Gail Speedy Mayeaux, UPC Chief Executive Officer from 2005 to November of 2017, and Chief Financial Officer Michael Malick recall the path they have travelled to reinvest DSRIP dollars into organizational capabilities in preparation for the transformation to Value Based Payment.
Millennium partner organization Universal Primary Care (UPC) is a Federally Qualified Health Center serving almost 9,000 patients in Allegany and Cattaraugus counties. In addition to central offices at 135 N. Union Street in Olean, UPC operates locations in Salamanca, Cuba and Houghton, NY.
In 2017, UPC received its fourth consecutive National Quality Leader Award given to only the top five percent of health centers across the country which exceed at least six of the Healthy People 2020 measures. UPC operations also hold Patient Centered Medical Home (PCMH) National Committee Quality Assurance (NCQA) Recognition – the Gold Standard for practice transformation. (UPC works closely with the Millennium Primary Care Transformation Team including Amy Pease, RN MA, Practice Transformation Consultant.)
How did UPC grow from a struggling $3 million organization challenged by debt in 2005; to today’s $9.5 million model of operational and patient satisfaction excellence?
Of the many key management team actions and decisions, supported by the exemplary efforts of the UPC team; UPC’s track record of continuously re-investing DSRIP funds to build a lasting organizational foundation, stands out as being critical to UPC’s ongoing success.
Recently, Millenniumcc.org travelled 80 miles south of Buffalo to Olean to speak to Gail Speedy Mayeaux, UPC Chief Executive Officer from 2005 to November of 2017; and Chief Financial Officer Michael Malick, to learn more about their approach to organizational growth, including lessons learned and pit falls to avoid along the way.
(Reader Note: To read specific sections, click on the link(s) as follows. To read the Case Study in its entirety; skip the links and proceed below.)
PART 1; BUILDING UPC: 2005 – 2017
Millenniumcc.org: What did UPC face in 2005?
Gail Speedy Mayeaux: In 2005, we were a struggling public health organization facing a sort of confluence of things. The first was that in 2005 and 2006, the two counties we served — Cattaraugus and Alleghany – were fully transitioning to the Managed Care Organization (MCO) model for Medicaid. This meant that clinic rates organizations like ours had initially relied on had now gone away. In our case, the average reimbursement rate for a Medicaid visit went down from about $70 to about $32, even though it was costing us about $68 to take care of that patient. So, in 2006 when I took over, we were about a $3 million organization and we were in an incredible amount of debt.
Millenniumcc.org: Where is UPC today?
Gail Speedy Mayeaux: Today, UPC – thanks to an incredible Leadership staff – is going to end 2017 at about $9.5 million in the black. We have been in the black as per our audit in 2007, and now are very well positioned. We’ve got solid assets. We’ve won the National Quality Award for the three years it’s been in existence. This award is typically given to the top performing health centers across the country. We are the only one in New York State – outside of Charles B. Wang — which is a health center outside of New York City, that has won it all three years.
We’ve also almost tripled in size. We’re at about 90 staff now, and we were about 40; and I have been UPC’s second CEO since I arrived in Feb. 2006.
I left the organization at the end of November for a different career opportunity which is very bittersweet. UPC has been such a huge part of me and I love this place. But it’s an importunity to slow down and have a little different life style.
Millenniumcc.org: When did things start to turn the corner for UPC, leading you to where you are today?
Gail Speedy Mayeaux: I think there were actually three key pivot years.
In 2008, we were able to almost make it pay to be an Article 28 Diagnostic and Treatment Center (DTC).
Being an Article 28 DTC means that you are licensed by the New York State Department of Health to operate a clinic required to accept all persons without regard to ability to pay.
So, our model is such that we are the largest Medicaid provider and uninsured provider, as well as one of the largest primary care providers in Cattaraugus and Orleans Counties. We have always accepted everyone. We take particular pride in that our sliding fee scale slides all the way to “zero” so a patient would not have to pay anything if they were truly indigent.
In 2008, we were also able to expense manage ourselves down to where we were almost able to break even.
Then in 2009, we became an FQHC “look-alike” and that allowed us to access a cost-per-visit payment, so in that scenario where it cost us $70 to do the visit, and we were only getting paid $35; when we were able to get the Medicaid wrap around payments as an FQHC “look alike”, we were able to recoup that $35.
