Episode Transcript
[00:00:01] Speaker A: Our focus and my focus from a clinical operations priority is really about taking advantage of where we are from an AI perspective and the availability of data.
And that is to say, how can I become more precise and targeted with what I'm doing? For whom? Think of it as the right care at the right time, the right way
[00:00:24] Speaker B: welcome to the A and M Significant Healthcare Voices Podcast series series featuring insights
[00:00:30] Speaker A: on healthcare trends and hot topics direct from industry leaders.
[00:00:35] Speaker C: Welcome To A&M's significant healthcare voices Podcast series. I'm Christina Park, Managing Director in Alvarez and Marsal Healthcare Industry Group. I'm joined by my colleague Susan Trimble, a Senior Director in our practice. We are thrilled to have Marilyn Eckley joining us today on the podcast. Marilyn is a Senior Vice President of clinical operations at CareSource, a nationally recognized nonprofit managed care organization. It is the largest Medicaid plan in Ohio and the second largest in the United States, serving over 2 million members across multiple states. Their mission is to transform health care by providing innovative programs and make a lasting difference in members lives by improving their health and well being. Marilyn also brings more than 30 years of healthcare executive leadership experience to her role, with deep expertise in clinical and provider operations, population health and large scale managed care administration.
Before joining CareSource, she held senior Executive roles at Amer health, Caritas and UnitedHealth Group and earlier in her career served in public sector leadership at Pennsylvania Department of Health and Human Services.
We're excited to have her here and look forward to a great conversation. Welcome to the podcast.
[00:01:40] Speaker B: Hey Marilyn, thank you.
[00:01:42] Speaker A: I'm excited to be here.
Great.
[00:01:45] Speaker C: We're going to jump right in and we want to get a little bit of what's going on over at CareSource. So with the Medicaid landscape facing one of its most consequential moments in years with the one big beautiful Bill act cutting federal Medicaid spending by almost $911 billion over 10 years with work requirements, increased eligibility redeterminations and other types of restrictions. On top of that unwinding a lot of the pandemic era, continuous enrollment has already reduced Medicaid by nearly 8% in fiscal year 2025 and anticipating the leaves the remaining population with even higher acuities and more complex needs.
Tell us a little bit about caresource and as in the middle of kind of the geographic expansion that you're anticipating, we've heard Nevada, New York, possibly Wisconsin and considerable membership growth over the next few years. As someone overseeing the clinical operations across the multi state plan, how are you kind of Thinking about the environment and what it might mean for care source's clinical priorities.
[00:02:43] Speaker A: Pruly unprecedented if you think about 30 years in the industry.
I think I've said that multiple times. But it is a very unique time for us to be in healthcare.
So we are very well aware of the environment. It becomes part of the DNA of everything that we're doing on a regular basis.
Particularly because we are looking at, to your point, the acuity of our membership is so high, the people left behind. And that is, to your point, a combination of many, many things over the last several years. So our tendency, I think, and having been in the industry is to think about rationing, if you will. We say doing more with less, but it tends to prioritize always in my mind starts to think about what am I not gonna do? And our focus, and my focus from a clinical operations priority is really about taking advantage of where we are from an AI perspective and the availability of data.
And that is to say how can I become more precise and targeted with what I'm doing? For whom? Think of it as the right care at the right time, the right way.
So in the past we segmented populations or stratified populations by looking at historical claims data, who was a high utilizer, high cost. We put you in care management and everybody else availed themselves of a smattering of programs not really orchestrated either.
[00:04:06] Speaker C: Right.
[00:04:07] Speaker A: Depending on the state, et cetera. We're really thinking about it in the context of what if we understood our members in a longitudinal way, A 360 of your members.
Think of it as I always say. Amazon knows more about me than I know about me. But they surely know how to reach me, how to engage me and how to motivate me to purchase something. Kind of see healthcare the same way. Our priority should be transformation, troop transformation, not what did we call it, sort of active inertia of doing the same thing over and over again, but harder.
I don't know how we can do that. It's no longer optimizing our way out of this through automation. It's truly thinking of how we transform. And that means you can't just do the same thing. It's not more care management, it's different care management or different population health management.
[00:04:54] Speaker C: I love that.
[00:04:55] Speaker B: Susan, I have a question here. So Christina mentioned that CareSource has been actively growing. I'm hearing you've expanded into Nevada's Medicaid market. You've grown your dual eligible footprint through programs like next generation MyCare, Ohio and you're Pursuing affiliations in new states.
When a plan scaling this quickly, how do you ensure clinical operations keep pace and that quality of care doesn't get compromised in this process?
