Innovators Semi-Finalist Organization: L.A. Care’s Daring Investment in Communities in Need

Tell me about the IHSS+ Home Care Integration Training Program?

California, like many states, has a program for Medicaid and for dual-eligible recipients, beneficiaries, if you have issues with ADL, activities of daily living, you can pick someone to be your at-home caregiver. But we were observing that most of the time, a patient picked a family member to be that caregiver. But here in LA, those caregivers automatically become part of the SEIU, and get a salary of $12.50 per hour. And we happen to be the health insurer for 52,000 of those workers. So we felt that if these were mostly family members with no training, we might be more effective if we invested in them via a voluntary training program. So three or four years ago, we created a ten-week training program, taught in the language of the caregiver—classes in English, Spanish, various Chinese dialects, and Russian—30-50 students in each cohort, with SEIU. They learn what managed care is, so that if their patient is in L.A. Care, we try to teach them how to use L.A. Care to the benefit of the person they’re caring for. And we teaching them basic observation skills, so if Mom is turning blue, dial 911. We also teach them caregiver burnout skills. So we’ve trained 4,200 of these In-Home Support Service Workers. And when they graduate, they get a certificate. But what we did not quite anticipate: many of these people have never graduated from anything. So they wear caps and gowns; we play Pomp and Circumstance; they bring the whole family to the event; and it’s wonderful. And I had one of the graduates come to a board meeting. And this guy got up and said, I am my mother’s caregiver, and this program has taught me the difference between my role as a son and as a caregiver, and this has made me better at both.

And the other thing we’ve done—we’re now monitoring the utilization of the healthcare services by the clients, and we’re beginning to get a body of data that shows that the utilization prior to the training goes down after the In-Home Support Service Worker goes through the training, because they are observing the patient, and they know whom to call at the plan. And I have to say, I’m really proud of this program because I think particularly during COVID, we’ve saved lives, because these folks who qualify and get an In-Home Support Service Worker, it keeps them out of nursing homes—which could have been a death sentence at the beginning of the pandemic.

You’ve been supporting direct efforts to bring more physicians in to serve the marginalized communities of color in Los Angeles, as well as to support family caregivers caring for plan members with disabilities. Tell me about them?

I’ve been here since 2015. And the idea [for the physician workforce-related programs] came up after I’d been here a year or so and realized that the distribution of primary care doctors here was very uneven, as elsewhere—and so the people who are on Medicaid or have no insurance, are generally living in economically depressed areas, where doctors don’t want to practice. And, less apparent, often, the doctors of color aren’t serving in those communities in large numbers. So how to get more doctors of color in there? With regard to the scholarship program, we’re a public entity, and we have some reserves, and so I went to the board and said, I think we should take five percent of our unassigned reserves every year for five years, and create a fund—and if we did that five for five years, it would create a fund of $155 million. So I proposed what has turned out to be a five-part program. And this part is the scholarship program. We have awarded—and we’ll have one more year—we’ve awarded eight full four-year scholarships a year to two medical schools here in Los Angeles. One is the David Geffen School at UCLA, and the other is the Charles R. Drew College of Medicine and Science.

Now, the Geffen School focuses on recruiting minority students, and the Charles R. Drew has only served minority students since its inception. So we went to those two schools and said, you can probably spot the students who will come back and work in the safety net. So they have picked the candidates. We have 32 in school right now, and the first will graduate in May. Half are women and all but two are students of color. So we have Black, Latino, and Asian students in training. And when I’ve met them all, they’ve all said, I wanted to go to medical school because there was someone in my neighborhood who was inspirational in helping others. The first group, seniors, will graduate in May, eight more. So, five groups of eight. And I’m going to make a proposal to our board to renew this program, because I think everyone feels we’ve done something significant. That hasn’t happened yet.

So these are full scholarships for tuition, room and board, and everything. And one student said in a speech, “The day I found out about this changed my life, because I had assumed that I would have to borrow the money; and now, because I will be debt-free, I can become a primary care doctor and serve the community I grew up in. She’s Latina. And most are from California. So we’re very proud of that, and that’s gotten a fair amount of attention.

And you’re funding three other programs under the Elevating the Safety Net umbrella, correct? The Provider Recruitment Program, Provider Loan Repayment Program, and Residency Support Program.

Yes, that’s right. The next two parts come in tandem; but when we have practices or clinics that operate in these communities where our members live, when they need to recruit a new physician, they cannot compete with Kaiser Permanente or the academic medical centers, that can offer higher salaries and more benefits. So we’ve created grants of $125,000 that we would award to a clinic or practice if they recruited a primary care physician or psychiatrist new to the safety net. And assuming that that physician was newly out of residency, and might have significant medical school debt, we said that if that doctor agreed to practice there for three years we would retire $180,000 of debt, which was the average amount of debt at that time. And we’ve awarded nearly 150 grants, and probably over 100 of those physicians have taken advantage of that medical school debt reduction program, since the program started in 2018. If the grant went to a clinic that hired a doctor, we’d give them another $180,000. So we were really giving them a packet of $305,000, to recruit a doctor. Because Kaiser can offer repayment of medical school debt as a benefit, and most of these clinics cannot do that.