In 2009, when our first cost per visit and wrap around rate were set, (the cost per visit was actually $102 per visit), that allowed us the model to become financially sustainable, but we had such a back log.
The other way you expense manage yourself is of course you do late payment to vendors. That’s what all struggling business do, that’s what we did.
At that point, when you have a sustainable model, now you have to start managing cash flow and managing cleaning up this vendor ledger.
Millenniumcc.org: What makes you an FQHC “look alike” vs. being a Federal grantee?
Gail Speedy Mayeaux: An FQHC “look-alike” means you meet all of the standards for Section 330 federal grant funding; but you don’t get any Section 330 federal grant funding. So why would you do that? Why would you meet all of these standards and 19 federal grant requirements?
From a business perspective, there’s no way to make that pay.
But from a humanitarian and community perspective, it’s the right thing to do for the people you’re serving; and you’re serving the most vulnerable population, but there’s always that battle: there’s no romance without finance.…”
The inducement to become a “look alike” is that it opens up a couple of benefits for you. Primarily, the biggest benefit is that it allows you to get cost-based reimbursement. So in the age of managed Medicaid, you are not always reimbursed the full cost of seeing the vulnerable patient; plus you are seeing at that time 10 to 15 percent uninsured. It allowed you to access cost based reimbursement for these folks who used Medicaid, while also allowing you to be financially stable. And that was the biggest benefit.
Adding Chief Financial Officer Michael Malick to the UPC team in 2012 accelerated the organization’s “infrastructure build” strategy and enabled Gail Speedy Mayeaux to focus on “wearing one hat” as CEO.
Millenniumcc.org: Were there any other important developments?
Gail Speedy Mayeaux: The final pivot point was June 20, 2012 when we became an FQHC grantee and Mike (Chief Financial Officer Michael Malick) came shortly after, we were still cleaning up the vendor ledger. That’s how long it took.
Millenniumcc.org: What did Mike as new Chief Financial Officer bring to UPC?
Gail Speedy Mayeaux: Mike implemented the strategy beyond ledger clean up. He began asking: “How do we start to use our resources to build out the infrastructure?” That was really what we tasked Mike with: “What do we look like when we finally don’t have all this debt?”
PART 2: UPC GROWTH HIGHLIGHTS
Millenniumcc.org: From 2012 to 2014; what were some highlights as you grew?
Michael Malick: As Gail said, it was establishing policies and procedures; daily routines on just managing the financials of the organization.
When I first started, one of the first things I was working on was satisfying the audit at the end of that year. And from that, working towards establishing the detail and accuracy of the financial statements that we presented to the Board and that we have on file for the government as far as meeting FQHC requirements.
Gail Speedy Mayeaux: I chuckle hearing this, because prior to Mike’s arrival, I had been serving as the CFO as well as the CEO; and we continually had a material weakness in our findings because we didn’t have the level of detail that we needed on the financial reports (and you can imagine as you try to divide yourself in half).
When Mike came on board, in his first year, he had to clean that up. Since Mike has been here, every subsequent year, we have not even had a finding; and the last three years, we have not even had an adjustment to a journal entry. Until Mike arrived, we did not have the systems in place. Mike was able to build those systems and put us on solid ground for the future.
Michael Malick: With the federal monies, we were able to not only reduce our vendor ledger but also increase our cash reserve which was huge.
Gail Speedy Mayeaux: Mike led that process to build our cash reserve and that was so formative for us. Because we never had that. That insight regarding the importance of cash on hand was huge, as well as working with the Board to structure our data to provide the kind of information they really wanted to know
There were a lot of highlights:
We moved into this clinic; so we went from a 7,000 square foot clinic to a 10,000 square clinic.
Then we added an additional 4,000 square feet here which enabled us to add Behavioral Health and Care Management.
We also added the Pharmacy program which was huge for us, and Mike implemented — from a financial perspective — how we account for Pharmacy and that was huge.
Mike also led the effort to bring Billing in house and led the development of policies and procedures. That really locked down the process so that people could hold themselves accountable, and the organization could hold people accountable.
By adding 4,000 square to its Olean clinic, UPC was able to offer Behavioral Health and Care Management services to its Medicaid clients.
PART 3: ENGAGING WITH DSRIP
Millenniumcc.org: It’s clear UPC did a tremendous amount of work to fortify your foundation and strengthen your business which set the stage for your continued growth. Given all this progress, why initially connect with DSRIP?
