"Digital health startups must ensure that they have a good business case based on reality"

Q. Can you tell us about Parkland Community Health Plan and your role as the Chief Strategy Officer?

Paula: We are a very large system. Most people know Parkland because it is the hospital where JFK was brought in way back in 1963 and since that time Parkland has grown tremendously. We have the main hospital, plus many community clinics, school-based clinics, lots of really great specialty programs, one of the largest maternity services in the country, a very large burn center, trauma center. So, it’s just a really sophisticated care institution.

A part of the system includes the Parkland Community Health Plan, which has been in service to our community since the late 1990s. We have a contract with the state of Texas to administer Medicaid benefits through the STAR CHIP and CHIP perinatal programs. And so, unlike Parkland Hospital, which serves Dallas County, we serve a seven-county area in the North Texas community. We partnered with about 35 hospital systems, plus 6000 providers in our network to take care of our 220,000 members in the North Texas area. We provide them benefits, ensure that they get access to care. We partner with many community organizations to make sure that we’re meeting social determinants of health and really serving the community through our health plan, as well as through the system.

As the Chief Strategy Officer, I’ve been helping design our path for the future. We started out as a very small plan when I joined about two-and-a-half-years ago. We were really more of a vendor management type of health plan. We had outsourced all of our activities, primarily, and really only had about 15 employees in our health plan. When our new CEO John Wendling, came on board in 2019, he said, “You know, I really want to be in charge of the service we provide. I really want to be connected to the members. I want to be connected to and provider network. And I really want to be the plan of choice.” The best way for us to do that was to take on responsibility for that service, directly. So, we’ve spent the last year transitioning away from our third-party administrator, bringing many of those services in-house and being responsible for that administration of the benefits ourselves. My role has been trying to create that path forward, taking John’s vision and creating strategic documents, work plans and action plans, along with the leaders throughout the organization to really fulfill on our mission, vision and values and our goals to be the party of choice.

Q. You mentioned running such a large enterprise with just 15 full-time employees while outsourcing other functions. Is it fair to say that you are now trying to reverse that, bring more of it in-house for greater control over resources and directly influence the quality of the services that you provide?

Paula: Yes, especially for the health plan, specifically so Parkland, the system, has about 16,000 employees and a huge service. But the health plan was almost a department of the hospital and really not even considered a separate organization. We’ve tried to mature the health plan as a related but a different organization with a different set of priorities and a different set of stakeholders because certainly, if you’re at the hospital, at the center is the patient. Our focus as a health plan, is the member, the provider and then, also our state agencies. Since our contract is with the state of Texas, we want to make sure that we are following the state’s priorities and their strategic mission for the Medicaid programs, STAR CHIP, CHIP Perinate programs. It’s really kind of aligning our priorities with their priorities and we thought the best way to do that was to really become more responsible and more responsive directly as opposed to indirectly. And so, look at all of the services that we are responsible for in our contract and determine the best way to do that in the most responsible way.

Q. You’re serving largely a Medicaid, low-income population. In the last couple of years how have the needs for this population changed and how has that in turn impacted your own strategic direction and your priorities?

Paula: The changes that have taken place over the last two years during the global pandemic have been very dramatic. We have seen an immediate shift to digital options, whereas we were very reliant on in-person healthcare and our members were very used to going to the doctor. Our physicians were very used to having patients in their offices. So, this dramatic shift to digital options has been rapid and I think, very exciting. I think that everybody’s been surprised at the way folks have embraced it, as well. There was always some trepidation – “I don’t think our members will use it. I don’t think our patients will use them.” But we really have seen this dramatic acceptance of the digital options.

We’ve also seen a lot of social determinants of health — needs for housing, food, different sorts of social services — as the pandemic kind of morphed and changed how people were working, whether they were working or not, whether they had transportation. Now we’re seeing a lot of requests for rides because gas prices are so high. A lot of folks are calling and saying that they can’t afford the gas that it takes to get to the doctor or to get to an appointment that they have to fill out their applications or that type of thing. So, they’re requesting help with transportation a lot more these days. So, we’re seeing these shifts in the different types of social needs that our members have and then, we’re trying to very quickly respond to those to meet their needs and to make it easy for them to access those services.

