Speaker 0: This is where health insurance leadership comes together. Becker's fourth annual spring payer issues roundtable brings together over 400 payer and health plan executives and more than 100 speakers to Chicago April. This year's event includes keynote conversations with the industry's top leaders and former president George W. Bush. For the full agenda and event details, visit beckershospitalreview.com and click on the events tab in the upper right.

We're looking forward to hosting you here in Chicago. Hello, everyone. This is Jacob Emerson with the Becker's Payer Issues podcast. Thrilled today to be joined by doctor Alice Chen, who is executive vice president and chief health officer at Centene. Doctor Chen, thank you so much for taking the time to be with me on the podcast today.

Speaker 1: Jacob, thanks for having me. I am delighted to be here.

Speaker 0: Absolutely. It's a pleasure to get to sit down with you, doctor Chen. And before we dive into everything we wanna talk with you about, a lot of the impactful work that's going on with you and your team at Centene. First, can you tell our listeners a little bit more about yourself, your background in health care, and what it is that you

Speaker 1: do today at Centene? Absolutely. So doctor Alice Chen, I'm the chief health officer at Centene. And just a little bit about Centene for those of your, listeners who may not know us. We are what I think of as a three m company, Medicare, Medicaid marketplace, so focused on government programs.

Last year, we serve more than 20,000,000 people across all 50 states. That's about one in 15 Americans. And when you look at our footprint, it's about the same across three all three lines of business. But in Medicare, 32 states, Medicaid, 30 states, and in Ambetter, our marketplace product, 29 states. As for me, I would say my career could be described as, focused on ensuring access and quality of care for underserved Americans.

And I come to the payer space, joined Centene almost exactly three years ago, 2023, with experience across multiple sectors. I think some people might call it a checkered history. I'm a primary care internist by training who's worked in community health centers, public hospitals now, at a free clinic volunteering, but I spent time in academia, philanthropy, public health, had leadership roles in delivery systems, government, purchaser, and out payer. And here at Centene, my role is tied directly to our mission, which is transforming the health of the communities we serve one person at a time. And by that, I mean, I oversee Centene's clinical policies and programs to improve population health for our members, specifically leading medical affairs, health equity, drivers of health, and clinical strategy.

And just a word about how we do this because I think it'll inform our discussion, which is, given our footprint, the way we approach population health, and frankly, our, I think, unique identity is around leveraging national size and scale for local impact through our state health plans. So it comes in many flavors, but two two big buckets are, one, we're really big on data. How do we use data across in Medicaid, for example, 30 states to identify trends, guide evidence based interventions that address community specific needs? So it's both a bird's eye view across multiple markets, but then tailoring them to the specific nuances of any given community. And that second part ties to that nuance piece, which is we look to partner with local, regional, and national organizations to have a similar mission, a focus on low income Americans and improving their health.

Speaker 0: Understood. Well, I I really appreciate you taking us through that, Alice. You had a fascinating career before Centene, and and now you're you're with one of the largest insurers in the country. You mentioned, serving around one in 15 Americans. That's absolutely incredible across your different your different product lines all over the country.

And I'm and I'm excited to get to talk with you today because I I really wanted to dive in first by talking about something really an exciting announcement from the company last year, that Centene helped launch the Maternal and Child Health Center for Policy and Practice as a founding member, which for our listeners who might not be familiar, it ultimately aims to improve maternal and child health outcomes in rural parts of the country in many states, but starting in Arkansas. So, Alice, can you can you fill us in on exactly how this all came about and why ultimately Centene wanted to be a part of it?

Speaker 1: Yeah. You know, it ties to what I was describing before about who we serve and how we approach our work. So as the largest Medicaid MCU in the country and by dint of that, the largest TANF payer, we have, very naturally a focus on pregnant women, new mothers, infants, children. In 2020, '4, I think was the last complete year of data, we were responsible for more than three hundred and thirty thousand births, a third percent of whom are high risk. So, again, when you look at who we care for and, where the vulnerabilities line, where we need to lean in, maternal childcare is clearly, a priority for us.

So we have a multi pronged approach, to just call it perinatal care, maternal child health. We have internal care management programs. We have value based care programs to partner with our providers to incentivize pre and postnatal visits. We have, partnerships with a whole variety of entities, including what we'll be talking about, to to expand access to evidence based models. And then another piece, which I think is really relevant because it's really in the water right now when you look at CMS, MMI, We focus on introducing and scaling technology enabled interventions, so things like telehealth, virtual health tools, remote patient monitoring, with a real focus on how do you strike the right balance of high-tech, high touch care.

