Rhonda Medows, M.D., FAAFP, is president of Population Health Management at Providence Health & Services. She oversees the Providence Health Plan, Accountable Care Organizations, Payer Strategy & Contracting, Physician Services, and the affiliated Pacific Medical Group. She also currently serves as a member of the Physician-Focused Payment Model Technical Advisory Committee to make recommendations to the U.S. Secretary of Health and Human Services on current and future physician payment models. Dr. Medows has an extensive background in government health programs including the Affordable Care Act, Medicare and Medicaid.

She is interviewed by Dora Barilla, Group Vice President, Community Health Investment for Providence St. Joseph Health, Senior Fellow for the Institute for Health Policy and Fellowship at Loma Linda University Health.

Dora Barilla: Hello everyone and welcome to Next Generation Community Health with Providence Saint Joseph Health. I’m your host, Barilla and today, we’re joined by Doctor Rhonda Medows. And we’ll be talking about, serving our dear neighbors. Well, let’s get started by first welcoming Doctor Meadows to the show. Thank you for joining us today.

Rhonda Medows: It’s a pleasure to be with you today.

Barilla: Thank you. Can you start just by telling us a little bit about your role at Providence Saint Joseph Health?

Medows: I have what I think is one of the best jobs in the whole wide world. I get to lead Population Health for Providence Saint Joseph Health. A health system that expands across seven different states. And I lead a team of individuals who are highly motivated, experienced and talented that focus on actually, improving the health outcomes, the care delivery, and the management of resources that serve our different populations. And by populations, we can think about them as communities. We can think about them as different program groups like Medicaid/Medicare or employees. But we get to actually, focus on the health, wellbeing, and resources that they need for their everyday living and better health.

Barilla: What a great opportunity.  It’s personally just a privilege to be working with you on a lot of this, and you’re just such a leader, not only within Providence Saint Joseph Health but around our country. Why is Medicaid such an important part of the population health strategy at Providence Saint Joseph Health?

Medows: Part of our mission at Providence Saint Joseph Health is our dedication to the communities and the people that are in what we call “our mission.” Those ministries of individuals consist of a whole host of different kinds of folks, and most especially we want to focus on those who are vulnerable or are poor with low income and low number of resources. We want to make absolutely make sure that all boats rise and we do things that are focused on improving the wellbeing of the people in our community, and their community health status. As well as the individuals themselves.

So, the people who are in the Medicaid programs, have low income and reduced resources who need to actually improve their health, quality of life, and wellbeing. They need additional interventions, services, and solutions that actually fit their daily needs. We want to help them be as healthy and as happy as they can be.

Barilla: That’s a wonderful opportunity. Going a little bit deeper, what are your passions and drivers around Medicaid? And, what drives you to improve the quality of the Medicaid program?

Medows: I have spent a great deal of my life and career focused on health, healthcare, health delivery and understanding that those things do not occur in isolation. They occur focused on the social needs and resources of the Medicaid population and people who are uninsured or just have limited resources and access, people who are vulnerable.

I’ve been a physician, a care giver, a whole host of different roles, a teacher of medical students who are working on the population in understanding the diversity of needs. So from every aspect and every position that I’ve been in, I’ve been focused on the patient or healthcare consumer. But this particular population is more vulnerable, more likely to suffer the winds of change in terms of, political change, regulatory change, healthcare funding, changes in terms of, resources, availabilities of physicians, specialists, access issues. There’s a whole host of things that are very specific and unique and have to be addressed. And without us doing that kind of work, we miss the mark. We actually end up treating the sickest when they are truly acutely ill. We miss the ability to actually have the most impact and help them be healthier, be productive, and lead better lives.

Barilla: Doctor Medows, I know that you’ve been a real strong leader and proponent of pushing the social determinants of health, which is again a new buzz word around healthcare. We’ve always been looking at it in terms of essential health services. Share a little bit about what’s driving you with that strategy and why is it so important for a population health strategy to include that?

