Q&A with AltaMed Health Services CIO Raymond Lowe: “Everybody Talks about Patient-centered Care, But We Live It.”

There isn’t a single healthcare organization that doesn’t consider patient-centered care to be a top priority. But at AltaMed Health Services – an FQHC serving more than 300,000 people in underserved communities – it’s more than that.

“Everybody talks about patient-centered care, but we really live it,” said Ray Lowe. Through its network of 40 clinics in Southern California, AltaMed seeks to provide “convenient, culturally sensitive care” for often-overlooked populations by “taking value-based care principles and applying them in care settings.”

Recently, Lowe spoke with Kate Gamble, Managing Editor and Director of Social Media, about how his team is leveraging data to more effectively care for patients throughout the continuum; the non-traditional methods being used to communicate with patients about cancer screenings; how they achieved Epic Gold Stars Level 9 – and what it means going forward; and why sometimes AltaMed has to be “a little more scrappy.”

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Bold Statements

We also think about what’s happening in social determinants of health with food scarcity, home housing and security, and behavioral health issues, which affect many of our patients that we serve. And so, we’ve actually tripled down in terms of how we’re providing value-based care for these patient populations.

If we can identify the right cohort and if we’re 80 percent right on that cohort, we can impact the patient population — which we did, versus some other areas where we got to be exactly perfect.

We’ve developed some very effective programs using text campaigns and photo novellas, which are like comic strips, to help educate patients. This way, they get it. They understand it and they’re actually able to act on it.

The power of any type of EHR is how it’s being utilized — not only by clinicians, but also by your patient population. Are they getting it, understanding it, and fully leveraging it?

We’re able to implement all of the patient engagement tools that the patient expects; whether you’re at AltaMed or Cedars-Sinai, we have the same level of engagement, so there’s no differentiation, which really closes down the health equity gap. That’s a big win.

Q&A with Raymond Lowe, CIO, AltaMed Health Services

Gamble:  Hi Ray, thank you so much for your time! I’m really glad we have the chance to catch up. The last time we spoke was in April of 2020, so obviously quite a bit has changed since then. But I’d like to talk about your core objectives at AltaMed and some of the accomplishments you’ve had in the last year. Can you start by giving a high-level overview of the organization?

Lowe:  Thank you, it’s great to be back and be doing a podcast with you. You and I met during the pandemic; a lot of growth and changes have happened within AltaMed since then. I would describe AltaMed Health Services as a large delivery network. At our core, we’re a federally qualified healthcare center. We treat more than 500,000 lives in the Medicaid space. We’re probably one of the largest FQHCs in the country.

We also have PACE, which stands for Programs for All-Inclusive Care of the Elderly. It has 5,000 participants, making us the second largest PACE organization. We developed a Medicaid full-risk program in our AltaMed Health Network where we’re actually serving about a quarter million lives.  We also have a managed services organization which performs claims and processing for AltaMed, as well as some other clinical entities.

 

Addressing social determinants

Gamble:  So now, almost four years since the start of Covid, what do you consider to be your core objectives?

Lowe:  We’re a Medicaid provider, which means everything is moving toward value-based care. As an FQHC, we’re very focused on how to take value-based care principles and apply them in the clinic; that’s even more challenging in an underserved, non-English speaking community where folks are also lowly educated.

It’s a very complex problem. We also think about what’s happening in social determinants of health with food scarcity, home housing and security, and behavioral health issues, which affect many of our patients that we serve. And so, we’ve actually tripled down in terms of how we’re providing value-based care in Los Angeles and Orange County for these patient populations.

I’ll give you an example. Last year, a program was launched in California called Enhanced Care Management (ECM), which is the top 5 percent utilizers of Medicaid services across the state. We received a cohort of patients and we’re looking at how do we meet those patients where they’re at and how do we intervene.

When you talk about treating people, only 20 percent is clinical treatment. The other 80 percent refers to social aspects; that’s where’ve rallied with our case workers and with community services to really change patients’ lives. Some of them have graduated out of our ECM program, and some have not made it through, but it’s really turned the corner on ED utilization in terms of overall health, as well as vulnerable populations.

Creating risk models

Looking more broadly at what’s happening in the Medicaid space, currently only about 4 percent of all providers across the country are looking at doing a value-based care approach. I believe that toward 2030, the feds are looking to fully move that patient population into a value-based care and ACO environment.

