WEBVTT
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Hey everyone, welcome back to Beyond Quality.
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Before we get to today's episode, 30 Seconds on an Upcoming Conference hosted by Rise, our season one collaborator.
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Rise West is being held September 2nd through the 4th in San Diego.
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500 plus Medicare Advantage senior leaders and provides direct access to OIG, attorneys, industry experts, and health plan execs.
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I don't think we've ever had attorneys be a key uh a key draw before, but this is the world we live in.
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Um it will have interactive roundtables, workshops, QA, and two dedicated tracks so you can focus on the topics that matter most to you.
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Use code beyond VIP at risehealth.org slash beyond to save 20%.
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Now on to our episode today: margin compression, MLR, and GLP1s.
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Oh my.
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Across the health plan industry and every line of business, uh, the financial backdrop right now is brutal.
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Benefit degradations, organization restructuring, and market exits are topics being discussed inside virtually every health plan in 2026.
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Let's get into this.
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I'd like to introduce my co-host today and our guest.
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My co-host is a consultant that works with me at RWC.
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She has deep experience in quality improvement with an exceptionally deep expertise in all things related to value-based care.
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Please welcome Paige Caprera.
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Hi, Paige.
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Hi.
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And then our guest today is the Chief Financial Officer at Community Health Choice, a health plan right here in Houston, where I live, uh, that serves underserved populations and does great work here.
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Please welcome Anna Mateya.
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Welcome, Anna.
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Thank you.
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Great to be here with you.
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So um thanks for joining us, yeah, Paige and Anna both.
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Um can you guys give the listeners just a little more background on yourselves so they can um understand kind of who who's on today?
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So, Paige, can you start?
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Sure, yeah.
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So Paige Caprera, I reside in Columbus, Ohio at the moment.
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Um, been in a couple of different areas around the country, um, Houston being one of them.
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I didn't live there, but I was there every other week for about a year and a half for business development position with um with an IPA CINACO out of um, or a national one.
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Um so we've been about 15 years in the Medicare Advantage space, um, a lot of provider relations, um kind of in private provider engagement background, but a lot with um traditional Medicare through the ACOs, as well as the clinically integrated networks and the independent physician association.
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So STARS is close to home in all of those realms, and also was um very fortunate to have a team of analytical strategists at Centen for a little bit that you know we've kind of consulted with each one of the regional plans.
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So we love the regional plan piece of of life.
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It's um it it those those local close-to-home plans make a huge difference in the communities.
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So yeah, happy.
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Oh, and I've I've been working with um community health for about a year and a half.
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So um yeah, happy to have Anna on with us too.
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Yeah, so excited.
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Yeah, uh, thank you, Paige.
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How about you, Anna?
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Yes, um, well, Anna Matea.
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I'm the CFO here at Community Health Choice, and I started my career back in 1988.
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So I've been in healthcare almost 38 years now.
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Uh had a little experience in the consulting area, the hospital side, I've sat on that side of the of the um of the bench, and then uh was part of a startup health plan, and then here at community.
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Um and I guess I'll share on a personal level uh as I'm moving towards the you know, the back end of my uh my career, uh health and fitness is something really important to me.
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And I started running and I I did um I did a marathon, you know, recently uh in my 50s, and so it's just been really interesting thinking about health and fitness being in the healthcare industry.
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Yeah, wow.
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I've uh I I started running when I was in my fifties too, and ran a half marathon a couple of I guess in 2023, and haven't run anything since.
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It was it was a big thing to check off my list, but my knee uh my knee felt it for sure.
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And I don't know.
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I gotta I gotta get back into it though.
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In Houston, it's not that easy, right?
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Anna?
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There's not um it's hot.
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It's hot.
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It's hot.
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It's hot.
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It's hot.
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Um well let's let's jump in.
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So Anna, we'll start with something kind of light and fun here.
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Not really.
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Um can you can you walk us through what keeps uh a health plan CFO up at night in 2026 and and how how does that differ from three to four years ago?
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Yeah, that's such a great question.
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You know, I as I'm thinking about the question, the you the role of a CFO is really to ensure the solvency of the organization and make sure that we're here for the long haul.
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And so we're we're constantly looking at what our forecast is for the future, setting that goal for what the future is, and then we're measuring performance to see how are we tracking against what those goals are that we set.
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And what makes that easy is when you have predictable situations, and we've just had so much uh change in our industry that creates a lot of complexity.
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Um medical cost is definitely an issue, it's always been an issue monitoring medical cost and setting rates, those are two important things.
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But uh I think the membership transition that we are experiencing more recently is a really compounding impact.
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Um, there's a lot of legislative impacts that are driving that on the marketplace side, the subsidy issue, whether the subsidies would be extended, and of course they were not.
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And so when that happened, the concern about membership contraction, and we did see some level of contraction different, maybe a little bit different than what was projected, but um that contraction has resulted in a change in the average mix and acuity of members, and it's impacted the revenue streams that we get for risk adjustment in in ways that were unexpected.
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And you you saw last year about this time where many health plans had to retract their earnings reports because of that, you know, that of that single factor.
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And so, you know, today there's just so much we are dealing with not just medical costs, you mentioned GLP ones, different cost drivers, um, setting prices for health care to ensure that healthcare is affordable and accessible, but then also these other factors around how our members are changing because healthcare is just becoming so expensive.
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Some people are just unable to choose to continue to uh afford insurance and how that's affecting other downstream impacts that that create lots of complexity for our organizations.
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Um, you know, you you back it up a few years ago our our issues were around coming out of COVID and um how healthcare had sort of compressed to lower levels of utilization, and so just major shifts in in what we're focusing on today.
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Do you do you feel like what we're experiencing today is is still related to the pandemic a bit or or are we are we beyond that?
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Well, we've definitely transitioned and there are things that are changing, but I I think uh I think there are still compounding factors that are that are happening.
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Um the pandemic, even though you know it started in 2020, the unwinding of the pandemic really we felt that um in 24 and the contraction of membership uh was really significant in uh the the rate setting process because oftentimes the the the revenue that we get is based on usually historical information.
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And so one of the issues that we find is that it takes so much time for that information to inform the revenue side of the house.
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But today you're experiencing new trends on the met you know on the cost side, and so that alignment between your revenue and expense is is a challenging thing to mix when you have that timing delay uh on what's informing your revenue.
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Um but I I do think care delivery is also still being assessed on on the impacts from the pandemic, how it was delivered, and what we've learned about um what is needed.
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Um you're seeing some of that transition now, uh certainly escalation in utilization levels, but we are still um being impacted by some of the learnings from COVID and care delivery.
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Well I was at Kroger the other day and um just a quick trip in there, and in every I've never like um they have the the the posts in front of the door to prevent cars from driving through there.
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There's like 12 concrete posts, right?
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Every one of them on both sides, on both doors, had had a sign for GLP 1s.
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And um like like advertising, hey, you can get your GLP one here at Kroger.
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Um and I know so many people on GLP ones and so many people experiencing amazing benefits that are affecting so many different parts of their life.
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Um not you know, well like weight is just the beginning, but when you lose weight, if you need to lose weight, it it positively affects so many other places in your life.
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So but it's so expensive and it's so you know, it's uh in the marketing and advertising that that big pharma and everyone else does for that.
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Just the cost is enormous, right?
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So I have to think um if I'm in some of those rooms at a health plan discussing finances, that's such a a big topic by itself, I would imagine, right now, with the GLP ones.
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Yeah, it's uh the GLP ones are definitely w what we're seeing is the the um the usage of those drugs, not exclusively for weight loss, but for certain disease states.
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And so that is uh what they're intended for, what what they're sure, what they're intended for and um where they're covered under your your plants.
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Right.
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And so we're we're seeing uh certainly in diabetes and uh other certain other disease states and cardiovascular uh cardio conditions where the GLP ones are indicated, and the impact on drug cost is really incredibly significant.
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Um the per the percent of total is you know exceeding 50% of your spend in certain certain disease states specifically for uh GLP ones, and that's increased to almost 70% in some uh more recent periods of time.
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And not that we can say that GLPs are the reason that you know plans are exiting markets, but you know, we see a lot of plans over the last few years exiting counties or exiting full states and even regional or some plans just closing down.
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Um when a finance team is looking at those numbers, like what kind of um what kind of things are tipping those scales?
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Again, probably not just GLP expenses, but like what what's the tipping the scale between like we're just gonna restructure things or change our benefits versus like we need to leave this market?
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Interesting question.
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You know, when I um was in a different organization, I did an orientation program for people coming into the plan.
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And one of the questions I would ask them is what do they think the single factor is that most influences an organization?
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Like think of one thing that most influences an organization.
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And since I was the CFO, people always said um money or uh you know something financial.
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And I'm sure there's you know, there's probably not one really right answer, but the answer that I was looking for is ownership, company ownership.
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And you think about healthcare organizations, you have private organizations that might be owned by a small uh you know, an individual, possibly larger organizations that are either nonprofit companies or for-profit companies.
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And that is really significant.
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For pro, you know, when you're in finance classes as a student, you learn that there's one objective for uh for-profit organizations that are owned by stockholders, and that is to maximize shareholders' wealth.
