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Health Equity Conversations

Nathan Chomilo (Part 2)

Through Health Equity Conversations, Joshua Liao hosts a series of discussions featuring people and groups around the country working to improve equity and health through systems change. 


In this episode, Josh spoke with Nathan Chomilo, MD, Medical Director for the State of Minnesota’s Medicaid & MinnesotaCare programs.

This is the second of two condensed parts of the conversation between Dr. Liao and Dr. Chomilo, and has been edited for clarity and length. A condensed version of the first part can be found here. For full-length discussion, please access the audio recording (available episodes accessible via Apple Podcasts and Spotify).

Joshua Liao: You said “put a pin in it” [with regards to quality metrics]. Let’s pick that pin up just for a second. We’ve had people and other conversations where this idea comes up that we have a lot of granularity around certain parts of health care, specifically clinical processes. There are two, three, four, five measures really getting down to granular detail about how we’re delivering care for a condition or disease.


We don’t have that granularity on the experience side, on the social drivers side, right? So in that way, it’s a bit lopsided. I’m curious if, either from the community conversations you’ve had or in your work, you’ve been thinking about that?

Nathan ChomiloI also think that granularity that you’re speaking to can also be a little bit of a double-edged sword. What I’ve seen is the more granular, the more someone, or a system or provider, can improve their scores just by changing the collection of data instead of actually changing the process. Versus when you talk about patient experience metrics, you’re going to have to change the process a lot quicker than potentially changing how you collect data, to better reflect the outcomes that you’re looking at.


One of the things that we’ve tried: we have these CAHPS [Consumer Assessment of Healthcare Providers and

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Nathan Chomilo, MD

Minnesota Medicaid & MinnesotaCare

Systems] surveys that go out to Medicaid enrollees, and we’re allowed to do some supplemental or trial questions each year. And last year we introduced a question that tries to get at this phenomenon that my colleague in Washington (Shaquita Bell at Seattle Children’s) has looked at: missed opportunities for care. Essentially, someone overcomes their transportation barriers, they find childcare, they get a half-day off of work, and they show up to clinic, but the bus was late. And they’re five minutes late to their appointment and are told, “we’re sorry, we cannot see you right now.”


That’s a missed opportunity because we don’t know if they’re going to be able to line all that up again to get back to the next appointment. So we wanted to try and capture that missed opportunity and if we were seeing any differences between race and ethnicity. And the [survey] question was essentially, “how often in the last six months have you showed up to an appointment and told it’s too late to be seen?” And when we asked those questions, among the folks that responded, there was a statistically significant difference between White enrollees and Black enrollees, with Black enrollees being more often told that they were too late to be seen when they showed up “late” to an appointment.


I think that’s the type of work, and those are the types of questions and experiences, in addition to the broader questions about discrimination, that’s an actual process that we could look at. What are our no show, late show policies? How are our plans and others looking at that when they select their provider networks? Are they measuring that, or holding providers accountable to any disparities they see in those? And that’s one way that we could try to address access, for example, through things like measurement, quality, and potentially even payment.


JL: Very few of these things come without funding. My understanding is that, maybe in some of the legislative sessions, there have been proposals that are aligned with some of the things you’re highlighting in the report. One, is that true? And two, are there things that you’re particularly excited about, in terms of things that are changing and aligning with what you’re trying to call to action and articulate through our report?


NC: Our report had three main calls to action. One is improving enrollment and renewal. The second was to improve culturally relevant care. And the third was engaging with the communities that Medicaid serves.


Under that first one of improving enrollment and renewal was expanding continuous eligibility. So once you enroll, you’re continuously eligible for a period of time even if you have a change in life circumstances. Currently, that’s an option for children on Medicaid, and the state plan amendment. Thirty-two states currently do that; Minnesota is not one of them, so wanting to catch up with the rest of the country there. But also taking a page from what we saw in Oregon – and since we’ve published, I think Washington has done this through the 1115 waiver –expanding that continuous eligibility from twelve months for kids 0-19, to seventy-two months for kids in those first six years of life. So basically, if you’re eligible for Medicaid at any time period in your first six years, continuing to be eligible if you have a change of circumstance. Again highlighting the importance, which we touched upon in the report, on that early childhood period of time and how so many of our disparities grow from there.


Certainly that’s going to require some degree of funding and change in process and measurement. And continuing what we’ve learned from the pandemic where we essentially had 27 months of continuous eligibility because of the Cares Act: how do we continue that for folks on Medicaid older than six, looking at twenty-four months of continuous eligibility for everyone. Again signaling that when we have these policies that require folks to reapply every six months or twelve months or with any change in status, we know that this disproportionally impacts Black community members. So this is a change that should be eligible for everyone, but that would disproportionately, in a good way, impact our Black community members.


Those are all pieces that do require funding. The continuous enrollment for twelve months for kids was in part of Minnesota’s governor’s budget proposal, and was in bills that made it all the way to conference committee here in Minnesota, but stalled out. Other funding to support navigators, to support community engagement, those types of things have been included in the governor’s budget proposals as well – and again stalled in our legislature this last session.


So there has been support in a broader sense to try to continue to improve our Medicaid policies to better address racial equity. I think some of that comes from the Minnesota House, which in 2020, passed a resolution declaring racism as a public health crisis and then had a select committee focused on racial justice that put out a report in December of 2020, that said these are the ways state government can better address racial equity. One of those was expanding Medicaid post-partum coverage to twelve months, which didn’t get captured in this report only because it already got passed.