We are an Epic shop, and we’ve built a number of risk models tied to this. When you look at ED admits and hospital utilization and how we can raise overall population health metrics and management, we built some very interesting risk models that actually associate core chronic diseases and dictate how we intervene, whether they’re coming out of the hospital or they’re in the community. We’re looking at how to identify that cohort, whether we offer them AltaMed Now, which enables telehealth appointments, or another option.

 

The 80-20 rule

Gamble:  Creating those models seems to be really significant because it gives you that baseline and shows where you need to go from there.

Lowe:  It’s hard work. It’s new work. And being a community provider versus being an academic medical center, it’s a different perspective. Unlike academic medical centers, which have rich data scientists and programs looking at analytics, we’re looking at it in terms of hypertension and diabetes — that’s the baseline, as to how do we manage those patient populations? How do we use our case workers to intervene? How do we use alerts from our HIEs so we know where people are and how to provide services to them?

I have clinical informaticists and a number of physicians, nurses and other providers that are part of my team. If we can identify the right cohort and if we’re 80 percent right on that cohort, we can impact the patient population — which we did, versus some other areas where we got to be exactly perfect.

If we have a disease state and we’ve quantified who we need to address, odds are we’re going to be able to go in and treat those patients. That’s the outcome we’re seeing as we look at our transitions of care programs or remote monitoring programs to provide more enriched programs to help the patients.

 

Gamble:  That’s really interesting. I can see the challenges in saying, ‘we have to get to 100 percent,’ because in the meantime you could be making a difference and moving toward the goal.

Lowe:  Exactly. Oftentimes perfect is the opposite of good enough. Of course, clinically we want to be perfect. But when you’re talking about defining a patient population, that’s going to ebb and flow, especially in Medicaid managed care, where patients can go in and out of plans every month. They may churn month over month. For us, the challenge becomes how we can manage that versus when you look at Medicare. Generally, they’re going to do open enrollment and be committed to that insurance provider for that year; it can have a different type of impact.

The other thing we’re looking at is value-based care. Our CEO, Castulo de la Rocha, spoke at an AltaMed meeting about how we want to do 5 touches when you come into our clinics to address concerns versus sending you out for referrals. It’s having primary care providers work at the top of the license, effectively using a referral type of system as well and/or building even more functionality into our ambulatory modules. We’re looking at also those disciplines and what our patients’ needs will be.

 

Out-of-the-box patient education

Gamble:  When you have communities who are often overlooked or have a lot of challenges, I can imagine that one of the roadblocks is follow-up care and making sure those needs are being met. Is that a big area for you?

Lowe:  It is. Again, we’re really proud that we provide culturally competent care, especially in a Spanish-speaking population. Take, for example, colorectal cancer screenings, which is a HEDIS measure and a CMS rating score. We’ve developed some very effective programs using text campaigns and photo novellas, which are like comic strips, to help educate patients. This way, they get it. They understand it and they’re actually able to act on it versus being told in clinical terms to do something, which can be confusing. We simplified that. We’re using all types of patient engagement tools — calling, texting, emailing, informing, opening schedules, etc. — so that we can accommodate the patient. If that doesn’t work, we’ll offer an instant televisit to meet their needs.

 

“No one is left behind”

Gamble:  You mentioned that the ECM program and working with case workers. Is that a key part of the process to get easier access to certain parts of the population?

Lowe:  That’s an interesting question, because case workers do help coordinate clinical care, but they also help with some of the social and environmental aspects and helping the teams that connect them to the community services that are out there. That plays such a vital role in providing sensitive care. If someone needs a food or housing referral, we connect them so that no one is left behind.

The ECM is part of that. But you have the 90 percent of the Medicaid patient population that can also leverage our services. When they come in and we ask SDoH screening questions, we want to know what you’re doing with that information — how are you acting on that information? How are you helping the patient find those social services that will help and improve their lives? We’ve done quite a bit of work on that through our website and applications.

 

Epic Gold Star Level 9

Gamble:  Interesting.  You mentioned before being an Epic customer, which obviously has a lot of advantages, but there are also some very high expectations. That makes it all the more impressive that AltaMed earned Epic Gold Starts Level 9. That’s a really impressive accomplishment. Can you talk about how your team achieved that?

Lowe:  Thank you. So, for those who aren’t familiar, when you go through an Epic install, Epic gives you grades all the way through the process to make sure you stay on their path and program.

Once you launch, they actually have a gold stars program which actually measures how effectively you’re utilizing Epic. It’s multidimensional: revenue, check-in, ambulatory, your MyChart utilization — there’s a whole compendium of things that Epic scores.