Medows: You know, it’s really important but as you were saying, this is not new. It’s just now kind of the phrase de jour. We’ve always known that people who don’t have access to healthy foods, to the places and time and resources to be in shape, to have access to utilities, to housing in general, to have access to regular medications, to treatment, to prevention, to self-management tools and resources to help themselves—all of those individuals, all of those people who are impacted by the lack of those so called “social services” or “social determinants” are actually folks that require additional specialized help, on an ongoing basis. So it’s not a one off and it has to be done in a way that integrates in with their health maintenance prevention as well as their healthcare.

If we do things in a siloed approach we miss our opportunity. For example, I’ve had an elderly gentleman who came in every time that I needed to do his blood pressure check. This man somehow found a way to come in and do his blood pressure check in my office, in Florida, like clockwork. But what I did not understand was a couple of things. When I saw that his blood pressure was never completely under control, I did what most of us do in a clinical sphere, I actually addressed his medications and tried to basically increase the medications or add a new medication to try to control his blood pressure. My opportunity of being missed was a couple of things. Number one was, while I was writing prescriptions for him, he was very nicely folding them up and putting them in his wallet and never filling them. So, he was walking around with a collection. So of course, his blood pressure is never going to be controlled. Number two, and the reason he never filled them, was because he either one, didn’t have a ride to the pharmacy or, two, couldn’t do the copay, right? Low income, limited resources, too embarrassed to say that, that was a difficulty. When I asked him about it and he told me that and I said, “You know, I’m not giving these things to you for a copy of my autograph. I’m actually giving you a written prescription with my signature with the intent that I really need you to take the medication.” He explained to me about transportation, he explained to me about the difficulty in making sure that he had the finances to pay the copay every month to get the medications. But then I said, “So, how is it that you’re always here for your blood pressure checks with me?” And he said, “Well, what I do is my nursing home, my assisted living facility, actually has a bus that goes to the shopping mall once a week. I make sure that my doctor appointments with you are on the day that, that bus goes to the shopping mall. And then I walk from the shopping mall to come see you.”

So, I always thought that he was in my office early, because he was just really timely. He actually was arriving several hours ahead of time, after being dropped off at the shopping center and then waited. He went to great lengths to be there, to follow the recommendations that his blood pressure be checked on a regular basis. But I missed the opportunity of realizing he had difficulty with transportation. He had difficulty with understanding that the importance not only of the medication but of the ability to just basically get the medication. So each time he would come in, I would see his blood pressure was not well controlled. I made an assumption that he had the pills, that he could access the pills, that he could pay for them. And he could not.

Had he actually ever filled all the prescriptions and taken them then we would have a big problem. But, I did not address all the things that he needed. It made me then ask other questions like, “Where do you live? Are you safe?” Right? “Do you have family?” Even though I thought that I had addressed these things, when you paint the fuller picture of the person as a whole person that’s a different way of treating them and their life overall. I asked him did he have difficulty with getting food that he needed? His favorite food group was what appeared to be one of my favorite food group, which is mac and cheese. Not so great for the diabetics with hypertension, et cetera, right? Not so great. And I said, “So what else do you eat?” So then we literally wrote out not only a nutrition referral for him that could be done at the nursing home where he lived but also to make sure that he actually did get the foods that he needed—not just the ones that he liked, the ones that he needed.

So we arranged for the nurse at the nursing home to do the blood pressure checks in tandem with me. We kind of reduced some of his difficulty getting back and forth. We arranged for him to get a 90-day supply of his prescription medication. We started from scratch and got his blood pressure  managed. When he came to see me, it was at a time that more correlated with when he could arrive as opposed to having to wait hours to see me. So you see, there’s all of those social things that people normally don’t think about. I’m thinking I’m doing a great job treating the medical need but I wasn’t paying full attention to the social need that needed to be addressed. Once we got that corner turned, his life becomes so much easier. And I can see the impact in his actual health status.

