Innovations from crisis

Dennis Vaughan:

Hello. I'm Dennis Vaughan, CEO of Optum State Government Solutions, serving as your moderator for our session, innovations from crisis, how will COVID-19 impact government programs of the future? This is not the first pandemic for humanity, and that won't be the last. When we look back at past pandemics and economic crisis, we see that sometimes we need to reach a low point to be willing to change how we think and how we act. For some quick examples, it was in the 17th century that Isaac Newton was sitting in his garden, quarantined during the bubonic plague. There, working from home, he saw the apple fall from the tree and came up with this groundbreaking theory of gravity. As a result of London's cholera pandemic, the science of epidemiology was born in the 18th century. The 20th century flu pandemic drove the discovery that DNA holds the genetic code.

Dennis Vaughan:

That pandemic may also be relevant for today because it also resulted in fundamental changes to the workforce. The worker shortage opened access to the labor market for women who took jobs outside the home in unprecedented numbers. Similarly, we see that COVID is directly impacting changes to the workforce in terms of how and where we work. Today, we have with us state governments subject matter experts to discuss potential innovations that may emerge from the current crisis and discuss how best to seize the opportunity to make these the reality of the future. To explore this important topic in greater depth, I've invited four industry subject matter experts to weigh in with their thoughts on how the COVID 19 pandemic is impacting our thinking about the health system and to discuss potential innovations that may come out of the crisis.

Dennis Vaughan:

Darin Gordon, a nationally recognized health care expert with 20 years of experience in public healthcare, finance, policy, and operations. Today, he serves as a commissioner for MACPAC, the Medicaid and chip payment and access commission, and he runs his own consulting firm, Spire Healthcare Strategies. Previously, he served as the Medicaid Director of Tennessee, where he was the longest serving director of TennCare.

Dennis Vaughan:

Sue Arthur is a COO at Optum. She has extensive private sector experience in financial services, insurance, life sciences, and state government, previously serving as the group president for commercial industry and international business at NTT and as vice president and general manager at DXE.

Dennis Vaughan:

Matt Salo is the Executive Director of the National Association of Medicaid Directors, where he has served since 2011. His organization represents all 56 of the nation's state and territorial Medicaid directors and provides them with a strong unified voice in national discussions, as well as a locus for technical assistance and best practices. Prior to that, Matt was the National Governors Association Organization where he worked on the governor's healthcare and human services reform agendas.

Dennis Vaughan:

Heather Cianfrocco is the CEO leading the Health Services Business for Optum. Heather also serves as the United Health Foundation Advisory Board and on United Health Groups Inclusion and Diversity Council. Before her role at Optum, Heather was the CEO of United Healthcare Community and State.

Dennis Vaughan:

Welcome, and thank you all for joining us. To get this started, Matt, I'll start with you to open up our discussion. What have been some of the most creative or surprising ways states have responded to the pandemic? What stuck out to you?

Matt Salo:

That's a great question. And thanks for that. And thanks for having us all here. Yeah. I wanted to preface this by saying that Medicaid is always been one of the frontline first responders in any type of national crisis emergency disaster, whether that be natural or manmade. So, as you said, we've had this before, we'll have this again, Medicaid is always going to play an outsize role in responding to the situation. I think I would kind of frame my answer a couple of ways. I think first, I think about some of the unique ways that Medicaid as a health benefit is reacting to this new circumstance. And then secondly, how state government is reacting to a very new set of circumstances.

Matt Salo:

In terms of Medicaid and trying to serve the 70 million Americans, who are the oldest, the sickest, the frailest, the lowest income among us, a couple of things that really kind of stuck out. One was we all talk about tele-health, I don't want to belabor that point, but what are we doing about tele-health for really hard to serve populations? And we've seen a couple of states and I think Colorado, Washington, come to mind where they're thinking through, how do we really get access for homeless populations? And what they're doing is they're either using Medicaid dollars or some of the CARES Act funding to actually provide, for example, backpacks, which include iPads or other types of communication devices, to individuals struggling with homelessness, to enable them to connect to their healthcare providers, or, there are also just pushing out smartphones to individuals again, to kind of help them, it doesn't do you any good to have access to Tele-health if you don't have a smartphone and you don't have a lot of data to use it.