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And you know, so that's basically you want to make money so you can pay dividends, uh, you know, keep an elevated price for um for people that are investing in your company.
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Uh the nonprofit organizations have a different structure.
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They're not owned by shareholders, they're not owned by anyone, they're community assets, and they have an obligation to um you know to serve the community.
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They're usually led by volunteer boards of people that are really looking at how you're spending your money to reinvest in your mission, and so they're very different uh kinds of organizations.
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And so your your question is really interesting.
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I think uh my career has been on the nonprofit side, so you know I have to acknowledge that.
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But I think as a uh some of the organizations that have exited have a lot of pressure being uh publicly traded and needing to perform financially, make the margin, and uh be true to their shareholders.
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As a mission-based organization, we are trying to serve the community and be a long-term safety net organization providing access to coverage.
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And so I think that does impact some of the decision making.
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But ultimately, um as the financial leader, there there are regulations that require us, all insurance companies, to have solvency levels.
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And we uh we have to meet those solvency levels consistently year over year, and um but the solvency levels is like a savings account, it's how much uh money you have in your your your account, and that's important because Texas Department of Insurance doesn't want insurance companies to go bankrupt and then leave members without coverage, and so they've put in these regulations that um that impose that.
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And so for us, um really there's a threshold of whether you can sustain a product, uh, ensure that it's financially viable and not uh impacting you to a point to deteriorate your your uh ability to be financially solvent.
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Does that make sense?
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Yeah, definitely.
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It's it's such an important, I think, dichotomy between for-profit and and non-profit or not-for-profit even, but you know, we we serve, Paige and I serve a lot of a lot of health plans that are either that are both.
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Like some are some are for-profit and and and some are not.
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And and and and I know many of the the non-profit plans or not-for-profit plans, they feel this obligation, like you feel, right?
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To to serve the community and to not exit if at all possible.
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And and we and we see so many of them, they're the last one standing in a county that is a very challenging county financially for a health plan.
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That's why you know everyone else has exited it, but but this community-focused plan who feels like they maybe have to cover the whole state or the or the whole area where they're in, they don't feel like they can uh unless unless they just have to.
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And I imagine that tension between sustainability and solvency and and serving the community, for someone like you, probab it's probably, you know, there's more tension there than than with anyone else in the organization.
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I'm just I'm I'm imagining.
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So um, yeah, that's gotta be that's gotta be difficult manage managing that tension.
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So I don't envy you on it.
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But uh but kudos to you guys for like I I know you you fight so hard to to serve.
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Um Paige and I also work in um you know, we do most of our work in the quality improvement space.
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And right, and and at least in in Medicare Advantage, there's you know quality bonus payments that are important from a revenue perspective.
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And there's there's there's there's there's revenue um you know um impacts obviously to to to Medicaid as well um that are that are very meaningful.
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But when when when there's so much when margins are tight and there's there's not a lot of money to just say, hey, here's some money to go hire a vendor or go launch an initiative, you know, when these quality bonus payments are so hard to get, cut points are getting tighter, um, there's not a lot of money to invest.
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How should quality leaders make the financial case to their CFO for continued investment?
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I um I appreciate that um question.
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I I feel that quality and finance is a really important partnership within a health plan, and those two uh departments need to work really closely, really medical affairs in totality, but but quality is a is a really important subset within the medical affairs area.
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Um what I would encourage quality leaders to do in working with the finance folks is to really make sure that you start with the things that you're doing today and um show what what are the measured results that you can demonstrate on the programs that you're administering today.
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And I feel like that establishes credibility with the finance leaders because they see you're going to measure the results of the programs that you're doing.
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You have a mechanism and a structure to do that, and you're tracking your success.
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And by having that track record, it builds confidence from the finance team that we we have a process, we have a partnership where if we make that investment, we'll be able to validate uh the benefit of that investment downstream.
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And and so often that's really the challenge is is um helping clinical leaders and other uh non-finance people in the organization understand what it takes to measure and evaluate financially whether something's working or not working, and and that's just such an important part.
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So I would encourage people to start with what are you doing and and sort of build that that uh that track record with with your finance team.
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Um the return on investment is the place that we start when we're talking about new initiatives, and a lot of people will go to uh peer-reviewed information and pull down you know statistics about this is gonna save you so much money.
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Um I would encourage quality leaders to really break it down and think about short-term versus long-term returns.
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Uh, so much of healthcare uh programs that we put in place are not things that have an ROI in year.
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It takes time, right?
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It takes, there's a there's a long run runway.
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And so uh there's a lot of pressure financially right now, you know, even on thinking, you know, if you put yourself in the CEO hat, um, answering to the board, there's a lot of pressure to perform today with all of these headwinds that we're facing.
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And so we have to have a balance between initiatives that will help us in the short run versus initiatives that will help us in the long run.
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And so thinking about sort of your two buckets of opportunity.
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And then um the other piece that I would say that people don't um maybe that out as well as we should when when ideas are brought to finance is the the cost.
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And we we think we know the cost, you know, it's it's easy if it's a vendor, you identify the vendor cost, but that's not really where it stops.
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You have internal resources that are needed within your own department.
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Your you know, your dedication to one project is going to take away focus on other projects.
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Um, but you're also probably going to need support from your IT partners, right?
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There's a few projects that I see that don't require some level of IT support.
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And so understanding how your uh Creating demand on other aspects of the of the company, other components, and what that lift is, how much time investment is needed.
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That is really important because we have limited resources in those support areas of analytics and IT.
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And being able to articulate what your need is, what that cost is relative to the value that you're getting at, and figuring out how you're prioritizing your portfolio of opportunities is really important.
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And separating the short-term versus the long-term aspect of that.
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Because the, you know, the other thing is you you could have a project that has great opportunity three years from now, but you're gonna get hit this year with all the cost.
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Well, it's gonna flip your PL this year adversely for the promise of two years down the road.
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And so, you know, understanding the timing of the the revenue and the expense is really important.
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Right.
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Such a yeah, no, it's such a helpful answer.
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And in in in lots of context around that, when when you say the cost doesn't stop with like the look if it's a vendor solution, right?
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Like that's so helpful too.
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Like if I'm if I'm a quality leader launching a new vendor to understand that to I need to like uh you know pull the thread all the way through, right?
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Like not stop at the vendor cost.
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And I and it makes me think I hear so many vendors say um say there's no IT lift for the required for it selection.
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Right.
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And uh but but typically when they when they say that um there is a huge lift maybe on the business owner to have lots of data to input into a system.
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So IT is probably well, it probably still there probably is still an IT lift, obviously, but it but even if not, there's a huge lift on the business owner, I feel like.
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So to go get their own data.
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It you know, it it may not be that let's say it's a file you're leveraging, you know, the same file you send to a different vendor or with that same vendor.
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So it's not a it's not something that you need to do incrementally to start up or to to implement.
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But once you get whatever the value is out of that project, oftentimes that result is something that you need to deploy some other place.
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You want to communicate that downstream to your providers, right?
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To change behavior, maybe.
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And so that also takes data interface, um, thought around your your how how you're gonna deploy that.
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Is that through a portal?
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Is that uh how is that gonna occur?
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And then internal resources around how you educate the provider community around that.
00:24:56.160 --> 00:24:58.480
So it's a provider relations investment.
00:24:58.720 --> 00:25:00.720
Do they have capacity to do that?
00:25:00.880 --> 00:25:06.559
Is that um is that the most important thing for them to be communicating on?
00:25:06.720 --> 00:25:07.599
Will they do that?
00:25:07.680 --> 00:25:12.400
And and if they don't, do you do you get the value out of what's being promised?
00:25:12.960 --> 00:25:23.519
So uh it it has to be thought through end-to-end as a project to to um to be considered.
00:25:23.599 --> 00:25:36.720
And and if the leaders that are thinking about these opportunities don't think about it from an end-to-end perspective, they're gonna get um they're gonna hit some barriers along the way, I feel.
00:25:37.119 --> 00:25:41.039
And and and probably not get the buy-in they need from finance, right?
00:25:41.119 --> 00:25:49.440
If they if they can't, if they haven't thought through that and can't articulate that that whole end-to-end um experience, yeah.
00:25:50.480 --> 00:25:55.440
Or for a finance team that's not as experienced to ask those questions that you're asking.
00:25:55.680 --> 00:25:56.160
Right, right.
00:25:56.400 --> 00:26:13.359
If you if you don't know what to expect as as a full system, if you don't know what to expect in a year and a half from this project, that project could essentially die, is what you're saying, because no one was ready for the additional time cost or bandwidth cost that would be expected.
00:26:13.519 --> 00:26:14.480
It's a really good.
00:26:14.640 --> 00:26:20.960
So uh if I'm hearing you correctly, it's what do we need to do to set up for this initiative?
00:26:21.119 --> 00:26:28.000
What do we need, like maybe the first six months for initiative, what does the first year look like, and what does two years down the road look like?
00:26:28.319 --> 00:26:30.319
And something something like that.
00:26:30.960 --> 00:26:38.640
Yeah, and and then I think it's really important to think about what your success metrics are on the back end, what are you trying to change?
