How “Dr. Mom” became the family CMO

Erika Grotto: Investing in the care of women, today on HFMA’s Voices in Healthcare Finance podcast. Happy 2023, and welcome to the podcast. I’m your host, Erika Grotto. On today’s episode, we’re discussing how the care of women can contribute to the cost effectiveness of health. I’ll be sharing an interview with Dr. Margaret Larkins-Pettigrew of Allegheny Health Network and Highmark Health. But first, we’ve got the first news segment of the year with HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.

Nick Hut: Hello everyone, and Happy New Year. To kick off 2023, we want to take a look at some of the key things to watch for in healthcare policy over the coming year. Full disclosure: We’re recording this the week before Christmas, and there’s a bill pending in Congress that would address a few things, including a scheduled 4% across-the-board reduction in reimbursement and would at least soften a 4.5% scheduled reduction in physician payments. So there’s reason to be cautiously optimistic that those things will be taken care of, at least to some degree. We have to watch and make sure that Congress actually passes this bill, but I think there’s cause to be reasonably hopeful that they will. But Shawn, even so, the reimbursement picture for hospitals is going to be challenging to say the least in 2023. What are some of the specific concerns you have, including with respect to outlier payments?

Shawn Stack: We’re still seeing historic increases in IPPS and OPPS. IPPS coming in at 4.1% market basket increase, the highest in 25 years, and then OPPS coming in at 3.8%, not much lower for calendar year 2023. But stacked up against inflation, which is hovering around 8%, and then of course, enormous bills for labor and wages that hospitals have been facing this last year., those increases don’t make much of an impact. But what I’ve been following and asking our hospital members to really take a hard look at and start modeling are the outlier thresholds for MSDRG rates on the inpatient side, which are coming in at, I think it was $30,859, an increase over $30,998 from this year, so a significant increase there on meeting that outlier threshold needs to be reached. And with the, you know, sunset or at least a little bit of a wind down for Covid and not seeing as many cases there, we could see some hospitals really hurting from that outlier threshold increase for inpatient and outpatient next year. So I think outpatient, the outlier threshold came in at $8,625 for calendar year ’23 where it was only $6,175 for ’22, so those are some of the big impacts reimbursement-wise that came out in the rules. And then as you said, the physician rule, we think some of that is going to be hopefully mitigated a little bit through this latest budget bill that Congress is working on. So we’re hoping that that, you know, 4-plus percent reduction on the physician side is going to be mitigated a little bit there. It’s 4.48% decrease in the conversion factor for the PFS rate.

Hut: Indeed, those are very important things to flag. What else are you looking at for this next year? Telehealth reimbursement, I know is on the minds of a lot of people. This new legislation this omnibus spending bill would extend telehealth waivers for two years, whereas as of now, they’ve been scheduled to expire five months after the end of the Covid-19 public health emergency, whenever that is. So what’s important about that, do you think?

Stack: Well, there’s a lot going on there with telehealth. There’s parity that’s being matched between the telehealth visit and in-person visit that could really be to the detriment of hospitals standing up telehealth programs. So if that does get pushed out, if those waivers do get extended out another two years, that would be truly good news for providers to mitigate some of those costs of standing up those more robust telehealth programs, as well as, we still have a lot of members, a lot of hospitals looking at the hospital at home programs that were included in those waivers during the pandemic years and time frame, and that would be a welcome advance if they extended those waivers another two years, which I know they’re considering now, right Nick?

Hut: They are. That language is in this legislation, so absolutely. I think a lot of people in the industry would be pleased to see those waivers pushed out another two years. This legislation also has repercussions for Medicaid enrollment. It gives states some clarity on phasing out the continuous enrollment mandate that has been in place during the pandemic. They can start—“unwinding” is the term people have been using—the additional enrollees as early as April 3. Conservative estimates put the net loss in enrollment at more than 5 million over a yearlong unwinding period. So this all has the potential to create significant headaches for the entire healthcare system. Shawn, what are you going to be watching for in this area?

Stack: One of the things we’re prepping our members and our hospitals for right now—and truly, patients as well, because keep in mind, it’s not just hospitals and healthcare providers that are, you know, experiencing these huge increases in inflation. Every time a person goes to the grocery store, they’re reminded of how much inflation’s gone up. I know I’ve seen it. But as these folks churn off of Medicaid as states do those redeterminations that they haven’t done in almost three years in some circumstances, many of those patients will qualify for bronze plans on the exchange, especially given the subsidies that Biden passed to offer subsidies to those exchange plans for next year. So you’re looking at patients having an out-of-pocket minimum of somewhere between $7-8,000 depending on where those out-of-pocket maximums and minimums come in for 2023. So at that point you’re looking at a self-pay patient for most services unless it’s catastrophic or some kind of emergency service. So hospitals are going to be charged with doing more screening for charity care, financial assistance, payment arrangements, collection activity, and of course, that’s not going to go on deaf ears. So remind Congress of what’s to come as those Medicaid programs unwind through now, this new proposed landscape is going to have some impact on not only providers but also patients across the U.S.