Matt Salo:

Another thing that I think of that's been pretty innovative, the state of Oregon is looking at how they're handling managed care contracts and their relationships and recognizing things like [inaudible 00:06:37] don't really work anymore in this context. And so what Oregon is doing is they're thinking about managed care withholds as a means of driving the plans and driving providers to focus more on equity, on reducing some of the disparities that exist along racial and ethnic lines. So to me, those are just a couple of examples of really different, really important things that are starting to take off. And I suspect will have kind of longer legs as we look out into the future.

Matt Salo:

But the second piece I think about, just from kind of a government standpoint, obviously because of the pandemic everybody's working at home and that's really allowed states to think about kind of structuring state government a little bit differently. It is allowing states to reduce their capital footprint. states are actually, Arizona is, they're closing state government offices because they've got people who are tele-working and are going to continue to tele-work as far as we can see. That's a huge help in terms of the overall budget and footprint.

Matt Salo:

But another thing that's really important is states have always been challenged with, as you're trying to drive, as you're trying to attract the best talent, you've got to get people to come and move into the state capitol. Now, if you're in Austin or you're in Nashville, that's pretty easy. A lot of other states have more challenges, but going virtual really allows states to attract talent across the rest of the state or from any other state potentially. And this is all really exciting.

Matt Salo:

And then the last piece that I would mention that I think is going to have a lasting impact is, traditionally in Medicaid, because it is a big ticket item, it's a $600 billion a year program and 50, 60, 70% of those dollars are federal. So it's really, really important that we do things absolutely right, because we've got an obligation to the taxpayer. Sometimes the obligation to do things by the book, absolutely correct every time, slows things down and makes you less nimble and less able to kind of react quickly. But what we're seeing now is that in a pandemic, in an economic downturn, there is huge value in being able to move really, really quickly.

Matt Salo:

And so what a lot of states are doing are creating what they call sprinter teams. And it's looking across the agency, not just at your deputy or your executive management team and saying, all right, let me examine people's work skills and skillsets, who is best able, who has the best aptitude for grabbing an issue, running with it, learning it on the fly, sprinting, doing something new, doing it really fast. And kind of creating these strike forces within their agency that are going to enable them to respond to a rapidly changing environment very, very quickly. I think that kind of thing is going to have a lot of lasting power. So there is exciting stuff within these challenging times.

Dennis Vaughan:

We're good. Let me open that question up to the group. So jump in, what do you see? What is striking you as innovative? So,

Darin Gordon:

I'll throw out there, just building a little bit on what Matt had brought up. I think oftentimes we get stuck on thinking about innovation, really more in the context of actually creating something brand new. And all the examples that Matt gave really fits in my definition of innovation, which simply means making incremental improvements on some of the things that we already have and some of the things that already exist. And so that's frequently accomplished by borrowing and adapting some of the ideas and approaches of existing technology that's already out there. And one of the examples I think about in that regard is what Arizona has done with their health information exchange.

Darin Gordon:

Now it's a platform and a technology that they already had out there yet. They were able to adapt it real time for the crisis. So what they did is basically made it where real time data is shared, not only amongst healthcare providers, but it's also shared with the state agency and also the Medicaid health plans that are serving Medicaid beneficiaries. So they're pulling information from the medical records and helping share information with regards to who's been diagnosed with COVID-19 and allowing obviously the healthcare system to adapt quickly to that. I think what's important here, what we're seeing happen. Historically we've all been focused on health information exchange and really thinking about it in the context of healthcare.

Darin Gordon:

But what we're seeing here now is seeing how we're able to leverage that and bringing in value to the public health system as well. And so if you look at what's happening there in Arizona, I think you're going to continue to see that build in other areas of the healthcare system, whether it's, again, building on top of the health information exchange systems, or even leveraging electronic visit verification systems also to collect and disseminate information regarding COVID and other public health emergencies.

Heather Cianfrocco:

Maybe just to jump in, another thought, was listening to Matt talk about it. And one of the things I think was so interesting about this is first of all, and to the point about the idea of the sprinter teams that we've seen many Medicaid agencies create. I think we saw, and from a health organization, it's been really interesting, obviously.

