Category: Medicaid Industry Who’s Who

Jim McInnis is Experienced Chief Executive, CAO, CFO, VP, and Builder of Mission Driven Companies & Relationships. Check out his LinkedIn profile HERE.

1.     Which segment of the industry are you currently involved?

I work with states and MCOs to manage long term care and support services and a variety of waiver programs.

2.     How many years have you been in the Medicaid industry?

Over 20 years, including my consulting and operations leadership roles.  Given how fast things move, the time feels a lot shorter.  It’s terrific!

3.     What is your focus/passion? (Industry related or not)

Having influence and impact in the community.  I often dabble in town politics.  I also like to see people I’ve recruited get promoted and make an impact.

4.     What is the top item on your “bucket list?”

Playing for the Boston Bruins, but that time has well past.  I’d like to do a tour of baseball stadiums with my sons and convince my wife and daughter to attend a couple games too.

5.     What do you enjoy doing most with your personal time?

I’m a gardener.  I could spend hours at a landscape nursery.

6.     Who is your favorite historical figure and why?

The Wright Brothers because despite the competition and failures they remained enthusiastic and committed to achieving.  They put their money and reputations on the line and subjected their work to hundreds of public trials.  Their character outlasted their business ventures.

7.     What is your favorite junk food?

Brownie edges.  Moist, cake-like brownies are over-rated – chewy and crunchy are the best.

8.     Of what accomplishment are you most proud?

After we had triplets, the support from our family that permitted us some sleep and allowed me to wrap-up my MBA.

9.     For what one thing do you wish you could get a mulligan?

My first month driving a car.  Not good when the insurance agent asks, ’you again?’

10.  What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Watching how states will move managed long-term care services to MCOs and how the MCOs will adapt their capabilities to serve consumer direction programs.  Until recently, these programs were untouched by managed care.  States grew the programs and established rules to encourage recruitment and retention of direct care workers.  Under new contracts, MCOs will need to sort out data integrity, provider network and fraud prevention challenges in a politically charged and disruptive environment.  Wage increases and union efforts to organize direct care workers will influence quality.  If you can’t find and keep a good direct care worker, then overall costs go up.  MCOs also will need to test and deploy new electronic visit verification (EVV) fraud tools that states delayed doing this year.

Mark Rakowski is the Vice President at Children’s Community Health Plan.

Check out his LinkedIn profile HERE.

1. Which segment of the industry are you currently involved?

Children’s Community Health Plan (CCHP) has participated in the Medicaid program in Wisconsin since our inception in 2006, and currently covers 125,000 members, including 3,200 children in a foster care medical home pilot.  We entered the Marketplace in Wisconsin in 2017, and covered 27,500 individuals in 2018.

2. How many years have you been in the Medicaid industry?

Beyond the 12+ years that CCHP has been in existence, I have been involved in Medicaid from a provider side over the 20 years that I have been with CCHP’s parent, Children’s Hospital of Wisconsin.

3. What is your focus/passion? (Industry related or not)

Being a parent of two boys myself, I am passionate about improving the health and well-being of children and their families, and advocating for low income populations to ensure that they are not left behind.

4. What is the top item on your “bucket list?”

Something sports-related, for sure.  I have already seen the Packers win a Super Bowl in person (sorry, Pittsburgh fans), so it would probably be taking my sons to an NBA Finals game.

5. What do you enjoy doing most with your personal time?

Traveling with my family.  We gravitate to beaches (St. John is our favorite), and also have enjoyed New York City as well as Europe.

6. Who is your favorite historical figure and why?

President Lyndon Johnson – I think his domestic accomplishments are often overshadowed by the Vietnam War, however under LBJ sweeping civil rights legislation was passed, including the outlawing of segregation, improved school funding for poor districts, the National Endowment for the Arts that funds public television was established, and LBJ also initiated Medicare, Medicaid and Head Start.  Before he was a politician, he taught disadvantaged Mexican-American kids in Texas where he witnessed firsthand the effects of poverty and discrimination, and made sure that education was a priority of his administration.

7. What is your favorite junk food?

Frozen mint Oreos

8. Of what accomplishment are you most proud?

We built CCHP from scratch and have grown from 26 members our first month to the largest Medicaid plan in our service area, covering almost 20% of all Medicaid members in our state, and are now one of the largest Marketplace plans in the state.

9. For what one thing do you wish you could get a mulligan?

I don’t really have any regrets that would need a mulligan.  Mistakes are just opportunities to learn.

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Addressing how health plans can sustain their investments in housing and other social determinants of health

Figuring out how to better engage providers and align incentives so that value-based arrangements are not just pieces of paper.

