Cara Henley
The best policy are those things that introduce exciting things that have happened in other parts of the country, or even other parts of the world, that we can test here to see how we can continue to improve and move the needle for people.
Jennifer Colamonico
You're listening to Vital Viewpoints on Healthcare. Let's get started. Today we're talking about something that's on the minds of just about every health care leader. How do you keep up when policy is changing faster than ever from shifting regulations to evolving implementation timelines? Organizations are being asked to make important operational decisions before all the answers are clear.
Joining me today for this conversation is Cara Henley. She's a regional director at Health Management Associates, based in New York. Cara is a nationally recognized Medicaid policy expert with deep experience helping health care organizations understand how policy changes affect operations, reimbursement, and long term strategy. She's worked with government agencies, health plans providers and community organizations to translate often complex policy into practical action, guiding organizations through everything from value based payment, behavioral health initiatives, 1115 waivers, large scale Medicaid transformation efforts, and more.
Cara, thanks for joining us.
Cara Henley
Thank you for having me, Jen.
Jennifer Colamonico
So you have worked in and around state health policy for a very long time. And you've seen lots of different federal, you know, administrations with significant policy change. But it does feel like those changes are just coming at us faster than ever. And, you know, obviously, any federal policy change is takes a long time to wind through regulation and approval and rulemaking and then state lawmaking.
So from your perspective, you know, how is the environment different today from previous times of, you know, what was major health care reform?
Cara Henley
We've always been in sort of a state of change. I feel like change is a constant in our industry. Every new administration, whether it be federal or state, obviously comes in with an agenda and an idea of how they think health care policy should look. It's obviously a huge area of spend and obviously then a huge area of priority when folks are thinking about the most efficient, best way to deliver those services, especially in the public domain, whether it be Medicaid or Medicare, in terms of how it's different, obviously we're feeling, a pace to your point, that feels very, significant in terms of the degree of change, the aggressiveness of the change
almost in cycle tied to, you know, the administration federally. So trying to figure out how to, pick a lane and stay with that lane in a way that feels like it insulates you from those changes. That's obviously what we're all trying to do in some cases. But it feels more and more that this is going to continue to be, a high priority area that is, subject to these changes.
And that's going to be the new normal. And so it's really about building organizational resilience and flexibility into your planning that helps you absorb and manage these changes as they come, as opposed to trying to pick a lane and expect change to go away.
Jennifer Colamonico
Oh yeah, that that's definitely it doesn't seem in the cards right now. You you lived through the Affordable Care Act implementation in New York. Do you find yourself drawing upon any lessons from that time? What still applies today?
Cara Henley
Definitely. I mean, we talk about a woodwork act, and I feel like we kind of came to that term during the ACA days because it was this idea of like, what type of change is this policy going to draw out, not just at the organizational level, but at the consumer level. And it really helped us try to think about things on the ground in terms of how does this change access?
How does this change an individual's experience of care? Who falls through the cracks when a change like this occurs, whether it's the ACA, H.R. one, or other major reform changes that come down through, managed care rules, it really comes down to the industry looking together at how this affects the individual. So I think a lot of the work we did analyzing coverage laws or coverage gain, who's going to be impacted, who is it touched?
That type of analysis that we did in the ACA, I find, is something that we're coming back to a lot as we think about H.R. one and other changes in Medicaid to help us almost granularly locally, try to identify the most at risk individuals that need engagement and outreach. But also, when we think about doing the analysis on the types of coverage changes that we may see in different markets as a result of several changes.
Jennifer Colamonico
You talk about this intersection of policy and operations. I know we talk about that a lot of time. But, you know, in particular, I think at the at the state level that resonates so strongly. So what does that mean? Why is that important? To think about how those two domains kind of intersect.
Cara Henley
I often joke that sometimes policy feels like a thing that's over here. And then the operations of an organization are over there. And I work with clients a lot, whether they be, payers or providers or advocacy organizations, who are trying to sort of insulate operations in a way where regardless of what federal or state policy changes are coming, you know, we can sort of say mission forward, all systems go.