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Heather Cianfrocco:

... we saw, and from a health organization, it's been really interesting, obviously very challenging. But some of the most creative and surprising things that I would say is ... The easy answer is that there was acceleration, but I think even more creative was it wasn't just sprinting. It was the amount and the complexity. So we talk about pandemics of the past and we even talk about public health and manmade and natural disasters of even, say, the past decade, but nothing ... The Medicaid program in of itself, state systems, and public health in general are so much more complex today with the convergence of data, technology, privacy and regulation, funding challenges, and then emerging population health concerns and challenges that don't look ... They don't appear equitably across our population, and our populations don't experience them in an equitable manner. So that complexity really was just highlighted. It shone a light on the complexity through this pandemic.

Heather Cianfrocco:

One of the things I experienced that I've never experienced in my career has been the sprinting, but the ability of collaboration, so quickly partners coming together, state agencies, in my experience, Medicaid, responding with incredibly pivotal changes in structure, payment, policy. Real time and not weeks, not months, not the public policy that we're used to of the past, but actually hours, days. Where if we had to pivot and open up an opportunity and to be able to have either payment acceleration to providers with fragile systems or whether it was getting new solutions to consumers quickly, what I saw was a big .... was really creative here was the ability to collaborate, put consumers first, figure out the funding, and all within a compliant and policy and appropriate manner, but figure out the details later and get people the care they needed.

Heather Cianfrocco:

And I think it showed up in a couple of different places. I have many states as an example. But I think to both Matt and Darren's points, we saw incredible acceleration in states in a very creative way using the technology and the data that maybe they didn't intend to use for years or we weren't even ready to receive for years. But we saw that accelerate, and I think that will be an example. We haven't even seen the full benefit of that yet. I think we're going to see that continue to play out over years.

Sue:

Thanks, Heather. I'll jump in a little bit on that thread and extend it over to public health. As we were working with states on both the response and the triage, the incredible amount of collaboration we saw and as we were all dealing with obviously the rate and pace of the pandemic, but opportunities to deploy new technology, opportunities to ... which come with all sorts of data and privacy and security considerations, opportunities to break down the silos for real and have access to data we haven't worked with before in technologies that we haven't worked with before in the middle of the pandemic, those were places we saw just this spirit of collaboration, the pace of business, our state partners working around the clock and removing every barrier to deploy differently, to think differently, to engage industry and industry partners to come together differently.

Sue:

So from the very basic of having the procurement and legal shining stars here, who every day just had to get enough gear deployed to state workers, such that they could work and run the government, to those same folks helping us figure out how to deploy new and complex technologies across multiple agencies, I think the regulatory awareness to be able to flip a switch and work across state lines and have practitioners practice across state lines, that opened up a significant labor pool that we didn't all have access to before.

Sue:

So as we think about where do we land here, where does this go, what are we left with, we have broken down silos. We've benefited from some regulatory change. We've delivered new technologies. So there is an opportunity here to keep going and plan for wartime public health, not just peacetime public health. So it's been an exciting time to support the industry.

Matt Salo:

Yeah. And maybe I'd just even build on that. And I like your framing of this as there being wartime public health and peacetime public health. And I think that really ... therein really lies some of our challenge. I've been with the Medicaid directors a long time. I was with the governors for a long time before that. And governors dealt with Medicaid and public health, so we had all of that underneath us.

Matt Salo:

But there has really always been this disconnect between the two. Medicaid and public health, they speak different languages, they've got different agendas, they've got different funding sources, they've got different constituents. And public health, broadly, wants to provide as much of a public good to as many people as possible for the public good, whereas, and I know Darren will resonate with this, the parameters around Medicaid have always been, "Well, unless it is a Medicaid identified service delivered by a Medicaid licensed professional to a Medicaid eligible beneficiary, it's not going to be covered. It's not Medicaid. It's something else."

