Public-Private Partnerships Are Key to Improving Health Equity - Dr. Aditi Mallick, Chief Medical Officer for Medicaid & CHIP at CMS

Mentioned in this episode: Link to Request for Information on Medicaid Access
https://cmsmedicaidaccessrfi.gov1.qualtrics.com/jfe/form/SV_6EYj9eLS9b74Npk

Dr. Rishi Desai: Hi, I'm Dr. Rishi Desai and today I'm honored to welcome Dr. Aditi Mallick to Raise the Line. Dr. Mallick is the chief medical officer for Medicaid and the Child Health Insurance Program at the Centers for Medicare and Medicaid Services. She brings deep experience in healthcare innovation, federal and state health policy, and clinical care and research to her current role. Before joining CMS four months ago, she was director of the COVID-19 Response Command Center at the North Carolina Department of Health and Human Services. I'll be tapping into the real-world perspective on the pandemic she acquired in that post. Dr. Mallick is also a clinical assistant professor of medicine at George Washington University Medical School. Thanks so much for being with us today.

Dr. Aditi Mallick: Thank you so much for having me.

Dr. Desai: So maybe we can just get started with learning a little bit about what got you started in medicine?

Dr. Mallick: I'm happy to. So, I'm the child of Indian immigrants. Both my parents moved from India at various stages of their lives and lived in London for a period of time. Then, when my mom was pregnant with me and my older sister was 18 months old, they took a vacation to Florida and decided, "Why would we live in London when we could live in Florida?"  I was born and raised in South Florida.  The defining moment of my childhood was when I was 12 years old, my dad -- who was forty-two going on forty-three -- was diagnosed with late-Stage 3 esophageal cancer that he ultimately passed away from nine months later. 

I saw firsthand as a child how hard the system was to navigate, especially for families that didn't have health insurance. This was pre-ACA. That experience of, honestly, helplessness and frustration is what made me want to be a doctor. Not that it would have changed the outcome for my own family, but feeling like no family should ever have to go through that and that if I were a doctor, I would understand how the system works and be a better advocate for people that need it. 

Then fast forward to when I was in college, I had the opportunity to take classes with Don Berwick, David Blumenthal and the late Paul Farmer, all of whom deeply inspired me and showed me this model for how to be what I lovingly call a "doctor plus" -- someone that engages in clinical medicine and sees patients but spends a large chunk of their time on policy and health systems improvements. That's sort of been the fire in the belly ever since for me. I'm so thankful that I still get to see patients on a regular basis and bring that to the work I do in policy, and vice versa.

Dr. Desai: I like that "doctor plus" idea. Maybe if you can just drill down on what the "plus" embodies and how you explain that part of it to folks that may not understand the words advocacy or can't really ground that with an example. Do you know what I mean?

Dr. Mallick: Yeah, yeah. So, I think about it as almost a translator role. You very often hear of people that are, for example, translators between the worlds of engineering and business or people that are translators between the worlds of law and technology. When I think of “doctor plus” really what I mean is translating what it is like to care for people in need. I'm a hospitalist. A lot of the patients that I see are acutely ill. So, I'm translating what it means to take care of people in sickness and in health to policy decisions. What does that mean for how we design payment? What does that mean for how we construct care teams? What does that mean for how we design a delivery system -- either at a local level, a state level, or now in my current role, at the federal level? 

That's what I mean by “plus.” I'm happy to give examples of specific projects if it's helpful, but I will say, lovingly, it's a hard thing to explain at a cocktail party or family dinners or Thanksgiving (laughs), because I think very often when you introduce yourself as a physician, the response is, "Oh, what's your specialty? Oh, you're not a cardiologist?" And there's like a set of follow-up questions that often leave people quite confused. But, I love what I do and I'm happy to explain it because I think it's just such a joy and privilege to be able to do what I do.

Dr. Desai: So maybe that would be a good segue. Can you talk a little bit about your role at CMS and what you do day-to-day, and also what some of your priority areas are like? What do you personally care a lot about?

Dr. Mallick: Absolutely. So, I'm the chief medical officer in the Center for Medicaid and Child Health Insurance Program (CHIP) Services at CMS. I don't know how much listeners are familiar with the Medicaid program, but it is the single largest insurance program in the country, and across Medicaid and CHIP through the pandemic it insures around eighty-five million people. My priorities are health equity, the social determinants of health, and advancing whole-person health. That includes work on data collection, quality measurement, and how are we testing and designing new payment and care delivery models in focus areas like behavioral health and maternal health. 

To the extent that there is a typical day, it involves a lot of conversations around policy development as well as stakeholder engagement. That's meetings like this one, meeting with colleagues at the state level, other federal agencies, and advocacy organizations to stay connected to what the issues are and really try and translate those real-world issues and problems into actual policymaking or into guidance or into communications and toolkits -- things that are really intended to move the needle on the areas of health equity, social determinants of health, and quality care innovation.