But really, what I find talking to organizations about as they're looking at their strategic planning, their long term outlook, even their shorter term outlook of a year or two, you don't want to have to make drastic changes, obviously, fundamentally to your mission or how you're providing services or serving your community. But there does have to be the sort of flexibility and adaptability and reflexive organizational, decision making that sort of embedded to respond to these changes, especially when we're talking about changes as drastic as the Redetermination.
You know, you mentioned the public health emergency. It's a great example. That was sort of a very planful, deliberate effort to notify enrollees that they were going to be losing their special enrollment because of the public health emergency tied to Covid. And there were a lot of lessons learned about how do you communicate and engage with people. And even in the best case scenario, government can't do it alone of providers and plans who are on the ground working with individuals aren't working in tandem on outreach, communication, etc..
What we've seen is there are still individuals, despite all the different, public relations campaigns, to advise them about what changes are coming in terms of getting, set for re enrollment. That's going to happen every six months, or, folks who are going to be subject to, community engagement, requirements. Folks still aren't getting the information in a way that they're activating and understanding these changes.
So if organizations don't sort of adopt, communication strategy or educate their front lines on how to talk to people about these changes and engage their communities, the consequence on the operational side, back to your question is you're going to see more folks without insurance who are learning about the fact that they don't have insurance at the front door, which is always a very tough time to be learning that your Medicaid coverage or other coverage has has lapsed.
So that's number one. So that's going to have a direct effect on your ability to recoup reimbursement on your revenue cycle. It's going to have access challenges for the people that you're trying to serve. The most. And it also staff need to be trained to be able to talk to folks about these things. To be able to, really activate them and encourage them and advocate for them.
If you're not able to help your staff and other organizational leaders understand the impact of these changes, then everything happens in a reactive sense. And I, you know, my my coaching, my consulting is always about how to build very proactive, very strategically mindful approaches to these things. So that way staff are capable of helping individuals as proactively as possible to help mitigate those risk areas that we're starting to spot and identify, that could be much worse.
Jennifer Colamonico
I know what you're saying about sort of the policy and the operations being such different worlds. I do feel that they kind of speak different languages, and I've seen, you know, you can overreact to policy and you can under react to policy. I guess it's sort of this, like, Goldilocks thing, right? How do you get the right amount of reaction?
Yeah. Because so much of federal policy oh, they're introducing this bill that's going to do XYZ. And no okay. It's first of all, it's not actually going to end up getting passed that way. And second of all, once it's implemented, you know, maybe only half of Z happen. So it's easy to overreact. Right. But I probably is. It's just as easy to undo react to your point.
And then all of a sudden people show up and you know, they don't have coverage. So what is it that organizations need to do to bring those two worlds together?
Cara Henley
Is a great question. And, you know, I live in that policy wonk world of like getting into the nitty gritty. The details can't help myself. Love it. But, you know, if I were to go to a board and give them that version, the it's it's not an effective way of decision making to your point, which is like how do you operationalize this?
How do you react to this in a way where we know sometimes the rulemaking process takes, several months to a year. We know that, the way states implement things can change how things roll out, legal challenges, restraining orders, things like that can obviously slow things down. And so again, to your point, how do you steer your ship in a way that you're not overreliant on these policy changes to the point that you are no longer moving forward on the things that your organization needs because you're waiting for policymaking?
We don't want to be in that world. But at the same time, building in that organizational resilience will need and flexibility so that you're not barreling forward with something that's going to be in contrast to these policy changes and therefore increased risk to your organization. So when some of these changes in HR one were first being proposed, we would create, sort of dashboards for organizations that helped people tier things in terms of risk, financially.
So for example, if grant making changed in some significant way, you know, when Doge was first announced, what funding streams are more at risk were or less at risk? Another way we've looked at this to your point, H.R. one doesn't affect all populations in the same way. So therefore not every organization has to activate the same type of engagement plan or engagement strategy.
So really looking with organizations at, you know, who are you serving, what types of coverage do people have? What types of Medicaid are they enrolled in. So you can really be much more precise in how you activate resources to change plans or adjust course, but at the same time, also communicate with your leaders, your board, to help them understand what's at risk and what isn't.
Because that's a huge piece that I think we don't talk about, which is folks are reading the news, folks are in the community, they're walking away with a certain preconceived notion of how this is going to change things and how it won't change things. And so bringing it back to facts and helping be precise in the specific impact that this will have, and then being able to create that range.
