Improving Outcomes & Value Through Managed Care: Dr. Caroline Carney, Magellan Health

Transcript

CHAD MULVANY

On today's episode of “Achieving Health,” I'll be joined by my colleague Erin Eshelman and special guest Dr. Caroline Carney, CEO of Magellan Health. They'll discuss the challenges and opportunities facing health plans and the role these organizations play in improving access, value and health outcomes. Stay tuned.

ANNOUNCER

This is “Achieving Health,” a podcast from Forvis Mazars, where we delve into the topics that matter most to healthcare organizations across the continuum of care. Our goal is to help you navigate the dynamic healthcare landscape and achieve health at your organization.

CHAD MULVANY

Welcome to “Achieving Health.” I'm Chad Mulvany. Thank you for joining me. For today's episode, we have a special guest, Dr. Caroline Carney. Dr. Carney is the CEO of Magellan Health, a global managed healthcare company that provides behavioral health and integrated care services for health plans, employers and government agencies. She'll be sharing insights on how health plans can improve outcomes while navigating financial and operational challenges, clinical complexity, and evolving technologies.

I'd like to welcome Dr. Carney to the podcast along with my colleague, Erin Eshelman, a Director on our Healthcare consulting team whose work focuses on performance improvement and compliance for health plans and organizations across the care continuum. Erin, I'll turn it over to you for what I'm sure will be a great discussion.

ERIN ESHELMAN

Wonderful, thank you so much. Dr. Carney, thank you so much for joining me for this conversation. Could you start by telling our listeners a little bit about your background in healthcare and how you came to your current role?

DR. CAROLINE CARNEY

Absolutely. And it's great to see you, Erin, and thank you so much for having Magellan Health on your “Achieving Health” podcast. We're really happy to be here. I will give you a quick background. I'm an internist and a psychiatrist and spend some number of years in academic medicine teaching, seeing patients, running a residency program, and doing research. And at the same time, I had the opportunity to work for a managed care organization as their behavioral health medical director.

And what I learned is that at a health plan, there is really an ability to act on data in real time as opposed to the research grant cycle, and to move more quickly. That was really suited to my personality so, over time, I began to move more and more in that direction. I spent some time as the chief medical officer of a state's Medicaid program before going full time into a managed care type of setting.

I also continue to do some clinical work through an FQHC, which is really important to me, just given the mission of FQHCs as well as my desire to stay relevant and keep those clinical skills alive.

ERIN ESHELMAN

Wow, that's very impressive. Thank you so much. Could you tell us a little bit more about Magellan Health for those who may not be familiar?

DR. CAROLINE CARNEY

Sure. Magellan Health is a global company focusing on the delivery of clinical behavioral health services and the management of behavioral health services and benefits for EAPs, for state and county Medicaid programs, for federal agencies, the military, and other health plans. So, in the process of that work, for some of those contracts, like the contracts we have with the military to deliver counseling to bases across the world, we actually provide the counselors who sit on bases and take care of our servicewomen and servicemen across part of the world.

In other cases, we are the full behavioral health carve out for a state where we do everything from soup to nuts in managed care, from processing eligibility all the way through paying claims, doing care management, quality reviews, building and maintaining networks, and everything that is required to manage the state or the county's behavioral health benefit. And in other cases, we do some work like that or all of those same tasks for health plans.

We also have small organizations that work alongside those management contracts to actually either deliver clinical services themselves, or we provide direct collaboration and oversight of organizations sitting in communities to provide those behavioral health services so that the state or county can have even, high-quality delivery of care.

ERIN ESHELMAN

Wonderful. That's a lot of wonderful work that's going on there. I'm going to turn to a different question. Health plan margins across Medicare Advantage, Medicaid, and commercial lines have come under pressure due to rising utilization and medical costs. From your perspective, what are the biggest financial challenges health plan executives are facing today.?

DR. CAROLINE CARNEY

Oh, every health plan executive and every employer and probably every family will answer this question the same way: that these costs are rising, without necessarily any change in the quality or outcomes of the services that we have. And we're grappling with all kinds of new things coming to the market. And we're trying to understand, again, as health plans, as employers, as families, whether some of those new devices, drugs, procedures coming to the market are really going to move the needle forward in terms of population health and individual health. We're all facing that same question.