Barilla: Thank you for sharing. What a great story. You know, we often say, “A patient isn’t compliant with their meds,” and we’ve got to change that language and you just beautifully outlined what’s the underlying causes of treating the whole person. And beginning to address some of those issues that are impacting not only that patient but probably so many others.

As we think about Medicaid, Providence Saint Joseph Health recently conducted a public awareness survey. And it showed there were pretty significant gaps in terms of understanding around what Medicaid is and who it serves and why it’s important. I’m wondering if you can share just any thoughts in terms of what you would like people to know and what you think is important as we move forward into whether it’s a conversation in our communities or a conversation with Congress?

Medows: I think that one of the key things, key findings that came out of the survey was a confirmation of what I suspected for quite some time. And that is a lack of understanding about what Medicaid does, who it provides services for and where it is already embedded into our everyday life either within ourselves, our family, our neighbors, coworkers. You would be surprised at how many people actually are using a Medicaid funded program or service. The survey basically showed that when people understood what Medicaid did and for who it served, they were actually very supportive of. They understood the purpose behind it and then how it in general worked to support healthcare for a vast majority of people in the United States.

When they said, well, people didn’t really realize that veterans could be on Medicaid, they didn’t realize that school-based services for children with developmental disabilities was paid for by Medicaid, that there were school based clinics where people could get, not only their flu shots but also get help with their asthma during the day so that a parent wouldn’t have to leave work… We want people to be productive, be able to support themselves, but we also want to make it so that it’s easier for their children to receive the care that they need on site. People didn’t realize that over half of the newborns, the births in the country, were actually paid for through the Medicaid program itself. And it’s not a freebie or a giveaway. If you think about it, that is the point in life when you want the most to have that healthcare system, that delivery, in place—at the moment, when they’re born and even before, through prenatal care. The perinatal period is critical in the life of not only the child, but the mother as well.

So when we talk about those babies coming in with healthcare services, the prenatal care that those mothers receive ahead of time, we’re talking about an investment in our future. On the other end of life, over 65, almost 70 percent depending on which state you’re in, of nursing home care is actually paid for by Medicaid. People honestly, did not know that that was a Medicaid funded service. They assumed it was Medicare. So, there’s a big confusion about the difference between Medicaid and Medicare. Medicaid is what pays for that skilled nursing, he nursing home, the residential place where people who are elderly, frail, disabled will live. That’s where they reside and that’s where they can receive care and other services. The solutions that actually help them have the best quality of life in the end stages of their life. People have forgotten and not understood how much Medicaid actually pays for things like hospice.

It is the largest single payer of mental health services in this country today. When we talk about making changes to Medicaid program enrollment, funding, or benefits and services, we’re talking about disrupting one of the few places where we actually have solutions in place to help people with mental health illnesses, from all ages, children to adults. We’re talking about everything from major depression to schizophrenia to addictive diseases, alcoholism—the whole nine yards: domestic violence, people who need ongoing counseling. It is also the place where a lot of people actually get services and ongoing therapy for things like disabilities and just… and learning disorders.

It all comes together there. When we ask people about the Medicaid program they may initially say, “I’ve heard about it but I don’t really know.” And then we give them a little bit of a challenge, we say, “Let’s see what’s in your wallet,” as that commercial says. “Let’s see what you have in your healthcare program.” Or, “What do you have that’s actually a service solution that you have, that you’re using right now, yourself?” And they’ll put out something and we’ll go, “You know that’s actually, funded by Medicaid.” And they’ll not even know it because it has a different name. There was a point when every time a state would roll out a new program they would give it a totally different name.

Unless you actually were paying attention you may not have realized that it’s a Medicaid funded program. When I ran Medicaid in the state of Florida and ran Medicaid in the state of Georgia we introduced programs that provided services that we knew were important to the, again, overall health and wellbeing of an individual. We considered it an investment. A lot of people don’t realize that prescription medications is considered an “optional” benefit. You can’t see me but I’m doing air quotes “optional” because obviously, if you diagnose someone with a condition… and there’s something that can be treated with medication management, you would believe that that would be an automatic. That’s not true.