Matt Salo:

And trying to cross that bridge, to cross that divide between those two has always been really challenging. Clearly, in the time of a pandemic and the time of a disaster, people are going to say, "All right, we're not going to worry about that right now. We're just going to ... We're reacting. We're sprinting. We're keeping people healthy." But we're going to get to a point where we've got a vaccine, where things start to return to normal, and it's really going to be incumbent, I think, upon all of us to say, "How do we then not just revert back into the old way of doing things where public health is over here and Medicaid is over there and never the twain shall meet?"

Matt Salo:

We've got to figure out how to keep them aligned. Some of that is on state government. State government has to figure out how do these two, oftentimes silos, just communicate better. But I think there also has to be broader federal leadership and thinking about what really is our end goal here.

Matt Salo:

And then I think the other piece that is also important is that it's not just public sector. It's not just public, public health, and public Medicaid. It really is private sector as part of this partnership as well. And how do we leverage data and information? We know that there are entities out there, that there are drug stores and there are other entities that, from an epidemiological standpoint, have an enormous amount of real time data on things like progression of symptoms and disease or even things like pregnancy based on what people are buying. And we need to be able to figure out ways that we can leverage the private sector technology and expertise and make it work from a public health perspective, while of course being very, very cognizant of the need to protect privacy, confidentiality, and security.

Darin Gordon:

Yeah. My experience has been that, not too dissimilar to what we're experiencing now, that public health and the healthcare system, Medicaid in particular, come together during points of crisis. We saw that back with the opioid epidemic, and there was a great partnership that transpired there and great coordination there.

Darin Gordon:

Obviously, we haven't seen anything of this size and scale. To Matt's point, I hope it sticks. I think there is clearly a relationship there that can function better than it has historically. But just like any organization, any complex organization, crises tend to get people to focus. And we hope that this continues.

Darin Gordon:

And echoing Matt's point, what's evident, it's been the case even in calmer times, but what this has shone a light on is that government alone can't do it. We had to see where government reached out and partnered with the private sector in order to accomplish some of the tasks in real time. So I think this is a great case study, that I hope that we take some of the learnings here in some of the positives and carry it forward so that we can start off from a better place and be in a better position for the next crisis that comes our way.

Matt Salo:

Yeah. And I think the next crisis that's going to come our way probably won't even be the next pandemic or the next what have you. And our folks are starting to think about this as well. It's what they call the secondary pandemic or the secondary public health impacts of what we're dealing with now.

Matt Salo:

So what we're seeing right now, childhood vaccinations are down, opioid overdoses and deaths are up, and those are directly attributable to what's going on in the world with the pandemic. And so even before we deal with the next big crisis, there are going to be some fallouts that are very much public health as well as health and wellness and insurance issues stemming from what we're in right now. And we've got to think about how are we continuing to partner on those.`

Heather Cianfrocco:

Matt, to that point, I think you bring up such a great point in it. And I think we also have to remember that, first of all, we're not even completely through this health crisis, right? I think we've learned a ton through it, and it may feel to all of us that we've been living in this reality now for so long and because of, I think, the pace of change and then the pace of the acuity of need that we're seeing.

Heather Cianfrocco:

But to your point, I think there's two aspects of this. First, we're still in it. And so there is a continued opportunity to keep learning, innovating, and changing and partnering between public health and state businesses like state employee and Medicaid.

Heather Cianfrocco:

But I think the other aspect is that, you're right, there's going to be an aftermath and we need to be preparing for that now. Some parts of the system were incredibly elastic, and then some were not. We saw that there was ... whether it is ... And to your point of childhood vaccines and preventative care in general, it has not come back. We're still probably seeing 30% year over year reductions in people getting really important health screenings. There will be an aftermath of that. And we need to get to work on that, not just for public health, but for 70 million Americans in Medicaid programs, which is a very large cornerstone of public health.

Heather Cianfrocco:

So I do think the opportunity to continue to evolve from this, we're still in it and I think we can still learn from it. The hope in my mind, I think, I see two opportunities. I think the first thing is when, as we get more nimble, as we get more ... and we can find digital applications, telehealth, and as Sue mentioned, as we can look and flexibility around where do we still get high fidelity, high quality, value-based care, but we can reduce costs, we can reduce waste, and we can get more efficient. And we see it in, as we talked about, even our own ability to adapt to a virtual environment.