And this is particularly relevant when you talk about the Heartland Forward. This is what the group that's sponsoring the Maternal Child Health Center for Policy and Practice. So just a little PSA about Heartland Forward. It they describe themselves as a do and think tank, focused advanced economic success for states in the primarily Midwest but also South. And so as part of that, the health land, Heartland Health Caucus, decided to focus on rural health.

And when you look at rural health, a few things really rise to the forum. One is maternal child health, one is mental health, and a third is, workforce shortages. And so how this came about was, our CEO, Sarah London, was approached a few years ago given, again, who we serve, what our focus is about participating in how Heartland Health Caucus, which is in the process of establishing the center. And just when you look at the alignment in terms of priorities and focus areas, and members and people who are trying to, improve the health of it, made intuitive sense for us to join forces. And so we really welcome the opportunity, to bring in, an all one Centene, all of Centene approach.

So it's our local health plan. It's our national team, both on the clinical side and the drivers of health and health equity side as well as our foundation. And the partnership itself focuses on midwifery as a proven high quality cost effective model to improve access and outcomes, particularly for women in rural areas. And our main goal is to expand education and improve the workforce pipeline there. So launched mid last year, already made some great progress.

Speaker 0: Wow. And and it does it makes a lot of sense approaching Centene specifically for this type of partnership. Like you said, Alice, given that you are the largest Medicaid MCO in the country, you you, provide coverage to hundreds of thousands of births, every year. And so you you mentioned the the senator is really focused on expanding access to community health workers, to doulas, to midwifery care, especially as in areas where labor and delivery units have closed. And I and I know when I when I speak from our perspective here at Becker's, that is something that we almost see, I'd say, every week at this point, across the country, a a maternity unit that is closed somewhere in the country.

It's something that we track very closely, and it seems to be a very, a growing trend nationally. So I wonder from from a population health perspective, you were you were mentioning mentioning earlier about some of the interventions that are important here. What what is the evidence telling you right now about which interventions move the needle most in these rural, Medicaid dominant populations?

Speaker 1: Yeah. And to level set our listeners, you know, you may see the headlines around rural health crises or, maternity deserts. Like you said, every week, there seems to be, another facility closing. But right now, 35% of counties are considered maternity deserts.

Speaker 0: Wow.

Speaker 1: I mean, where they lack any obstetric clinician. And in over a thousand counties, there's not a single birthing facility available. So when you think about rural Medicaid populations, actually, so it's not just rural, but, like, within Medicaid populations, rural communities face unique barriers. And so when you put together the fact that the women themselves are oftentimes higher risk profiles in terms of medical, behavioral, social risk factors plus maternity deserts and care fragmentation, you pretty logically get poor outcomes. And so, love that you asked about the evidence, because, again, we're really focused on both using our data across 30 markets to identify themes and issues, but then implementing models that have evidence of impact.

Because just as an aside, as a government payer, we really do take our fiduciary responsibility very seriously. And so if we're using, taxpayer dollars to fund government programs, we wanna make sure those dollars go to evidence based interventions and then also ensure that we're evaluating the impact of our intervention. So in terms of the top three care models that we're looking to invest in, one is, for average risk pregnancies, midwifery led models, because they're associated with lower rates of c section, preterm births, low birth weight infants. And again, that's why we, with Heartland Forward, are really focused on expanding the workforce for rural areas. Second would be community based doula care.

Lots of observational studies and Medicaid demonstrations showing, again, reductions in low risk c sections and preterm birth along with improved, engagement in patient reported experience. What's interesting there is that the greatest benefits are reported in some of the most vulnerable populations, so Medicaid insured, rural, black, native population. So it really does seem to have a mitigating effect on some of the structural barriers. And then the third, what I'd say, strongly evidence based care model would be, group prenatal visits, which, again, particularly among Medicaid populations and communities with limited access to traditional prenatal care, have been shown to reduce, preterm births, as well as patient or member engagement, and satisfaction. Aside from those models, I just wanna make, another really key point, which is when you look at the moms, the majority of maternal deaths actually occur after delivery.

