RWJBarnabas Executive Views Social Determinants as Catalyst for Change

The coronavirus pandemic created challenges and opportunities for change as Paul Alexander, MD, MPH, took the reins as chief transformation officer at the New Jersey health system.

As the new chief transformation officer at RWJBarnabas Health, Paul G. Alexander, MD, MPH, had an unexpected challenge foisted upon him after he started the job in February: a global pandemic. While COVID-19 changed his course of action, it also presented opportunities to accelerate transformation, and showcased the need to address social determinants of health, one of the keys to improving healthcare, he says.  

Among other positions, Alexander formerly served as vice president and chief medical officer of government programs for Horizon Blue Cross Blue Shield of New Jersey]and regional chief medical officer for UnitedHealthcare. His background in the payer market brings an interesting perspective to the West Orange, New Jersey­–based healthcare system, which includes 11 acute care hospitals, and is in the process of transitioning to value-based care. RWJBarnabas Health was created through the 2015 merger of the Robert Wood Johnson Health System and the Saint Barnabas Health Care System.

Alexander's journey and lessons learned along the way serve as a guiding post for other health systems who are grappling with their own transformation initiatives in the midst of the pandemic. Alexander, who also serves as senior vice president, recently spoke to HealthLeaders about his first few months at RWJBarnabas. His comments have been lighted edited for space and clarity.

HealthLeaders: What are your three primary goals in your job as chief transformation officer?

Paul Alexander: Improving identification and management of patients that have rising healthcare needs. That's the group I think that we can impact the most. The second is maximizing our resources to really benefit from the financial opportunities that value-based programs offer. The third is very much about social determinants of health. For me, health equity is of the utmost importance.

HL: You came out of the payer market. How are those experiences going to be helpful to you in this role?

Alexander: The experience that I bring is an understanding of the importance of care management, outreach to our members, and looking at quality metrics as outlined by HEDIS (Healthcare Effectiveness Data and Information Set), as well as our contracts with health systems. In the payer space, it's very much about data and cooperating with providers that are in network to deliver high-quality care consistent with the triple aim, which is ensuring appropriate utilization of services, ensuring good quality outcomes, and creating access.

Having that focus as a chief medical officer of government programs [at Horizon Blue Cross Blue Shield of New Jersey], I was responsible for Medicaid, Medicare, and long-term support services, and having to deal with populations that, historically, either were disconnected from the healthcare environment or individuals who were in need of additional support in order to maintain health and wellness.

The value of bringing that [experience] to the health system has allowed me to take a much broader perspective on what's taking place now on the provider side to be congruent with what I saw on the payer side as an opportunity.

How do you evaluate your effectiveness based on the metrics that are created? Sometimes folks look at process. I think process metrics are great, but outcomes metrics is really where the rubber meets the road. [For example], in a diabetic, looking at outcomes in terms of the impact of medication to reduce a hemoglobin A1C. How do we measure that? How do we create processes that will allow us to improve outcomes performance? Readmissions is another outcomes performance metric. Satisfaction is another interesting metric. Looking at member experience with the healthcare provider, their hospital, and their overall health, I am bringing that sort of insight to population health.

HL: Where does value-based care stand in your market?

Alexander: I can't give you a percentage of our market that's in some sort of value-based or shared services program … it's varied throughout the system. Value-based care is increasing when you look at our payer contracts. Horizon and United are introducing value-based care. Part of it is total medical expenditure; part of it is quality, but at the end of the day, it's also about utilization. When you look at the system as a whole, we still have facilities with a very high percentage of fee-for-service, like Medicare fee-for-service. So in those facilities, we have the bundled payment program, such as complete joint replacement programs, et cetera. We haven't yet maximized the opportunity that is offered by these programs in terms of financial outcome. More importantly, have we really evaluated how we're utilizing our internal resources?

Paul Alexander, MD, MPH (Photo courtesy of RWJBarnabas Health)

HL: What strategies are guiding your approach?

Alexander: In terms of strategy, we have an opportunity at the health system to utilize our resources in a manner that makes sense. It's a very dynamic, forward-looking system with great resources throughout. My goal is to try to identify those resources along with best practices [for] population health.

