Rae Woods (00:15):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle health care's most pressing challenges. I'm Rae Woods.

Abby Burns (00:24):
And I'm Abby Burns.

Rae Woods (00:25):
Abby, our listeners should be hopefully well aware of the fact that last year the Trump administration enacted one of the biggest changes to healthcare policy in a generation. And they should know that because you and I have spent a lot of time talking about this on Radio Advisory.

Abby Burns (00:40):
Right. We've covered the nearly $1 trillion in cuts to Medicaid that we're going to see over the next decade, which is going to happen through things like work requirements, more frequent eligibility checks, restrictions on provider taxes and state-directed payments. That is the nitty-gritty, but the bottom line is that about 7.8 million Americans are expected to become uninsured and their now uncompensated care is going to fall on the shoulders of provider organizations.

Rae Woods (01:06):
It will fall on their shoulders because these changes haven't actually gone into effect yet, and they won't until January of 2027. Abby, does that sound like a lot of time to prepare?

Abby Burns (01:19):
I mean, it did sound like a lot of time last year when some of these things passed, but not anymore when 2027 is about eight months from now. And I think that's why we are more and more hearing providers use the word scramble to describe how quickly they are working to put processes in place or develop new partnerships to prevent their patients from being inadvertently disenrolled from coverage.

Rae Woods (01:43):
Which is why we have been so eager to have this conversation today, so that we can hopefully help make some of this work feel less like a scramble and more like a strategy. So in today's conversation, we want to share what leaders can do as soon as today, and frankly, what many have already started doing to ensure access for vulnerable populations and preserve provider margins. To do that, we've invited Optum patient access expert, Sunay Shah. Sunay, welcome to Radio Advisory.

Sunay Shah (02:16):
Hey, happy to be here. Can't wait to dig in.

Rae Woods (02:21):
We are staring down the barrel of policy changes that are going to come into effect in January of 2027 that will mean a lot more administrative work to ensure that patients who are eligible for Medicaid can actually maintain that coverage. This is something that frankly, we've been getting a lot of questions about at Advisory Board. I think you have gotten a lot of questions about this too. This happens to be a big area of expertise and a big area of personal passion for you. Can you explain at a high level what you do?

Sunay Shah (02:51):
Yeah. Yeah. So at Optum, I am focused on trying to leverage our tools, our resources, our capabilities to make it easier for patients to access care. So while the impact of Medicaid changes from a policy perspective are very large and meaningful, I as well have been spending a lot of time to think of how do we make sure this is integrated into how we deliver our solutions and make sure that we can minimize any impact to patients.

Rae Woods (03:20):
I think everyone is thinking about how to navigate this right now, partially because of the magnitude of the potential cuts, which we spend a lot of time talking about, but also the urgency to act, the range of stakeholders that could be involved in managing and working through these new requirements. But at the same time, even though we're feeling this scramble, changes in Medicaid aren't new.

Abby Burns (03:42):
Right. We have managed before through ACA's expansion of Medicaid, the end of the COVID era of public health emergency, which had temporarily suspended Medicaid redeterminations. Some states have already tested work requirements like the ones that we see coming into effect through the One Big Beautiful Bill Act.

Sunay Shah (04:00):
I feel like dealing with complexity, dealing with changes is something if you've been working in this space for a long time, is really not surprising. We should be informed by what we've done in the past and there's lots of good lessons that we could learn to incorporate into the future here with the redetermination being reduced down to six months.

Rae Woods (04:17):
I appreciate you saying that there is some muscle memory that leaders can use either because of changes that have happened at the federal level or because of examples we can learn from at the state level. I'm in particular thinking about what's happened in Arkansas and what's happened in Georgia. What happened in those states?

Sunay Shah (04:37):
Yeah, lots to learn in those. I don't even think I can say there was mixed results. The results are pretty shocking. I'll give you a couple of examples. Georgia's more recent, they called it pathways to coverage, okay? And this was rolled out in the 2023 timeframe. And when you look at the overall expectation was that somewhere around 360,000 patients may be eligible for this particular expanded program under Medicaid, the state themselves had said that they wanted to get 25,000 patients enrolled in that first year. About halfway through that program, they had less than 5,000 enrolled.

Rae Woods (05:12):
Oh, wow.