Wanda Seiler is the Senior Director at Alvarez and Marsal, LLC. Check out her LinkedIn profile HERE.

1.Which segment of the industry are you currently involved?

I work primarily in Long Term Services and Supports (LTSS).  My areas of emphasis are Medicaid eligibility and Home and Community Based Services.  I’ve assisted states with waiver transformation, quality improvement, critical incident reporting, payment transformation, provider billing documentation, shared living, and the development and implementation of software to support human service administration.

2. How many years have you been in the Medicaid industry?

I’ve worked in the industry for over 30 years, including as a policy analyst for a state Medicaid agency, and in leading state behavioral health and developmental disabilities agencies.  I’ve been consulting with states for the past 10 years.

3. What is your focus/passion? (Industry related or not)

My passion is developmental disability services and I’m particularly interested in transformative efforts that improve both the efficiency and quality of long term services and supports.

4. What is the top item on your “bucket list?”

I’d like to spend some time in Italy, touring and perhaps taking some cooking lessons to learn the tricks and secrets for preparing great Italian meals.

5. What do you enjoy doing most with your personal time?

Hiking an boating with my two best friends – my husband and my dog, and doing just about anything with my granddaughters.

6. Who is your favorite historical figure and why?

Abraham Lincoln.  I think his second inaugural address best illustrates his ability as a leader – to know what to say to unite a nation during a critical juncture in our history.  Leadership in never easy, but truly great leaders are distinguished by leading others through difficult times.

7. What is your favorite junk food?

Gabbert’s popcorn – cheese and caramel mix.  Is it obvious that I spend a fair amount of time at Chicago O’Hare?

8. Of what accomplishment are you most proud?

Bringing financial stability to a state developmental disability agency that had a significant structural deficit.  In a single budget cycle, I was able to correct the deficit and over my eight-year tenure as Director of this agency, eliminate all waiting lists for services.  During this time – all service providers achieved and maintained national accreditation demonstrating that efficiency doesn’t have to compromise quality.

9. For what one thing do you wish you could get a mulligan?

When working in state government, I didn’t maximize the use of information technology (IT) solutions.  We did a small IT project that yielded significant returns for people and families receiving services.  Frankly – I wish I would have done much more of this during my time in state government.  Information systems are foundational to the effective administration and delivery of human services.

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

1. I think states will likely be challenged by Federal audits focused on long term services and supports.  State systems struggle to perform LTSS rate setting, billing and claiming creating a significant financial risk to home and community-based services.
2.  Intellectual/developmental disability services are at a critical juncture. Many state I/DD agencies will begin a slow and difficult transition to managed care.  Many will explore value-based purchasing but must first crack the code to determine the outcomes that should be purchased and then how they can be measured.
3. With control of the US House of Representatives switching following the mid-term elections, Medicaid should be safe from block grants.  It will be interesting to watch the remaining non-expansion states consider their options.  Perhaps the most interesting focus will be on the concept of “personal responsibility” in transitioning non-working Medicaid participants to work.  It will be an interesting, “chicken or egg” discussion in understanding if people need health insurance to maintain employment or if Medicaid will be the carrot, they need to seek and retain employment.  As LTSS tries to navigate through a devastating workforce crisis – every worker will become increasingly important.

Alison Croke is President and CEO of Wood River Health Services. Check out her LinkedIn profile HERE.

Which segment of the industry are you currently involved?

I currently serve as the President & CEO of a federally qualified health center in Rhode Island.  We provide medical, dental, behavioral health, case management and other support services to our patients, regardless of insurance status or ability to pay.  We have many Medicaid patients, but we also have patients who are uninsured or underinsured.

How many years have you been in the Medicaid industry?

I have been in the Medicaid industry for 20 years.

What is your focus/passion? (Industry related or not)

I grew up attending an all girl Catholic college preparatory academy run by the Sisters of Mercy.   The mercy mission instilled a passion for social justice, the importance of giving back to your community, and the value of women’s leadership.  I enjoy mentoring young women who are interested in health care administration, and I’m lucky to work at an organization whose mission is to improve their local community.

My other passion would be for all New England sports teams, with the Patriots at the top of the list.

What is the top item on your “bucket list?”

I don’t have one particular item on my bucket list -and I have no desire to jump out of an airplane.  I would love to travel more and see some of the beautiful cities in Europe like Prague.  And if I happen to meet Queen Elizabeth somewhere along the way, that would be great.  Also, would love to attend certain sporting events once- a Super Bowl, the Kentucky Derby, etc.

What do you enjoy doing most with your personal time?

I love to play with my dogs and take them running.  I also enjoy watching Patriots games.

Who is your favorite historical figure and why?

