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This is Laura Dirdle with the Becker's Healthcare
podcast.
I'm thrilled today to be joined by Joanne
McFall, market president of Keystone First and AmeriHealth
Caritas, Pennsylvania
at AmeriHealth Caritas family of companies.
Joanne, it's a pleasure to have you on
the podcast today. Thank you so much, Laura.
I really am glad to be here today
with you.
Now I'm looking forward to our conversation. I
think it'll be just amazing to hear more
about some of the great things that you're
doing and really to share how you're thinking
about the future as well. But before we
dive into that discussion, can you tell us
a little bit more about yourself and your
background?
Sure. Absolutely.
As the market president for,
essentially our Pennsylvania Medicaid business, we we operate
under two plan names, Keystone First and AmeriHealth
Caritas, but we both plans,
are part of the Pennsylvania Health Choices Medical
Assistance Program. So just to set the stage
on that. And so I have been with
the organization for 24 years now. I I
came in from the provider side
working for,
a Philadelphia based hospital system
and then a large
outpatient
outpatient therapy
organization. So
24 years ago, I came to the payer
side
and have had the opportunity
to work
in a variety of different
types of roles in within our organization,
starting as a business analyst in our IS
department
and then worked my way up through our
project management organization
and,
a few other roles on the sort of
corporate side of of our organization
before switching over to the health plan side
about 10 years ago. And so for me,
it's been a really amazing journey to be
able
to bring both of those parts together because
we still exist in an organization where
our local health plans,
have a a set of responsibilities,
and then we're supported
by our corporate organization for a lot of
the back office functions. So I've kinda played
in both worlds, and and my job now
is to really bring those 2 together.
Well, that sounds like quite a huge responsibility
indeed and and certainly
something very needed within the health care space
right now. Given that role, and your focus,
what are some of the biggest issues that
you're following in health care?
Absolutely. I can, dig into that. You know,
one of the things just to sort of
set the stage,
currently in Pennsylvania,
through those two health plans, we support,
just about 833,000
Pennsylvanians,
who are part of the HealthChoices,
medical assistance program.
So,
you know, for for us, really, the the
big challenge
that,
that we've been facing is, you know, the
impact of the post pandemic
Medicaid unwinding.
So, you know,
as over the course of the last, you
know, 14 months or so,
more than 23,000,000
Americans
have lost Medicaid coverage
during this unwinding
of of the pandemic,
essentially, in an a a disenrollment
freeze. So during the the publicly declared pandemic
emergency,
states could not
implement their regular disenrollment processes,
due to
the pandemic. And so
over the course of the little over a
year now, the states have been restarting
those disenrollment activities and that has resulted in
that significant
drop in the 23,000,000
Americans who no longer have that Medicaid coverage.
So we've been seeing as as as we
support our our members and our population
through that unwinding and working with individuals and
families to ensure that those individuals who are
still eligible for those state programs remain eligible.
But
having seen that significant drop in the enrollment,
what we're seeing is that the remaining enrollees
are tending to be sicker and having higher
rates of utilization
than what the states may have anticipated when
they were setting Medicaid budgets.
So we have the challenge there of, you
know, the state funding
not meeting the reality of of current utilization,
and then we also have the impact of
inflation.
And, you know, across the health care industry,
we're seeing higher costs for staff,
for real estate, for supplies and other essentials,
and health care providers are seeing those higher
costs for
equipment, medications, and the other supplies
that they need for their work. So
we have a little bit of a challenge
navigating,
you know, between
the realities of the state funding and the
realities of the cost of doing business in
the health care industry.
You know, that's such a fascinating point and
especially thinking about,
everything that's occurred over the last 4 years
from the pandemic and then, you know,
the period afterwards,
certainly for the Medicaid enrollees and trying to
figure out, you know, as you mentioned, how
to make sure people that need coverage still
or are eligible still for coverage have it,
what to do, for those, you know, who,
are no longer eligible. And then 2, for
those who are eligible, with those costs increasing,
I can imagine it just really,
shifts the way you're thinking about,
coverage and funding and everything else.
Absolutely. Absolutely. And and recognizing that the providers
themselves, the hospitals, the physicians, you know, all
of the ancillary
providers, you know, are are really dealing with
that reality of,
you know, the
the increase in in costs associated with the
delivery of services
and then trying to be able to match
that, you know, with
paying for those services, you know, as an
insurance,
organ you know, a payer organization.
Absolutely.
Definitely a huge, huge challenge,
and something that I can imagine will continue
to evolve in the next couple years. And
speaking of the future,
what are you most excited about, and what
makes you nervous?
Well,
what I'm most excited about is,
the opportunity that we have,
as as a
Medicaid, you know, managed care organization
to
really address the social factors that impact health
in a in a more structured way.
You know, as a as a a very
community based and mission driven
managed care organization, you know, for over 40
years,
we have been focusing
on supporting our members
and our communities in addressing those needs. So
we're not new to
helping people who need assistance with,
with housing or housing related issues, people who
are looking for education and and workforce
development and employment opportunities, or people who simply
have challenges in accessing healthy food for themselves
and their families. So what is exciting is
that states the the states with which we
contract are now looking at
incorporating,
you know, those efforts
and reimbursement for those efforts into,
you know, state Medicaid programs,
with the recognition for
how collectively we can address those social factors
and then have a corresponding
impact on improved health and life outcomes for
the people that we serve, which in theory
then, you know, can put people on a
path for
not having to remain dependent on government programs.