Part of it is how good the Epic analyst team is at building and utilizing it and where we still need to go. Because again, the power of any type of EHR is how it’s being utilized — not only by clinicians, but also by your patient population. Are they getting it, understanding it, and fully leveraging it? It’s that cooperation and the governance that we use across organization. Because there is just a litany of functionality that you can release.

And when they’re releasing things into the clinical business areas, you have a very keen eye on 1) new functionalities, 2) what do I need to come back and optimize and reinforce, and 3) the quality perspective. We look at the provider satisfaction — how do we make the job easier for the provider? What’s on storyboard? What are the alerts and what needs to be actioned? We’re also looking at nursing and clinical practice and what we can do to make it easier for them, as well as streamlining it. This is some of the great work we’re doing with our clinical informaticists.

At AltaMed, we also have dental systems, we have a strong HIV/AIDS VBO program, and we have other disciplines to look at the whole patient.

The Medicaid picture

Gamble:  There’s so much going on. You mentioned governance; can you talk a little bit about the governance structure you have in place?

Lowe:  You know, governance is not easy. Governance is hard. It’s key to have a clear focus from the executive team right from the start. We’re very focused on value-based care and continued growth and optimization around that.

In California, we went from having an overage into having a deficit. Medicaid, of course, varies from state to state. Fortunately, our governor, Gavin Newsom, is making a commitment to community health centers and the work we’re doing, but we know we can’t necessarily rely on it. And there are other things happening in the Medicaid space where they’re going to full capitation under the Alternative Payment Model (APM). Instead of having more of a traditional fee for service model, we’re now going to be reimbursed from a whole capitation perspective based on patients and the clinic.

Providing a safety net

Again, when you look at Medicaid, patients are going in and out every month. There’s also Medicaid Redetermination, which was waived during the pandemic. Now, folks have actually fed into the insurance requirements for Medicaid; that can have a pretty big effect, because patients might no longer be part of it. It might be because it didn’t meet their needs, or it might be because they moved or changed their phone number. There are some very simple things that could unintentionally knock people out of Medicaid. But from a FQHC perspective, we have HRSA that provides the oversight. I think the beauty of AltaMed is that we have the ability to treat — and we will treat — anybody and everybody, independent of their ability to pay. That’s why safety net organizations were built.

I’m really excited about the quality of what we’ve done at AltaMed. If you look at HEDIS measurements, normally we’re 80 percent or higher for a half-million people. From a Medicare standpoint we’re setting at a 4 or 4.5 stars rating, so there’s quality across the board in how we treat patients.

 

Eliminating health disparities

Gamble:  It makes sense. You want to know that the tools are being used to the best of their ability, but it’s such a complex environment.

Lowe:  It is complex. There’s a number of tools that are out there that we have to deploy as well. I’m just so happy that we’re able to implement all of the patient engagement tools that the patient expects; whether you’re at AltaMed or Cedars-Sinai, we have the same level of engagement, so there’s no differentiation, which really closes down the health equity gap. That’s a big win.

There are so some rich analytics from a clinical perspective and how we’re aligning that. In addition to Epic, we’re also using Hopkins ACG model to become more sophisticated in terms of how we’re treating and identifying the cohorts. And of course, my physician informaticists are working with the providers on what we need to streamline and where do we need to fast-track.

To your point, it’s a very interesting as to how you pick and find your way through. But again, we stay very quality focused. We stay very patient outcome focused in terms of our prioritization.

 

Being “scrappy”

Gamble:  The informaticists seem to play a really key role in all of this, especially given the way that your organization is set up.

Lowe:  They do, and I have to say, people don’t often talk about clinical informaticists. You have Dr. CT Lin at University of Colorado — he’s the godfather of clinical informatics. Everyone loves him. He’s got his ukulele and his bowtie, and of course his physician perspective.

But for me being a non-physician, it’s so important to have people who understand technology; people who are practicing medicine and walking in their shoes. They have to train, and they have to understand the work so that it’s part of the decision-making process.

Some organizations have a lot of structured governance where you will go and review, which is a process. I think we’re a little bit more scrappy in terms of how we make decisions. We go back to our executive physician leadership team and our Epic governance to show, this is what we’re doing, this is how we’re moving through it, and this is what we’re building out.

 

Gamble:  It seems like you’re able to be agile and not fall into the trap of having too much red tape.