00:26:38.880 --> 00:26:59.519
And uh having and usually quality people think in those terms uh what are those success metrics that I'm going to measure that's going to prove that I'm generating the outcome that that I'm wanting, and uh showing how you're tracking that and how that number's changing over time.
00:27:00.559 --> 00:27:07.279
And back to that you said at the beginning, you know, bring bring similar things that are doing well.
00:27:07.359 --> 00:27:16.240
So you can say we're adding all to this, but on the other side of that, that vulnerability piece of like this is also where we have failed.
00:27:16.400 --> 00:27:25.839
We've measured it, and we thought we you know we had these expectations, but even showing you know, an expectation that we had, we planned as well as we could possibly plan.
00:27:26.079 --> 00:27:31.599
These are the missteps that we had, and this is why this situation failed, and this is why we need a different initiative.
00:27:31.839 --> 00:27:39.759
So not just like I'm I'm hearing like not just successes, like but just show that you can measure whether it's good or bad.
00:27:40.000 --> 00:27:40.240
Yeah.
00:27:40.400 --> 00:27:40.640
Yeah.
00:27:40.960 --> 00:27:42.480
I think that makes a big difference.
00:27:43.359 --> 00:27:47.680
I think uh willingness to fail is important for healthcare.
00:27:48.400 --> 00:27:56.799
Um it it's you know, it's not always gonna be perfect, and there you're you're not always gonna do things that have the impact that you want.
00:27:56.960 --> 00:27:58.400
So you want to fail fast.
00:27:58.559 --> 00:28:01.680
Um, but how do you know if you're failing fast if you don't measure it?
00:28:01.839 --> 00:28:07.519
So that's where you know, I just completely what you just said, Paige, is so important.
00:28:07.839 --> 00:28:15.839
Um being able to measure and then just coming forward and acknowledging that and changing and iterating off of that learning.
00:28:16.559 --> 00:28:27.200
The best advice I got very, very early on in my career from a quality leader, a clinical quality leader, was you know, she was exiting and I didn't know her well enough.
00:28:27.359 --> 00:28:29.680
I knew her well enough to know that she knew everything.
00:28:29.920 --> 00:28:49.839
I just asked her like I just need like on your way out, like one piece of advice, and she just said, fast failures, just fail quickly and get right back up and maybe fail again, but maybe be successful, and that has really made a huge thing, a huge difference in the way I you know communicate about different different initiatives.
00:28:50.079 --> 00:29:02.240
But when I was in um grad school, it was at the University of Arkansas, and we had a big like uh partnership with Walmart because they're based there.
00:29:02.480 --> 00:29:10.559
So um we're meeting with the Walmart executives and doing this big project and they tell us their motto is is ready, fire, aim.
00:29:10.799 --> 00:29:13.680
Um right, like they they want to move fast.
00:29:13.839 --> 00:29:19.920
And I've heard health plan leaders give great presentations on the importance of making fast decisions, right?
00:29:20.079 --> 00:29:33.200
Not not not um not struggling with the same the same decision for weeks or months and and continuing to talk like in an executive steering committee, continuing to talk about the same things without making a decision.
00:29:33.680 --> 00:29:41.039
Now everyone can't the ready-fire aim, you you you obviously they're big enough, they can make a huge mistake and still be okay, right?
00:29:41.200 --> 00:29:54.960
Like everyone is not in that position I I get, but but what you guys are saying I still agree with um fell fast, innovate, you know, do try try new things um and and you know be willing to risk.
00:29:55.039 --> 00:29:55.279
Yeah.
00:29:55.599 --> 00:29:56.480
Yeah, definitely.
00:29:56.640 --> 00:29:58.480
Innovation comes from failure.
00:29:58.640 --> 00:30:03.200
Like if you don't come up with anything new if everything is working just right.
00:30:03.759 --> 00:30:07.279
But um, I know we're we've taken a lot of your time.
00:30:07.359 --> 00:30:19.920
I just want to ask one last if we're so 2030, there are so many things that are you know supposedly happening with CMS and HPMS and everything, like 2030, all of these things have to be in in a row.
00:30:20.079 --> 00:30:25.519
Um what do you think we're gonna be talking about instead of margin compression?
00:30:26.799 --> 00:30:32.640
Um well, you want to know what I'd like to be thinking talking about instead of margin compression.
00:30:32.880 --> 00:30:48.720
You know, I I shared with you that that I started running late in life, and I've uh just been thinking a lot about uh the healthcare industry and what we uh focus on.
00:30:48.960 --> 00:31:04.480
And you know, maybe this is this may be a little bit non-traditional financial uh feedback, but I would really love to see the industry get to a space where we could shift more to a healthcare focus.
00:31:04.559 --> 00:31:15.359
And we we talk about healthcare, uh, you know, I think about my days on the hospital side, and our you know, our measures of success were hospital census, how many people were in the beds, right?
00:31:15.599 --> 00:31:17.759
Uh that was an important statistic.
00:31:18.079 --> 00:31:42.319
And um we we built a lot uh of healthcare, bricks and mortar, and and I think there's an opportunity maybe for healthcare to be um to shift more virtually, um, and that there's also an opportunity to have more focus on on health uh as as opposed to uh just sick care.
00:31:42.880 --> 00:31:50.640
And I would love to see us figure out a way with quality to reset what our quality metrics are.
00:31:50.799 --> 00:32:02.640
I I look at the the quality metrics that we use today, the HETUS metrics, and they're so you know process measured, and they're such things that people don't really care about.
00:32:02.720 --> 00:32:13.119
You know, they don't really care about the idea of whether I got my well visit by itself is not a satisfying thing for me as a mom to you know to think about.
00:32:13.200 --> 00:32:18.400
It's really I want my child to be healthy and learning and thriving.
00:32:18.640 --> 00:32:29.119
And so, how could quality metrics shift more to measures of things that people really care about as an older person, you know, your true mobility.
00:32:29.359 --> 00:32:50.640
Um and I I would love to see us figure out how healthcare providers are truly incented to measure those things and um use that as the brand the barometer of success and integrate that into value-based contracting where there's more uh alignment.
00:32:50.720 --> 00:33:16.720
I you know, part of the issue I see is that you've got so many separate entities, you've got hospital entities, um, health uh provider entities, and if we could have greater integration of the financial incentives of those organizations in delivering care that aligns with what outcomes people really care about, that's what I would love to see in 2030.
00:33:17.279 --> 00:33:18.880
Yeah, I think that's amazing.
00:33:18.960 --> 00:33:28.000
I when I first started in the ACO world, like the traditional Medicare world, it was the whole point was to keep people out of the hospital, right?
00:33:28.160 --> 00:33:30.400
To lower the cost and improve quality.
00:33:30.880 --> 00:33:39.839
But when you're attached to a health system, like you're saying, the heads in beds was what the margin was expected on the hospital side.
00:33:40.000 --> 00:33:42.319
So you're in complete contrast with each other.
00:33:42.400 --> 00:33:49.279
And I feel like in the last 15 years things are getting better, but they're not they're not completely aligned.
00:33:49.359 --> 00:33:55.359
Like you're saying, we are we are not truly in the healthcare space, we're in the sick space.
00:33:55.519 --> 00:34:02.480
Like let's you know, figure out how we can help the sick people, but we're needing to move more towards healthy.
00:34:02.559 --> 00:34:16.480
And um, the last thing I'll say about that too is we talk a lot, or I I especially talk a lot with our clients about making sure that they understand the um the spirit of the measure.
00:34:16.639 --> 00:34:20.239
I used to make fun of that that statement, but now I use it all of the time.
00:34:20.480 --> 00:34:24.559
Like, what what is CMS really trying to do with these measures?
00:34:24.639 --> 00:34:33.599
And we have health outcome surveys, which is you know very Medicare in-depth, but um but they're trying their CMS is trying, right?
00:34:33.760 --> 00:34:39.920
They're trying to get to where we can measure outcomes versus those process measures.
00:34:40.000 --> 00:34:48.639
Um, but it does we had to like wedge people in or like step by step to get, but it's been a long enough time that we've been measuring breast cancer screening.
00:34:48.719 --> 00:34:51.280
Like, what are we doing with those screenings?
00:34:51.599 --> 00:34:54.159
What are we doing with the wellness exams?
00:34:54.559 --> 00:34:57.840
But yeah, I I completely, completely agree.
00:34:58.400 --> 00:35:04.800
Is there a measure you think that that approaches um uh something that people care about more?
00:35:04.960 --> 00:35:16.639
I I was talking with our quality director, and there's engagement with uh some of the accrediting organizations around testing new measures and coming up with new measures, and I was really excited about that.
00:35:16.719 --> 00:35:19.280
And I said, Well, what's the new measure that they're talking about?
00:35:19.519 --> 00:35:22.480
And then I was a little bit disappointed when I heard what it was.
00:35:23.199 --> 00:35:30.320
You know, it didn't uh transcend to what what I was hoping to hear, but um I was wondering if you had thoughts on that.
00:35:30.719 --> 00:35:40.239
I have a lot of thoughts on that, and I'm sure Rex does do, but my initial thoughts are we're getting to a good place when we talk about blood pressure controlled, right?