Dr. Desai: At a very broad level, Medicaid was set up to give access to folks that don't have a lot of money, that are economically disadvantaged. How well would you say it's going? How well are we doing through the use of Medicaid at accomplishing that goal?

Dr. Mallick: It's a good question. I think about access in two different ways. One is access to coverage, which is distinct from access to care and services. If we take that first bucket of access to coverage, we are seeing record-breaking enrollment in the Medicaid and CHIP programs. In the most recent publicly available enrollment data, nearly eighty-five million people are enrolled and get coverage through the Medicaid and CHIP programs. For context, since February 2020 -- so right before or at the start of the Public Health Emergency -- enrollment in Medicaid and CHIP has increased by about fourteen million people, or about 20%, in about two years. 

Part of that is due to Congressional action that ensured that states would keep people with Medicaid enrolled for the duration of the Public Health Emergency (PHE) and states were prohibited from dis-enrolling people from Medicaid for the duration of the PHE as a condition of accessing enhanced funding for their Medicaid programs. But that continuous coverage requirement extends only through the end of the month in which the Public Health Emergency ends. So, whenever the PHE ends, that continuous coverage requirement will go away in that same month, and the enhanced Medicaid funding will go away in the quarter that the PHE ends.

All of that is to say we've done a great job on access to coverage, in part because of statutory requirements from Congress. Once that continuous coverage requirement ends, states will have twelve months to initiate eligibility renewals for everybody involved in Medicaid and CHIP to help connect them to ongoing coverage. That's a very active area of effort for the agency. So, to the first part of the question on access to coverage, a lot of work is underway and there have been really historic gains in coverage through the public health emergency. 

On access to care and services, I think it's a slightly different story there. We've seen quite a bit of variability state-to-state depending on the service in terms of access and utilization over the course of the Public Health Emergency. Particular areas of concern are around behavioral health and decreased utilization of those services, and just folks finding it really hard to access those services.

We've similarly seen disparities -- and I think it's well documented in the public press -- in maternal health outcomes, perinatal care and maternal mortality and morbidity, all of which sort of stems from access to high quality, equitable health care services and supports. So that's, I think, where we have quite a bit of work to do and quite a bit of work underway. I will take the opportunity to plug something. We actually have a request for information (RFI) out right now on medicaid.gov on access in the Medicaid and CHIP programs to really get concrete about where the issues are and what the strategies and solutions would look like using all of the levers available to CMS to help improve and strengthen access for Medicaid and CHIP beneficiaries -- both access to coverage as well as access to care and services.

Dr. Desai: A lot of our audience is very familiar with Medicare and Medicaid, but CHIP is less familiar to folks. Do you mind explaining a bit of the history of CHIP and how you think of CHIP? I mean, some people talk about CHIP as essentially being "Medicare for All" but for kids. So, do you mind just walking through that?

Dr. Mallick:  So, CHIP is a joint federal-state program -- in the same way that Medicaid is a joint federal-state program -- that provides health care coverage to low-income, uninsured children with family incomes that are generally too high to qualify for Medicaid, or at least that's how the program was conceived when it was enacted in 1997. 

CHIP actually gives states a fair amount of flexibility in designing their programs. Specifically, states can determine which benefits are covered, and then can set the level of premiums and cost-sharing for those benefits. Under CHIP, states can operate their programs in a couple of different ways. Some states choose to operate the program as an expansion of Medicaid. Elsewhere, it's a program that runs entirely separately from Medicaid, or a combination of both approaches. Most states are a combination of the two where parts of the CHIP program are separate or parts are run as an expansion of Medicaid. The distinction is that separate programs may require differences in premiums and cost-sharing for the beneficiaries. Medicaid expansion CHIP programs follow Medicaid cost-sharing rules, which essentially allow for limited or no cost-sharing or premiums. 

CHIP, like Medicaid, is a major driver of health equity, and disproportionately insures Black, Latinx and other children from communities of color. So, when I think about how the CHIP program interfaces with the Medicaid program and some of the other priorities we talked about -- our overall priorities of coverage and access, equity, innovation, whole-person health -- those apply to CHIP just as they do the Medicaid. That's inclusive of things like integration of physical and behavioral health, making sure that kids have timely access to high-quality care, and that we're able to measure where and how they don't have timely access to high-quality care.  Those are all priorities for CHIP, just like they are in the Medicaid program.

Dr. Desai: Your experience in North Carolina is very interesting to me because, obviously, you have a perspective from the state level and now the federal level. What did you notice in terms of health equity? What advances did you see when you were in North Carolina? What stories are often not told because the attention is just not there?

Dr. Mallick: From my time in North Carolina, the two biggest things I learned about equity are the importance of data and the importance of relationships. On the data front, you can't fix what you can't measure. North Carolina was one of the first states in the country to mandate collection of race and ethnicity data on COVID testing, and then again as part of the COVID Vaccine Management System.  That allowed us to identify parts of the state -- down to the census tract level, actually -- where we were seeing lagging testing rates or lagging vaccination rates. We then linked that to our case rate data so we could focus our efforts on those communities. 