Over half of them occur between, you know, seven days to a year postpartum, and it's largely driven by cardiovascular, maternal, cardiovascular conditions, mental health, and substance use disorder. So really CBD and behavioral health. And so that then leads to looking at, like, what are the evidence based interventions from a policy side? It's about continuous, coverage and proactive engagement through twelve months. What's the really good news is almost every single state has expanded, Medicaid eligibility for women, twelve months postpartum.

So that enables us as a Medicare managed care plan to really lean in and engage them around blood pressure control, you know, diagnosing and addressing postpartum depression, addressing substance use disorders. And then that leads to the second piece, which is integrated care models where you actually integrate chronic care, physical health, behavioral health, substance use disorder services, are really strongly supported by the evidence in terms of not again, for these high risk women, creating more holistic whole person care models as opposed to kind of fragmented parallel interventions, is are the types of models that we're looking to.

Speaker 0: Understood. So more midwifery doula group prenatal care models, hopefully scaled across the country and across Centene's Medicaid markets. And I have to say, it's also been very interesting, Alice, over these last few years, seen state Medicaid programs incorporate things like doula coverage, into their into their clinical pathways. It really seems to be a government private industry effort here, to incorporate more of these interventions all over.

Speaker 1: I think that's a wonderful development because, again, I think following the evidence, figuring out what the, most cost effective member patient person centric interventions is a place where having a Medicaid agency incentivize it allows us as MCOs to step up and really be that partner.

Speaker 0: Yeah. Definitely. Definitely. And I wonder going back to you mentioned you have a fiduciary duty, to to get the best outcomes, on behalf of of providing this this government service all over the country. And so what are some of the the maternal and and child health metrics that, Centene is really prioritizing internally right now?

And and how does this partnership with Heartland help you build a better data infrastructure so that you can track these outcomes that really matter beyond, just the care delivery?

Speaker 1: Yeah. Absolutely. So data has been a strong focus for us over the last few years writ large, focusing on a core set of outcome and quality metrics that we feel represent safety and effectiveness of maternity care across the perinatal continuum. And working with a group like Heartland enables us to really hone in on starting with a state but then a region, to then use that data in a, proactive way to kind of tailor our interventions, continuing to evolve the programs, and make sure that those outcomes continue to improve over time. So some of the key, so obviously, all health plans, look to HEDIS.

And so we have the obstetrical specific HEDIS metrics. But in addition to that and this is where, again, partnering with other entities, whether it's providers or regional leaders like Heartland Forward who are potentially able to to aggregate more diverse types of data is very helpful because some of these aren't claims based. I mean, the ones I'm about to talk about. So we need to look at charts and we need to partner with providers, but things like low risk c section rates are a key measure of obstetric quality because we know that, c section bursts can be associated with increased maternal morbidity, higher risk in subsequent pregnancies, and, of course, increased costs. And so if we can avoid those, that is a good thing.

We also track preterm birth and low birth weight rates, which we see as a measure of the efficacy of prenatal and perinatal care. We track severe maternal morbidity rates because that gives us a signal around how effective has the prenatal care been in terms of proactively and aggressively identifying gaps in diagnosis response care coordination. The ultimate metric, mortality rates, so maternal and infant mortality rates is something that we track as a sentinel, indicator of, you know, the most severe and preventable adverse outcomes as, when possible. Not all of them obviously are preventable, but, given our rates compared to other industrialized countries, clearly, we have a lot of room for improvement. And then lastly, neonatal intensive care, you know, or NICU admission rates, which, again, not all are preventable, but are also a indication for us of prenatal care comprehensiveness and quality.

So taking a broader view than just HEDIS and making sure that we, have complete high integrity data and then sharing that data with our providers and our other partners is core to how we think we're gonna be able to create a shared accountability framework and truly move the dial in terms of outcomes.

Speaker 0: Well, clearly, a lot that goes into this beyond just the claims data, Alice. And and to your point, a lot of work still needs to be done, to improve improve these maternal health outcomes compared to, other industrialized countries. And so in that vein, this is such a massive topic. So are there other strategies or initiatives you could share with us that Centene has been pursuing recently, to really address the these maternal and and child health outcomes overall?

Speaker 1: Yeah. Thanks for asking that because this is a this is an area where I'm really proud of our teams, because we really have we're not where we need to be. I don't think any anyone is in The United States, but I think we really have stepped back and created, a comprehensive, holistic approach, that includes, focusing on access, on member engagement, education, self management, on our care management resources, as well as care coordination, provider partnerships, technology enabled. But I think it was pro vendors. Like, sometimes people will call them vendors, but they're really also providing care, and then community based organizations as well as, you know, think do tanks like, Heartland Forward.