Some of the therapies… the dental, vision those kind of things were people think, “Well, those are optional services.” But, in fact, if you can’t see and if you can’t hear, how are you supposed to function? That impacts not only your life and overall health but your ability to basically take care of yourself, your family and sustain your own living. So, all of those things come into play. There’s a great misconception about what Medicaid is that’s confused a lot in the news, in the media, about who else is covered. I will have to say that over the course of the last year, a great amount of information has been released and shared to educate the public on what this means. One of my favorite new media, new for me not for you, is watching all of the communications go out through Twitter, through Instagram, through social media, educating people and people educating their neighbor about Medicaid and what does it cover, and what does it provide, and the “did you know” kind of a thing.

Are you willing to speak up when the issues came up about the announcement about the opioid crisis. People were like, “What are we going to do? How are we going to manage this?” We have one effective tool for at least, low income family and that is, Medicaid. Does it need to be improved? Absolutely. Does it need to be better coordinated? Absolutely. Does it now actually, pay for services and actually pull together networks of providers to help individuals? Yes. It needs improvement, but yes, it is already there. So to disrupt it would take away the little bit infrastructure that we have.

Barilla: And now we can add a podcast to that inventory of educational information. What a wonderful breakdown in just five minutes. So that people really can begin to understand what it is and we can begin to have those conversations and know that this… when we make decisions around Medicaid that it’s impacting our communities, our families and a lot of people that we know and love. Thank you for sharing and breaking that apart in a very simple way so  people can understand and, hopefully, our listeners can use this and share and educate some of their family members on the different components of Medicaid.

You mentioned that you had experience in different states and had some unique care models and tools for the Medicaid population. I’m wondering if you could share a little bit about what you’re doing for those insured by Medicaid within Providence Saint Joseph Health and talk about those care models and what that means to our patients, communities and clinicians.

Medows: One of the big bodies of work and one of the strategic priorities that we put forward is that we need to do a much better job in taking care of the Medicaid population and those individuals who are still uninsured and in need of care in our communities. We first did the work as if we would do any patient population health type effort. We started with an assessment of the populations themselves. We needed to learn who were the people in our communities who utilized our hospitals, doctors, clinics, emergency rooms, et cetera. So we did the drill down, the analysis of where they were receiving care. We found a couple of places where we knew that we would have to make some improvements in the agile care of complex patients and complex populations of which, Medicaid and the people who were dual eligible for Medicaid and Medicare really exemplify.

So that for that population we realized a couple of things. One, we needed to do a better job in terms of providing ambulatory access, preventative services, home care. We know that a large percentage of the population in Medicaid are young, tend to be relatively healthy. But they have some conditions that could be helped by having digital health solutions, consumer solutions, things that they could actually use to manage themselves. Any of us, including ourselves sitting here on this podcast, who do not have a smartphone would probably be not considered part of this generation. Because what we figured out is there’s no reason why we can’t use some of the social media tools that everybody uses to help leverage self-management, patient education, connectivity with healthcare providers and professionals, that kind of thing. So, ambulatory, digital health, using some of the consumer tools, tying people in a little bit tighter. We needed to do a better job of doing that upfront or upstream as opposed to simply reacting when they come into the emergency room. Because, when they come into the emergency room, something is acutely wrong or off, there’s a concern. It may or may not be actual true emergency but there’s something that has them concerned. We needed to get ahead of that, go upstream and either try to prevent that need from occurring by anticipating it or offering them alternative sites and sources of care that did not involve going to an emergency room or a hospital. So the ambulatory access, the digital health access, doing a better job of coordinating, a little bit more proactive outreach to populations, in general.