Heather Cianfrocco:

Can we make more available? Can we do more for public health? We know we spend so much on public health and our outcomes are not where they should be. Can public health and Medicaid really partner better? And I think the opportunity of that is, with cost reduction, we can do so much more for more of the population.

Heather Cianfrocco:

And then I think probably we can't not have a discussion about this. The second area is social determinants of health. We saw those. You can't have a discussion without talking about social determinants of health. It is just part of our public health system today. And maybe we didn't talk about this-

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Heather Cianfrocco:

It is just part of our public health system today. And maybe we didn't talk about this standard five years ago, but we talk about it today because we know how much it drives good health. I think that's going to be our next opportunity. We're going to see that there is an aftermath to the disparities and also to the social barriers. We're making great investments in them. I think we know the North Carolina NC Care 360 is the first in the country where we've actually seen collection, identification, screening, provision of services for social need, and then a referral back to be sure that the service that was needed was completed. That's going to change I think so much of not just Medicaid and state programs, but all of public health, when we start incorporating the social determinant determinants of health into our public health agenda. And I think that could be our weapon against an aftermath from this pandemic.

Sue:

Yeah, I would agree with that, Heather. The closer we get public health, the social determinants, the homeless, what's happening in education right now, think back to Katrina. We know years later the education impacts we're long and hard. So all the ways we can help to think about using this pandemic to more tightly connect public health and the health care system, the delivery system, the administration of programs, I think is a great opportunity.

Sue:

The other observation I would make having just learned more in the last six months about public health than I probably have in a long career in government health care is the ability for industry and technology to be reused to support public health is really extraordinary. Think about for a long time on the Medicaid side, industry has been pointed at a standard architecture on behalf of the states, a roadmap, frameworks for how the programs run, reuse, pressure on breakthrough technologies. And I think there's an opportunity to use some of that modeling or frankly that technology. While we unlocked some of the data, we've unlocked some of the silos and there is opportunity to deploy in some consistent ways technologies that create sustainable environments and help the states deal with technical debt and light investment that has built up over years.

Darin Gordon:

I just want to build on all that. One of the things that I see that coming out of out of this, and again to Heather's point, we're very much still in it, but I see this as a bit of an accelerator to many promising trends that we've been talking about for awhile, struggling with in some cases. Whether that be, to Heather's point, around social determinants of health. I see that there's going to be a lot of progress that comes out of this, and we'll be moving the ball much further the field than we have to date because we see in a very real, tangible way the impacts that if we don't address those social determinants of health, some of the negative impacts and the unequal impacts that occur.

Darin Gordon:

I think the same is true about health equity. We've been talking about that some time now. And I think for a variety of reasons, even outside of healthcare, I think there's been such a bright light shining on the opportunities there. And to Sue's point, I mean, a lot of what we need to do and can do in that area is going to begin with thinking about our data differently and how we capture some of this information so we can better identify those areas of opportunity.

Darin Gordon:

And I think the same is true, obviously tele-health, and Matt mentioned that in the very beginning, we've made more progress in a short period of time than we have in my decades of talking about tele-health. And we'll see how the regulatory environment changes there. But I also want to throw value-based purchasing into that mix. There are some things about value-based purchasing that are being challenged during this time, to Matt's earlier point around HETUS. It's a little complicated in the midst of a crisis and significant downturn in utilization. However, I will also note that value-based purchasing arrangements have actually been a force that has helped some providers weather the significant changes in utilization that are out there. So I think it reinforces the importance of value-based purchasing, and hopefully we'll move that down the field of evolution as well.

Matt Salo:

Yeah. And I think that's a great point. And clearly the trajectory of where Medicaid programs were going pre-pandemic was the slow and steady march away from the paying for volume, purely unmanaged fee for service world towards a better coordinated, better managed paying for value type of world. I think Darren is exactly right. The pandemic is showing us that this was the right trajectory. It's now a chaotic environment to be continuing that journey. But I think it really underscores how important that is.