Gail Speedy Mayeaux: I think that goes back to what we’re really all about. We’ve talked a lot about the business strategy, but I don’t want to lose sight that everything we have ever done has ultimately been to meet the needs of our community.
Even before we were an FQHC, we cared about the needs of the Cuba, Houghton and Olean communities. What do these communities need? How do we provide services to these communities? How do you make certain that the services are quality driven? And how do we make sure that it respects where somebody is? So, when DSRIP came along, the impression was – from both the business of health care and health care itself – what appealed was the idea of really creating a system that is patient friendly, patient centric that removes duplication and cost.
When we talk about reduced hospitalizations and reduced ER use, what’s really critical, and what sometimes gets missed, is how traumatic it is for a family member to be in the hospital or to be in the ER… and how that can have such long lasting implications if you don’t have insurance.
Or if you work part time – and are working almost full-time hours – but because you’re part time, you don’t have vacation time. Or you do have vacation time, but you don’t have enough. Now you have a personal financial implication. What if you’re a single mom and you don’t have access to care, and you need to take your 5- year-old to the ER for an ear infection which was the number four reason that our people were using the ER … but you also have a 7-year-old and a 3-year-old and your child came home off the school bus complaining “I have an ear ache” and the first thing you have to do is get him fed, get him ready, get school work done; then you’re going to the ER with these three children and you might not get home until 9 PM at night… and who’s going to want to get up and go to school tomorrow?… and how is that child going to be successful?
I think a lot of the appeal of DSRIP was making healthcare rationale for all of us. For myself as a consumer; as an employer and as a family member of people who use the healthcare system.
On the business side of DSRIP, we spent a lot of time hearing about Value Based Payment back in 2013; we recognized that if we were going to be what we needed to be for our community, we also needed to be prepared to financially support the model. And I think that was important.
And the final thing was understanding that there is a regionality to healthcare and even though we are in a very rural area, we expect our patients to make that travel — especially if they are going to see a specialist — so how do we develop the relationships that will at least grease that wheel.
PART 4: DEPLOYING DSRIP DOLLARS –
ADDING DATA ANALYSIS TO PREPARE FOR VBP
Millenniumcc.org: You began connecting into the DSRIP program, and after signing an MPA, you began to earn DSRIP dollars. How would you describe what you began to earn?
Gail Speedy Mayeaux: Part of the DSRIP financial model is that you were going to engage in transformation and at the end, you were going to receive grant dollars for that action of engagement. And because we were always going to get paid in arears, that’s when Mike and I started talking about, if we’re going to do this, we are going to adopt those things that are going to get us paid that essentially when that money comes in, it is unencumbered.
And we had many conversations, and I would ask Mike, “what are we going to do with this money?” And Mike would respond, “well, what’s the strategy?”
Michael Malick: We spent a lot of time understanding where we had come in terms of making the organization stable and strong; and what would best serve the mission? That’s what drove a lot of the discussions.
Gail Speedy Mayeaux: Right from the beginning we both said: “This is unencumbered money we weren’t expecting, how do we invest this money in what we need to get ready for Value Based Payment? This was constant. This is new. This is unencumbered. This is found money, what does this organization need?”
Millenniumcc.org: And so, what was your strategic reply?
Gail Speedy Mayeaux: We began by funding OMAs and a Data Analyst.
So the first time we said, we recognize that we have a lot of burden on our providers and we need the nurses to help the providers more, but we can’t just squash that work down and lay it flat. So we need Office Medical Assistants (OMAs) to help with those things an OMA can do so the nurses can help the provider more.
And on the flip side we said, “We need better data.” The thing that drove us was that fear around understanding our data.
Michael Malick: In preparation for Value Based Payment and whatever that would bring, we determined we needed a Data Analyst, an IT person who could do data mining.
Gail Speedy Mayeaux: One of the best things we did there was we hired a Data Analyst that was not from health care. She came from banking and is somebody who can look at data without any sort of bias. She didn’t have a bias as to whether a number was good or bad. What she cared about was it accurate?
Millenniumcc.org: What would be examples of that “accurate data”? What types of data sets did she bring to you?