The fourth element, the Residency Support Program, involves our also funding 14 primary care residency slots in five different programs here in Los Angeles, to build a pipeline to bring more doctors into the community, because we know that physicians are more likely to stay in the community where they do their residency, and we wanted to encourage that.

Speaking more broadly, do you think that people are starting to realize that health plans can be involved in improving the health of communities?

Not as much as I’d like. You know, 80 percent of Medicaid is contracted out to health plans to run, not the state. I think the tipping point was in 2017, when they were trying to repeal the ACA [Affordable Care Act]; fortunately, that effort never got out of the [U.S.] Senate. A lot of people don’t realize that Medicaid is a bridge to help people out of poverty. And a lot of people started saying, hey, wait a minute, Medicaid’s a good idea, why do we want to hurt Medicaid? And because we are a public entity, we have no shareholders. No one can accuse us of making obscene amounts of money; we’re limited by our contracts to make about 2 percent margin. And the money I’ve taken from our unassigned reserves and reinvested into these programs, in a for-profit plan, that would have gone to the shareholders.

Do you think the pandemic has opened a window or door to re-visioning healthcare and health in certain ways?

Yes. What COVID-19 has done is demonstrated that the inequality in our society is a health issue. 93 percent of our members are on Medicaid. Now, most people don’t realize that 30 percent of those people work; they have jobs. But they have low incomes. So when the pandemic and the recession hit simultaneously, two things happened to our working members. First, they either lost their jobs immediately, because they were in a service industry; or two, they had to go into work because they were in a service industry, and they couldn’t work remotely. And we had 30 percent of members working full- or part-time; but there was a 200-percent increase in applications for food stamps by our members. Also, our members probably were the most infected, the most hospitalized, and had the highest death rates. About 48 percent of our members are Latino, and they’ve had 3 times the amount of infection, hospitalization, and death; same true of our Black members, who represent about 12 percent of our enrollment. Now, our Asian members did not have as high rates of illness as the other two cohorts. To me, that’s a demonstration that income inequality is a huge indicator of health status and health outcome, and we’ve all talked about that forever, but now that’s right there in front of you.

How can we become more conscious, more aware, of what it takes to make and keep people healthy?

I’m not sure whether COVID has advanced this, but clearly, the environmental conditions you live in have a tremendous impact on your health, and on your healthcare. For example, the 130-bed MLK Hospital—at one point last January, they had 130 patients in all their licensed beds filled with COVID patients, because the population around them was getting sicker. Now if you go to a place like Cedars-Sinai, they might have had 45 percent of their beds filled with COVID-infected patients, at their peak. So there was a different demand put on them. So when you have limited resources and a vulnerable population, there will be more competition for those limited resources, and affluent people will have far easier access to doctors. COVID has made that more clear to us, and I’m finding it’s stimulating more community discussion about how we disburse the resources. And my friend Dr. Bachelor, who runs MLK Hospital, has said it eloquently. She said, we need payment parity, which is why you have more competition for resources in poorer communities?

What’s your vision for the next few years?

What I would like to see happen is that I’d like for us to be able to integrate social services into the care plans of our most vulnerable members. We have a member, and we might realize through looking at claims or dialoguing with them that they have a food insecurity problem. They’re eating ramen noodles or soup all the time. But why aren’t we the agent for the food stamp program, so that I can qualify to enroll that person? Otherwise, that person has to give the same information we already have stored in our computers, to another bureaucracy, and have to get requalified six months later. So whether it’s food stamps, social services, etc., why can’t we integrate and be synergistic about how we apply for them? Because most of those social services will reduce the demand for healthcare services. In January here in CA, the state allowed us to engage in “in lieu”—in lieu of a medical service, I can give you a meal—food as medicine. We’re beginning to experiment with that. That will be very important. And the other thing that will happen because of the programs the Biden administration has put in to make access to the individual market exchanges more affordable, we’ll see more people with access to care. And that’s something we can do right away. We can make those kinds of additions, and I see that happening more, in the near future.

Is there anything that you’d like to add?

With regard to the integration of social services and healthcare, when you look at other first-world nations, they do spend more per capita on social services in the U.S., and coincidentally, they spend less on healthcare. If you’re investing in things that will improve health, your healthcare expenses might go down. I had someone describe it to me this way, once: there’s a sharp curve in a highway, with a steep cliff. Cars keep flying off and crashing at the bottom. We can either put a guardrail on the road or station more ambulances at the bottom. And in the U.S., we’ve been doing more ambulances than guardrails.