00:35:40.320 --> 00:35:42.639
It used to just be, did you take the blood pressure?
00:35:42.960 --> 00:35:45.360
And now it's is the blood pressure within control.
00:35:45.519 --> 00:35:49.199
So we're talking about how are we actually having a positive outcome?
00:35:49.440 --> 00:35:59.760
And same with um the A1C measures, they've all changed, the names have changed, but in reality, we've been measuring, are you um within a good range?
00:35:59.920 --> 00:36:07.760
And that used to just be is it below like have different ranges for different measures depending on which health plan you are working with?
00:36:08.079 --> 00:36:17.199
And um, but one of the measures that kicks me all the time for the SNP for SNP plans is did you do their HRA?
00:36:17.760 --> 00:36:19.360
And well, what do you think?
00:36:19.519 --> 00:36:25.679
Do you know how many plans do HRAs and have no clue what what they're supposed to do with those HRAs?
00:36:25.840 --> 00:36:29.119
Like, that is a wealth of knowledge on how to take care of those members.
00:36:29.519 --> 00:36:34.320
And so I I feel like the next step needs to be like the all of those outcomes.
00:36:34.480 --> 00:36:39.119
Like let's take every process that we're measure that we're doing and turn it into.
00:36:39.280 --> 00:36:42.079
And it seems like it's it's tracking that way.
00:36:42.159 --> 00:36:44.559
I just they're trying CMS security.
00:36:44.800 --> 00:36:53.360
Yeah, if we could get the HRA to have a goal for the for what you want the patient to do, um, and then are they successful in achieving the goal?
00:36:53.760 --> 00:36:56.719
Uh that would be you know a really great place to be.
00:36:57.280 --> 00:37:03.920
We have a the the newest measure in Medicare Stars is is a depression measure finally.
00:37:04.079 --> 00:37:15.280
We've we haven't really had one like this where and I and I feel like that's a meaningful measure that's actually going to do you know do do some good, or at least it's got a good spirit behind it, like page the right.
00:37:15.440 --> 00:37:21.679
But where, you know, because we're actually assessing like if you are diagnosed with depression, did you actually receive follow-up care?
00:37:21.840 --> 00:37:24.000
Like, like you know, what was there a next step?
00:37:24.239 --> 00:37:35.280
Not not just did you get diagnosed, not just did you do this, but actually is the health plan doing in the in the system doing something to help to help the the member on that journey, right?
00:37:35.440 --> 00:37:37.119
So but we have a long way to go.
00:37:37.599 --> 00:37:41.920
What what you're asking for, it should not be as aspirational as it feels, right?
00:37:42.079 --> 00:37:57.760
Like like it should not be like it should be where we already are, but it it it feels so aspirational what you're asking for to say mean measures that really really mean something and and uh you know to the to the patient as well.
00:37:58.239 --> 00:38:03.440
But we'll yeah, we'll keep doing doing work and uh and hopefully get there at some point.
00:38:04.719 --> 00:38:06.960
So Ana, thank you so much.
00:38:07.119 --> 00:38:08.880
Uh we will we'll we'll wrap there.
00:38:09.199 --> 00:38:10.400
Actually, one one last question.
00:38:10.480 --> 00:38:22.559
Just uh like if if people want to know more about you or want to follow you, um is there is there are you uh active on social media or can they like follow you on your on the community website or anything like that?
00:38:22.960 --> 00:38:25.119
Um I I do have a LinkedIn account.
00:38:25.199 --> 00:38:34.159
I'm not super active social uh on social media, but um I you know if people want to connect with me certainly through LinkedIn, um that is definitely an option.
00:38:34.639 --> 00:38:41.039
Well we will we will tag you um when we get this recording back and and get it ready to post.
00:38:41.119 --> 00:38:45.599
We'll have some snippets of you saying the wonderful things that you've been saying.
00:38:45.760 --> 00:38:47.440
So you've been a great guest.
00:38:47.599 --> 00:38:48.719
I could talk to you all day.
00:38:48.880 --> 00:38:56.000
Uh this this finance discussion is not we haven't we haven't had this discussion yet with a guest as far as this aspect of finance.
00:38:56.079 --> 00:38:58.880
We've talked to actuaries, but but not the CFO.
00:38:58.960 --> 00:39:04.639
So this was really really insightful for me and I think for Paige and for all all of our listeners.
00:39:04.800 --> 00:39:05.920
So we really appreciate it.
00:39:06.639 --> 00:39:08.000
It was great to be with you all.
00:39:08.880 --> 00:39:09.199
Okay.
00:39:09.440 --> 00:39:10.880
Well, hey, uh thanks everyone.
00:39:10.960 --> 00:39:11.840
We will talk next time.
00:39:12.719 --> 00:39:13.199
Bye bye.
00:39:13.280 --> 00:39:13.679
Have a great day.
00:39:13.760 --> 00:39:13.920
Bye.
00:39:14.239 --> 00:39:14.719
Thanks, Anna.
00:00:01.199 --> 00:00:04.000
Hey everyone, welcome back to Beyond Quality.
00:00:04.160 --> 00:00:10.160
Before we get to today's episode, 30 Seconds on an Upcoming Conference hosted by Rise, our season one collaborator.
00:00:10.400 --> 00:00:14.320
Rise West is being held September 2nd through the 4th in San Diego.
00:00:14.560 --> 00:00:23.679
500 plus Medicare Advantage senior leaders and provides direct access to OIG, attorneys, industry experts, and health plan execs.
00:00:23.760 --> 00:00:28.800
I don't think we've ever had attorneys be a key uh a key draw before, but this is the world we live in.
00:00:28.960 --> 00:00:36.159
Um it will have interactive roundtables, workshops, QA, and two dedicated tracks so you can focus on the topics that matter most to you.
00:00:36.399 --> 00:00:41.600
Use code beyond VIP at risehealth.org slash beyond to save 20%.
00:00:42.479 --> 00:00:48.399
Now on to our episode today: margin compression, MLR, and GLP1s.
00:00:48.479 --> 00:00:49.200
Oh my.
00:00:49.600 --> 00:00:55.200
Across the health plan industry and every line of business, uh, the financial backdrop right now is brutal.
00:00:55.439 --> 00:01:04.319
Benefit degradations, organization restructuring, and market exits are topics being discussed inside virtually every health plan in 2026.
00:01:04.719 --> 00:01:06.000
Let's get into this.
00:01:06.319 --> 00:01:09.200
I'd like to introduce my co-host today and our guest.
00:01:09.359 --> 00:01:12.959
My co-host is a consultant that works with me at RWC.
00:01:13.200 --> 00:01:18.799
She has deep experience in quality improvement with an exceptionally deep expertise in all things related to value-based care.
00:01:18.959 --> 00:01:20.640
Please welcome Paige Caprera.
00:01:20.879 --> 00:01:21.519
Hi, Paige.
00:01:21.840 --> 00:01:22.159
Hi.
00:01:23.519 --> 00:01:34.560
And then our guest today is the Chief Financial Officer at Community Health Choice, a health plan right here in Houston, where I live, uh, that serves underserved populations and does great work here.
00:01:34.719 --> 00:01:36.239
Please welcome Anna Mateya.
00:01:36.400 --> 00:01:37.200
Welcome, Anna.
00:01:37.920 --> 00:01:38.239
Thank you.
00:01:38.400 --> 00:01:39.920
Great to be here with you.
00:01:40.640 --> 00:01:44.480
So um thanks for joining us, yeah, Paige and Anna both.
00:01:44.560 --> 00:01:51.760
Um can you guys give the listeners just a little more background on yourselves so they can um understand kind of who who's on today?
00:01:51.840 --> 00:01:52.799
So, Paige, can you start?
00:01:53.200 --> 00:01:53.760
Sure, yeah.
00:01:53.840 --> 00:01:58.159
So Paige Caprera, I reside in Columbus, Ohio at the moment.
00:01:58.319 --> 00:02:03.120
Um, been in a couple of different areas around the country, um, Houston being one of them.
00:02:03.200 --> 00:02:16.240
I didn't live there, but I was there every other week for about a year and a half for business development position with um with an IPA CINACO out of um, or a national one.
00:02:16.319 --> 00:02:34.960
Um so we've been about 15 years in the Medicare Advantage space, um, a lot of provider relations, um kind of in private provider engagement background, but a lot with um traditional Medicare through the ACOs, as well as the clinically integrated networks and the independent physician association.
00:02:35.120 --> 00:02:49.280
So STARS is close to home in all of those realms, and also was um very fortunate to have a team of analytical strategists at Centen for a little bit that you know we've kind of consulted with each one of the regional plans.
00:02:49.360 --> 00:02:52.639
So we love the regional plan piece of of life.
00:02:52.719 --> 00:02:59.120
It's um it it those those local close-to-home plans make a huge difference in the communities.
00:02:59.280 --> 00:03:00.560
So yeah, happy.
00:03:00.719 --> 00:03:04.879
Oh, and I've I've been working with um community health for about a year and a half.
00:03:05.120 --> 00:03:08.639
So um yeah, happy to have Anna on with us too.