And then, more specifically, what we did was take the information that we learned about the populations in each of our communities. We went and risk stratified where people were in terms of their healthcare needs and their health status. So we identified people with chronic medical conditions who were in the emergency room a lot, who were being hospitalized frequently, who had any more than three to five medications, who had a whole host of things that were screaming to us, “I need additional help. I need help managing, preventing acute episodes, and managing and preventing emergencies.” We identified those individuals and then we sat down and figured out what interventions would actually be most impactful for those individuals? We have very experienced, very much trained and very compassionate Care Managers that actually now, work with those high risk or complex populations.

They reach out to them using the information that we have given them. We identified the people who were high risk. We have a good picture of what they have been dealing with health wise. And then, with the help of community investment, health intelligence and a whole host of people in the population health and care management, we pulled together and improved the information that we use for the Care Managers to help the patients. We improved it by not only listing their clinical conditions, their medical conditions but enhancing that with the information about mental health, the social factors impacting their health, their use of smoking tobacco, alcohol, that kind of thing, whether or not there were any issues with getting good nutrition. We basically put in the social factors that impact an individual.

We mapped the individual communities to social factors that impact their local community, and we can tell at a block level, a city block or a country mile (I’m not sure) what they have around them. So, we know where there are food deserts. We know where there may be communities or populations that have in general, lower educational levels, lower income levels, difficulty in getting to grocery stores with good food, fresh food sources, places where the emergency room may be the primary source of care because there’s inadequate access to other places, where there may be more crime, where there may be more issues that actually can impact the overall person, the family, and the community coming together. All that being said, each of our communities in Providence Saint Joseph Health, we gave them the information, the data. We gave them an idea of how many people were complex, or high risk. And we worked with them on actually, developing playbooks, Medicaid playbooks that focused on how do we break this down and figure out how do we improve the upstream, ambulatory, digital health, all those type of sources. How do we do the things in the emergency room that basically help people kind of distinguish between an emergency and an urgent and then figure out how to educate them on how to take care of things that are not an emergency someplace else.

If they are emergency and they have to be admitted to the hospital, how do we manage them in a hospital in a more effective way? And then how do we start planning for their efficient transition out of the hospital either to home, to rehab, to a nursing home? If they’re homeless, how do anticipate that need for them to have someplace to go to when they’re discharged? How do we make sure they have the medications when they leave, the resources, and the transportation to get to the follow-up appointments after the hospitalization? We know that if we don’t do those things, people will come back to the emergency room, they’ll be readmitted to the hospital. It becomes a vicious cycle.

So how do we anticipate and do that? One of the great lessons in developing the playbooks in each community, in each region was understanding that, you know what, we don’t have to do this by ourselves. We can work with community partners, healthcare partners, social service partners, food banks, shelters, utility companies. The list of people and entities that actually are doing something already and want to do more, has been phenomenal. It is actually just coordinating them together. And then we have to do the work of actually putting process and formality to this so we can actually do it at a scale that is going to be impactful.

Barilla: It sounds like this is a very intentional strategy and a significant focus with some very skilled professionals. Can you share a little bit about why is Providence Saint Joseph Health investing so many resources into a Medicaid strategy?

Medows: This is a labor of love, this is who we are. We firmly believe that we are accountable, responsible for our dear neighbor. We believe that it is our responsibility to do all that we can. We have in our Promise Statement, “Know me, care for me, ease my way.” It was one of the things that attracted me to Providence three years ago when I came. That is actually embedded in what we do. A lot of people can kind of talk to a mission statement, value statement, guiding principles. This is embedded, this is our promise going forward about what we do. So, focusing on the poor and vulnerable is not an option, it is a labor of love, of commitment, and it is our purpose.

Barilla: Knowing that some of our listeners are really with you on that journey in terms of just sharing that passion. or maybe we have some others on the other side of the fence, what is it that you’d like to share in terms of our challenges our country is faced with in terms of Medicaid and the future?