ERIN ESHELMAN

Do you believe that the pressures are cyclical or structural?

DR. CAROLINE CARNEY

Oh, they’re absolutely both. That's a great question, Erin. So, let's talk about one that may be cyclical first: coverage gaps. Coverage gaps like we'll be seeing in 2027 due to H.R. 1 are an example of something that's cyclical and changes depending on the makeup of the politics in the country, who sits in the House and the Senate and in the president's seat.

So, H.R. 1 will effectively take individuals off of the Medicaid rolls. Estimates range anywhere from single digit to double digits, depending on the state. And that is something that may change, may get whittled away, may get even stronger depending on what the next elected Congress does or the next elected president does. Those kinds of things tend to be pretty cyclical in our country.

The same is true of rate changes for providers, say, through Medicare. Wherever something is based in a political process we’ll see cyclical change. And it's the job of the health plan and an organization like Magellan to take those changes, embrace those changes, and make sure that we still are able to deliver the same kind of high-quality care that's accessible to all of the members who have the benefit to receive that type of care.

Another cyclical thing, interestingly, is the type of substance abuse independence that we fight. A few years ago, we all were talking every day about the opioid crisis. And I want to be clear that the opioid crisis is still there, it's still very present. But in the past few years, we've seen stimulants come back into action and are now exceeding opioids in being the most common drugs found in overdose deaths.

So, cocaine and methamphetamine are back. And that's a cyclical thing that we've seen over time. The drugs of choice wax and wane. So, the programs that we need to offer, the kinds of policies we need to pass, the kinds of laws we need to pass, the kind of research we need to do to make sure that we're addressing treating individuals with substance dependence is really important, but somewhat cyclical, because you don't hear as much on the news about the opioid crisis anymore.

You'll start hearing more about the stimulant crisis in the days ahead. So, just think of those kinds of things, both the benefit changes and what we see in society in terms of need for treatment. Those really do affect the shape of the kind of delivery of care that our providers need to give, the kind of research that needs to get done, and how health plans ensure that individuals can access the right services.

The structural changes, I think really if we narrow back down to just behavioral health, some of those won't change. The utilization trends that we've seen for behavioral health, while they may have sounded cyclical at first, I believe they are now at a place where they are structural. I’m happy about that, that individuals are going out and getting services that they need, that anxiety, depression, and other conditions in young adults and adolescents are being addressed and that the services have to align to match what our population needs. I don't think that that will ever go away.

I think we've gone to the other side of individuals raising their hand and saying, yes, I do need help and it's okay to go get help. So, I think that's a structural change. Another one is the advent of the GLPs and the use of those. That's a structural change, that medication class of drugs is with us now.

And what we do in order to manage coverage policies, what we do to ensure that the right individuals get those medications and that individuals who shouldn't be using those medications are not accessing those. That's really a structural change in what we have moving forward. There are others like that, but they tend to do when we have new medications that come to market or the rise of a new condition.

ERIN ESHELMAN

Fascinating insights. Thank you so much. Which trends concern you the most over the next three years?

DR. CAROLINE CARNEY

The most immediate is related back to what I mentioned earlier about H.R. 1. So, the trend for H.R. 1 to potentially see many, many people lose coverage from the Medicaid benefit is concerning to me, because that doesn't mean that those individuals don't need care. They will be out facing a job market that's tough for even the best of folks to be able to apply.

And if you take someone who is suffering from mental illness and trying to navigate the job system, it will be challenging for those folks or someone who has a severe chronic medical disease that doesn't meet the criteria to stay on Medicaid, they will be disadvantaged, I think, in being able to navigate that market as successfully as others, particularly if the economy shrinks and there are fewer jobs.

So, I'm putting it that way because, again, all those individuals still will need to access care. So, they'll need to go to safety net places like FQHCs, where there may be a sliding scale, fee-for-services, or other sites of care that are set up like an FQHC. There will be higher pressure on those institutions to serve more individuals.

So, we really will need to think about how we fund those institutions and get providers to those institutions to provide care. And typically in the past, when coverage has gone away, we see a higher pressure on emergency department utilization and crisis services, as opposed to being able to do more preventive care and find things earlier to prevent that emergency department visit.