Worst case, mid case, low case. How much do you need to disrupt yourself in these different scenarios and give people that sort of scenario based planning. So again triggers can result in different actions happening. And you know what they are ahead of time. And then there are no surprises. And there are no, significant consequences that you're unprepared for.
Jennifer Colamonico
Who do you typically work with inside organizations? As you're talking, I'm thinking, oh, that's a strategy function. And then I'm thinking, oh, that's kind of a finance function. And maybe it's all of the above, but, you know, who's who. Well, maybe I should say who do you typically work with and then who should you be working with?
Because maybe those are two different answers.
Cara Henley
You know, and this varies by organization. Strategy can sometimes live in different places in organizations depending on their, different setup. But I would say, you know, those that are responsible for external affairs and strategy tend to be the ones that come first to us with the questions. Sometimes it is the the president, CEO, executive director office, sometimes, to your point, that sort of strategy work, especially when we're thinking about some of the financial modeling, sits in a CFO or, director of finance, office.
So there's no real wrong door you need to think about not just how you're communicating with the board and the community, but how you're talking to your frontline staff and, and coming up with and devising messaging. And, you know, we do a lot of strategic messaging through our full portfolio of support. So oftentimes what this happens is it begins as a strategic planning conversation.
It begins as you know, we have some big change happening. How do we need to revisit our strategic plan to really adapt and be nimble and responsive to the environment. And then from there, we devise a work plan that helps the organization really identify how to implement these strategic ideas in sort of real world action. And again, my job is not to be overly jargony over policy, because that's not going to be if we're writing a comment letter.
Sure. Right. If we're helping an organization think about the advocacy environment, then we want to get right down into the nitty gritty details. But if we're trying to roll this up, really to help with that strategic level of decision making, what are those top three items that really come out that need to be addressed? Is it the fact that people are going to potentially need to activate in a way that they don't understand?
Is it, you know, your reimbursement is going to change and therefore you need to change how you're forecasting your revenue? Is it we need the state to make decisions about how they're going to proceed in light of shifting priorities federally, based on an area where we've been very invested in Medicaid reform. So, again, once we figure out those top 3 to 4 priorities around what we know is coming, then that helps us drill down into the action and bring the necessary leaders on board to activate in their areas to be able to, come up with those on the ground.
Workflow changes or staff training changes or communications changes.
Jennifer Colamonico
So what is the hallmark of an organization that does this? Well, I mean, you talked about the different, you know, groups that you may work with. And has that changed over the years in terms of, you know, what nimble organizations look like?
Cara Henley
Yeah, I mean, I don't know if it's changed necessarily, although I will say, many organizations I think have gained more resilience and have gained more, sophistication and understanding of these changes. You mentioned the ACA. I mean, that was obviously a huge, significant policy change for many states, particularly large states that have large Medicaid programs like New York, like Massachusetts, like California, Texas, Florida.
So I would say organizations have really learned that this is a huge piece that needs to be paid attention to, I would say, some attributes of organizations that I see as very successful are those with leaders who are adaptable and flexible and willing to lean in when these changes come, they see themselves as connected to the community and understand that they serve a really important sort of linchpin function in making sure, individuals who are receiving health care and state leaders, you know, they are the connector, in many cases, to making sure the community, is engaged and activated in the appropriate way, but also organizations that are not overreactive, you know, again, you want to find that really comfortable middle ground of you don't want to just up and change everything and create, a state of sort of frenetic over responsiveness where you feel very much at the mercy of these changes. Again, the goal is to help your staff, your board, your patient community, your broader community. See the steady hand and leadership and help them understand that you're in a position to absorb this, but also absorb it in a way where we're going to continue essential services.
We're going to continue making sure folks are connected to the right setting and the right and most appropriate action based on what's changing and a point of sort of education and advocacy, that helps the community understand and and feel comfort that those organizational leaders are capable of absorbing this and making those adjustments.
Jennifer Colamonico
Let's talk about Medicaid for a moment. I'm just thinking about, this idea of overreacting or under reacting. And I feel like, I'm an HR one makes changes to a lot of things, but it makes a lot of changes to Medicaid programs. And I think that there are huge segments of health care that sometimes ignore or minimize help, maybe not ignore anymore, but, you know, certainly, feel that they have the luxury of not, worrying as much, you know, about Medicaid changes.