Lowe:  There’s a lot of complexity, so it’s being able to align on outcomes and stay focused on the triple or quadruple aims in quality, cost, ease of access, and provider satisfaction. That’s our guiding star. And you can also add in legal, regulatory, and other areas. All of this helps us make better decisions.

 

AltaMed’s growth spurt

Gamble:  So, you’ve been with the organization since 2018. I can imagine it looked a bit different then.

Lowe:  Right. So, AltaMed had grown quite a bit during the Obama era. We really raised the maturity of the organization to full enterprise level. It was a holistic digital transformation from front data center, all the way out to the endpoints. We didn’t have guest wireless when I first got there. Cybersecurity was very limited. We were using NextGen, which is a great product as well.

But now we’ve moved on to Epic. We’re on Workday. We’re on Cisco from a NIST protocol, and we’re hitting all of those marks. From a cybersecurity perspective, we immigrated PACS systems. We’ve developed women’s service lines. There are so many areas in which we’ve grown during that 6-year journey.

 

Gamble:  It’s kind of an interesting dichotomy. The organization’s growing, you’re bringing in these systems, but at the same time there’s more and more focus on the individual level.

Lowe:  Absolutely. Everybody talks about patient-centered care, but we really live it. We really live it. And it comes down from the top. Our roots are here in L.A.we started as the free East LA Barrio clinic in 1968; back then, there was no care in areas like this. Our CEO told us he would see people lined up around the building just to get a ticket to get in—not necessarily to get care.

Through his leadership, we’ve grown to more than 65 sites here in Los Angeles and Orange County, with 5,000 employees and 500,000 lives affected. It’s an amazing story of how to help equity in a Medicaid market, how you combine the quality of care, and how you can reach out to the community and be part of the community. That’s how we drive change.

 

Gamble:  You mentioned briefly AltaMed’s all-hands meeting. I would think that’s a tremendous opportunity to bring people together to connect and share in the mission.

Lowe:  It’s a great point. I have a team of about 130; within the auditorium, there are 5000 people and 500 leaders at AltaMed, and the work we’re doing is impacting 500,000 people we may never see. The work we do is so important; we may not be a huge team, but we have to be excellent in terms of how we perform, and we are. I’ve been fortunate enough to lead us in implementing full enterprise-level tools so that it’s very robust, from the data center and networks all the way up through the application stacks.

 

Keep moving ahead

Gamble:  It speaks to how much the organization has evolved in 5 or 6 years.  I’m sure it’s been interesting for you to be part of that.

Lowe:  Every year is a journey of something new. I remember talking to Cisco back when we were just doing core functionality. Now we’re pretty much a full Cisco shop, which is taking our organization to the next level. When you stratify what’s actually happening and all the electrons are flying in and out and you know that it’s been built correctly and it’s not going to collapse, you can keep moving ahead.

There have been a lot of conversations about technical debt — folks have to address it. It’s a problem. And in terms of cybersecurity, we have to be aware that we can have all the defenses we want, but the weakest links are individuals, who might let somebody in.

We had a recent incident where all the tools were working, but somebody let somebody in and they got access. We had to make some pretty dramatic changes in order to understand what was happening from a legal perspective so we could shore things up. But people really need to be vigilant in terms of what’s happening.

 

Gamble:  That’s definitely scary. Do you have a CISO, or at least a dedicated security leader?

Lowe:  I do have a VP of cybersecurity who reports to me, Tom August. Tom has been with me since March of 2023, and he’s really driven the NIST adoption. We don’t have a large cyber department, but through his leadership and with an amazing guy named Rob Rice, we’ve deployed a number of tools to understand that environment so that we actually have control of what’s happening at all the endpoints. We have about 7,000 endpoints, and so it’s important that we’re monitoring those and seeing what’s coming through and what’s being blocked.

 

Gamble:  It’s so important. All it takes is one incident to wreak havoc.

Lowe:  Exactly. It’s what keeps you up at night. If something happens, how do we communicate? How do you respond to it? How are you going to recover? That’s really, really important. We can’t underestimate what’s happening in the cyber world. The bad guys and girls are very tricky. We have to know how we’re going to react and how we’re going to keep them out.

 

Gamble:  That is very true. Well, I could definitely talk to you more, but I think I should probably let you go. But it’s been so interesting to hear about what you’re doing.

Lowe:  Kate, thank you. I really appreciate what you and Anthony do to help tell our stories. We all really help each other in healthcare, and I’m so pleased that AltaMed has amazing tools to improve care.