another thing that Dawn likes about working in Medicaid is that it forces you to look at equity issues. She shared an example from Carebridge: over 50% of the company’s members in some states have a preferred language that is not English. Therefore, she and her team have made incredible investments in hiring bilingual clinicians, which makes sense considering the company is at-risk for these members whether they engage or not. Communicating with members in their preferred language impacts Carebridge’s bottom line since they see better patient results when clinical conversations happen in a patient’s own language.

While this is an example, it illustrates the larger point. Although many say it’s harder to be successful in Medicaid, Dawn prefers to view innovation in Medicaid as an opportunity to meet people where they are.

• Employer-sponsored insurance: Dawn explained some of the issues that plague the employer-sponsored insurance system, a main one being that we don’t see employers or employees demanding what they deserve. According to research, employees care most about cost yet we still see employers primarily focused on provider choice even though that’s less important to employees. Quality is another issue in the ESI space because data is hard to obtain. This lack of emphasis on cost or quality can actually make innovating in the employer-sponsored landscape more challenging, because without customers focused on outcomes, it’s hard for excellent solutions to stand out.

Dawn would also like to see the metrics employers use to measure success change. Many companies still use employee complaints as their primary metric, making them extremely averse to instituting change. She urges employers to evaluate what they’re getting for the money they’re spending and employees to get savvier about how they make healthcare decisions.

• CMMI refresh: I asked Dawn about her thoughts on the strategic refresh CMMI issued last year and specifically what would be her north star if she was planning for the organization’s next ten years. Building for scale is her recommendation. As providers transition more deeply into value-based care models and participate in more of them, CMMI needs to focus on how its models interact with all the other models and innovation out there and if what’s being tested is structured in a way to allow for scale.

34:03–40:17: Supporting long-term care needs

• Long-term care issues: I provided an overview of the issues with long-term care insurance and then asked Dawn if she thinks anything works well in the system. She described LTC’s challenges as near limitless, but that the movement away from nursing homes in recent years is a positive. For many decades, LTSS services were almost exclusively delivered in nursing homes, so people with ADL limitations had to go into a nursing home. However, in the last five years or so, more Medicaid funding has gone to home and community-based services than nursing homes. She sees this as a massive shift and indicator of progress since the home environment optimizes for independence and cost.
• Carebridge’s model: To explain Carebridge’s model, Dawn used an example — an older adult who needs help bathing. In the Medicaid context, this individual could receive personal care services, in which a paid home care worker helps them bathe. However, this might not meet the patient’s preferences since bathing is a very personal act that the patient wants to do on their own. Carebridge recommends the right tools to be independent, healthy, and safe. This individual might be better served by getting a tub transfer bench, a long-handled shower nozzle, and grab bars, allowing them to bathe on their own. With the explosion of SDoH-oriented Medicaid benefits, members have access to a wide array of services but might not be using services in the highest value combination. Carebridge partners with Medicaid health plans to serve the home and community-based services population in a way that promotes members’ independence, functioning, and community inclusion.

40:17 — End: Management & Leadership advice

• Leading teams: I wrapped up my conversation with Dawn with a brief discussion of leadership and management. I asked her about what she prioritizes when leading teams: transparency, having a shared understanding of success, and treating team members as individuals. She deploys a strengths-based approach to leadership, trying to identify individuals’ strengths and giving them opportunities to leverage them. She also loves being on and leading teams of people who possess a diversity of strengths rather than trying to mold everyone into a singular model manager.
• Lesson learned: I asked Dawn about lessons she’s learned from failures or mistakes. She described how she enjoys diving in and getting her hands dirty, but this has meant that it’s taken time for her to learn how to delegate effectively. She’s found that it can be disempowering when her team members feel like their boss is doing the work alongside them in a negative way. So, over time, she’s figured out when she should go deep versus when it’s best to let her team take the ball and run with it.
• Working in public service: I closed my conversation with Dawn asking her what surprised her most about working in public service. She says to anyone considering working in government to go for it! She worked with incredibly smart and hardworking people at both the federal and state levels and is grateful to have had the opportunity to do and accomplish important things with them.

Thank you, Dawn, for joining us on this episode of The Pulse Podcast! Subscribe for our new releases on Twitter, Spotify or Apple podcasts.