Do you think that that, has that gotten better at all? And then what is it that everybody should be thinking about with regard to these Medicaid changes? Obviously, that acutely affects some people more than others. But it does have those ripple effects. And so how I guess, you know, how should organizations be thinking about this and how are you helping them to understand if they maybe have a blind spot there about the impact of these changes on their business?
Cara Henley
Yeah, I would say, at least in my experience, folks seem to be the appropriate level of concern about H.R one. Right. Again, the goal is not to overreact. And obviously those organizations that are more reliant on Medicaid have to be activated in a way than organizations that maybe are less reliant on Medicaid. But to your point, I think everyone understands that there is a role and there is an impact that they will see because the changes on H.R one are so significant that, even if you are, an organization where your core constituency is in the commercial market or your core constituency is in the employer market, there are so many layers to these changes that are coming that are going to have, again, that ripple effect in terms of, you know, the air in the balloon when you move, it doesn't stay out. It moves to somewhere else in the system. And so if you think about a payer, for example, that has a medicaid portion of their business, a Medicare portion of their business, and a commercial portion of their business, if you make a change over here, that's going to change things in terms of scale of enrollment or activities that we're not planned for or funded previously, or, things that are going to affect, like the risk profile of who's enrolling in a way that is pretty substantive over how you are planning prior to H.R. one. That's not going to just have an impact over here, where it sits cleanly and is isolated. That's going to have an impact on your operations and finances across your whole organization. And there's such a strong need for folks to be connected to vocational services. And so, again, if folks are all of a sudden looking for ways to connect to employment, whether or not you necessarily saw your role as interfacing with the health care system, to be able to bridge these resources, those bridges are going to need to be built to create these pathways for individuals.
So again, I feel like any organization that has some reach where individuals who are impacted by new requirements that have to do with volunteer opportunities, employment opportunities, or even, individuals who are losing access to Snap benefits and then you're talking about schools and children and activating resources for families. It's really hard to see an organization that can completely ignore these changes right now.
But again, it's looking around resources in your community and connecting those dots. This is going to require a lot of multi-stakeholder efforts that go across the board to translate this into those functional areas where we can really build, pathways and supports for, for people or even if someone does lose their Medicaid coverage as a result of this, what does that activate in terms of that individual still being able to find access to pathways to get them connected to, employment or other things that are going to help them continue to not fall through the cracks and be able to be connected to the broader sort of ecosystem to support them getting necessary healthcare. If they lose their coverage.
Jennifer Colamonico
You and I both live in New York, and, I, you know, New York is unique in so many ways, not the least of which is, you know, it it has, some very immediate potential implications with its, 1115 waiver up for renewal right now in the midst of changing, so they just maybe talk a little bit about that, right?
How New York had restructured its system around 1115, which is now, you know, potentially going to be changed. So I'm just curious as to kind of, you know, what your assessment is.
Cara Henley
I think, again, it's really just a matter of, you know, New York has always, like many states, tried to be innovative and value oriented. It's a very large Medicaid program. And so when you're thinking about how to organize resources efficiently, you're trying to move the needle on things like value and outcomes. And I think New York's been a real leader.
In several iterations of its waiver, whether it was disrepair, Medicaid redesign, care management for all, there's been so many, initiatives that are looked at as really national examples for how to think about population health and moving towards systems to try to improve, access to care and think about things like health related social needs. So I think, again, it's just this interesting complexity.
Again, I'm thinking about the clients that we work with, John in New York, who are trying to navigate all these layers of change, the change coming from federal, the changes that are going to be happening state as the waiver gets negotiated and finalized over the next year, and what kind of models will be, continued or sustained through that?
The obvious constant state of New York being, again, a very large program with many interrelated systems that have to react to all of this. I think, again, when you're thinking about that risk mitigation, you really have to have, a nimbleness and sophistication in knowing what are those things that are sort of core and essential that remain, but what are those variables that you need to sort of set yourself against to trigger what type of action?
You know, again, if something were to happen in the budget, we know that there are certain floors and certain ceilings that we need to think about when it comes to those things that are Medicaid funded. If all of a sudden the amount of federal funding or support the state were to get were to change significantly, that means there's going to have to be a state plan that responds to those things.