So, you know, we all recognize
that by putting the resources in the right
place,
we can, you know, have an impact not
only on the individuals we serve, but the
future of these programs as a whole. So
that to me is what's really exciting and
being able to
focus our collective
resources
on those programs. You know, we've worked with
a number of different food based organizations
in, Pennsylvania
to
address food insecurity and implement
food as medicine programs in which people have
access to
medically tailored
meals that can help prevent readmission for conditions
related to diabetes or heart disease.
We've worked with
local health systems and nonprofit organizations, and we
we implemented a program in 2021
called housing smart that was aimed at reducing
emergency room utilization
by
supporting
stable housing and support services for people who
are experiencing
homelessness
and also comorbid,
mental health conditions.
So
these investments
make a a very big difference in,
you know, the overall health of our population,
and and create that path forward for individuals.
I also wanna say that one of the
exciting things that we've been doing, is is
working with
what we're calling a pardon
program
where we have individuals who participate in our
workforce development programs. And one of the things
that we've we hear constantly is that people
face the barrier of having
a criminal background or a criminal record even
after having
served their, you know, their debt to society,
so to speak. And the existence of that
record
precludes people from certain certifications
and jobs,
getting educational
opportunities or getting loans or being a foster
parent or coaching a child's sports program.
So in Pennsylvania,
our former governor,
really worked over the last few years to
transform
the process by which,
an individual can seek an application for pardon
from the governor.
And by
streamlining and improving that process,
we've seen a much higher success rate of
people who have been applying for pardons,
who are granted those pardons, who can then
have their record expunged, who can then move
forward with those opportunities that may have been
out of reach for them because of the
existence of that record. So our role is
to ensure that everyone is aware of those
programs,
that people are,
trained to coach individuals through the process,
because you have to follow all the all
the steps and and be eligible
and tell your story
in order to move forward with the process.
And so the success of that has been
really inspiring in terms of being able to
connect people back into those workforce or educational
opportunities.
That's fascinating to hear. You know, and really,
innovative to have that opportunity to connect with
folks as you mentioned,
and really, you know, bring up these programs,
bring up the,
available services to them so they can get
their jobs. They can,
have access to other opportunities,
you know, and not have some things in
their past stand in their way. So that's
really fascinating to hear and a cool thing
you're doing for the community.
Yeah. Absolutely. And, again, you know, really looking
at how we can,
focus our efforts on
the things that can be most success successful
in in helping people to
not only address health issues, but also those
barriers that they face on a regular basis
in in getting,
connected with the supports they need for overall
health and life outcomes.
Absolutely. Fascinating and it's just amazing to hear.
Now, before we wrap up our conversation, I
was wondering what do you think the most
effective health care leaders will need in order
to be successful over the next 2 to
3 years or so? What's
top of mind for you especially as, you
know, health care industry changes,
communities change, and, you know, really the way,
people think about and approach health care is
rapidly evolving.
Oh, absolutely. And, you know, I think that
for me,
especially someone that, that came up through, you
know, to this opportunity,
without,
you know, a fundamental finance background. Right?
The the biggest, you know, key area is
gonna be, you know,
being able to focus even more
minutely
on the financial aspects of our business. You
know? As I said, we're facing, you know,
we're facing
challenges with, you know,
state funding opportunities because we exist at the
mercy of of state budgets and and states
are challenged with those budgets and the funding
that is available for
managed care and and Medicaid programs.
And then you couple that with the reality
that we talked about in terms of rising
costs and rising utilization and higher acuity of
our membership. So really being able to
focus
in great detail on the specific
drivers,
that impact, you know, the the the financial
aspects of the business. So related to,
you know, where are we seeing increasing utilization
trends? Where you know, what are the specific
services or,
you know,
benefits
that
are driving those increases in the trends and
then being able to take that information and
develop programming
that doesn't
it's not successful because it's limiting benefits and
services that are available, but in fact, targeting
and implementing
the types of programs that can then
impact, you know, the the the health services
that people utilize or,
you know, the the care that they need.
We can make, you know, the the better
we do at making investments in providing
really good,
strong, and consistent prenatal care for our members,
then that
prevents,
you know,
premature births and having babies that have to
be,
in the NICU for, an extended period of
time and who may then face
lifelong physical health challenges as a result. So,
you know, it's targeting
the best places to create those interventions
to be able to create you know, to,
promote better outcomes on the end. So it
it's really about slicing and dicing the data
that's available,
for our business and then using that data
to target programs that can have the biggest
impact for us. So,
that's really, you know, if I had my
crystal ball, it's really about, you know, being
able to
put all of those pieces together in a
way that allows us to to do more
and have greater impacts in light of the
changing,
health care financing and cost,
environment.
That's an amazing,
thing to think about and and certainly, I
can imagine easier said than done, but so
so crucial,
to understand the global picture,
bird's eye view of what's happening in the
industry and then be able to proactively
take
action, and and create those programs and initiatives
that are going to most, impact the community
and be most needed.
You know, I I just think I I
appreciate your example, especially thinking about the prenatal
care in the babies and new families, being
able to, serve them in an important way
just gets things started off on the right
side and then, going from there. So a
crucial, crucial part of building community and and
connections.
Absolutely.
Well, thank you so much, Joanne, for joining
us on the podcast today. This has been
such a fun conversation, and I look forward
to connecting with you again soon.
Absolutely. Same for me as well, and I
I'm really grateful for the opportunity to to
speak with you and to share this kind
of information with your audience.