Sunay Shah (05:12):
So that's a very specific example where they just were not executing. And when you look at why, it's the same things you would expect. It's bureaucracy. And you guys can imagine it, right? It's more process, it's more forms, it's more documentations, and all that's not really patient-centric. If you ever filled out anything in a state policy, whether it's a gun license or FMLA or any other state website program, they're hard to navigate. There's a reason why we support the products that we support to help with Medicaid enrollment in the first place, because it's very difficult for patients to navigate these websites.

Rae Woods (05:52):
And that's why in Arkansas, we saw a significant portion of Americans losing Medicaid coverage, but we did not see a significant change in employment status. So said differently, they lost coverage, not because they weren't working, they lost coverage because of exactly the administrative hurdles you're talking about. And these should be warning signs of what we don't want to happen across other states as this moves into a federal level policy as opposed to a handful of states.

Abby Burns (06:19):
Right. And we use the words administrative disenrollment or unenrollment rather than ineligibility.

Sunay Shah (06:25):
Yeah. Meaning that, "You could have been eligible if you just gave us the paperwork," right?

Rae Woods (06:31):
And we should just name why that's a problem. It's obviously a problem for the individual people who are losing access to coverage, but we should name why this is also a problem for provider organizations, for Medicaid plans. Why is this a risk?

Sunay Shah (06:48):
From a provider health system perspective, when you have organizations that have large percentage of their patients that are coming in on Medicaid program or self-pay uninsured and don't even know they could qualify for Medicaid, those dollars tend to be uncompensated. Those tend to be write-offs impacting the financial viability of that organization. The second is just your public health risk. Now you've got patients avoiding care. The third is patients themselves, the mental strain that it places. And then if you are not getting any preventative care and you're waiting until a catastrophic event, then you are now going to be a high dollar case that's going to continue to extract value out of the health system for something that if you had, say, for example, gotten an annual physical that may have caught something earlier for a lower dose or lower treatment and you don't have an acute event that now has to be treated within the hospital. And all of that is just very foundational to the viability of your healthcare in your state.

Rae Woods (07:46):
Yes.

Sunay Shah (07:46):
That's why they're called safety net hospitals. They provide safety for people, provide safety for the overall health and wellbeing of your community. And so there's such a ridiculous domino effect of what Medicaid program complexity, increased cost and increased administrative burden does for the entire health system, your communities, and for your state.

Abby Burns (08:05):
Yeah. So now I appreciate that you're bringing in really a wide range of stakeholders that are impacted by these changes. And I want to lean in on this for a second because we know that the negative impacts of falling off Medicaid show up across all the different groups that you just named. One of the things that makes it hard to solve for this is it's not necessarily exactly clear who can or should be involved in the work to try and keep eligible patients on Medicaid. Can you help us understand which stakeholders are we even talking about when we're thinking about some of these efforts?

Sunay Shah (08:38):
Yeah, phenomenal question. And of course, the obvious answer is everyone, but then when you have everyone in the kitchen, it's really hard to make a recipe. So I think it comes down to who's going to lead. And I think that when patients feel uninformed about how to get help, the default state is to go to the ED. So I think that is really where I see the most acute level of urgency to connect with patients is to try to get health systems where patients are coming for their clinical encounter on a very reactive way to think about things proactively. And then you've got a whole other series of stakeholders like you described, Abby, right? You've got state agencies themselves, you've got community organizations, you've got policy stakeholders, you've got partners that also have skills and resources that you can leverage. So now you've got kind of your network of resources that can then help hospitals and health systems with their objective of trying to help deliver care within their community.

Abby Burns (09:39):
And I have to imagine that only adds additional layers of complexity, especially for, for example, provider organizations that work across multiple states. The way you engage one state agency or the time that that state is working on may be very different from the state next door or the state in the other region.

(09:56):
So now I'd love to focus on health systems for the purpose of our conversation today, to your point of this is where a lot of this work starts. You work with health systems across the country here. Can you give us a sense for what normal looks like when it comes to how health systems think about their role in keeping eligible patients on Medicaid?

Sunay Shah (10:16):
Ooh, normal. Wow, what a loaded word in normal. I mean, default state is probably a bit chaotic. Again, my background, I'm a product guy. I think of things as like scale and how do I put standardized processes in place to scale? So when I think of what I try to put into place in solving this, that's my lens. And so when I look at customers that we work with, it is the opposite. Everybody has their own approach. Everybody kind of has their own ad hoc way of going about things. And so I don't know that there's a one size normal approach to this. We can certainly talk about some themes.

Rae Woods (10:51):
Yeah. You used the word chaotic. I think I would use the word reactive when I think about health systems standard approach. Would you agree with that?