And so some specific examples, we have a very robust care management program called Start Smart for Baby where we, leverage data to identify pregnancy as early as possible, do risk stratification, and then reach out to members in a very tailored way driven by their needs and their assessments. And, again, and in a whole person integrated physical behavioral, meaning mental and substance use disorder, social care model that includes comprehensive education and also integrate some of our drivers of health initiatives like, food is medicine. So, for example, we're piloting a program as part of Start Smart for Baby to provide funding to high risk members so they can order healthy food, blood pressure cuffs for folks who have high blood pressure and prenatal vitamins. All the things we know are core to just having a healthy pregnancy, but, like, trying to reduce or eliminate the barriers to being able to take those actions. We also just rolled out a first years of life program to support kids, from birth to two years taking advantage of that continuous eligibility postpartum to engage the mom and then hopefully keep those kids, covered.

I mentioned before, technology is a big piece of our strategy, particularly when you think about rural communities, and just how do you leverage scarce resources, in the community and then outside the community, so that they don't have to spend hours traveling. So we do, traditional virtual health and telehealth where we, use that to enable earlier prenatal care and access to specialty services like maternal funeral medicine or perinatal mental health or substance use treatment, which may not be available in your community. But then we also have been leaning heavily into, remote patient monitoring, and we have a great project in, with Silver Summit Health Plan in Nevada where members are monitoring their blood pressure at home with nursing support, so that, again, because you only have that nine month window, if you can have someone check their blood pressure at home because they're even if they're plugged into care, they're not in their doctor's office that much. So the remote patient monitoring allows us to kinda keep a finger on the pulse of how people are doing and then proactively reach out and get them in and make sure that we can, get their blood pressure and diabetes controlled.

And then, you know, we talked about midwives, which are a big, area of focus. The doulas are another, that I also had mentioned before. We have partnerships with community based doulas where we actively work with, again, community based organizations to help them understand how do you even partner with an MCO. How do you bill an MCO? So we do a lot of technical assistance in order to enable CBOs and community organizations to effectively partner with us.

And then the last thing I would mention is we, partner with community health centers. So we have a three year project with the National Association of Community Health Centers and together, launched the maternal child health innovation initiative to identify best practices and create a forum for exchange and adoption across community health centers, which are the single largest source of primary care for low income Americans and particularly Medicaid. I think they serve one in five Medicaid members right now. So the focus will be, leveraging again, or hear hear similar themes across all these initiative, a virtual care model to improve blood pressure control, during pregnancy for community health center members.

Speaker 0: Wow. I mean, just so much exciting and impactful things going on across the company, Alice. So I hope you will keep us updated on on what some of these, pediatric remote monitoring, maternal health initiatives, besides what we talked about with Heartland, what you ultimately achieve through all of these. Before we go

Speaker 1: I love that.

Speaker 0: What what else are we missing? Any other final thoughts you wanna share with us or final bits of advice you wanna share, while you have the ears of a lot of other health plan leaders from across the country?

Speaker 1: Not so much advice, but, probably a ask, which is I think of Medicaid as a canary in the coal mine for US health care. And within Medicaid, I think of rural health as a canary in the coal mine, you know, within Medicaid. The challenges to maternal child health and rural settings is not unique, but the interventions that are successful there can oftentimes be scaled to less vulnerable settings. And so, you know, the way we've leveraged national insights and resources for local impact, data technology provider, pro vendor partnerships, is something that I would love to see our peer organizations do as well. You know, there's not a lot of lot going on in health care these days.

Right? Just kidding. There's so much going on in health care, but to me, in this time where a lot of payers and providers, particularly in the government space, but frankly across the ecosystem because we're all tied together, in times of pressure, I think this is a time to double down on maternal child health, because it is the future, of our country. And I think we'd love to see providers, payers, and policymakers converge around the right policies, the right practices, the right support, similar to how we're doing with Heartland Forward.

Speaker 0: It's a great call out for this current moment in time, doctor Chen. So I wanna thank you so much for taking the time to sit down with us, for sharing your insights with our listeners, and for telling us a little bit about all the impactful work going on under your team at Centene. We we really appreciate it.

Speaker 1: My pleasure. Thank you so much for having me.

Speaker 0: Absolutely. And to our listeners, if you'd like to listen to more podcasts from Becker's Healthcare, you can visit beckers hospital review dot com.