And the final thing is any indication that preventive care that might find a cancer earlier or find hypercholesterolemia earlier and address that to prevent downstream bad outcomes like heart attack from happening, folks will not have access to those kinds of services in the same way and that really concerns me. Taking off any other hat, but just being a physician that really, really concerns me in what we'll see ahead.

The other part that concerns me is a full-on rush to AI before we really know the implications of AI. So, we've already seen some of that with people going straight to ChatGPT or Claude or Copilot to type in their symptoms and say, hey, this is what I have. I could tell you funny stories about patients who we've seen come through who do that. And it's interesting to see how wrong someone can be. It's like reading a reading a tarot card or something, all these generalities that someone then brings in to say, oh, I have this diagnosis and you have to treat me for that. There is power in individuals having knowledge, and I support that. It is really important for people to be empowered about the symptoms they have and the conditions they have to get the right kind of help.

I am concerned about when the information is wrong. The information leads someone to make a very bad decision about their treatment and using non-evidence-based care, or just to be so scared that they shut down and they don't access treatment at all. I think there are bad implications for that alongside the good implications like empowering people with knowledge.

The other trend that, outside of something purely clinical, is that we continue to be in this endless cycle of fee-for-service code billing in our country, with no clear accountability for quality or outcomes in that set of circumstances. I am very concerned about that, because that still incentivizes delivering more and more and more services, whether or not they're really needed, whether or not they really should be done, whether or not there's really a clear outcome to be driven by that service just because it is fee-for-service billing. And I think we need foundationally to shift how we do this across the country.

ERIN ESHELMAN

Those are all really important points. Shifting gears again a little bit, although referring back to one of the concerns that you just mentioned, many plans are balancing affordability expectations from employers and government purchasers while managing increasing clinical complexity. Where do you see the greatest opportunities to improve value without simply shifting costs?

DR. CAROLINE CARNEY

Like you said, Erin, go right back to the fee-for-service billing. We have to really remove away from our reliance on fee-for-service medicine to episode of care and outcomes-driven performance. In some cases, that's easier, right? If you have a knee replacement, you can sink that in a discreet window of time with a follow-up period that is typical for anyone who has a knee replacement.

With all the known complications that could happen that would be included under that episode of care, for instance. We already use episode of care models in a way when we use DRGs, for instance. And behavioral health is slow to adopt DRGs. We have contracts today with hospitals that are DRG driven, and it really takes the pressure off of a utilization management process, for instance, because there is a lump sum pay for the hospitalization.

My concern is, in a fee-for-service billing environment, that kind of accountability for what happens inside the episode of care goes away. I have been listening in on a discussion from inpatient providers about getting CPT codes to create a suicide care plan, and to help arrange follow-up visits to ensure that an individual discharging from an inpatient facility has a suicide care plan and is getting that follow-up care.

And the conversation is around creating or using CPT codes to prove that that was done, so they can bill more for the episode of care in the hospital. And being a provider for many years, an inpatient hospitalist provider, I was stunned to hear that this conversation is going on because that's what you're supposed to do inside an inpatient hospital stay for someone who came in the hospital with suicidal ideation. So, to think about creating new codes to bill more for that doesn't seem right to me as a provider.

And as a consumer, it will potentially drive up costs even more. So, how do we look at that? How do we look at creating the kind of episodes of care that we should have to fairly reimburse providers for the work that they should be doing at the level of care that they are providing?

I think that's really important, and that's what a lot of the work ahead of us will be about. I really think we have to pay closer attention to that and really understand where the healthcare dollar is going. It affects all of us, whether it's in our role sitting inside a health plan, or as a provider, or you and me as consumers of healthcare ourselves.

We have to think about where the healthcare dollar is going. I've told folks in my company that, you know, I wish there was a money tree in the backyard. There is not. So, we have to manage our business in the way that we would manage our personal finances and really be aware of where the dollars are going and is there value for what we're getting in that process? As a consumer, you should be asking the same thing.

ERIN ESHELMAN

Thank you so much for that. My next question, I think, touches upon exactly what you just mentioned. Behavioral health expenditures continue to rise across virtually every market. How should executives think about behavioral health spending as a cost center or an investment opportunity?

DR. CAROLINE CARNEY

Executives should absolutely be in support of covering evidence-based models of care and driving toward networks of providers who are willing to engage in evidence-based models of care, like measurement-informed care, like following care pathways, like collaborative care models, and taking a population view of screening for behavioral health so that there can be early intervention along the way.