Hut: Absolutely. So thank you for the perspective on that. In this segment, we’ve given you all I think just a taste of why these are interesting but certainly challenging times for the healthcare industry. We’ll definitely be bringing you the latest developments on these stories and many others throughout the year. So Shawn, thanks for the expertise. Happy New Year again to you and to everybody listening.

Stack: Thank you, Nick. Happy New Year.

Grotto: When I was a kid, there was a series of cough syrup commercials that featured a sick family that came to the matriarch for help. The tagline was “recommended by Dr. Mom.” It’s been decades since that ad aired, but there’s a reason it’s so memorable. According to the U.S. Dept. of Labor, women make 80% of the healthcare decisions in the United States. A few publications citing that statistic are now calling “Dr. Mom” the “chief medical officer of the family.” The interview I’m sharing today is about how to reach and influence those so-called CMOs. My guest is Dr. Margaret Larkins-Pettigrew, senior vice president and chief diversity officer of the Allegheny Health Network and Highmark Health. She’s also passionate about maternal and fetal health and is a professor of OB-GYN. She says that taking better care of the women in our society can contribute to better health for everyone.

You specialize in women’s health. You speak on women’s empowerment through wellness. And women, as it happens—and we’ve talked about this on the podcast before—but women account for 80% of healthcare purchasing decisions. They’re kind of the ones who take their kids to the doctor. They’re the ones who push their spouses to go to the doctor. At least, in my house that’s how it is. So it seems to me that taking care of the women is good for everybody, right, but how can we take better care of women both in a healthcare sense and in a societal sense? I realize that’s probably a question we could spend days on, but briefly.

Margaret Larkins-Pettigrew: Oh, absolutely. So, women are health, basically, and we can not do what we do and do it well unless we really begin to invest in the care of women. I always start with the fact that women are the core of the home. And what women do—and now we have 330 million people—product children, healthy children that begin to grow up and be part of our ecosystem, our economic system. And so women are health. We need to know that women, if we keep women healthy, we keep our societies healthy. And so it starts in our healthcare systems and how we treat women and then spills over to our communities, and then of course, both of those together mean that we’re going to have a healthy society. So it’s the investment, the intentional investment in understanding and taking care of women.

Grotto: How can we take better care of our women?

Larkins-Pettigrew: By having women at the table. First of all, the leaders should create space for women in any system—whether it’s healthcare, business, whether it’s in government—there’s not enough women at the table who understand the life span of women. So we’re not just talking about women in their menopausal state. We’re talking about from menarche, when we begin to go into womanhood, to menopause and beyond. And understanding that every last one of those cycles in our lives changes us in some way to the better and that as long as we’re taking care of them we’re taking care of ourselves, we can be the top of our tier as it relates to being productive and contributing. I don’t think that people who are in charge currently take that very seriously and make sure that they understand that investing in women’s health is the key to making sure that we are productive as a society but productive as our medical institutions as well. Because when you look at the data that’s been with us for many, many years and why there’s such a high rate of maternal and infant mortality based on preventable causes and what that savings would be if we took the time to understand women in all of those aspects, we would understand that this is a big area that we need to focus on in order for us to continue to be financially stable. But we haven’t invested in it.

Grotto: Something that we have been talking about a lot at HFMA is cost effectiveness of health—not healthcare, but health—and keeping people healthy in cost effective ways. And it feels like taking care of women in this way that you’re talking about really fits in with that cost effectiveness of health idea.