For example, if there were periods of time where we were seeing spiking cases among Latinx populations, we could look down to the census tract level to see where testing rates were low -- in particular in Black and Latinx communities or majority-minority communities -- and deploy state-funded testing resources to those places to actually set up testing sites outside the grocery store or in the parking lot of the church or mobile testing vans. That was as close to real-time data as we could get which allowed us to be as nimble and agile as we could in deployment of state resources for testing, and then later in vaccination. 

On the relationship front, I will say one of my favorite catchphrases is "equity is a team sport." It really requires the mobilization of individuals, communities, community-based organizations, and private sector organizations alongside all levels of government. The specific example I'll share is we launched a FEMA-sponsored community vaccination center in Greensboro, North Carolina that did thousands of vaccinations a day. What contributed to the success of that was we had faith-based organizations bringing buses of people; we had schools bringing soccer teams and sports teams; we had multi-generational households showing up. We had bilingual community health workers who spoke Spanish and could navigate folks with limited English proficiency through the entire process. We publicized on Spanish language radio, in Black-owned newspapers, in a variety of Hmong communities and Southeast Asian communities...all of that required partnerships across the public and private sector with individuals and communities to really mobilize people around a shared goal.

Dr. Desai: Do you feel like, given where we are now with COVID and similar mobilization, have you seen that play out over the last couple of years as well?

Dr. Mallick: Do you mean similar mobilization for non-COVID things?

Dr. Desai: Yeah.

Dr. Mallick: I think it depends on the specific circumstance. I think one of the great learnings around relationships is that it holds true in other healthcare contexts. So, on the health-related social needs, for example, or social determinants of health, really having strong relationships between clinical providers, community-based organizations and social services agencies is how you create systems of closed-loop referrals. You can screen folks for, for example, housing instability, food insecurity, or intimate partner violence in a clinical setting, but then actually be able to follow up with a referral to a social services agency or community-based organization that has resources to help that person, and then close the loop back to the clinical provider to be able to follow that person's health and health outcomes as they relate to their social needs. 

So, there is that model. It certainly works, and I think the more we can do to encourage that model -- it's already happening -- but the more we can do to encourage that model through care delivery systems, payment mechanisms, funding, and oversight activities, I think, will serve us well to be able to help people in meeting health-related social needs.

Dr. Desai: We have a lot of students and early-stage career health professionals in our audience. I'm curious what advice you might give them at this stage now that they've just gone through a massive pandemic? How do they become the “doctor plus” you mentioned?

Dr. Mallick: I think about this one a lot, and I will say I have benefited many times over the years from the advice and counsel of folks that have come before me. Three things I'll say. One is to define your "why." Why do you want to be in healthcare? Why do you want to be in medicine? Why do you want to be a clinician or whatever it is that you want to be? What are you hoping to do and why? The more introspective and focused you can be in the answers to these questions, the more I think it will sustain you over time. 

My experience in medical training, and now in a career as a “doctor plus” is there are some really hard days. I find myself needing to remind myself why I choose to do this. Having a "why" has sustained me on the really hard days. I mentioned what I experienced firsthand as an adolescent, and it sustains me to know that doing this work helps prevent hardship, pain, and suffering for other people's families. 

The second thing I'll say is help however you can. Early in the pandemic, I was three months postpartum when the world shut down. I felt this urge to be useful, but I wasn't sure how. I reached out to one of my mentors for advice and he said, "You know what? Just reach out to people. Help first. You can figure out the rest and ask questions later. Just go to people that you think are doing good things and might need help and just offer help and they'll tell you what they need." 

That was eye-opening to me because there really are a million different ways to serve in this moment. So, I'd encourage you to dive in somewhere. Honestly, really anywhere. Whether it's in your community, whether it's in a local healthcare facility, even being a caretaker within your own family if that's meaningful and impactful to you. You'll kind of figure it out as you go. I have found that there's a real joy and satisfaction that comes just from knowing that you can look in the eyes of the person that you're helping. There's a joy of being a physician, in my mind, but there's countless other ways to tap into that joy of helping another person.

Dr. Desai: Sometimes there's "analysis paralysis" where you're not sure what to do so you do nothing. So, I think just jumping in is great advice.

Dr. Mallick: Thanks. The last thing I'll say that's been helpful to me in navigating a variety of career transitions, even early in my career, was to build a council of advisors. For every twist and turn that I've had in my time in medicine, I've turned to a set of five to seven people who I trust and respect for their guidance. We keep in touch, we collaborate wherever possible, and that's helped me a lot over the years. I also try to be that advisor or sounding board to others to pay it forward, because you don't have to go through this journey alone. In the same way that you can be of service and offer help to others, don't be afraid to ask others for help and build that council of folks that can guide you and mentor you along the way.

Dr. Desai: I think that's probably a good place to end on. I sincerely appreciate your insight and your approach to this. I think it's very measured and your story is just remarkable. I think it's great. Thank you for joining us today.

Dr. Mallick: Thanks so much for having me.

Dr. Desai: I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.