When I started this job, I said, "What are we doing in terms of acute inpatient, ED [emergency department] transition, or transition from home to acute care? What does that look like? How's the information flowing?" But I found that the post-acute setting was going to be a bit of a challenge. The post-acute care opportunities, I owe to the pandemic.

As the numbers for the epidemic started to increase and the hospital was becoming challenged with emergency room utilization and overpopulation in the ED and the lack of inpatient bed availabilities, there was definitely a need to develop a process to transition some of these patients home with support, who may not require acute care.

We went through evaluation, looking at patient presentation, identifying any comorbid conditions, reaching out to the patients directly to determine what sort of infrastructure they might have had at home, looking at medications … and also took into consideration some social determinants—concerns about housing insecurity and looking at food—to ensure that there was an effective post-acute setting to monitor these patients.

So what does monitoring look like for us? Monitoring blood pressure and oxygen and a lot of the population health team reaching out directly to the patient in the home on a regular basis in response to COVID-19. We also implemented telehealth along with that. The necessity provided me with an opportunity to understand a lot faster how to implement a full care continuum from inpatient to post-acute. I will continue to look at the value proposition in terms of how we can expand this throughout the system.

HL: How has the pandemic itself transformed your system and approach to delivering care?

Alexander: It's been effective in increasing awareness around health equity—or inequity. However, you look at it, given the impact to low income and minority groups, it raised my awareness that whatever program we put in place, whether it be telemedicine or hospital at home, to be successful we really have to take into consideration social determinants of health. The mortality [rates] in communities of color, as well as in individuals who are older or disabled with chronic disease, their likelihood of dying is much higher. This needs to be [considered] in the strategy of whatever program I develop; we have to not lose sight of the importance of social determinants.

It's multifactorial, in that there also has to be trust with the health system. We've got [to have] individuals from the community—who actually know the communities that they're working in—to reach out to our patients and provide a little bit of continuity in terms of knowing what circumstances individuals are living in.

With COVID-19, awareness increased around implicit bias. What does that look like if an individual is doing a telemedicine call? How is that conversation going to be addressed? Who monitors that conversation? These biases are real, and it does have an impact on health outcomes. How do we begin to assess and manage that moving forward? So those are the challenges I'm looking at when I think about our path into transformation.

HL: What role does innovation play in helping you address these issues?

Alexander: In response to COVID-19, the innovation of using technology in the patient's home was pretty important. Folks were a little apprehensive about it initially, including myself. [We have to] ensure that it works, and it delivers value. As we expand our technology for individuals who either don't have access to a physician or live in a rural setting, we have to ensure that we're maintaining their privacy and they do have the appropriate level of connectivity. One thing I'm always concerned about when we look at social determinants and look at telemedicine is many of the individuals may not have appropriate broadband coverage on their phone. They may pay for minutes and may not be able to spend all that time on clinical calls. How do we begin to address that? I do think, moving forward in terms of the interface between patients in the home setting and our care managers and physicians is the future. The other part is actually having feet on street, having nurses and physicians who are managing care in the home. If delivered in a safe environment, home is probably better than going to the hospital.

HL: Moving forward, what is your biggest challenge?

Alexander: One is that we have a very large health system. Eleven acute care hospitals is not an insignificant number of nurses and doctors that have been doing well in their own space. [We need to] create some sort of innovation where all of us are working together across the system and maximize the resources that we currently have in place. It's an interesting conversation because I want everyone to know that they're doing a great job, but I also want them to buy into maybe we could do an even better job if we are all working towards the same initiative and we're aligning our resources. My initial thought was this would happen in a couple of months. I can blame it on the pandemic gratefully because everything's delayed, right? Realistically, this is going to take much longer than I initially thought.

HL: Three years from now, what do you hope to say you've accomplished?

Alexander: I really would like to accomplish two things. One is to [master] our performance on value-based contracts, both with CMS, as well as with [commercial] payers. Two is to get a better handle on how to manage social determinants, in care and improve outcomes for disadvantaged populations, which has always been a priority for me.