00:03:09.039 --> 00:03:10.319
Yeah, so excited.
00:03:10.479 --> 00:03:12.080
Yeah, uh, thank you, Paige.
00:03:12.240 --> 00:03:13.199
How about you, Anna?
00:03:14.080 --> 00:03:16.240
Yes, um, well, Anna Matea.
00:03:16.319 --> 00:03:21.919
I'm the CFO here at Community Health Choice, and I started my career back in 1988.
00:03:22.000 --> 00:03:24.960
So I've been in healthcare almost 38 years now.
00:03:25.120 --> 00:03:38.960
Uh had a little experience in the consulting area, the hospital side, I've sat on that side of the of the um of the bench, and then uh was part of a startup health plan, and then here at community.
00:03:39.120 --> 00:03:51.439
Um and I guess I'll share on a personal level uh as I'm moving towards the you know, the back end of my uh my career, uh health and fitness is something really important to me.
00:03:51.520 --> 00:04:04.159
And I started running and I I did um I did a marathon, you know, recently uh in my 50s, and so it's just been really interesting thinking about health and fitness being in the healthcare industry.
00:04:05.599 --> 00:04:06.879
Yeah, wow.
00:04:07.120 --> 00:04:16.480
I've uh I I started running when I was in my fifties too, and ran a half marathon a couple of I guess in 2023, and haven't run anything since.
00:04:18.079 --> 00:04:24.399
It was it was a big thing to check off my list, but my knee uh my knee felt it for sure.
00:04:24.480 --> 00:04:25.040
And I don't know.
00:04:25.120 --> 00:04:26.480
I gotta I gotta get back into it though.
00:04:26.560 --> 00:04:27.839
In Houston, it's not that easy, right?
00:04:27.920 --> 00:04:28.240
Anna?
00:04:28.319 --> 00:04:30.399
There's not um it's hot.
00:04:30.800 --> 00:04:31.360
It's hot.
00:04:31.600 --> 00:04:32.000
It's hot.
00:04:32.160 --> 00:04:32.639
It's hot.
00:04:33.120 --> 00:04:33.759
It's hot.
00:04:35.040 --> 00:04:36.959
Um well let's let's jump in.
00:04:37.040 --> 00:04:40.319
So Anna, we'll start with something kind of light and fun here.
00:04:40.480 --> 00:04:41.040
Not really.
00:04:41.279 --> 00:04:51.519
Um can you can you walk us through what keeps uh a health plan CFO up at night in 2026 and and how how does that differ from three to four years ago?
00:04:51.839 --> 00:04:53.759
Yeah, that's such a great question.
00:04:54.000 --> 00:05:03.600
You know, I as I'm thinking about the question, the you the role of a CFO is really to ensure the solvency of the organization and make sure that we're here for the long haul.
00:05:03.759 --> 00:05:17.519
And so we're we're constantly looking at what our forecast is for the future, setting that goal for what the future is, and then we're measuring performance to see how are we tracking against what those goals are that we set.
00:05:17.759 --> 00:05:29.199
And what makes that easy is when you have predictable situations, and we've just had so much uh change in our industry that creates a lot of complexity.
00:05:29.519 --> 00:05:38.560
Um medical cost is definitely an issue, it's always been an issue monitoring medical cost and setting rates, those are two important things.
00:05:38.800 --> 00:05:47.920
But uh I think the membership transition that we are experiencing more recently is a really compounding impact.
00:05:48.240 --> 00:06:00.000
Um, there's a lot of legislative impacts that are driving that on the marketplace side, the subsidy issue, whether the subsidies would be extended, and of course they were not.
00:06:00.240 --> 00:06:26.800
And so when that happened, the concern about membership contraction, and we did see some level of contraction different, maybe a little bit different than what was projected, but um that contraction has resulted in a change in the average mix and acuity of members, and it's impacted the revenue streams that we get for risk adjustment in in ways that were unexpected.
00:06:26.879 --> 00:06:39.040
And you you saw last year about this time where many health plans had to retract their earnings reports because of that, you know, that of that single factor.
00:06:39.279 --> 00:07:01.839
And so, you know, today there's just so much we are dealing with not just medical costs, you mentioned GLP ones, different cost drivers, um, setting prices for health care to ensure that healthcare is affordable and accessible, but then also these other factors around how our members are changing because healthcare is just becoming so expensive.
00:07:02.000 --> 00:07:14.240
Some people are just unable to choose to continue to uh afford insurance and how that's affecting other downstream impacts that that create lots of complexity for our organizations.
00:07:14.720 --> 00:07:32.480
Um, you know, you you back it up a few years ago our our issues were around coming out of COVID and um how healthcare had sort of compressed to lower levels of utilization, and so just major shifts in in what we're focusing on today.
00:07:33.360 --> 00:07:42.800
Do you do you feel like what we're experiencing today is is still related to the pandemic a bit or or are we are we beyond that?
00:07:44.560 --> 00:07:54.399
Well, we've definitely transitioned and there are things that are changing, but I I think uh I think there are still compounding factors that are that are happening.
00:07:54.560 --> 00:08:20.560
Um the pandemic, even though you know it started in 2020, the unwinding of the pandemic really we felt that um in 24 and the contraction of membership uh was really significant in uh the the rate setting process because oftentimes the the the revenue that we get is based on usually historical information.
00:08:20.720 --> 00:08:30.319
And so one of the issues that we find is that it takes so much time for that information to inform the revenue side of the house.
00:08:31.839 --> 00:08:45.519
But today you're experiencing new trends on the met you know on the cost side, and so that alignment between your revenue and expense is is a challenging thing to mix when you have that timing delay uh on what's informing your revenue.
00:08:46.080 --> 00:09:01.840
Um but I I do think care delivery is also still being assessed on on the impacts from the pandemic, how it was delivered, and what we've learned about um what is needed.
00:09:01.919 --> 00:09:14.559
Um you're seeing some of that transition now, uh certainly escalation in utilization levels, but we are still um being impacted by some of the learnings from COVID and care delivery.
00:09:16.480 --> 00:09:30.559
Well I was at Kroger the other day and um just a quick trip in there, and in every I've never like um they have the the the posts in front of the door to prevent cars from driving through there.
00:09:30.639 --> 00:09:33.519
There's like 12 concrete posts, right?
00:09:33.759 --> 00:09:40.639
Every one of them on both sides, on both doors, had had a sign for GLP 1s.
00:09:41.039 --> 00:09:46.399
And um like like advertising, hey, you can get your GLP one here at Kroger.
00:09:47.039 --> 00:09:57.919
Um and I know so many people on GLP ones and so many people experiencing amazing benefits that are affecting so many different parts of their life.
00:09:58.159 --> 00:10:07.120
Um not you know, well like weight is just the beginning, but when you lose weight, if you need to lose weight, it it positively affects so many other places in your life.
00:10:07.759 --> 00:10:18.559
So but it's so expensive and it's so you know, it's uh in the marketing and advertising that that big pharma and everyone else does for that.
00:10:18.720 --> 00:10:20.320
Just the cost is enormous, right?
00:10:20.399 --> 00:10:30.639
So I have to think um if I'm in some of those rooms at a health plan discussing finances, that's such a a big topic by itself, I would imagine, right now, with the GLP ones.
00:10:31.200 --> 00:10:45.360
Yeah, it's uh the GLP ones are definitely w what we're seeing is the the um the usage of those drugs, not exclusively for weight loss, but for certain disease states.
00:10:45.519 --> 00:10:57.120
And so that is uh what they're intended for, what what they're sure, what they're intended for and um where they're covered under your your plants.
00:10:57.519 --> 00:10:57.600
Right.
00:10:57.919 --> 00:11:17.120
And so we're we're seeing uh certainly in diabetes and uh other certain other disease states and cardiovascular uh cardio conditions where the GLP ones are indicated, and the impact on drug cost is really incredibly significant.
00:11:17.600 --> 00:11:32.639
Um the per the percent of total is you know exceeding 50% of your spend in certain certain disease states specifically for uh GLP ones, and that's increased to almost 70% in some uh more recent periods of time.
00:11:34.399 --> 00:11:49.600
And not that we can say that GLPs are the reason that you know plans are exiting markets, but you know, we see a lot of plans over the last few years exiting counties or exiting full states and even regional or some plans just closing down.
00:11:49.840 --> 00:11:59.360
Um when a finance team is looking at those numbers, like what kind of um what kind of things are tipping those scales?
00:11:59.440 --> 00:12:10.399
Again, probably not just GLP expenses, but like what what's the tipping the scale between like we're just gonna restructure things or change our benefits versus like we need to leave this market?
00:12:12.080 --> 00:12:13.039
Interesting question.
00:12:13.200 --> 00:12:21.440
You know, when I um was in a different organization, I did an orientation program for people coming into the plan.
00:12:21.679 --> 00:12:29.360
And one of the questions I would ask them is what do they think the single factor is that most influences an organization?
00:12:29.519 --> 00:12:33.360
Like think of one thing that most influences an organization.
00:12:33.440 --> 00:12:40.960
And since I was the CFO, people always said um money or uh you know something financial.