Gail Speedy Mayeaux: All Federally Qualified Health Centers need to report out on uniform data systems every year. We have a software overlay system called the Center for Primary Care Informatics (CPCI) that mines our data for us, and our Data Analyst came to me and said, “I ran the UDS and our colorectal cancer screenings dropped… and this is why…” and she had dug through and had realized that because the test name changed and we were ordering the colorectal cancer screenings diagnostic imagining differently, it was no longer connected in CPCI and it looked like we were no longer as compliant as we should have been.
And what was really key about that was the IT department started saying: “Wow, we need protocols when a lab name changes; when a diagnostic image changes, when an insurance field changes… you don’t go changing an HAR without letting us know so we can re map it.”
On the flip side, she has worked with our billing manager. She has every insurance we work with in the system. They went through and categorized insurance by payer so that we got better data that showed we were even seeing more Medicaid patients than we thought we were doing. So as those kinds of things that having an analyst on staff really brought to the table.
And it was really interesting because the more we saw that she could do, the more we saw we needed additional help. And in the next year of funding, that’s what we did.
PART 5: INVESTING IN SUPPORT STAFF
Millenniumcc.org: So, one of the first thing you did was invest in human resources?
Gail Speedy Mayeaux: Yes, and most of our investments with the DSRIP dollars have been in staffing… but not necessarily revenue producing staff. A lot of support staff!
Because in the next iteration, we realized that if we were really going to make a difference in people’s lives, we needed additional Care Coordinators. And then when we received the Maternal and Infant Health Grant, we brought on Community Health Workers; but then we built out data a little bit more.
Millenniumcc.org: After investing in support staff to continue to strengthen the organization, what was the next thing you did with your DSRIP dollars?
Gail Speedy Mayeaux: At the same time, we received Health Resources and Services Administration (
In a Care Management model, those patients that are healthy, you just want to get messages out to them so they do their annual screening, this person manages that.
We also added four Community Health Workers for Maternal and Infant Health,
They do home visiting with our pregnant moms. The goal there is to reduce pre-term labor, to have healthy weight babies, and to ensure that the baby gets immunized and that mom does post-partum visit follow up.
We have two Community Health Workers in Cattaraugus and two in Alleghany county and they do home visiting and they also come on Fridays and participate in a roll call meeting with all of our OB providers, and RN Care Managers.
They discuss what’s happening with patients. It adds into that OB meeting social determinants of health. We have that meeting on Friday so that whoever was on weekend call would know who could potentially come in on labor or who potentially was having a problem, so that they were not going into the weekend cold.
Millenniumcc.org: What other things did you do with your DSRIP dollars?
Gail Speedy Mayeaux: We added a Billing staff member to focus on credentials and we added a Clinical Secretary to provide the medical staff more support and an Ultra Sound Tech. We were a 60-person organization in 2014 and we added 20 staff people in 2015.
PART 6: WATCH OUTS ALONG THE WAY?
Millenniumcc.org: What “watch outs” did you think about as you received DSRIP dollars?
Michael Malick: The one thing we were very careful of was to not use those monies to cover any shortfalls in operations. That money was earmarked and dedicated to infrastructure building.
Gail Speedy Mayeaux: When you’re a safety net provider and you’re living off of 2 and 3 percent margins, it would be easy to use that money as a windfall.
We were truly blessed that we were in a financial position through the 343B pharmacy program; the HRSA grant, all the improvements that we had made on the financial side of the house, that we could use this money and really earmark it to investments.
We were careful to not to use the money to buy computers or anything like that.
But back in the days when we were poor, that’s exactly what we would have used it for. We would have used it to clean up some of our vendor debt. When you are operating on thin margins, and you receive unencumbered money, you have to put it into survival.
We were blessed, and I think we recognize that.
READY FOR VBP IMPLEMENTATION
Millenniumcc.org: When you step back from all of this continued investment, how has this prepared you for VBP implementation?
Gail Speedy Mayeaux: I think we’re in pretty good shape now. I think we understand, from a data perspective, there’s going to be differences such as who payers think you treat and who you think you treat. There is always going to be this data disconnect.
So in order to get ready for VBP, without payer data – and that’s something that’s in the pipeline to arrive but that’s not here yet — you had to get your data ready.
You have to be able to challenge if it says that your colorectal cancer screening last month was 53 percent, but this month is 45 percent; don’t just say “well, that’s not that wild of a swing, it’s only 8 percent.”