Queen Elizabeth I is fascinating to me.  She led her country through a historical period where intolerance was commonplace and was able to demonstrate that tolerance and acceptance was the better path.  She allowed England to flourish and become a place where authors and playwrights could thrive, and also position the country for the future position as a super power and global leader.  Without her bravery and determination, we would not have classics like Shakespeare and Marlowe.

What is your favorite junk food?

This is a tough one.  It’s hard for me to resist anything chocolate.   But I also sometimes splurge on movie theater popcorn with butter.  I always feel guilty after though.

Of what accomplishment are you most proud?

When I worked for RI Medicaid, we built many new managed care programs that expanded access to care for members.  I worked on a team that created the RIte Smiles program – a dental managed care program for kids.  By contracting with a managed care plan, the state was able to not only raise rates for providers, but improve the quality of dental care kids received, and create a much larger network of dentists that would treat children on Medicaid.

For what one thing do you wish you could get a mulligan?

I do not regret any of the career choices I’ve made in the last 20 years, as they have led me to where I am today.  I am sure that as a young professional just out of graduate school I made some naive mistakes and misjudgments.  I have many people to thank for mentoring me through those early years and being very honest with their feedback.  Without their help, I would never have made it!  I have learned to be much more humble in my professional interactions.  Most people do not care what your title is -they care that you are committed to your work and follow through on your word.

What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Now that the Congress does not consist of one majority party, I believe the efforts to repeal and replace the ACA will not receive much traction.   However, state budgets, especially in our state, continue to be stretched by health care expenditures, often making Medicaid programs a target for budget cuts.  I would consider the aging population, the opioid crisis, and better access to mental health treatment are the top 3 issues in the coming months.

 

Jeff Leston is the President of Castlestone Advisors. Check out his LinkedIn profile HERE.

1. Which segment of the industry are you currently involved?

We are in the fraud prevention, health identity protection and oversight segment.  We developed tools that use the existing payment (credit/debit) networks to deliver real-time encounter information to health plans right from the point of care. Inexpensive and very effective.

2. How many years have you been in the Medicaid industry?

I’ve been in and around health insurance and health IT world for over 30 years, and about the last 10 in Medicaid.  In the early ‘90s I created the first use of artificial intelligence for health insurance fraud detection at a Blue Cross plan.  Like what Castlestone does, the technology we used was born in the credit card industry.

3. What is your focus/passion?

Professionally and personally related, I hate to get ripped off.  Finding hundreds of thousands of dollars of fraud in a co-op I lived in in New York was part of the inspiration for starting Castlestone.  My personal passions are music and ice hockey.  I’m lucky because I have a great musician and a hockey player growing up in the house.  I also love to follow investments, particularly in technology companies.

4. What is the top item on your “bucket list?”

Other than certain professional goals, I want to teach 8^th grade algebra.  I remember being scared out of my wits on my first day of algebra when the teacher just started throwing formulae up on the board.  I decided I could do it better and show students where it applies in the real world and explain it as a language of numbers.  I also want to go to a Stanley Cup Finals game when the Pittsburgh Penguins are playing.

5. What do you enjoy doing most with your personal time?

My wife and I have 15-year old twins, Adam and Joanna, and we are very involved in their activities.  Joanna is a dedicated musician and performer.  Adam is a hockey player, which takes us a lot of time.  I’m also the President of the high school’s hockey club, which I enjoy.  The most satisfying thing is watching them, and their friends mature and grow skillful in their pursuits.

6. Who is your favorite historical figure and why?

I like to read about people who really changed the world, the way we think, and how society operates.  They were the rebels and often shunned in their own time, until history caught up with them.  Galileo, Charles Darwin, Dr. Martin Luther King, and Sigmund Freud all changed how we perceived the world around us, often against powerful societal and religious forces.  Isaac Newton wanted to explain the elliptical orbits of the planets, so he invented calculus.  Ernest Rutherford figured out the structure of the atom with none of the instruments available to scientists today.  Marie Curie took it a step further to explain radioactivity.  People didn’t know what to make of Jimi Hendrix when they first heard him.  He still sounds great and original today.

My favorite historical figure above all is Roberto Clemente, whom I watched play for the Pittsburgh Pirates growing up.  What he did on the field, off the field, his passion and pursuit of excellence at all times and his concern for the culture he came from should be a role model for a lot of people.

7. What is your favorite junk food?

I have been addicted to pistachio nuts since I was a young boy.  Also, a big fan of tortilla chips and a good hot salsa

8. Of what accomplishment are you most proud?

So far, it is the US House passage of HR 6690, Fighting Fraud and Protecting Seniors Care Act of 2018.  I’ll be even more proud when it passes the Senate.  I’ve been an advocate, analyst and designer of smart-card anti-fraud solutions and data-oriented solutions for a long time.