00:12:41.440 --> 00:12:50.559
And I'm sure there's you know, there's probably not one really right answer, but the answer that I was looking for is ownership, company ownership.
00:12:50.799 --> 00:13:05.120
And you think about healthcare organizations, you have private organizations that might be owned by a small uh you know, an individual, possibly larger organizations that are either nonprofit companies or for-profit companies.
00:13:05.360 --> 00:13:07.200
And that is really significant.
00:13:07.360 --> 00:13:21.919
For pro, you know, when you're in finance classes as a student, you learn that there's one objective for uh for-profit organizations that are owned by stockholders, and that is to maximize shareholders' wealth.
00:13:22.159 --> 00:13:32.480
And you know, so that's basically you want to make money so you can pay dividends, uh, you know, keep an elevated price for um for people that are investing in your company.
00:13:32.639 --> 00:13:35.759
Uh the nonprofit organizations have a different structure.
00:13:35.840 --> 00:13:45.440
They're not owned by shareholders, they're not owned by anyone, they're community assets, and they have an obligation to um you know to serve the community.
00:13:45.519 --> 00:13:58.080
They're usually led by volunteer boards of people that are really looking at how you're spending your money to reinvest in your mission, and so they're very different uh kinds of organizations.
00:13:58.240 --> 00:14:00.879
And so your your question is really interesting.
00:14:01.120 --> 00:14:08.000
I think uh my career has been on the nonprofit side, so you know I have to acknowledge that.
00:14:08.080 --> 00:14:22.559
But I think as a uh some of the organizations that have exited have a lot of pressure being uh publicly traded and needing to perform financially, make the margin, and uh be true to their shareholders.
00:14:22.799 --> 00:14:34.000
As a mission-based organization, we are trying to serve the community and be a long-term safety net organization providing access to coverage.
00:14:34.080 --> 00:14:37.919
And so I think that does impact some of the decision making.
00:14:38.159 --> 00:14:48.159
But ultimately, um as the financial leader, there there are regulations that require us, all insurance companies, to have solvency levels.
00:14:48.480 --> 00:15:16.960
And we uh we have to meet those solvency levels consistently year over year, and um but the solvency levels is like a savings account, it's how much uh money you have in your your your account, and that's important because Texas Department of Insurance doesn't want insurance companies to go bankrupt and then leave members without coverage, and so they've put in these regulations that um that impose that.
00:15:17.200 --> 00:15:35.440
And so for us, um really there's a threshold of whether you can sustain a product, uh, ensure that it's financially viable and not uh impacting you to a point to deteriorate your your uh ability to be financially solvent.
00:15:35.840 --> 00:15:37.840
Does that make sense?
00:15:38.240 --> 00:15:39.840
Yeah, definitely.
00:15:40.399 --> 00:15:53.919
It's it's such an important, I think, dichotomy between for-profit and and non-profit or not-for-profit even, but you know, we we serve, Paige and I serve a lot of a lot of health plans that are either that are both.
00:15:54.240 --> 00:15:56.879
Like some are some are for-profit and and and some are not.
00:15:57.039 --> 00:16:07.440
And and and and I know many of the the non-profit plans or not-for-profit plans, they feel this obligation, like you feel, right?
00:16:07.600 --> 00:16:13.120
To to serve the community and to not exit if at all possible.
00:16:13.200 --> 00:16:21.919
And and we and we see so many of them, they're the last one standing in a county that is a very challenging county financially for a health plan.
00:16:22.000 --> 00:16:35.840
That's why you know everyone else has exited it, but but this community-focused plan who feels like they maybe have to cover the whole state or the or the whole area where they're in, they don't feel like they can uh unless unless they just have to.
00:16:36.000 --> 00:16:51.679
And I imagine that tension between sustainability and solvency and and serving the community, for someone like you, probab it's probably, you know, there's more tension there than than with anyone else in the organization.
00:16:51.840 --> 00:16:53.600
I'm just I'm I'm imagining.
00:16:53.840 --> 00:16:58.480
So um, yeah, that's gotta be that's gotta be difficult manage managing that tension.
00:17:00.480 --> 00:17:02.159
So I don't envy you on it.
00:17:07.039 --> 00:17:14.400
But uh but kudos to you guys for like I I know you you fight so hard to to serve.
00:17:14.640 --> 00:17:19.920
Um Paige and I also work in um you know, we do most of our work in the quality improvement space.
00:17:20.000 --> 00:17:29.839
And right, and and at least in in Medicare Advantage, there's you know quality bonus payments that are important from a revenue perspective.
00:17:30.000 --> 00:17:41.200
And there's there's there's there's there's revenue um you know um impacts obviously to to to Medicaid as well um that are that are very meaningful.
00:17:41.599 --> 00:18:02.160
But when when when there's so much when margins are tight and there's there's not a lot of money to just say, hey, here's some money to go hire a vendor or go launch an initiative, you know, when these quality bonus payments are so hard to get, cut points are getting tighter, um, there's not a lot of money to invest.
00:18:02.480 --> 00:18:08.480
How should quality leaders make the financial case to their CFO for continued investment?
00:18:10.559 --> 00:18:13.519
I um I appreciate that um question.
00:18:13.680 --> 00:18:31.839
I I feel that quality and finance is a really important partnership within a health plan, and those two uh departments need to work really closely, really medical affairs in totality, but but quality is a is a really important subset within the medical affairs area.
00:18:32.079 --> 00:18:54.640
Um what I would encourage quality leaders to do in working with the finance folks is to really make sure that you start with the things that you're doing today and um show what what are the measured results that you can demonstrate on the programs that you're administering today.
00:18:54.880 --> 00:19:04.240
And I feel like that establishes credibility with the finance leaders because they see you're going to measure the results of the programs that you're doing.
00:19:04.400 --> 00:19:10.880
You have a mechanism and a structure to do that, and you're tracking your success.
00:19:11.440 --> 00:19:29.279
And by having that track record, it builds confidence from the finance team that we we have a process, we have a partnership where if we make that investment, we'll be able to validate uh the benefit of that investment downstream.
00:19:29.519 --> 00:19:49.119
And and so often that's really the challenge is is um helping clinical leaders and other uh non-finance people in the organization understand what it takes to measure and evaluate financially whether something's working or not working, and and that's just such an important part.
00:19:49.279 --> 00:19:58.319
So I would encourage people to start with what are you doing and and sort of build that that uh that track record with with your finance team.
00:19:58.640 --> 00:20:15.039
Um the return on investment is the place that we start when we're talking about new initiatives, and a lot of people will go to uh peer-reviewed information and pull down you know statistics about this is gonna save you so much money.
00:20:15.279 --> 00:20:24.400
Um I would encourage quality leaders to really break it down and think about short-term versus long-term returns.
00:20:24.640 --> 00:20:35.279
Uh, so much of healthcare uh programs that we put in place are not things that have an ROI in year.
00:20:35.599 --> 00:20:36.880
It takes time, right?
00:20:37.039 --> 00:20:39.920
It takes, there's a there's a long run runway.
00:20:40.400 --> 00:20:57.359
And so uh there's a lot of pressure financially right now, you know, even on thinking, you know, if you put yourself in the CEO hat, um, answering to the board, there's a lot of pressure to perform today with all of these headwinds that we're facing.
00:20:57.599 --> 00:21:06.240
And so we have to have a balance between initiatives that will help us in the short run versus initiatives that will help us in the long run.
00:21:06.319 --> 00:21:10.319
And so thinking about sort of your two buckets of opportunity.
00:21:10.799 --> 00:21:25.680
And then um the other piece that I would say that people don't um maybe that out as well as we should when when ideas are brought to finance is the the cost.
00:21:26.400 --> 00:21:34.319
And we we think we know the cost, you know, it's it's easy if it's a vendor, you identify the vendor cost, but that's not really where it stops.
00:21:34.559 --> 00:21:38.000
You have internal resources that are needed within your own department.
00:21:38.160 --> 00:21:44.720
Your you know, your dedication to one project is going to take away focus on other projects.
00:21:44.960 --> 00:21:51.519
Um, but you're also probably going to need support from your IT partners, right?
00:21:51.680 --> 00:21:56.400
There's a few projects that I see that don't require some level of IT support.
00:21:56.559 --> 00:22:10.400
And so understanding how your uh Creating demand on other aspects of the of the company, other components, and what that lift is, how much time investment is needed.
00:22:11.039 --> 00:22:18.079
That is really important because we have limited resources in those support areas of analytics and IT.
00:22:18.799 --> 00:22:34.559
And being able to articulate what your need is, what that cost is relative to the value that you're getting at, and figuring out how you're prioritizing your portfolio of opportunities is really important.
00:22:35.839 --> 00:22:39.839
And separating the short-term versus the long-term aspect of that.
00:22:40.000 --> 00:22:49.039
Because the, you know, the other thing is you you could have a project that has great opportunity three years from now, but you're gonna get hit this year with all the cost.
00:22:49.200 --> 00:22:56.160
Well, it's gonna flip your PL this year adversely for the promise of two years down the road.