Sunay Shah (11:01):
Very much. Very, very much, Rae. Yeah. Reactive leads in my mind to what I would consider chaotic because I want things to be predictable, expected. And really it comes down to three levers, right? It comes down to process, it comes down to the people, and it comes down to the type of technology that you're using to drive efficiencies. And so if you're looking at, is there any sort of standard approach across people process technology? No, not really, but there can be. And I think the sequence that I would start in is, number one is know your workflows. Do you have the right process in place? We talked about it earlier of patients coming in through your emergency department. That is not where you want to put your live agents engaging with patients in the emergency department as your default state. Let's try to move away, to your point, from reactive to proactive.

Rae Woods (11:56):
Let's go there because a reactive approach, a chaotic approach, wrong people, wrong process, wrong technology isn't going to work when the median health system margin is a whopping, what, 1.1% and there's $84 billion of uncompensated care on the table. If it's not waiting until the patient is in the ED, when should this process actually happen?

Sunay Shah (12:23):
It needs to happen in multiple dimensions. Hospital health system, being proactive, as soon as you have an opportunity to get a clinical engagement, you get that patient in the application funnel, see if they would qualify for a program proactively. Meaning if they're coming into the ED, fine. How do you stop the bleeding? You can't change that to begin with. Get them enrolled, get them engaged, and then make sure they stay enrolled and you proactively work with them, get their annual physicals set up, and now you're in management mode.

(12:57):
The second is, if you get them during a scheduling event, if somebody's calling in to schedule a visit, then you want to make sure you screen them. If they identify self-pay on insured, screen them, see if they would qualify for a program. So that's how you start getting proactive.

Rae Woods (13:11):
What you're saying is that yes, the ED is still going to be an important place where you're going to be having these conversations, but it's not only the ED. It should be as early as possible in the patient journey, which might be in scheduling.

Sunay Shah (13:25):
Yeah. And it's also the how, right? It's also how you engage with patients when they're in the ED. It's not the appropriate time to start sitting side by side with them, going through the detailed application process. They're not in that state of mind to be like, "What's your household income? What was your last employment? What were the last addresses that you have? Where does your family live?"

(13:45):
So here's an alternative, educating the patient that this is some of the information you're going to need to fill out, giving them a QR code to scan. Most people have a mobile phone and say, "Hey, just answer this handful of questions when you have time. Here's a number that you can call and engage with a live agent to help you with this if you have any questions. This is going to help make it easier for you to afford care." Leave them a QR code and a business card. Hand that to them. "Hey, when you get home, fill this out. We have live agents that are going to be there to answer your questions and make it not so intrusive and not so insensitive to the state of mind that they're in when they come into the ED."

Abby Burns (14:25):
Appreciate what you said earlier about there's a lot of heterogeneity when we look at health systems across the country and how well set up they are. What does it look like when a health system is actually set up to engage with patients in that way? How common is that?

Sunay Shah (14:39):
Yeah. I mean, some of the customers that we work with have found success in building trust with patients through a more patient-centric, patient-driven way. So for example, we have customers that have posters and business cards with the QR codes for a patient portal to self-screen and self-complete applications outside of the ED. And they literally have these posters and multi-language formats. They have business cards that they hand out to patients and patients are engaging with this. Now, do they get lost to follow-up? Yes, of course. But for the long run, upwards of 15% increase in the number of patients we screen just with the opportunity for patients to use a QR code to enroll.

Abby Burns (15:22):
Wow.

Sunay Shah (15:23):
It's meaningful impact, yes. It goes back to workflow as well. Workflow is very variable as well. So we've seen also benefits in improving workflow, but in terms of getting to your direct question of, is anybody doing the QR code successfully? The answer is yes.

Rae Woods (17:27):
We're talking about some technical solutions, right? Making sure that we are doing this at the right place, not just the ED, going as upstream as possible, having the right workflow, the processes, the technology. But I want to run at a bit of a human element for a moment here. We're talking about engaging with patients in perhaps their most physically and financially vulnerable state, and then we're asking them to actually engage more at a time when consumer and patient trust is at an all time low. So this is more than just an administrative solution for an administrative problem. How can providers think about building trust as part of this work?