[00:05:20] Speaker A: That's a horrific question because obviously when you're growing and you're growing quickly and differently, it becomes really important to think about proactive planning and growth, right? Not opportunistic. And I think that's the one thing I really like about this organization is it's not opportunistic growth. It's really thoughtful growth. And to your point, Susan, into the dual space, into the LTSS space and before doing that, starting to create the infrastructure both in the clinical and the broader organization to manage that kind of growth. So you think about being proactive, you think about again, how do I not deteriorate? Quality gets into that issue of precision. Where I grow becomes less dependent on the nuances of the program. If I have a really good understanding of the population I serve. But it takes that other stuff out of it. Say I know what the population is, what they need, what resource I need to avail them. So. So it's really putting the member. It's so cliche, but it so true. Putting the member at the center of all of this. And so it's designing in a really precise and thoughtful way to target members. And I would say one of the things that really gets ouchy for people in the context of growth in large scale organizations like our own is we talk about things like standardization and what's local and what's centralized. And so you use all these words because we go back and forth. I have, as you alluded, worked in a number of different organizations, organizations, and we always think about what should be local and what should be centralized. And particularly in government programs and the nuances of states, everybody is unique, as they say. You've seen one Medicaid program, you've seen one Medicaid program, if you've seen one. And I think that's true. So I tend to think of it more as consistency.
That versus standardization or centralization.
You want to have the guardrails, the parameters we define the care source way of doing things based on collecting that data and understanding what works and what doesn't work, then apply that consistently but not rigidly. And I may be a little nuanced, but it's really important because I think the idea of what sits where becomes a moot point if you're really centering on who needs what in terms of the members.
[00:07:33] Speaker C: The other thing you talked about, which I want to dive deeper into Is AI given kind of where. Where we live in today's world? And you really talked about targeting and engaging your members and those being really pivotal in terms of how you're reaching the Medicaid population today. Talk to us a little about a little bit about kind of how given AI's domination in the industry, Caresource sounds like you're already leaning in with Caresource GPT supporting a lot of your capabilities and piloting capabilities in care manager home visit workflows. From our understanding, with a goal of about 80% of automation of operations in call centers over the next few years, can you tell us a little bit more about what your vision and view is of using AI as an enabler in your operations?
[00:08:18] Speaker A: Yeah, I'm going to make two distinctions. There's AI and I think a lot of people talk about that and we say 80% of our operations will be utilizing AI. There's the. I call that optimization. Optimization of existing workflows in many respects, or improving workflows, but still kind of staying on the same chassis, if you will. So CARES was just leaning in. You're absolutely correct. I mean, we're looking at opportunities in ways that again, I'm quite impressed. Relatively new to this organization with the bureau, very innovative spirit. We have a CEO who's as many are, but somebody who leans very much into this and we're doing that AI and there's a really strong goal to optimize. However, there's also equally as much around transforming and that's what we were talking about AI, not as a way of just doing faster, using agents, but what if I were able to expand on the identification of what used to be high, medium and low risk? What if we started to think about people in terms of their impactability and engageability? What have we created algorithms that started to identify trends in things like geographic trends, cultural trends that technology is now there to be able to understand who needs what and when. It also allows us then to, yes, move to that optimization perspective of do I need to call you 15 times in a month? Look, I would starve to death before I'd pick up the phone and order a pizza by talking to somebody. If I can't do it online, I don't want to do it at all. That is a preference of mine, Right. And yet Marilyn still writes checks. Right, so. So those are the things about me that are inconsistent but matter to people who engage with me. That's the kind of information that AI can give me.
[00:10:03] Speaker C: I love that it goes back to the target and engage. It's a whole new way of thinking about targeting populations. And then how do you uniquely kind of engage with them? But it's kind of creating consistency of this is a new way of doing that. You're able to get to the nuances and see specificity of it in a much, much more effective way.
[00:10:22] Speaker A: You're really actually saying to AI, tell me what you're finding by looking at every possible. It opens up, quite frankly, the ability to use all sorts of data. Now I understand that we have to remain very thoughtful. There's ethical implications of that. But certainly people know my grocery shopping habits and that reflects how they motivate me to do certain things. That's, that's what we're, that is our new world order. And I think that's the exciting part. Not go do something faster but do it differently.
[00:10:53] Speaker B: Let's talk about another population. The dual eligibles. Those of us in the industry, we know they're among the most complex and highest need people. What do you see as the nuances for serving this population and where do you see in the industry? That there's gaps in how they're approaching it.
[00:11:11] Speaker A: Yeah, I appreciate the question. The dual eligibles are in my mind the reminder of what complex whole person care is all about. Because when you say the nuances of it, I think there are similarities in terms of a vast array of needs that people bring to the table. But when you think about the dual eligibles, you're adding complexity of navigating multiple systems. That's the thing that I see as the greatest nuance. And you're really talking about providers and community groups as well. Providers, sometimes two managed care companies representing Medicaid and Medicare, depending on the structure. So if I would say the nuance is that I think it's just basically amping up the degree of pressure to have somebody, a person or their family stitch together a very complex disintegrated system in ways that you might not see in a TANF population or another population.
And so that to me is always the reliance I think that we have placed on the member and their families to be able to piece it all together.
So if I was going to think about the industry, and even where we fall short is we often talk whole person care. We get it, but we haven't structured the system as a whole person system. It's a series, often of teams and providers who are organized around benefits, if you will, as opposed to, again, it goes back to the person.