Matt Salo:

And one of the things that has really stuck out in terms of one of the economic challenges for not just Medicaid, but the health care system writ large is the pandemic has really kind of impacted the health system in two broad and very, very different ways. On one level, it's hitting those who are on the tip of the spear. The hospitals, the ICUs, the need for ventilators, the need for PPE, nursing homes, other long-term care facilities where you're seeing the transmission of the disease, where you're seeing worker burnout and worker death, and a pretty sizable number of the 200,000 deaths so far.

Matt Salo:

All of those providers who are on the front line need additional resources. There's no question about that. But the flip side of that, that doesn't get talked about quite as much, is what about everybody else? And to the extent that people are listening, and we hope that they do, when you really embrace kind of social distancing and sheltering in place and not going to a crowded, chaotic healthcare facility unless you absolutely need to, what that translates into is a broad swath of the healthcare infrastructure, dentists, pediatricians, mental health services providers, addiction providers, school-based health providers, who are seeing their utilization go to 80% of normal, 50% of normal, 20% of normal, zero. School-based services can't have utilization if there's no school. So how are we going to support all of those kind of hidden ... I hate to use that phrase, but it's a relatively unseen problem, providers who aren't seeing patients. How do we support them? They are businesses. And if they go six, nine, 15 months at utilization rates like this, they're just going to go out of business.

Matt Salo:

And then when the pandemic starts to taper down and life kind of returns somewhat to normal, and there's that huge pent up demand that we always see when people kind of go uninsured, or technically uninsured, for a period of time, who's going to be there to see them? And to me, this really just calls out the failing or the failures of a pure pay for volume system. And that there's got to be a way, through managed care or other types of value-based purchasing approaches, to think about how do we support all of those other providers in meaningful ways that are going to look very, very different? And I think that's really incumbent upon all of us not to lose sight of that.

Heather Cianfrocco:

I'm so glad that you raised that both Darren and Matt. And Dennis, you can see you have a very engaged panel just on this question alone. We've covered a lot of territory. But I'm still glad you raised some of the other provider types, mental health specifically. So I think the two things that we've seen from, to your point about value-based constructs and value-based care, and maybe the example with HETUS is what we've really been probably trying to do for a long time is, it isn't the concept that doesn't work. We just need to evolve it, and we need to evolve it outcomes based, and it's complicated, and it takes some time, and process is still important, but we're getting there.

Heather Cianfrocco:

But when you look at it in a context of some of those other provider types that you mentioned that are so critical to overall health and wellbeing, like mental health and substance abuse, I think the opportunity is we saw how fragile the system was and how fragile the payment cycles are. And when you take a mental health provider, the ability to provide that stability that we saw in many more sophisticated value-based provider types, it provides stability, it provides predictability, like Medicaid programs get managed care. So you know sort of your inflows and you know your outflows, and then obviously you're incentivized to really ensure appropriate total cost of care. I think the ability to bring those other providers into the system, and as we've moved to tele-health, we're able to change hopefully cost structure while ensuring still really strong outcomes, patient engagement and high quality individual experiences.

Heather Cianfrocco:

But then we can bring them into the game of total cost of care and total cost of care reduction, appropriate total cost of care reduction, appropriate utilization, that's I think the opportunity, and that's what I really think is the pivot bringing the rest of the provider types in with predictability of payment, and then being able to bring them into an opportunity where we actually have everybody's got skin in the game on making this a more efficient system. That could be the most significant change of what we see in this pandemic.

Matt Salo:

Yeah. And I think that's really important. And I know that our folks are really starting to think very seriously about what is the future here? So as Darren alluded to, part of the reason why we're kind of going gangbusters on tele-health is it's one of those things that's waived by HHS, actually it's the office of civil rights, as part of the emergency declaration. And it's basically civil rights is not going to be enforcing HIPAA with respect to tele-health during the pandemic. And that's great. And that has been a lifesaver for a lot of people.

Matt Salo:

That's going to change. At some point, OCR is going to go back to enforcing this. There may be some legislation here. Things will change, and we're going to have to be really mindful of what does the future of tele-health look like? Because it's not going to be just, "Oh, we're going to replace every single one of these kind of physical visits that we used to have now with FaceTime or whatever." We're going to have to think about reimbursements. We're going to have to think about the total cost and quality of care. We're going to have to think about ... Some of it will be good. The access will be greater. People won't need to worry about taking three hours off of their day that they don't have to transport to and from a facility. They can just FaceTime when they're ready.