00:22:56.400 --> 00:23:02.240
And so, you know, understanding the timing of the the revenue and the expense is really important.
00:23:02.799 --> 00:23:03.359
Right.
00:23:04.240 --> 00:23:06.880
Such a yeah, no, it's such a helpful answer.
00:23:07.039 --> 00:23:17.519
And in in in lots of context around that, when when you say the cost doesn't stop with like the look if it's a vendor solution, right?
00:23:17.599 --> 00:23:18.799
Like that's so helpful too.
00:23:18.880 --> 00:23:27.200
Like if I'm if I'm a quality leader launching a new vendor to understand that to I need to like uh you know pull the thread all the way through, right?
00:23:27.279 --> 00:23:29.039
Like not stop at the vendor cost.
00:23:29.279 --> 00:23:38.640
And I and it makes me think I hear so many vendors say um say there's no IT lift for the required for it selection.
00:23:39.359 --> 00:23:39.519
Right.
00:23:39.839 --> 00:23:51.680
And uh but but typically when they when they say that um there is a huge lift maybe on the business owner to have lots of data to input into a system.
00:23:52.559 --> 00:24:01.839
So IT is probably well, it probably still there probably is still an IT lift, obviously, but it but even if not, there's a huge lift on the business owner, I feel like.
00:24:02.000 --> 00:24:04.480
So to go get their own data.
00:24:05.119 --> 00:24:15.119
It you know, it it may not be that let's say it's a file you're leveraging, you know, the same file you send to a different vendor or with that same vendor.
00:24:15.279 --> 00:24:21.519
So it's not a it's not something that you need to do incrementally to start up or to to implement.
00:24:21.920 --> 00:24:33.039
But once you get whatever the value is out of that project, oftentimes that result is something that you need to deploy some other place.
00:24:33.519 --> 00:24:37.200
You want to communicate that downstream to your providers, right?
00:24:37.440 --> 00:24:39.440
To change behavior, maybe.
00:24:39.680 --> 00:24:48.000
And so that also takes data interface, um, thought around your your how how you're gonna deploy that.
00:24:48.079 --> 00:24:49.119
Is that through a portal?
00:24:49.200 --> 00:24:51.279
Is that uh how is that gonna occur?
00:24:51.519 --> 00:24:56.079
And then internal resources around how you educate the provider community around that.
00:24:56.160 --> 00:24:58.480
So it's a provider relations investment.
00:24:58.720 --> 00:25:00.720
Do they have capacity to do that?
00:25:00.880 --> 00:25:06.559
Is that um is that the most important thing for them to be communicating on?
00:25:06.720 --> 00:25:07.599
Will they do that?
00:25:07.680 --> 00:25:12.400
And and if they don't, do you do you get the value out of what's being promised?
00:25:12.960 --> 00:25:23.519
So uh it it has to be thought through end-to-end as a project to to um to be considered.
00:25:23.599 --> 00:25:36.720
And and if the leaders that are thinking about these opportunities don't think about it from an end-to-end perspective, they're gonna get um they're gonna hit some barriers along the way, I feel.
00:25:37.119 --> 00:25:41.039
And and and probably not get the buy-in they need from finance, right?
00:25:41.119 --> 00:25:49.440
If they if they can't, if they haven't thought through that and can't articulate that that whole end-to-end um experience, yeah.
00:25:50.480 --> 00:25:55.440
Or for a finance team that's not as experienced to ask those questions that you're asking.
00:25:55.680 --> 00:25:56.160
Right, right.
00:25:56.400 --> 00:26:13.359
If you if you don't know what to expect as as a full system, if you don't know what to expect in a year and a half from this project, that project could essentially die, is what you're saying, because no one was ready for the additional time cost or bandwidth cost that would be expected.
00:26:13.519 --> 00:26:14.480
It's a really good.
00:26:14.640 --> 00:26:20.960
So uh if I'm hearing you correctly, it's what do we need to do to set up for this initiative?
00:26:21.119 --> 00:26:28.000
What do we need, like maybe the first six months for initiative, what does the first year look like, and what does two years down the road look like?
00:26:28.319 --> 00:26:30.319
And something something like that.
00:26:30.960 --> 00:26:38.640
Yeah, and and then I think it's really important to think about what your success metrics are on the back end, what are you trying to change?
00:26:38.880 --> 00:26:59.519
And uh having and usually quality people think in those terms uh what are those success metrics that I'm going to measure that's going to prove that I'm generating the outcome that that I'm wanting, and uh showing how you're tracking that and how that number's changing over time.
00:27:00.559 --> 00:27:07.279
And back to that you said at the beginning, you know, bring bring similar things that are doing well.
00:27:07.359 --> 00:27:16.240
So you can say we're adding all to this, but on the other side of that, that vulnerability piece of like this is also where we have failed.
00:27:16.400 --> 00:27:25.839
We've measured it, and we thought we you know we had these expectations, but even showing you know, an expectation that we had, we planned as well as we could possibly plan.
00:27:26.079 --> 00:27:31.599
These are the missteps that we had, and this is why this situation failed, and this is why we need a different initiative.
00:27:31.839 --> 00:27:39.759
So not just like I'm I'm hearing like not just successes, like but just show that you can measure whether it's good or bad.
00:27:40.000 --> 00:27:40.240
Yeah.
00:27:40.400 --> 00:27:40.640
Yeah.
00:27:40.960 --> 00:27:42.480
I think that makes a big difference.
00:27:43.359 --> 00:27:47.680
I think uh willingness to fail is important for healthcare.
00:27:48.400 --> 00:27:56.799
Um it it's you know, it's not always gonna be perfect, and there you're you're not always gonna do things that have the impact that you want.
00:27:56.960 --> 00:27:58.400
So you want to fail fast.
00:27:58.559 --> 00:28:01.680
Um, but how do you know if you're failing fast if you don't measure it?
00:28:01.839 --> 00:28:07.519
So that's where you know, I just completely what you just said, Paige, is so important.
00:28:07.839 --> 00:28:15.839
Um being able to measure and then just coming forward and acknowledging that and changing and iterating off of that learning.
00:28:16.559 --> 00:28:27.200
The best advice I got very, very early on in my career from a quality leader, a clinical quality leader, was you know, she was exiting and I didn't know her well enough.
00:28:27.359 --> 00:28:29.680
I knew her well enough to know that she knew everything.
00:28:29.920 --> 00:28:49.839
I just asked her like I just need like on your way out, like one piece of advice, and she just said, fast failures, just fail quickly and get right back up and maybe fail again, but maybe be successful, and that has really made a huge thing, a huge difference in the way I you know communicate about different different initiatives.
00:28:50.079 --> 00:29:02.240
But when I was in um grad school, it was at the University of Arkansas, and we had a big like uh partnership with Walmart because they're based there.
00:29:02.480 --> 00:29:10.559
So um we're meeting with the Walmart executives and doing this big project and they tell us their motto is is ready, fire, aim.
00:29:10.799 --> 00:29:13.680
Um right, like they they want to move fast.
00:29:13.839 --> 00:29:19.920
And I've heard health plan leaders give great presentations on the importance of making fast decisions, right?
00:29:20.079 --> 00:29:33.200
Not not not um not struggling with the same the same decision for weeks or months and and continuing to talk like in an executive steering committee, continuing to talk about the same things without making a decision.
00:29:33.680 --> 00:29:41.039
Now everyone can't the ready-fire aim, you you you obviously they're big enough, they can make a huge mistake and still be okay, right?
00:29:41.200 --> 00:29:54.960
Like everyone is not in that position I I get, but but what you guys are saying I still agree with um fell fast, innovate, you know, do try try new things um and and you know be willing to risk.
00:29:55.039 --> 00:29:55.279
Yeah.
00:29:55.599 --> 00:29:56.480
Yeah, definitely.
00:29:56.640 --> 00:29:58.480
Innovation comes from failure.
00:29:58.640 --> 00:30:03.200
Like if you don't come up with anything new if everything is working just right.
00:30:03.759 --> 00:30:07.279
But um, I know we're we've taken a lot of your time.
00:30:07.359 --> 00:30:19.920
I just want to ask one last if we're so 2030, there are so many things that are you know supposedly happening with CMS and HPMS and everything, like 2030, all of these things have to be in in a row.
00:30:20.079 --> 00:30:25.519
Um what do you think we're gonna be talking about instead of margin compression?
00:30:26.799 --> 00:30:32.640
Um well, you want to know what I'd like to be thinking talking about instead of margin compression.
00:30:32.880 --> 00:30:48.720
You know, I I shared with you that that I started running late in life, and I've uh just been thinking a lot about uh the healthcare industry and what we uh focus on.
00:30:48.960 --> 00:31:04.480
And you know, maybe this is this may be a little bit non-traditional financial uh feedback, but I would really love to see the industry get to a space where we could shift more to a healthcare focus.
00:31:04.559 --> 00:31:15.359
And we we talk about healthcare, uh, you know, I think about my days on the hospital side, and our you know, our measures of success were hospital census, how many people were in the beds, right?
00:31:15.599 --> 00:31:17.759
Uh that was an important statistic.