Sunay Shah (18:11):
Most hospitals, health systems, academic medical centers, they view themselves as a pillar within their communities. And I think if you lead with that, you will build trust with your patients. And specific examples would include partnering with your local community agencies to say the same message and repeat it over and over to your community, that there are resources available to patients to help them afford care and that patients should not feel abandoned to that. And despite the fact that many of the programs that patients have to navigate themselves are hard and complex, that they have ways in which they can make it easier. And if you lead with that, then you will build trust with your patients, and then the patients will go through the obstacles that are in their way knowing that somebody has their back to get them through those obstacles.

Abby Burns (19:12):
Could you share maybe an example of when you've seen that work in practice?

Sunay Shah (19:18):
Yeah. So I talked about the one example with a QR code. The other example that I've seen, and this was something that we did at an organization in South Carolina and in a suburban type of environment, good amount of Medicaid patients that they supported within their community. This was something related to workflow where you had resources that were overstaffed within the ED that were idle, were not engaging with patients. They felt themselves as workers that it was uncomfortable and not productive for them to engage with patients. So when we looked at this, we said, "Well, why don't we have some of these operators go into our inpatient setting?" And so we modified the workflow where now instead of the live agents sitting within the ED, now live agents were spending more time and staffed in the inpatient settings where it is a bit more agreeable for patients to engage with application completion. They have idle time, they're in a different frame of mind, and now the cost of an inpatient stay is becoming very, very substantial. They're also more concerned and worried about that. And so they're more receptive and engaged.

Rae Woods (20:30):
And in both of those examples, the workflow needs to change, the time in which we do this needs to change, the place that we do this needs to change, but a little bit of humanity actually goes a long way. Even saying to that person in the ED, "Hey, I know you're overwhelmed. This is really scary. I can give you a big form to fill out now or you can fill it out later. And by the way, we're going to call you and follow up when things are a little bit calmer in your life to try to figure this out." Or, "We are going to connect with you when you get your bill or when we do try to get you to schedule your follow-up visit with your PCP after having this emergency visit." And doing all of that is something that can solve for the technical solution while still trying to build and regain and maintain some trust along the way.

Sunay Shah (21:14):
Trust is so multidimensional. We talked about the community feel and the importance for health systems to work with other organizations within their community. That's an opportunity.

Abby Burns (21:24):
Sunay, when people do get connected to help here, what's on the table for the type of help that they might receive? You get connected to someone in the ED or in the inpatient setting. What are those live agents helping with?

Sunay Shah (21:38):
A lot of it is gathering documentation, gathering information, and ensuring that the information gets entered into an application accurately, correctly, submitting the application to the state agency, and then ensuring that if there's any issues in the application, those issues get result addressed in a timely manner.

Abby Burns (22:00):
So meaning to prove eligibility, i.e., This individual is meeting the work requirement. Are there other types of help on the table?

Sunay Shah (22:07):
Yes. I mean, there's other help on the table that hospitals and health systems absolutely should wrap around. A lot of times we're narrowly focused on application and enrollment support and ensuring we get that complete. But yes, let's say, for example, our patient goes through a screening process and they don't qualify for Medicaid or program that we're supporting the organization on, a lot of times we'll hand that case off to someone else internally within the hospital and health system to see if there's other programs. So for example, perhaps some philanthropic aid that we don't participate in or work, that's within our purview. We don't necessarily help with ACA market plan enrollment, however, that is something that we can hand the patient off to another resource to help with.

Rae Woods (22:49):
What happens if you find out that the patient isn't meeting the work requirements, meaning it is not actually a paperwork and administrative problem, but it's actually a problem of them not meeting the requirements?

Sunay Shah (23:01):
That's where you have state agencies and state resources and state programs that we would like to connect and work more closely with to guide the patient to.

Rae Woods (23:10):
I am hearing a handful of examples of health systems trying to say, "Well, we can provide that employment. We can provide that volunteer opportunity." In fact, the CEO of Centene at the health conference last fall made a big statement about how they were going to be helping specifically with job opportunities, trying to hire more people in as doulas, as an example. We hear examples of health systems saying, "Come volunteer to guide patients around my hospital so that you can meet the work requirements. And then we'll also help you with the paperwork requirements," which we've been talking about, "but if there is actually an employment issue where we're not meeting the new bar for Medicaid eligibility, we can help there as well." And that is an example of a newer muscle that health systems are getting into.