Matt Salo:

But if access explodes in a good way, what does that mean from a cost perspective? And as I said earlier when kind of alluding to the challenges of people who don't have phones, what good does tele-health access have? What good does it do you if you don't have a really robust, expensive data-

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Dennis Vaughan:

If you don't have a really robust, expensive data plan to be able to truly take advantage of that. So we're going to have to really think very, very seriously about what actually does the future of telehealth look like? And it's going to be very, very nuanced.

Darin Gordon:

And I think, to that point, Matt, I think if we don't look at in the context... We talk about the increased utilization of telehealth. And I think we make value judgments on that, and I think you highlighted a couple of things that are very positive there. I think the other thing we have to look at is what are those services that are being experienced through telehealth replacing? I mean, I think we would all argue that non-emergency visits to the emergency room being done via telehealth would be a positive improvement, both for the member, as well as for the health care system at large.

Darin Gordon:

So I do think we do need to be thinking about what it it replacing? Is it those high value services that may or may not be problematic if telehealth is the main venue for that? Or is it the low value services? In which case, telehealth would be a great improvement.

Matt Salo:

It's incumbent upon us at payers to kind of think through, when you talk about replacing, telehealth is replacing an inappropriate physical visit to the ER. We all agree on that. But I think it's incumbent upon us as payers to really track whether or not there is actual savings to the system when that happens. Because Darren, you've lived this for so many years. The list of innovations or changes or things that come along, this is a cost saver. This will save the system. The list of those is as long as my arm. The list of those that actually demonstrated real world savings in a finite period of time to a state budget are much, much smaller.

Matt Salo:

So we got to be careful, we got to be thoughtful about how do we actually capture that when we can do it?

Dennis Vaughan:

Hey, thank you everybody. I really appreciate the conversation and your insights in this topic. I do want to wrap up and give you each an opportunity for the quick elevator speech. What are the key points that you would really encourage us to sustain as our new normal after this pandemic? So let's start off with Sue.

Sue:

All right, thank you Dennis. And thank you to the panel for a great discussion together. I think I would love for us to embrace this spirit of collaboration, to hang on to the silos that have been broken down, to be thinking broadly about where innovative technology that is already in state government can be exploited more broadly, and to hang on to the regulatory flexibility where it has worked, and it is proven, and it is making material difference in how we're both addressing the containment issues, but also the sustain issues. Thank you.

Dennis Vaughan:

Heather.

Heather Cianfrocco:

So, I'm going to go back to one thing we talked about, and then one thing I don't think we got to talk about. And the first is value-based care. So again, I think we're on a journey on this, and I think Darren's got a lot of experience in this. Just because it's hard, it's complex, and there's a lot of services here doesn't mean it can't be done.

Heather Cianfrocco:

We've learned a lot from Tenncare's bundling experience, and I think, like the conversation we had, we need to move to outcomes, more involve more in the system. The data will help us, the technology's going to help us, we're going to get more efficient.

Heather Cianfrocco:

But the bigger thing we really didn't talk about today, but I think this is the game changer, it's the consumer aspect. So we've got to remember that, as our system was adjusting, the consumer was adapting with us. The consumer's more engaged, the consumer is going to be a more critical part of their public health, of their personal health, and of their health care navigation and their health care spending.

Heather Cianfrocco:

So I honestly think it's that ability to engage the consumer. And there's multiple ways we do that. Biggest thing I see is devices, technology in the home. Like we're doing today, but in the health care, really in the personal health care space. And bringing remote monitors, sensors. We're already investing in that as a health organization. We're highly invested in that. I think the collaboration that Sue talked about, that's just going to accelerate that. And then we're all in this together. With engaged consumers and collaborative partners.

Dennis Vaughan:

Very good. Thank you. Darren.

Darin Gordon:

So I obviously echo everything Sue and Heather have said, and I'm confident, knowing Matt as long as I have, I'll probably agree with a lot of what he says. But I'll try to add something additional.