Many studies show that individuals who have depression, for instance, have a worse time monitoring and caring for chronic medical illnesses. If you have depression, it's more challenging to show up at work fully and do your job in a way that could be done if you weren't depressed. So, finding individuals, treating them, providing the services they need ahead of time so they can stay engaged in all of their roles, whether that's a role inside their family, their community, or their work is extremely important. Employee turnover costs employers money and adequately treating, finding, treating behavioral health illness is really part of maintaining a sustainable workforce going forward.

And we have to look at that benefit just beyond the employee herself or himself, but also to their family. If I am an employee who has a child who is struggling and I can't get services for that individual, I'll be more distracted as a mom and worried about what my kiddo is facing and how they're doing. If that benefit helps take care of my family, all the better.

We need to think about that kind of investment on a humane level, but also from an employer's pure play employer perspective of I want to keep a workforce coming to work every day, showing up every day and not turning over. The behavioral health treatment really is foundational to that.

ERIN ESHELMAN

So, building upon that a little bit, what evidence are you seeing that integrated behavioral health strategies can improve total cost of care?

DR. CAROLINE CARNEY

There are longstanding models, Erin, like collaborative care that ultimately produce higher quality and have downstream savings. There are outpatient treatment models that rigorously follow measurement-informed care that have been shown also to lead to total cost of care increases. And using measurement-informed care, no one is dictating to the provider what they use, what type of modality they use.

Maybe it's someone who uses cognitive behavioral therapy versus interpersonal therapy versus short-term problem-solving therapy. It doesn't tell a provider you have to use one modality or another, but it tells the provider you need to follow objectively the outcome along the treatment path so that there is a way to provide feedback to the patient. Give yourself feedback on whether that individual truly is getting better or not, and see the junctures where there may need to be a change in tactic or an addition of another type of service along the way.

It has been shown to increase quality and reduce costs. Similarly, collaborative care, which is a model that's set up in the primary care setting, really starts going on the population health track to do screening of individuals who are coming in for their primary care visit, and having an infrastructure set up to support those primary care providers, and having a psychiatrist and a care manager helping them to manage, to make medication or treatment recommendations for that patient, to help navigate that patient to higher levels of behavioral health care if needed, so that we find things early and treat them before something bad happens downstream.

That model has also been shown to be effective for many types of behavioral health conditions, and improves quality and reduces cost of care. Care pathways are a type of model that ensures that providers are following evidence-based care, and at various junctures, are doing the right things for that individual.

So, for instance, if an individual is on an atypical antipsychotic, a care pathway will tell either the primary care provider providing that medication, or the psychiatrist or a nurse practitioner that these are the sets of labs you need to check. This is a frequency that you should check those labs. These are the types of side effects that should be monitored over time and really formalizes that care pathway so that the boxes are getting checked for that patient along the way to ensure the highest quality of care.

I think all of those are the types of interventions, as a field, behavioral health really should be moving toward more holistically. Another part of that is not playing around the rules, for instance, to get someone into a level of care like to use as ketamine or to get transcranial magnetic stimulation, unless they actually truly meet the criteria for that.

And why is that? Because we know when individuals meet the criteria, what the likelihood of success is going to be for that person. And we know then the value of the healthcare dollar has been spent wisely. If we flood individuals into those services who really don't need those services, what we've done is we've changed the threshold for success.

We may have created side effects or long-term effects for patients who wouldn't have had them had they not had a service that wasn't really needed because the right care pathway hadn't been followed earlier along. So, it all really flows together. And the ultimate goal with any of the modalities that I've talked about is to prevent people from entering the worst days of their lives, to prevent people from ever having a crisis situation, or ever feeling or attempting suicide, from ever going into a behavioral health hospitalization, because we've been able to successfully identify them and treat them along the way.

And we reserve those kinds of services for those who really do need that intervention and a team around them when a crisis situation or an inpatient hospitalization is needed.

ERIN ESHELMAN

Many organizations are integrating behavioral health into broader healthcare operations. What advantages does a dedicated behavioral health company bring to clients compared to behavioral health being one component of a larger payor organization?

DR. CAROLINE CARNEY

That's a terrific question and really gets to the crux of what is a behavioral health carve out, like Magellan, and are companies like Magellan still needed if we think that holistic care of an individual is the way to move forward. And I really want to stress that behavioral health carve outs in no way prevent holistic care of an individual from going forward and being the best model of care.