9. For what one thing do you wish you could get a mulligan?

I was once offered a position in New York with a very high-quality research and investment company as a technology analyst.  I wish I hadn’t turned it down so quickly.  I don’t know if I would have taken the position, but I didn’t give it the time and thought it deserved.

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

Managed Medicaid

Some states are moving ahead with Managed Medicaid, (North Carolina) while others are debating its value (Iowa) and a recent article by Chad Terhune of Bloomberg discusses the payments to Managed Medicaid and the limited oversight that accompanies those payments.  Congress is stepping up its hearings on Managed Medicaid oversight and what CMS and the States should do about it.

Work Requirements /Eligibility and Expansion

Hardly a day goes by where there is not a news story about work requirements in various State waiver applications.  Post-election, where some states approved expansion of Medicaid, Congress is or should be looking at oversight of expansion.  The recent story of California enrolling 450,000 ineligible people onto their Medicaid program is not lost on Capitol Hill.  Louisiana’s legislature voted down a bill to allow for income verification.  That brings me to the third point:

Funding the Programs

We are at a point where we really don’t know whether Medicaid is a State program or a Federal Program.  If Medicaid is a Federal Program – the Federal Taxpayer has funded 100% of expansion, now 90%- then increased Federal Standards and oversight are needed.  Congress was making more noise about this with recent reports and hearing.  If it is a State program, States will have to put in place better accountability and integrity measures in exchange for some level of Federal funding.  Right now, we have neither.  Medicaid is now the largest budget line item in many States, and even with 90% Federal Funding, it is beginning to crowd out programs in education and infrastructure, and taxes are increasing to meet the cost.  The program ownership, funding and oversight will become a front and center issue.

9. For what one thing do you wish you could get a mulligan?

A: I’d be happy to redo the last 5 years of my life, BUT I’d redo it the exact same way. 🙂

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

1. Drug spend (specialty drugs our pace IP spend
2. Clinical integration (combining EHR data with claims data to actually make a difference)
3. i2i, we’re killing it! 🙂

9. For what one thing do you wish you could get a mulligan?

A: Redo’s are always hard, but I would take one for the multiple moves of family around the country for job opportunities.  This was disruptive for the kids.

10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?

1. Financially, plans are being asked as are providers to take less in compensation due to the ever-rising costs of care and supplies.  This is NOT sustainable for more than 3 years due to the drag it will place on GDP and tax burdens of the people.  We have been witnessing to the failure of the most recent design of healthcare modeling, costs and untruths. Yes the likely hood of a new program will evolve, but with this come more regulations and restrictions that take  provider time from patientsThere likely will be a deployment of new benefits which involve personal responsibility from the members.  Plans WILL move from a Risk corridor arrangement as currently set,  to an admirative services only payment process such as we have with various Medicare programs. Single payer may still be living

2. Infrastructure and telecommunications will need to be harmonized. Some relaxation as to HIPAA regulations will be needed to allow more robust communications with all stakeholders and data sharing for measurements.  Today we see a quagmire of efforts to use mobile devices, electronic communications etc.  This is a great idea ; however we have the highest costing patients (members over 50 YO) bucking the improvements and struggling with new forms of communications.  The demographic is not willing to adopt many of the new areas of communication based on lack of understanding, fear and frustration.  It will take a few years for this to subside.

Look for adoption and proliferation of IT super hubs and servers that embrace block-chain type transactional information.  The use of similar hubs and techniques such as with twitter, Facebook to improved communications to patients, providers and payment process. Legislation will be offered to embrace much more for IT compatibility across all systems. Increased transparency to cost of services will evolve though IT systems to align awareness of true prices instead of predatory pricing we see today with many oncology and transplant medications. The increased use of real time data for “Value based” care will be coming along.

3. Science never stands still. The ethical issues growing out of research is complex and often too perplexing for the human mind to cope with.  Improved understanding of the elements of humans will be pushed to the front of research. Payment for research will need to be allowed.

Look to see within the next 5 years and maybe sooner a better understanding of pathophysiology of human disease- gene sequences and informative attributes of cause and effect.  Phage deployment and advanced nanobots with  Crispr/Cas9 and newer versions of gene manipulations are moving at light speed to approved therapy.  The possible end of a PCP visit other than the patient attending a diagnostic session to take samples for a gene related medication to be made as personal medications.  The market disruption may be phenomenal as we know it today. Curative actions/steps may out pace chronic treatments with current consumption of marginal medications. The mere removal of chronic conditions such as diabetes, COPD, arthritis, cardio vascular issues would be very disruptive regarding payment, profits  and how payments are to be arranged?