What are those likely things that are going to happen because every state has, I think, a personality in terms of what are those things that they're going to turn to to mitigate those impacts that were not planned for. So how can you use that directionally to then set yourself on the right course? So that way you're not feeling like you're in this, whiplash of change that's going to happen as the state proceed forward with its waiver and with the implementation of H.R. one.
New York is going to see a significant, significant impact, from H.R. one, in terms of how it has historically structured its Medicaid program. So, again, it's all about, how you can partner in the public space to be communicative. Again, there's like a space for, I would say, making it clear to state officials, to federal officials, members of Congress, a lot of folks will sometimes not take advantage of all these options when really laying out what the facts of regardless of where we are on either side of the issue.
What does this mean for your community? What does this mean for the people were serving? How can we give you facts that will help you make really good public policy decisions that don't end up costing us, or creating consequences that we're not thinking about because we're thinking about these things in isolation. It's really important to like, message and communicate with both state and federal leadership in tandem.
While there are these two very significant things happening at the same time, but then again, making your plan so that, you know, regardless of what happens, you've got, you know, your next 2 to 3 action items set to be able to activate on in the event of different scenarios.
Jennifer Colamonico
So, one of the question that we always ask, on this program, if you had a magic wand and you could change one thing about how health care organizations are able to respond to these policy changes and shifts, how would you wield that magic wand?
Cara Henley
Well, obviously, since we're talking about policy so much and state changes, I would love to be able to give every organization, you know, their own crystal ball to be able to anticipate what's happening next. But we know we can't do that. So I think, you know, it would be great to always say that we should have a system that's very aligned on sort of the goals for our population, and then land on what those goals are, to try to make sure that we're always following sort of a, policy angle that gets us to that place.
But we're always going to have folks with different ideas. And that's really what we're talking about here is every four years or eight years, whatever the case may be, whatever election cycle you are in, we're going to have policy leaders that want to test. We're going to have policy leaders that come in with new, theory is around how we're going to improve our, our health care and our human services system.
And so, again, I would love to give folks the ability to be able to see five years ahead so that they can always be planful and moving in the right direction. But at the same time, I think you know what we're talking about here, building in that sort of strategic resilience and flexibility, that's the best we can do.
And we do want new ideas like I think that's the exciting part about the policy space is sometimes we do tend to look at things, obviously in terms of what they're costing us. And particularly right now, you know, again, being in New York and folks being most concerned about the risk of very large numbers of people, at risk of losing coverage and then thinking about how do we lean in and implement these things in the most thoughtful and best way possible to make sure that, you know, we as organizations can be here tomorrow and be in a strong and sustainable place, but also how we can make sure people are, able to access what they need, in the best way possible. Obviously, we want to be able to test new ideas, and the best policy are those things that introduce exciting things that have happened in other parts of the country, or even other parts of the world, that we can test here to see how we can continue to improve and move the needle for people.
And so that's like the upside. The upside is we're going to be able to continue to experiment and find ways to connect those things that are, you know, being rolled out by CMI or those value based, type arrangements that New York is going to pursue for its Medicaid program or other innovative population health models that can be tested locally at the state.
So we want to have a system that continues to adapt and change for those reasons, but also figure out the best way to to mitigate when we feel like those policy changes are going to come at a cost to make sure that we can continue to serve our mission.
Jennifer Colamonico
Yeah. So I think that's the first time that we've had the magic one will be to create other magic instruments.
Cara Henley
So I'd like.
Jennifer Colamonico
That to use the magic wand to give people crystal balls. That would be excellent. But in lieu of that, they have you and, fortunate that they, that they do and the planning that you provide, folks. So, thank you for your time today. Thank you for your insights and, and the work that you do. And, you know, we'll we'll continue to ride this wave of H.R. one and see how it, how it unfolds.
But we really appreciate the work that you do. So thank you.
Cara Henley
Thank you.
Jennifer Colamonico
This episode of Vital Viewpoints on Healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid, from the latest managed care and enrollment market share by additional performance data to up to date RFP calendars, and state by state overviews, HMAIS has all the information you'll need.
This podcast was produced by myself. Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