Companies like Magellan bring years of experience into navigating the complexity of the behavioral health delivery system. It is very complex, including fraud, waste, abuse, claims processing, particularly for things like braided funding, which most people have never heard about, for network development, for care management of all the kinds of behavioral health conditions that sit under that title. There are many, many, many different kinds of conditions that all have nuances that require different sorts of interventions.

So, many health plans put resources towards services that drive high costs. So, if you run an algorithm to say, pull out all of my highest-cost patients, you will find NICU babies and transplant recipients and persons suffering from often terminal diseases like cancer, typically at the top of that list. So, resources go toward managing those conditions. That isn't the wrong thing to do, but because most behavioral health conditions fly under the radar in terms of cost, the health plan may not even recognize that that population is sitting out there where some of the nuances in the data that we see, given the kind of history that companies like Magellan bring forward.

So, just because care at a health plan may be considered holistic, with one team doing it, it doesn't mean that the conditions are being addressed or even seen. And oftentimes, the care manager may not have behavioral health expertise or an understanding of a completely different set of network issues to navigate an individual into. Magellan works across many models to make holistic care work, whether that is being the full behavioral health carve out for, say, a state, and working closely exchanging data with the physical health plans that are in the state, creating processes for referrals back and forth, and doing the kind of work that means we're communicating regularly with those health plans.

If we're sitting as a behavioral health carve out inside of a of a health plan, we really have models that have been shown to work over and over. In some cases, we can wear that health plan’s jersey, so to speak. We answer the phone as the health plan, not as Magellan. We work in the health plan’s system so that all of the information is sitting under the same hood and doesn't need to be exchanged in any way.

But we're able then to bring that kind of behavioral health expertise that we can uniquely bring and support that health plan with. We go to rounds, we bring psychiatrists into rounds with their medical directors. We do everything in a way that ensures that there is communication and connection with the medical side of the plan, so that no one falls through the cracks.

And importantly, we can discuss openly what patients should be managed by who or should it be co-managed? Is the person's primary condition, for instance schizophrenia, and until the schizophrenia is managed well and under control, there's really little chance of having other things managed along the way, like screening for colorectal cancer or something. So, that would be the kind of patient we talk about and would say, hey Magellan, you take the lead on this one.

If we have a person who has depression but has just had a cancer diagnosis, we know the depression needs to be managed, we’ll make recommendations about that and how to get those services. But that individual may be best primarily managed by the medical team on the health plan. So, again, that kind of collaboration and communication happens every day, whether we're working inside the health plan systems or working inside our own, and have the mechanism set up to bring everything together. We believe in whole person care, and having a carveout is in no way a contradiction to whole person care.

ERIN ESHELMAN

You touched upon AI earlier. Organizations are investing heavily in technology, AI, and automation. How do you distinguish between technology investments that truly improve outcomes and those that simply create new costs?

DR. CAROLINE CARNEY

So, we have a lot of really spirited discussions about this across the industry as well as inside Magellan. When I step back and think about it, I first think about where AI can be used to reduce operational processes that in no way, shape or form make the healthcare that an individual is getting better, but make it easier for that individual to work with the health plan and to access the system, or for the provider to work with the health plan and access the system, whether it's asking about benefits or claims, whatever it might be. Where can we reduce administrative burden to streamline those processes, make data more available, and make answers correct every single time because we have been able to drive that answer to the kinds of questions being asked.

I think AI is worth its weight in gold in helping those operational processes get to more efficiencies along the way. I think AI in the clinical space also has the ability to do that. In terms of taking notes, for instance, the clinical notes during the interaction that a provider then has the time to read and sign off on, as opposed to taking time to dictate or running to the next patient and keeping dictations for the end of the day where information starts then getting sloppier because the patient you saw at 8:00 in the morning and you're now trying to dictate at 6:00 in the evening in a whole day of patients, starts becoming more challenging to do.

So, AI helps get around some of those kinds of operational issues that don't mean that we've provided better care, but we've now provided more efficient care that lets a clinician truly do the art of being a clinician. So, I'll talk about it from that perspective. Where I think we still have concern about AI is, can it replace, truly replace, a provider?