Say instead, “this is a 10-year measurement and we dropped by 8 percent. There’s something wrong with that. And really challenge your data all the time. And we’ve really created that culture.
For example, we have 99 percent asthma compliance rate… and if you have somebody from healthcare, you wouldn’t challenge that number.
But having someone from outside of healthcare say I’m going to challenge that number because that seems outrageously high. That’s healthy.
I think we’ve made the investments in Billing staff so they are ready for this
I think we now have the Patient Access staff that are now ready to help patients bend that curve on avoidable ER use and avoidable hospitalizations; as well as helping people stay healthier… we’re doing right now falls prevention class two days a week; and diabetes education.
We’re also getting embedded in that prevention model and we’re living and breathing it all the time. And I think that prepares us.
Millenniumcc.org: What would you say to another organization about VBP?
Gail Speedy Mayeaux: Your opportunity with Value Based Payment is really for a finite time. Nobody knows exactly is that three years? Five years? Seven years?
The VBP opportunity is that you are going to have a pool of unencumbered money because you are going to be paid in arears that you can use for infrastructure.
For us, it was really critical to say: “We have got to bake in our costs now so that when we get to a value based payment arrangement, we will have those resources that will stay unencumbered and so we can stay a step ahead of where we need to be from a financial perspective so that we’re ready.” So, we hopefully will always have the assets in place so we can respond to either the needs of the marketplace or needs of our patients.
Michael Malick: It’s critical to understand our total cost of care per patient and building the infrastructure so that as patients age or as we predict we will be caring for more of the sicker or fragile patients; we can analyze what is going to cost us to be able to provide that same level of care and be successful for these patients.
We will always see anybody regardless of their ability to pay or their condition, but we need to be able to proactively manage.
Millenniumcc.org: Have you begun the process to engage with other key providers in a VBP arrangement?
Gail Speedy Mayeaux: We are a member of two formal Accountable Care Organization (ACO) arrangements, and we are working with some of our peers to look at potential Independent Practice Association (IPA) development regionally.
We are a member of the Community Health IPA Community Health Independent Association (CHIPA) and a member of Upper Alleghany Health Systems Clinical Information organization that is a Medicare ACO.
SNAPCAP (Safety Net Association of Primary Care Affiliated Providers) is also looking at the possibility of IPA development.
Millenniumcc.org: How would you ultimately describe your readiness for VBP because of the investments you have made?
Gail Speedy Mayeaux: I think we are ready to pull the trigger.
Michael Malick: We have positioned ourselves to be ready. There is always an unknown, but I think we have positioned ourselves to make adjustments… I think we’ve done most of the ground work already.
Gail Speedy Mayeaux: We really understand our data; using the Uniform Data System (UDS) measures as a proxy, we can deliver on quality; we’ve built out the infrastructure to the point where if you don’t make your sub specialty appointment, we’re going to follow up on it and we are going to reschedule it or find out why you couldn’t go and we’re going to get you there.
I really think we’ve put all the services we can in place. Are there future enhancements? Certainly. Have we invested every dollar completely the right way? I guess we’ll find out.
Millenniumcc.org: What can another organization ultimately learn from your experience? How you have spent a significant amount of time asking the strategic questions; looking at your mission; and ultimately, investing in the future?
Gail Speedy Mayeaux: If it were 10 years ago, and we’re poor UPC again, and we’ve used the first two years of DSRIP funds to really stop gap; and now we read this discussion on the Millennium website, and you get that pit in the bottom of your stomach that says, “What if we’re not ready? We’ll get even further behind!”
I guess the message would be, all is not lost. There are essentially two years left in DSRIP, three years left in payment. There are private funders out there – if you’re not an FQ to help you build out your infrastructure; there are partners out there willing to share, and the SNAPCAP partners are amazing and will share whatever they have.
And if you can’t afford to invest 100 percent of those dollars; try to do 75 or 50 or even 25 percent of those dollars to get ready…and that’s at least a little bit down the road.
Lastly, I don’t think we did everything perfectly. We made the best decisions we could at the time. It was very iterative.
We’d love to tell you we sat down and always had extremely strategic meetings and identified all the staffing positions that we needed, but the truth of the matter of it is, we just continued to have informal discussions that involved the Medical Director, Clinical Operations, Care Management, Behavioral Health, IT…. We really tried to get as many of the senior leadership folks involved as possible. That involvement has ultimately been key to it all.