00:31:18.079 --> 00:31:42.319
And um we we built a lot uh of healthcare, bricks and mortar, and and I think there's an opportunity maybe for healthcare to be um to shift more virtually, um, and that there's also an opportunity to have more focus on on health uh as as opposed to uh just sick care.
00:31:42.880 --> 00:31:50.640
And I would love to see us figure out a way with quality to reset what our quality metrics are.
00:31:50.799 --> 00:32:02.640
I I look at the the quality metrics that we use today, the HETUS metrics, and they're so you know process measured, and they're such things that people don't really care about.
00:32:02.720 --> 00:32:13.119
You know, they don't really care about the idea of whether I got my well visit by itself is not a satisfying thing for me as a mom to you know to think about.
00:32:13.200 --> 00:32:18.400
It's really I want my child to be healthy and learning and thriving.
00:32:18.640 --> 00:32:29.119
And so, how could quality metrics shift more to measures of things that people really care about as an older person, you know, your true mobility.
00:32:29.359 --> 00:32:50.640
Um and I I would love to see us figure out how healthcare providers are truly incented to measure those things and um use that as the brand the barometer of success and integrate that into value-based contracting where there's more uh alignment.
00:32:50.720 --> 00:33:16.720
I you know, part of the issue I see is that you've got so many separate entities, you've got hospital entities, um, health uh provider entities, and if we could have greater integration of the financial incentives of those organizations in delivering care that aligns with what outcomes people really care about, that's what I would love to see in 2030.
00:33:17.279 --> 00:33:18.880
Yeah, I think that's amazing.
00:33:18.960 --> 00:33:28.000
I when I first started in the ACO world, like the traditional Medicare world, it was the whole point was to keep people out of the hospital, right?
00:33:28.160 --> 00:33:30.400
To lower the cost and improve quality.
00:33:30.880 --> 00:33:39.839
But when you're attached to a health system, like you're saying, the heads in beds was what the margin was expected on the hospital side.
00:33:40.000 --> 00:33:42.319
So you're in complete contrast with each other.
00:33:42.400 --> 00:33:49.279
And I feel like in the last 15 years things are getting better, but they're not they're not completely aligned.
00:33:49.359 --> 00:33:55.359
Like you're saying, we are we are not truly in the healthcare space, we're in the sick space.
00:33:55.519 --> 00:34:02.480
Like let's you know, figure out how we can help the sick people, but we're needing to move more towards healthy.
00:34:02.559 --> 00:34:16.480
And um, the last thing I'll say about that too is we talk a lot, or I I especially talk a lot with our clients about making sure that they understand the um the spirit of the measure.
00:34:16.639 --> 00:34:20.239
I used to make fun of that that statement, but now I use it all of the time.
00:34:20.480 --> 00:34:24.559
Like, what what is CMS really trying to do with these measures?
00:34:24.639 --> 00:34:33.599
And we have health outcome surveys, which is you know very Medicare in-depth, but um but they're trying their CMS is trying, right?
00:34:33.760 --> 00:34:39.920
They're trying to get to where we can measure outcomes versus those process measures.
00:34:40.000 --> 00:34:48.639
Um, but it does we had to like wedge people in or like step by step to get, but it's been a long enough time that we've been measuring breast cancer screening.
00:34:48.719 --> 00:34:51.280
Like, what are we doing with those screenings?
00:34:51.599 --> 00:34:54.159
What are we doing with the wellness exams?
00:34:54.559 --> 00:34:57.840
But yeah, I I completely, completely agree.
00:34:58.400 --> 00:35:04.800
Is there a measure you think that that approaches um uh something that people care about more?
00:35:04.960 --> 00:35:16.639
I I was talking with our quality director, and there's engagement with uh some of the accrediting organizations around testing new measures and coming up with new measures, and I was really excited about that.
00:35:16.719 --> 00:35:19.280
And I said, Well, what's the new measure that they're talking about?
00:35:19.519 --> 00:35:22.480
And then I was a little bit disappointed when I heard what it was.
00:35:23.199 --> 00:35:30.320
You know, it didn't uh transcend to what what I was hoping to hear, but um I was wondering if you had thoughts on that.
00:35:30.719 --> 00:35:40.239
I have a lot of thoughts on that, and I'm sure Rex does do, but my initial thoughts are we're getting to a good place when we talk about blood pressure controlled, right?
00:35:40.320 --> 00:35:42.639
It used to just be, did you take the blood pressure?
00:35:42.960 --> 00:35:45.360
And now it's is the blood pressure within control.
00:35:45.519 --> 00:35:49.199
So we're talking about how are we actually having a positive outcome?
00:35:49.440 --> 00:35:59.760
And same with um the A1C measures, they've all changed, the names have changed, but in reality, we've been measuring, are you um within a good range?
00:35:59.920 --> 00:36:07.760
And that used to just be is it below like have different ranges for different measures depending on which health plan you are working with?
00:36:08.079 --> 00:36:17.199
And um, but one of the measures that kicks me all the time for the SNP for SNP plans is did you do their HRA?
00:36:17.760 --> 00:36:19.360
And well, what do you think?
00:36:19.519 --> 00:36:25.679
Do you know how many plans do HRAs and have no clue what what they're supposed to do with those HRAs?
00:36:25.840 --> 00:36:29.119
Like, that is a wealth of knowledge on how to take care of those members.
00:36:29.519 --> 00:36:34.320
And so I I feel like the next step needs to be like the all of those outcomes.
00:36:34.480 --> 00:36:39.119
Like let's take every process that we're measure that we're doing and turn it into.
00:36:39.280 --> 00:36:42.079
And it seems like it's it's tracking that way.
00:36:42.159 --> 00:36:44.559
I just they're trying CMS security.
00:36:44.800 --> 00:36:53.360
Yeah, if we could get the HRA to have a goal for the for what you want the patient to do, um, and then are they successful in achieving the goal?
00:36:53.760 --> 00:36:56.719
Uh that would be you know a really great place to be.
00:36:57.280 --> 00:37:03.920
We have a the the newest measure in Medicare Stars is is a depression measure finally.
00:37:04.079 --> 00:37:15.280
We've we haven't really had one like this where and I and I feel like that's a meaningful measure that's actually going to do you know do do some good, or at least it's got a good spirit behind it, like page the right.
00:37:15.440 --> 00:37:21.679
But where, you know, because we're actually assessing like if you are diagnosed with depression, did you actually receive follow-up care?
00:37:21.840 --> 00:37:24.000
Like, like you know, what was there a next step?
00:37:24.239 --> 00:37:35.280
Not not just did you get diagnosed, not just did you do this, but actually is the health plan doing in the in the system doing something to help to help the the member on that journey, right?
00:37:35.440 --> 00:37:37.119
So but we have a long way to go.
00:37:37.599 --> 00:37:41.920
What what you're asking for, it should not be as aspirational as it feels, right?
00:37:42.079 --> 00:37:57.760
Like like it should not be like it should be where we already are, but it it it feels so aspirational what you're asking for to say mean measures that really really mean something and and uh you know to the to the patient as well.
00:37:58.239 --> 00:38:03.440
But we'll yeah, we'll keep doing doing work and uh and hopefully get there at some point.
00:38:04.719 --> 00:38:06.960
So Ana, thank you so much.
00:38:07.119 --> 00:38:08.880
Uh we will we'll we'll wrap there.
00:38:09.199 --> 00:38:10.400
Actually, one one last question.
00:38:10.480 --> 00:38:22.559
Just uh like if if people want to know more about you or want to follow you, um is there is there are you uh active on social media or can they like follow you on your on the community website or anything like that?
00:38:22.960 --> 00:38:25.119
Um I I do have a LinkedIn account.
00:38:25.199 --> 00:38:34.159
I'm not super active social uh on social media, but um I you know if people want to connect with me certainly through LinkedIn, um that is definitely an option.
00:38:34.639 --> 00:38:41.039
Well we will we will tag you um when we get this recording back and and get it ready to post.
00:38:41.119 --> 00:38:45.599
We'll have some snippets of you saying the wonderful things that you've been saying.
00:38:45.760 --> 00:38:47.440
So you've been a great guest.
00:38:47.599 --> 00:38:48.719
I could talk to you all day.
00:38:48.880 --> 00:38:56.000
Uh this this finance discussion is not we haven't we haven't had this discussion yet with a guest as far as this aspect of finance.
00:38:56.079 --> 00:38:58.880
We've talked to actuaries, but but not the CFO.
00:38:58.960 --> 00:39:04.639
So this was really really insightful for me and I think for Paige and for all all of our listeners.
00:39:04.800 --> 00:39:05.920
So we really appreciate it.
00:39:06.639 --> 00:39:08.000
It was great to be with you all.
00:39:08.880 --> 00:39:09.199
Okay.
00:39:09.440 --> 00:39:10.880
Well, hey, uh thanks everyone.
00:39:10.960 --> 00:39:11.840
We will talk next time.
00:39:12.719 --> 00:39:13.199
Bye bye.
00:39:13.280 --> 00:39:13.679
Have a great day.
00:39:13.760 --> 00:39:13.920
Bye.
00:39:14.239 --> 00:39:14.719
Thanks, Anna.