So how do we really create this place where the Data, the teams, the workflows, all of that are thought of in a system, again, not individualized programs. So we have fallen short. And I think for us that's really where we are starting to see a lot more. And how do we integrate this so that you're looking not at dual eligibles from a benefit package, but again, as a person, one could envision a world where the funding source means nothing. And what means everything is just simply understanding what does this person need regardless of how it's being paid for and how do we orchestrate all of those resources around that. And again, I'm going to go back to what we talked about with AI, having a common understanding of your population and getting our heads out of the like the funding stream. And having been a former government worker, I can tell you that's how we organize in government too.
Medicaid funding streams and having been in child welfare 4e funding streams and all these things end up disintegrating the way people work together. And I think that's really kind of where we're going now.
AI or technology, just broadly is allowing us to see how we can architect better systems. That to me is how I look about that population complex. Yes. Unworkable. Absolutely not. Not with where we're going. Not if we start with a member at the center. This is just a person. What do they need? How do they engage? How do I impact them? And then aligning the resources agnostic of the benefit package.
[00:14:03] Speaker C: Yeah. And kind of breaking down the barriers in the walls around all those different.
[00:14:07] Speaker A: Yeah.
[00:14:07] Speaker C: Sort of entities and organizations and things. Yeah.
[00:14:10] Speaker A: I'm sorry, but that nuance though is also because when you say breaking down the barriers, you know, that's where providers, and community providers in particular become really, really important to me. Which we often in managed care world or healthcare world bifurcate that out. I mean, I think we need to be much more engaged with the provider. That's really where the disintegration actually hurts us the most. We need to start really thinking about how we're integrating with providers, giving them the data that they need.
[00:14:37] Speaker C: I'm going to take a slight different turn because I want our listeners to be able to get a little bit of insights from you and in your career. If you were to talk to the next generation coming up of women trying to build their career in healthcare and engage, what words of wisdom would you offer to them as they're thinking through kind of getting into healthcare and really kind of focusing a career in this path? What would you say to them?
[00:15:02] Speaker A: I'd say this to a woman who was going to be on Broadway. I'd say it to a woman who's going to be in healthcare.
I think that, number one, go try everything before you're 100% sure. I've had terrific people in my life who've given me opportunities because I nudged me that way because I wanted. And I don't want to say this is all women, but we tend to want to be 100% sure we can do it. We have to do that. I would say don't wait until you feel fully baked to be able to go out and pursue what you want. And that's really important to me. I think that is number that. That's something that I was fortunate enough to have women in my life, mentors in my life who just happened to be women, really open up doors for me.
Secondarily, I would say do not give up on who you are.
And by the way, for your listeners, Christina, you know, you've known me for 100 years, and the one thing that has helped me and I think is a superpower is that I will always be authentically me. And it doesn't always feel like the path that you should take, because there's a lot of reasons to engage in mutual pretense with everybody and the performative nature of it. But at the end of the day, after this many years, my superpower has never been being performative or political. It's just being authentically me. And I have had such a fabulous career as a result of being welcomed by organizations who appreciated who I was. And if I couldn't be me, knowing that that wasn't the place for me. And there are lots of places to work in healthcare and lots of places to work in the world, and you will thrive being authentic. And the third thing I would say is pay it forward over and over again. Put aside the idea sometimes, and hopefully not so much, but I think that women can feel like we've gone through a lot to get to where we are when we're fairly successful. And I would consider all of us successful women in healthcare.
And there can be a tendency sometimes not, you know, to revel in the fact that we made it through. Right. And you got luck to the rest of you. And I think paying it forward is, again, aren't they life lessons, though if you could say it, try. I mean, I would say that in your career, in anything you do, don't be 100% sure. Just try it, for God's sake. You'll be what if it's great, what if it really works out?
So, yeah. I mean, not to be too don't. I want to bring a tear to anybody's eyes, but I'm telling you, there's no other magic to it. And I hate to say I'm old enough to know those things are really the case. Maybe. Finally, I have one more tip. Know what you don't know. I have decided in my career that the most important thing that you can know is that which you don't know. What's the old saying? It's not what you don't know that hurts you, it's what you know for certain that really gets you in trouble.
Yeah, I think.
[00:17:43] Speaker C: I think that goes hand in hand with your authentic self. Be true to that, right? For sure.
[00:17:48] Speaker A: Yeah. I mean, that's. Thank you for asking. Because I think so. Very few times we focus on those parts of what really makes us successful. It's not the subject matter, it's the person. And just how do we get to that Being you?
As I can tell, my. The hosts in here, the hostesses have been here. Your authentic self.
[00:18:10] Speaker B: Thank you, Marilyn. This has been such a fantastic conversation. Thank you so much for sharing your insights with us today and to our listeners.
[00:18:17] Speaker A: It's been fun. I would like to request being on it every week if possible.
[00:18:22] Speaker C: It's always great talking to you. You have so many fantastic insights. It's been a wonderful opportunity to work with you over the past. We'll just call it several years. So thank you so much. I really appreciated it. And to everyone who joined us, thank you for listening. And for more information about A and M and to find more of our podcasts, please visit www.alvarez and marcel.com healthcare have a great day.