Abby Burns (23:58):
There's another thing that I'm curious for your take on here, Sunay. When we think about the policy landscape more broadly around Medicaid work requirements, the administration has been very clear that they're focused on rooting out fraud, waste, and abuse as a big part of, I guess we can call it Medicaid reform, including going as far as withholding Medicaid funding to states where they believe fraud is happening. I want to be clear, in this conversation, we're singularly focused on the role that health leaders and their partners play in keeping eligible patients on Medicaid, but I'm curious in your experience, is the national conversation around what the administration is calling the war on fraud showing up in your conversations about the new Medicaid provisions and how folks are navigating those?

Sunay Shah (24:43):
It's interesting to think about the question from an intention perspective and an action perspective. Because intention to remove fraud is one thing, it's the actions that are taken that seem to be different. And what I mean by that is, if we take the examples that we started early in the conversation across Arkansas and Georgia, the idea of eliminating fraud and patients that are just sort of milking the system to get financial coverage, the consequence of trying to remove fraud added even more complexity. And when you add more complexity, you increase the risk of fraud. If you just do fell sweeping proclamations without thinking through the details, you unintentionally may create other loopholes. And so I agree with and align with the need that Medicaid is intended for a very specific type of patient of the specific part of our population. It's not intended to be a subsidy for hospitals and health systems. It is to aid those that need it so that they can get back on their feet, be contributing members of society and find coverage through their own means.

(25:57):
What I don't understand in the way in which this policy is being rolled out is that as you instill these work requirements, how much more complexity is that adding and is it really going to get rid of waste? And I think time will tell whether that happens or not, because my opinion, in order for this to really get rid of fraud and waste, you need trust. Goes back to trust because at the end of the day, our systems are too complex already, and if we're going to add even more complexity, you're not going to get at the heart of the problem because you're not getting at the trust of, "Hey, is this person using this program in the appropriate way or not?"

Rae Woods (26:31):
There's also something even simpler that I'm thinking about, which it just really, really behooves organizations to get quite good at documentation so that they can show that they are merely trying to keep eligible patients and maintain their access to coverage, which is, as we had described, hard to do. It is certainly something that health systems can do on their own. They can partner with other organizations like Optum. They can partner with their state agencies, with their MCO, right? There's a host of folks that are willing to help with this scramble as we've described it. Here's my question though. If folks do everything that we've described in this conversation, they're focused on the right process, the right people, the right technology, how much can a provider organization blunt the impact of these impending Medicaid cuts?

Sunay Shah (27:23):
A meaningful amount. And I think it can actually help to achieve a lot of the objectives of helping patients stay on coverage and get appropriate coverage as they qualify for it. And that is going to require coordination. It's going to require precision and it's going to require partnership. All of those factors have to contribute to this and we have to move away from being reactive to proactive.

(27:48):
Don't wait for these problems to hit your organization. You have to get ahead of it and have a strategy, have a plan, and then execute it extremely, extremely well. You need a flywheel of feedback of what's working, what's not working, so that you can then course correct and make the changes rapidly as the programs evolve because we're looking at the surface level of complexity without the policies even being into effect. Once these policies even become into effect and state agencies start reading and reacting, they're going to change their application forums. They're going to change their requirements.

Rae Woods (28:19):
Yes.

Sunay Shah (28:19):
This is going to qualify as an employment requirement. This volunteer experience may qualify, this one won't. How do we get that information fed quickly back to our organization again so that we're supporting the right patients with the right programs at the right time?

Abby Burns (28:37):
Well, Sunay, thank you for coming on Radio Advisory.

Sunay Shah (28:39):
My pleasure. This was a blast. Thank you for the time and the conversation.

Abby Burns (28:48):
Rae, I don't know about you, but I'm feeling incredibly energized by this conversation. What is one of the main things that you are taking away?

Rae Woods (28:55):
Well, I'll give a positive and a negative. I will say I am more aware of the fact that there is immense variability in the current state of how health systems think about keeping patients on Medicaid. I am also incredibly hopeful about their ability to learn from each other. Is that what you were going to say?

Abby Burns (29:18):
You literally took the words right out of my mouth.

Rae Woods (29:20):
Well, learn from each other, meaning the other providers, but also lean on other stakeholders, the partners, the state organizations, the health plans. Everybody can and should be leaning in here.

Abby Burns (29:32):
And I will say, this is a place where we have been getting a lot of questions from organizations. This is an area where leaders are more focused than ever. So I'm really excited about what the next eight months hold when it comes to standing up some of these things.

Rae Woods (29:45):
And we should remind folks that across the next eight months and beyond, we will be here to help.

Abby Burns (30:15):
New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Abby Burns, as well as Rae Woods, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week.