Medows: Probably the biggest challenge—in addition to the usual dealings with cost of care, coordination of care, information, data sharing, those types of things that we’ve had long history of and we still need to address effectively—is just the volatility of our environment, the changes politically, the news stories, the regulatory environment, all of those things that are changing or that are threatened to be changed. One of my greatest concerns is when the news came out about there being work requirements added for Medicaid beneficiaries to have to… In order to be able to continue Medicaid coverage, was that it either wouldn’t be communicated well enough, that it wouldn’t be administered well enough to prevent people who really need their services from either being discouraged, dismayed, not able to jump through whatever hoop is being put before them, and that they would just kind of give up because most of them are actually in the battle day-to-day of survival, in general not just for healthcare itself. So my concern was that they would get misinformation, wrong information, they would be discouraged, that they would just stop.

The other is that there are people who, whether they’re taking care of a child who is chronically ill with a serious condition or is an elderly family member, or it’s a Veteran who has served our country and is just trying to get the services for everyday living and life, that they either get discouraged, they get lost in the shuffle, they got lost in the confusion. So it behooves us to make the effort to communicate with them that they need to continue in the programs that they’re enrolled in. If they believe that they’re eligible to still apply, to still try to enroll. If they need assistance, there are always social services, there are community partners, and there’s even us, right? We even help people with enrollment, getting through their process, to still try. To not just resign, to not just give up. One of the things that happens during change like this is again, people stop trying to enroll. Enrollment drops. The people who are most concerned with budgetary reductions are happy. But then, there is a bunch of people who are unserved, care is delayed, sometimes catastrophically so. And they end up in the emergency room, in the acute hospital centric area with greater healthcare costs and suffering greater pain. So, that’s probably number one. Keeping them engaged, keeping them hopeful and keeping them enrolled.

Barilla: You obviously have a very influential voice around the country. We have a lot of listeners today who perhaps own businesses or can be a key influencer. What would you like to say to them, and what’s the message that you’d like them to carry?

Medows: I think that the key message is to open your mind and open your heart to who is actually being served in Medicaid, community health, public health programs. Recognize that it is your neighbor. It can be your family member, your coworker, maybe even you; it can be your elderly parent, your child—to remember that and not forget that. It’s really easy to think of them as ‘other’, until you realize that ‘other’ is actually us. I would say that if you are an employer, particularly if you are a small employer, small business, to remember that probably a significant portion of your workforce is probably using Medicaid programs for a variety of different reasons.

Some of the people that you think, “Well, maybe they’re on the exchange or maybe they’re on another program”—all of those programs are under duress and under a flux and change. And people, when they can’t get what they need, will default to care that is more costly, less effective, less efficient and leaves them with more consequences. So, if you’re a business owner, you have an investment in your workforce. If you are a regulator, a politician, you have a commitment, a promise that you’ve made to your constituents and to your citizens to basically make sure that the most basic things that they need, their health and wellbeing, are actually met in a respectful, dignified and compassionate way.

Barilla: Thank you for reminding us that “they” is “us.” Went a great way to really end our interview. But I want to give you an opportunity, is there anything else that you’d like to add or share with our listeners today?

Medows: I don’t know what else I can add other than to say that everything that we have is wholly connected. When we make a change in Medicaid, when we make a change in the people who are in an individual insurance programs through the exchange, when we make a change to employer-based insurance, to Medicare, it all is connected. Remember, even though we talk about we don’t have a really good healthcare system, it’s still a connected loop. It’s like a balloon. If you reduce funding, services, access on one end, you will squeeze people to another. You’re not actually making a change unless you address healthcare cost, healthcare quality, access, appropriateness of care, appropriate use of resources. So to try and do something in isolation, in silo, is more harmful if it is not well thought out, disciplined, with an eye one again, the end user, the actual patient.

Barilla: Thank you, Doctor Rhonda Meadows, for joining us today and for your passion and vision around this issue, and for your leadership in our country. I know you’ve inspired me today and, I am sure, many of our listeners. I’d like to thank everyone for listening and encourage you to join us for our next podcast, and thank you for being a part of our journey as we to people throughout the country. And for those individuals that are sharing what they’re working on that are bringing health and life to our communities. There’s good work going on out there, and thank you for being a part of our conversation.