Larkins-Pettigrew: First of all, women take a lot on their plates, right. We’re always trying to do everything—not only have children, raise children and be part of the workforce as well. But that also means that we have to take care of ourselves in order to take care of everyone else that comes into our lives. Whether we’re with children, without children, it really means that we have to take care of ourselves to be the best selves. So that should start very, very young. I think about the Cinderella complex that we all have. We’re born and we’re cultivated to be these beautiful women who grow up and get married and we have this knight in shining armor come along and carries us off and takes care of us, and we have this white picket fence. Well, that Cinderella dream, although that might be a piece of it, it is not all of it. And in order to get there, to understand that we should have many, many outlets in our lives that increase our mental wellness and all the wellnesses that I talk about all the time, we have to invest in all of them. And I’ll just run through them really quickly, what I talk about all the time because I think understanding wellness and not thinking about illness is where we always need to concentrate on. So we think about wellness, physical wellness, and what that means in every single decade of our lives and every single journey that we go through in our lives. Understanding that our physical wellness is so important, and that incorporates everything from looking at our bodies, examining our breasts, going to our wellness visits, to understand that something is wrong with our bodies that we present it for the right care. Eating well and drinking well and doing all those things to make sure our physical wellness is taken care of. But then we have to think about our mental wellness because it all ties together. Every single piece of wellness as it relates to women all ties together. And so when you talk about mental wellness, what’s happening with our mental health? I mean, women—and if you take just the post-partum period—post-partum period for women is very, very stressful. Increase in depression, increase in suicides, lack of surrounding of wholesome care. In that space alone, think about it. If we could give women the entire chair of a village that is present, understanding what they’re going through as their hormones are changing them again, hopefully get them back to themselves again. Just that phase of it will save women the mental anxiety that comes with this post-partum, not to mention all the other things that we go through, menopausal changes. So mental wellness is great. Another part of it, mental wellness, but we have to think about emotional wellness as well, right? And so, we are emotional beings, and that’s OK, but how we respond in that emotional way that does not increase our hormones, that really make us not as healthy because we have, our catecholamines and all those things we talk about as physicians is important, and that comes from being emotional human beings. Then we go into spiritual wellness, financial wellness, sexual wellness, which I talk about a lot. But a big one is social wellness. Who is around us that is allowing us to be our best selves, to empowering us, to make sure that the 70,000 hours that all of us put into a work life really is something that we want to do? We want to come to work, we want to be the best we can be, and we want to come with our authentic selves and enjoy what we’re doing. So the whole issue of wellness for women and empowering women in the healthcare space and beyond makes a significant difference for who we are and how productive we are in our society.

Grotto: That’s quite a lot to think about. How can we educate and empower patients to make decisions that improve their health and wellness, and how much of that responsibility should be on the patient versus a provider or others in the industry?

Larkins-Pettigrew: The whole issue of how we really become partners with our members, if you’re a payer, partner with our patients if you’re a clinician, and partner with our communities, it’s all about partnership. And in any partnership, it’s important that both of the partners understand one another, right? Before you go into any agreement, before you sign any contracts, it really is about understanding what’s being offered and what you need to actually put into the partnership. And I think we miss the mark a lot when we don’t invest in that. Patients need to understand what we’re saying to them. Just think about basically the literacy—and when I talk about literacy, I talk about both patient literacy, I talk about payer literacy, I talk about the clinician literacy—how are we communicating with one another so that we’re partners? It’s all about education, but education at what level so patients understand what is expected of them and that clinicians understand what is expected of them as well, as they introduce partnerships of health and healthcare. And so that is where it has to start. It has to start with, if I am the payer, I need to understand what my audience is, who my members are, what my members want, right, and then I need to make sure that they can get access and access all the products that they need to in order to make their lives better. And so it’s all about understanding all of that piece. And then, that’s the payer side of it, endorsing new members to say, if you come in to my plan, then here’s all the things I’m going to offer you, and what else can I offer you that will help you get up in the morning, take care of your children, get to work on time, do all the things you need to do to bring joy into your life. But then at the clinician space, what about the clinicians? You are really selecting physicians, clinicians, folks who you want to make sure that they are enhancing your life as far as the wellness space, they have to have a literacy, understanding what your literacy is, and being able to really communicate with you in a way that you’re partners, that you sign a contract together. I need to understand that you don’t understand, so when you walk out of my office, it shouldn’t be about whether you’re going to be compliant—that word—whether you’re going to come back for your visits. It should be about, let’s talk about that. Let’s have this two-way reciprocal relationship so that we are in partnership together. Because that spills over into the entire community, and so when we talk about healthcare and who’s giving the healthcare, it has to incorporate all those complex legs that we don’t spend enough time thinking about.

Grotto: I’ve noticed, depending on who you talk to, sometimes—sometimes—there seems to be this idea that if I am unhealthy, it is my fault and that there is something that I didn’t do that I should have done. And there is a patient’s responsibility care for themselves, right?

Larkins-Pettigrew: Right, right.

Grotto: We know that it’s bad for us to smoke. We shouldn’t smoke, but—

Larkins-Pettigrew: Yeah. But there’s this blame game.

Grotto: Yeah. It seems to be. It seems to be.

Larkins-Pettigrew: There’s this blame game, which really will turn patients away from you, especially as a healthcare system. And this example that this very prominent author gave. She said she went in and she was in preterm labor. You know, wealthy, did everything she had to do. And so they’re asking her about her health, they’re asking her, do you smoke. So right off the bat, it’s like, you must have done something to cause you to get to this space. So, do you smoke? Do you drink? Do you use any drugs? You sure you don’t use any drugs? You sure you don’t—and so, she’s sitting there thinking, I have not done any of this stuff. I have gone to my visits. I’ve taken care of myself. But in her mind she’s thinking, why are you trying to find a reason for this to happen when I don’t know why it’s happening. So help me understand what is happening because I’ve been doing all the things you want me to do. So that’s one case. And another situation is, patient comes in and she’s having lots of bleeding. And so she needs a hysterectomy. But she has a drug problem, and she’s addicted to heroin. And so the anesthesiologist says, well, we can’t do the surgery because we don’t know what’s going to happen with your anesthesia. You’re under anesthesia. Go away, kick the habit, then come back.

