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the conference website. That's the beckers hospital review.com events page. See you in Chicago. 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.