Darin Gordon:

I hope that this... We've highlighted a couple times about how the breaking down of silos during the crisis, not just within government, but also working with a private sector, has been just fun to watch. And the innovations that come out of that have been super impressive. And I just hope we continue that. You've seen things with, like the NIH, where they've done their shark tank-like activity, and bringing together scientists from all around the world focused on a common problem.

Darin Gordon:

And even, not just the scientists, but then also bringing in industry that can actually help scale those concepts that they're coming up with to solve very real problems in the system. And we saw similar things with regards to the X-price activity that's going on out there, as well, in regards to testing.

Darin Gordon:

And I just think that how quickly that's coming together. How it's bringing great focus to a common problem. And breaking down some of the barriers to actually make it happen in a government framework has been super impressive. And we've seen it in crisis before, but nothing like we've seen it on this scale. And I hope that that continues, because there's still plenty. Even when we get to the other side of this, there will be plenty, and there have been for decades, is plenty of other problems that I think that type of approach can really add tremendous value.

Dennis Vaughan:

Very good. Matt.

Matt Salo:

All right, I get to wrap that up. Well, I guess the benefit is that I can just say, "Yes, yes, and yes." I mean, all of those points are really, really good, and I ascribe to all of them.

Matt Salo:

Without getting into any more detail, I would just hammer home the point that the pandemic and the downturn have really just exposed the long-standing challenges of racial and ethnic disparities, and inequities. Not just in Medicaid. Not just in the broader healthcare system. But really, in society, much more broadly.

Matt Salo:

I think it is absolutely incumbent upon us, and Heather, I really love your focus on the beneficiary, the consumer theme, as being part of the answer there. We really need... We can no longer afford to sort of pretend that doesn't happen or say, "Well, yes, but it's too complicated." So I think the situation, the pandemic, has laid this bare. And I think we are now called to fix it. And I think we will.

Matt Salo:

And I think, just maybe the last point I would make is I'm always hopeful that this is an opportunity for Medicaid to display to the nation at large, and to policymakers, state and federal, that this is a very, very good program. And this program works, and it is filled with people who are extraordinarily hard working and nimble, and trying to do as much as they can without ever enough resources. And that this is a program to be proud of. And a program to continue to support.

Matt Salo:

But on the same hand, it can't continue to be looked to to solve all of the nation's healthcare problems or all of the nation's social determinant of health problems. Medicaid is asked to do a lot, and it does a lot really well. But we're going to need everybody. We're going to need other people with our stone soup to help contribute. Again, whether it's on the social determinant side, housing has to step up, transportation, food security. Those folks are going to have to step up to help us figure this out. And then just...

Matt Salo:

We can't, in thinking purely of the pandemic and the economic downturn, we, the states, can't do this on our own either. The federal government, Congress, has got to get more serious about providing support and stabilization and relief to state governments through this difficult time, or we're not going to be able to do anything.

Matt Salo:

So hopefully that doesn't crystallize this recording in time too much. But I can't let this go by without making that pitch, because without that, I don't know how we're going to do any of the things we've talked about.

Dennis Vaughan:

Very good. Thank you. I do want to thank you Matt, and Darren, and Heather, and Sue, for joining us today. Digitally. And for your insights. Thank you for our listeners and our participants who are joining us from home or wherever you're joining. Thank you for your time and interest.

Dennis Vaughan:

I really appreciate, as the panel has shared, that the perspective on innovation is not just on a technology or something that we do. It's about how we think about problems, and what we understand about the situation and the world around us. And elements like the social determinants of care, and health equity, that the pandemic has changed our thinking about that. And the question will come, then, "What do we do about it?"

Dennis Vaughan:

The word epidemiology, there's probably more people who understand that word today than did in January. And so, our understanding about public health, and the value of public health in our community, the impact that they can have, I think has profoundly changed. And the respect that they have earned and achieved through the response to the pandemic has been fabulous. So this is really a great opportunity for us to pause and consider how do we think differently about the problems that we face, and from that is the great springboard of how do we act? What do we do with that new thinking?

Dennis Vaughan:

So thank you very much for your time.

Sue:

Thank you.

Heather Cianfrocco:

Thank you.

Matt Salo:

Thank you.

PART 4 OF 4 ENDS [00:50:22]