And at this point, I would suggest that that's not the case, in particular for psychotherapy. If an individual goes to an AI-like chat, we don't know what information that has been trained on and they can get whatever that model has pulled off the internet, Instagram, you name it, whatever sources it's being fed may not be accurate in that individual may not get accurate information.

There are companies that are modeling against clinical notes and creating the AI experience to deliver psychotherapy. None of those models, in my mind, are good enough to replace a therapist today. They may be out of state where they can enhance the work that the therapist is doing between visits, and provide the kind of needed support that individuals might have if they, you know, have a visit on one date and their follow up visit isn't for two weeks, providing those kinds of supports and education and information along the way may be very helpful to that patient if they're using the right AI that's been trained on the right models to get there.

AI helps providers in thinking through complex cases. It helps really fill out the differential diagnosis list, but it doesn't look at the patient in front of you, and it doesn't consider all the social determinants of health sitting around that patient. And it doesn't know what the stressors are that that patient might be facing.

Maybe that patient is the primary caregiver for aging parents. All of the kinds of things that truly make medicine an art, today AI simply can't deliver because it is not the human connecting with the human and understanding all the complexity that surrounds the medical part of an individual, the physical part, the mental part of an individual sitting inside what I consider health, which is all the other things that are happening in that individual's life, that whole-health view of someone. And that's the art of medicine where I think AI is not at a place to take over what clinicians do best today.

ERIN ESHELMAN

Wow, that's very, very important insight. Thank you so much. Executives often talk about moving from a reactive to a proactive model of care management. What does that look like in practice at scale?

DR. CAROLINE CARNEY

I love that question. And it's something that will go back to AI and one of the useful benefits of AI in helping us to look at data and look, you know, whether it's claims data, lab data, genetic data pulled together as a whole to find individuals who may be at risk for a condition and to work with that individual earlier than, say, that condition may have been diagnosed.

So, for instance, if an individual is found through genetic information and other healthcare indicators, that might lead to an earlier onset of colorectal cancer, perhaps then we start screening earlier, as opposed to what the guidelines would suggest for the general population, because we have the data and the information that tell us straight away that that person may be at higher risk and the information in the hands of that provider to be able to counsel their patient and say, you know, let's get you in for screening earlier because the model is showing us you could develop this earlier.

Let's be on top of it and never let that happen. We have models that look at suicidality and individuals’ risk for having a suicide attempt in the future. We've been deploying those models since the pandemic and find individuals based on their utilization data, their medication data, whatever is pulled in from the past that would be predictive of someone perhaps having a suicide attempt in the future.

We can then look at, is that individual getting services today, or is there an individual out there who we see who could benefit from services and get them into needed care if they're not there? If nothing else, it allows us to have the conversation and ask the question of someone if they're struggling, can we help you get to the right kind of help?

Those models are really powerful. And it, you know, it's the kind of work that I think shows data at its very best and using data at it’s very best to help people from having a bad outcome. The challenge with any of these kind of models, Erin, I have to bring up is operationalizing those. So, if in a health plan or a health system, one group sits on all the data and they have the list of all the people who need an intervention, but that list never truly gets operationalized by the folks who are doing that outreach to the patient, never gets exchanged with the provider who can have the conversation with the patient, then we've done all of that work for naught.

And so, the real key is understanding how to take the data generated by AI or old-fashioned algorithms to develop prediction, to get it in the hands of those who can use it and make the needed connection with individuals.

ERIN ESHELMAN

When you look five years ahead. What do you believe will define the most successful health plans?

DR. CAROLINE CARNEY

Oh, that's a that's a good question. Number one, those that deliver on what they said they would do. So, if I am out there saying, you know, we will pay your claims timely, that health plan that pays that claim accurately and timely every single time for those providers in the network will be successful. The providers will not have a hesitation working with a health plan like that who delivers on their promises.

Similarly, for working with the covered individuals on that health plan, ensuring that they can get into providers when they're needed, ensuring that those providers are high-quality providers, doing what we say we do and delivering on that every single time, that will bring us all together. And I really think that that's where we need to be.

There's too much in healthcare that has a health plan opposing a provider, opposing a member. We need to similarly be on the same page and define what good, great, and outstanding look like and drive to that together to get ultimately to what's best for all of us listening to the podcast, for you and me, everyone we know to get the best healthcare that they deserve.