Grotto: Wow.

Larkins-Pettigrew: Can you imagine? Can you imagine that, you know, I have a medical problem because one of those medical problems is, I’m addicted. I’m addicted. But I have this other problem that’s going to kill me first, probably. But you as a provider saying to me, this is your fault. I’m not going to take the risk because this is your fault. And you need to take care of that problem before I help you take care of this problem. And it should never be that. It should be this wholesome, comprehensive, wraparound care that we give to all of our patients that make them want to be part of us. When they walk in, they’re going to say, this is who I see, this is why I’m having such a great visit, this is why I know that I’m going to trust my provider to give me what I need. I’m going to trust the entire system because the entire system cares about me. We have to look at every part of our case management of all patients that come into our systems. We have to think about health and what that means in a preventive space, and how do we keep our patients healthy so that on the other end of it, they’re not using our emergency rooms as their physician or their medical home. And then if they are, how do we fix that? How do we make sure that there’s someone in that space that says, let me get you connected so that we can take care of your chronic illness in a better way so that we’re not spending those emergency room dollars over and over and that we’re really checking these boxes as we go along to say, how do we give more effective, more affordable, but quality care that really deals with the holistic patient. And when it comes to women, we fail an awful lot.

Grotto: Thank you so much for joining me on the podcast and sharing your thoughts.

Larkins-Pettigrew: My pleasure. Take care of yourself.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is the director of content. Our president and CEO is Joe Fifer. If HFMA certification is among your goals for 2023, congratulations, because there’s never been a better time. New study tools are available to help you earn a certification, and there’s more to come, so sign up for that course today. Find the right program for you at hfma.org.

Moms are being called the “family CMO,” but who takes care of the women?

Figures from the U.S. Department of Labor state that women make 80% of the healthcare purchasing decisions in the United States. But according to Margaret Larkins-Pettigrew, MD, MEd, MPPM,a senior vice president and chief diversity officer of the Allegheny Health Network and Highmark Health, women are not being given the care they need by society or the healthcare systems within.

“If we keep women healthy, we keep our societies healthy,” she said. “It starts in our healthcare systems and how we treat women and then spills over to our communities. Both of these together mean that we’re going to have a healthy society.”

Investing in wellness

Investing in the physical, mental and social wellness of women could contribute to better health for all, Larkins-Pettigrew said. Particularly for their physical and mental health,  concerted efforts supporting women during transitional periods of life are key. During the post-partum period for a mother there’s an increase in depression and suicide and a marked lack of care available to the mother, she said.

“If we could give women … understand what they’re going through as their hormones are changing again, [we could] hopefully get them back to themselves again,” she said. “Just that phase of it will save women the mental anxiety that comes with [the post-partum phase], not to mention all the other things that we go through, like menopausal changes,” she said.

On the social side, help can come through ensuring women have people around them who are empowering them and ensuring they have the best life they can, she said.

Contracts and the blame game

Contracts between any two parties, but particularly between patients and their providers and payers, must come with an understanding of expectations and duties on both sides, Larkins-Pettigrew said.

“If you come into my [health] plan, then here’s all the things I’m going to offer you,” she said. “What else can [the health plan] offer you that will help you get up in the morning, take care of your children, get to work on time, do all the things you need to do to bring joy into your life,” she said.

On the physician side, patients need to feel as if they have a partner in their care, that their voices are heard and that their goals are understood, Larkins-Pettigrew said. Too often, patients are held responsible for their health issues and not offered help or guidance. She gave the example of a woman who went into pre-term labor and endured questioning from her provider about smoking, drug use and other behaviors that could have contributed to the issue, leaving her to think the provider was simply looking for a reason to tell her that she was at fault.

“She’s sitting there thinking, ‘I have not done any of this stuff. I have gone to my visits. I’ve taken care of myself.’ But in her mind, she’s thinking, ‘why are you trying to find a reason for this to happen when I don’t know why it’s happening?’” she said. “There’s this blame game, which really will turn patients away from you.”

A holistic view

The industry should take a comprehensive look at care for all patients to ensure they receive the best possible care and are active participants in it, Larkins-Pettigrew said.

“We have to look at every part of our case management of all patients that come into our systems,” she said. “How do we give more effective, more affordable, but quality care that really deals with the holistic patient?”