Q. One thing I must comment on is how remarkable that you say you made some assumptions about your population and that those assumptions need to be reviewed because they may be wrong. You talked about rideshares and enabling these through mobile apps. What kind of digital enablement have you invested in response to this in the last couple of years and the emerging demand from your patient?

Paula: One that has been a great success is an app called – Pyx. It was originally developed to combat loneliness in an older population and when we were approached by Pyx, we said, “Well, is it possible to change the focus of the app for our pregnant women and children’s members?” My history and career have been spent mostly in the women’s and children’s arena and I’ve felt that oftentimes just after delivery, women are somewhat isolated. They may not have the opportunity to interact with friends and family as much as they normally would or during their prenatal period. So, is it possible that this app could be used to combat loneliness in the postpartum period for women? It turned out to be a really great tool.

What we’ve found is that women will engage with the app in the wee hours — between, say, midnight and 2 am — maybe they’re up for a feeding in the middle of the night and they just open their phone, and they engage with the app. It’s designed to really almost be an engagement tool to offer information, resources, tell a few jokes, create a little humor and lightness and so we realized from our members that are using the app that it really was addressing a need. Some of those needs that have come up even include say, for example, women who have experienced a pregnancy loss – and this is often an overlooked group of women who need assistance. So, connecting them with behavioral health services or counseling for their grief has been addressed.

The other thing that we found is that women will engage with the app to find things like food or rides to the doctor. And we have also incorporated our value-added services into that app and often ask — “Did you know that we offer home-delivered meals for women in our health plans? Have you taken advantage of that value-added services? If not, this is how you get it. Did you know that we have rides? Did you know that we could connect you to a resource that can help with your rent?”

It really has been a great tool that folks can use on their own time — it meets them where they are and addresses their needs in a unique way. And it’s been highly successful. We’re really proud of that.

Q. It’s a very targeted need for a very targeted population segment. I’ve had the CEO of the Parkland Center for Clinical Innovation, Dr. Steve Miff, talk about some very interesting work that he and his team do in the context of looking at risk factors for things like preterm births, etc. Can you talk a little about that? I’m assuming part of that work relates to your work as well.

Paula: Indeed, it does. We work quite closely with PCCI, and they have pioneered some programs with the health plan to address kids with asthma as well as preterm birth. And so, some of the things that they are doing with us is to identify those members who are in need of additional help with their disease state or maybe, to take a look at how do we predict, for example, preterm birth? Are there indicators that will help us to prevent, say, a second preterm birth? We have refined preterm birth to over time to ask — What have we learned from this iteration? How can we change the algorithm to identify more women who may be at risk? Is there another factor that we can insert into that algorithm to improve our results even more with the pediatric asthma program?

They’ve really helped us to take a look at what are those factors that can contribute to exacerbation of their asthma. Are there things that we can do either in an interaction with the member or the patient or the family to enhance their knowledge of their medication utilization? Or, are there environmental factors, say, in their neighborhood or in their apartment complex or in the house that they live in? How can we partner the PCCI data with our disease management vendor to identify who we need to actually go out and visit in the home? And is there something that we can do, for example, partner with the Dallas Housing Authority to or the city to say, perhaps there’s a code violation in the location where they live, that needs mold remediation or perhaps they need some type of environmental change, pest control, things like that so that we can remove that environmental trigger or their exacerbated asthma. So, it really is a unique way to use the data to then create an action to improve the outcomes.

Q. And I couldn’t help but notice that most of the data that you refer to is as more in the nature of social determinants than clinical or medical. In the work that you’ve done with PCCI and the analytics work that you have invested in, can you share a few nuggets that you’ve learned that otherwise you might not have?

Paula: I think that one of the things we have learned is that all of these factors go together. You can eliminate or at least minimize one factor, but then, another pops up. So, you really do have this iterative process of addressing one need or one factor, and then, the next will appear. The data helps you identify the next factor that you need to address. So, I think that it is a continuous learning and improvement process. And just by using that data, refining it and looking at the next option to address it is just a continuous learning process in a highly collaborative way — What data do we have, how can we use it, how can we develop conclusions from this data and how can we incorporate it into our day-to-day work?