ERIN ESHELMAN

Thank you. And maybe building upon that a little bit, if you were advising healthcare executives today, what are the three strategic priorities they should be focused on over the next 12-to-24 months?

DR. CAROLINE CARNEY

Aside from delivering on what you say you can do and should do, I think we have to look at the disruption of health plans that's ahead of us, and think about where we can be that disruptor. Let's disrupt ourselves before we get disrupted by some external force, because we need to change. Models of the past are not necessarily models of the future, given changes in the way people are accessing healthcare today.

So, number one, figure out where you can be a disruptor. Number two is think about where you really can sustainably grow and learn how to say no to something that may be a drag on your margin. Even if the revenue looks great, it doesn't matter what that revenue is. Ultimately, if you're losing money in the process or have to build so much that's not scalable because it's for one contract, you really have to learn that process of keeping your strategy focused and learning how to say no to the next shiny penny that comes along.

And the third on the theme of the shiny penny is to do diligence in what technology you're bringing in. During the pandemic, there were so many companies that would come through and say, hey, use this app, use this app, use this app, and does any of that really change the trajectory of spend? Do people stay engaged with it for more than a month or two? What does that new technology do for the ultimate outcome of high-quality care for your member?

Be really diligent in the process of what you bring into the company, because every time you bring in a new technology, you have to integrate it with existing technology and that creates more expense.

So, think about it really clearly. I can't say it enough. The ultimate goal of every health plan should be ensuring that our members get the best care that they need. And look at, so look at what you're doing with that really critical eye.

ERIN ESHELMAN

That's wonderful advice. Thank you so much, Dr. Carney. If you were advising a newly appointed health plan executive today, what advice would you give them that we haven't already covered?

DR. CAROLINE CARNEY

I would tell every single one—and I do do this—is to listen to frontline staff, understand what your frontline staff are experiencing. Listen to the call center calls coming in. Talk to the people who are processing claims. Talk to the folks who are trying to assess quality of care. Talk to the network folks. Look at all of those functions from the perspective of how the work is getting done every day.

So, I can't speak loudly enough about how important that is. The second is to pay attention to the news that's around us. What's happening in the country and across the world creates stressors that ultimately end up in our health. If we have young individuals who are terrified about climate change and the expansion of military conflicts across the globe, you know, all of the things that are pressures, how is that going to show up in our health?

And so, we really need to pay attention to the news outside of just the health care news that's coming forward, because it matters to how it's affecting populations. And the final is build your team and have a team of people you communicate well with and trust because you can't do everything and you shouldn't do everything.

You have individuals who are experts in finance and ops and name your function. Use those experts to their fullest extent because they can inform and work together to get the whole team to a better place. Healthcare is not a one-man job. It is something that really should be done by a team. And so, that final bit of advice is build that team.

ERIN ESHELMAN

That’s wonderful. And your response really speaks to your extraordinary career and all of the leadership that you provided in the healthcare space. So, thank you so much, Dr. Carney. I want to thank you again for joining me today and sharing your insights with our listeners. It really has been a great conversation, so informative, and I appreciate the time that you've spent with us.

CHAD MULVANY

I'd like to thank all of our listeners for tuning in. You can follow “Achieving Health” on Apple Podcasts, Spotify, Amazon Music, or wherever you listen to podcasts. You can also now find us in the Health Podcast Library. If you want to learn more about the topics we discuss here, be sure to check out the show notes for related content.

You can also subscribe to our healthcare FORsights and follow us on LinkedIn to get regular insights and updates. And I welcome you to reach out to me, my co-host Shawn Stack, and the team at Forvis Mazars if you have any questions about how these topics may affect your organization.

Shawn and I will be back next week on Wednesday, October 28, for the next round of “Washington Watch” updates. Until then, here's wishing good health for you and the communities you serve.

ANNOUNCER

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The information set forth in this podcast contains the analysis and conclusions of the panelists based upon his, her, or their research and analysis of industry information and legal authorities. Such analysis and conclusions should not be deemed opinions or conclusions by Forvis Mazars or the panelists as to any individual situation as situations are fact specific.

The listener should perform their own analysis and form their own conclusions regarding any specific situation. Further, the panelists’ conclusions may be revised without notice, with or without changes in industry information and legal authorities.

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