There is a lot of alignment in some of the efforts at the state level and the legislature to say, how do we really improve our programs across the board and focus on racial equity? How do we have community involved from the beginning, and how do we fund that in a sustainable way? The report calls on us to find out ways to make this as part of the normal processes. As I’m going through my budget proposals, policy proposals, have I actually connected with the communities most impacted by the disparities that we’re trying to address? If not, what is my plan for that? And how do we embed this in the everyday processes of our Medicaid agency?


JL: I think coverage is the foundational step. But at least in my view, access doesn’t equal coverage because then you need [system] capacity and the workforce [among other things]. What about those delivery models and the payment pieces around that?


I know that’s not the focus of the report, but if we widen the aperture a little bit here – if and as [changes] take hold, and you get people covered and they’re able to have continuous coverage and that access, what do you think needs to happen on the payment and delivery model side to be a good complement?


NC: That’s the big question where I think there’s a lot of ideas floating out. There isn’t as much literature to really guide us, so some of it we’re just going to continuing to keep trying and see what happens. Some of the things are focused where our levers on the Medicaid agency side are around either the providers we directly work with through fee-for-service, or the Medicaid managed care organizations that cover in Minnesota 80% of our enrollees.


So what are the levers we have in asking them, what are they doing to address racial equity and health equity? We even in our most recent request for proposals that managed care organizations had to fill out, asked about specific outcomes in specific communities. We know that there are big gaps in maternal and infant mortality for African American and American Indian communities in Minnesota, so asking [managed care organizations]: what are you doing to address these gaps? Specifically, are your provider networks reflecting the communities that you’re covering? What’s your own path to anti-racism, and what’s your path that you expect others you contract with, who actually serve our enrollees, to be on towards anti-racism? And build from there.


We’re also trying to look at ways to gather learnings from the COVID-19 response. Some of my work last year wasn’t only with Medicaid, but with our Department of Health and our COVID-19 vaccination response helping lead the equity work there. One of the things we were able to do was look at the Social Vulnerability Index, CDC’s SVI metric, that is geographic-based indice of disadvantage and really try to target resources, target community clinics, target campaigns of information around vaccination to areas that we know had higher scores of SVI.


We’re starting to look at, is that a potential lever that we have within Medicaid to really identify enrollees who are experiencing different disparities in outcomes, and see if they’re more commonly in a certain geographic area? So then, can we work to actually potentially build – whether it’s reimbursement, or targeted messaging, or campaigns – to areas that have higher social disadvantage. We actually put out a report led by Minnesota Community Measurement, part of the PTAC program, to look at a concept of what would this look like to have specific geographic-based areas to focus on amongst folks looking at the indicators of diabetes care and vascular care, for example.


I think, as you say, merging how do you identify disparities; but then how do you actually tie that concretely to levers along the lines of payment, quality, and measuring. I think that’s where the rubber is going to meet the road as we move because we’ve done a lot of work measuring – but how do we move that to accountability, both for ourselves and for folks who take care of Medicaid enrollees.


JL: Let me end with one final question. Some people say you can define inequities in many different dimensions, and they’re not too dissimilar – they overlap sometimes related to race, income, ethnicity. As you think about this report focused on U.S.-born Black Minnesotans, what can be taken and leveraged for that to address equity in other populations? If someone were to say [the task of achieving equity] just seems so big because there are so many target populations, what would you say to people that have that view?


NC: I often end talks about health disparities and health equity with the statement that we really can’t focus on health equity if we’re not dealing with structural racism, just based on how our society has been structured along the lines of race. While there are these many intersections, I think racism intersects all of them and it’s one of the defining reasons we have some of the disparities and inequities we have.


I think we need to start there and we’ll find that it really does impact all of the communities that we’re really focused on. What we put forth in this report is reflecting on [really focusing] on talking to the U.S.-born Black Minnesotan community and [coming] out with these calls to action based off of those conversations. But if you look at the Presidential Task Force on Health Equity that President Biden put forth; that had way more resources than we did; talked to hundreds of experts; talked to community members for hours and hours on end; and put forward a document with fifty-five different recommendations and five broad areas of priority – it overlaps very, very closely with our calls to action.


So I think if you really focus on communities that are most impacted by disparities and build from there, the improvements and the work will impact other communities as well. You can do that while at the same time recognizing that even within the U.S.-born Black Minnesotan community, it’s not a monolith, and folks’ experiences do differ based of their age, and their geography, and their sexual orientation, and religious affiliation, and other things. So I think you can hold those things at the same time. But I think that if you start with the communities that are most impacted and build from there, you’ll continue to see improvements across the board.


I think we’re at a moment where I think folks are feeling disheartened by a number of things that are going on in our society, and wondering if things can ever really change. I think what I take refuge in is that when you work directly with community, it brings a new life to the work. It really draws you closer to seeing where the opportunities and potential are that we really haven’t tapped as society, as we could. Then being able to bring that to these spaces – being able to be on this conversation with you, and talk about work that is really community-driven and focused, to me shows us that we’re moving in the right direction. It’s going to take a while but that we did not get where we were overnight either. So all of these disparities that have evolved took generations of policy decisions; and it’s going to take us a while to get out of it, but it doesn’t mean it’s not worth trying and it’s not worth doing; and that we can see lot of tangible impacts really quickly if we continue on.


JL: Dr. Nathan Chomilo, thank you for the work you’re doing in Minnesota in this area. I look forward to hearing updates and watching from afar, and maybe in the future having you back for a follow-up conversation.


NC: Thanks so much Josh for having me and I would love to be back on.

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