Q. All this also raises questions around who pays for all this. You’re investing a lot in technology, data and analytics. Can you talk to us about the economics of it all?

Paula: That is one of the things that we struggle with. We’re always on the receiving end of, “Hey, I’ve got a great idea for you, or, have I got a great product for you?” So, one of the things that the strategy department does is helps the rest of the organization really value whether something is a good deal for us or not by asking — Is there an ROI, an actual dollar amount that we can quantify, a clinical benefit to this program?

One of the things that we were presented with recently was an opportunity to look at a maternal intervention, sort of a disease management strategy, and the proposal looked like it could save us millions and millions of dollars, but it’d also cost us millions of dollars! We dug into our own data to see if we had that many women in our health plan with that particular type of issue. Going in and fact-checking that proposal made us decide that probably wasn’t our best expenditure to make.

We’ve tried to refine that process over time to really look at the offerings that we get with a critical eye to see if it really is a good expense because our funds are limited and we really do have to be very thoughtful about where we put our funds and so that we’re not just sort of taking a chance, risk or gamble. But we really do want to assess those opportunities to see if they make good business sense.

Q. So if a startup founder with an interesting solution that could apply to the population, wants to reach out and share their story and their offering, with you, what’s your advice to them before they even approach you?

Paula: I would say — make a good business case and make sure that it is based in reality because some of the things that I’m going to ask, if you tell me you’re going to save me 10 million dollars, is — How did you come up with that amount? Which members are you going to affect? What types of interventions would this take? Who’s going to make those interventions? How is this going to work?

It’s always like, you’re going to have to prove it to me. You’re going to have some solid details behind it, and there must be some homework to it. How is it that you can do this for me that I can’t do myself, because in some cases I often wonder, could I just take that and do that internally because it’s essentially a make-by decision, right?

So, you’re going to have to convince me that I need to buy it versus make it. And is there some special sauce that you have that I don’t have? So, I think those are the kinds of questions that I would ask, and I think that it behooves someone who is trying to really convince someone else to buy their product. You know, “What’s in it for me? How am I going to benefit from this? And how can you show me that that cost is going to pay off?”

Q. Where does your patient figure in all this? You’ve got a low-income population, there’s the emerging digital divide so, are all these cool tools and digital health solutions serving the needs of those that they’re meant for? Or are they just exacerbating the gap? How do you factor that question into your decision-making and how do you make it easy for your population to adopt this solution knowing that they are looking for these?

Paula: One of the things that we have always asked is – “Is this tool or digital intervention going to cost our member money? Will it require more data or bandwidth? Will members have to pay for a service in some way? Certainly, during the pandemic, we heard a lot about digital deserts and whether low-income pockets of communities had access to the internet or to data. So, that was one of the questions that we asked — Can anyone with any model of phone use this? Are there barriers to engaging with this digital option?

What we found, especially with that one, is that there were very few barriers and it was very easy to use. It was open to lots of different types of phones — old or new. So, there were just very few barriers and that led us to really engage with them because removal of those barriers is key.

Q. Do you end up subsidizing some of the costs as well to your patients?

Paula: One of the things that we do offer as one of our value-added services is the Lifeline Program. We try to encourage our members to take advantage of these federal programs that are available to get access to data phones to enable better engagement. We also look, for example, across our provider networks, and some of our pediatric providers already have a digital option. So, working with them to make sure that we connect our members to that information is something we do.

Parkland as a system uses Epic and we have care everywhere. There are digital ways to engage with our providers who offer telehealth services. We want to make sure that we communicate that to our members to ensure they understand what’s available to them.

How do we get them the tools? Certainly, with our health system, one of the things that we have talked with them about is how to bring telehealth services out to the community in a location where the community gathers. So, rec centers, community centers, FQHCs and different locations out in the community, if they have space and equipment, we can assist them with setting up those digital hubs so that is one way that I would say, is not a direct subsidy, but it is a creation of that access point. So, trying to think innovatively and trying to identify those locations where the community gathers so that they have sort of automatic and inherent access to it – that’s how we do it.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity