Latest / Becker’s Healthcare Podcast / Bridging Healthcare, Addiction Medicine, and Medicaid Access with Rahul Vanjani

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Bridging Healthcare, Addiction Medicine, and Medicaid Access with Rahul Vanjani · Becker’s Healthcare Podcast

• 0:02
  - Every health system executive right now is being
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  - upper right.
• 1:00
  - This is Scott Becker with the Beckers Healthcare
• 1:03
  - Podcast.
• 1:04
  - I'm thrilled today to be joined by a
• 1:05
  - brilliant physician leader, someone who's at the actual
• 1:08
  - absolute intersection of primary care and addiction medicine.
• 1:12
  - We're joined today by doctor Rahul Vanjani.
• 1:15
  - And doctor Vanjani is gonna talk about both
• 1:18
  - what he does,
• 1:20
  - his company,
• 1:21
  - and and and and his focus and a
• 1:23
  - lot more.
• 1:24
  - Doctor Fanjani, can you take a moment and
• 1:26
  - introduce yourself and tell us a little bit
• 1:28
  - about your career and background and and how
• 1:30
  - you ended up founding the company you founded
• 1:33
  - too?
• 1:34
  - Thanks for having me, Scott.
• 1:36
  - Yes. I would love to. I'm Rahul Vanjani.
• 1:39
  - I'm an internal medicine and addiction medicine physician,
• 1:42
  - and I'll say upfront that I come out
• 1:44
  - all of this first as a clinician.
• 1:47
  - I serve as medical director at Amos House
• 1:49
  - in Rhode Island where I care for people
• 1:51
  - experiencing homelessness,
• 1:53
  - substance use disorders, and a lot of overlapping
• 1:56
  - social and medical challenges.
• 1:58
  - A lot of my clinical work over the
• 1:59
  - years has been in models built exactly for
• 2:02
  - these types of patients.
• 2:03
  - I've, worked in street medicine,
• 2:06
  - helped stand up a community health worker program,
• 2:09
  - a transitions clinic for people coming out of
• 2:11
  - incarceration,
• 2:12
  - and a recovery clinic. So my whole career
• 2:14
  - has been spent with the patients who are
• 2:17
  - hardest for the system to hold on to.
• 2:20
  - And that that turns out to matter a
• 2:21
  - lot for, the company I've started and the
• 2:24
  - work we're doing.
• 2:25
  - So I'm also the CEO and cofounder of
• 2:27
  - ITO Health, I ITO Health.
• 2:30
  - We started ITO as a group of clinicians
• 2:32
  - and case managers because we kept running into
• 2:35
  - the same problem in care delivery. We're really
• 2:38
  - good at identifying our patients' needs,
• 2:40
  - their competing social needs, specifically.
• 2:43
  - No insurance, food insecurity,
• 2:45
  - unstable housing, no transportation.
• 2:48
  - But we haven't historically had the infrastructure in
• 2:51
  - health care to actually solve them efficiently.
• 2:54
  - So a patient might qualify for Medicaid,
• 2:56
  - SNAP, WIC, disability programs, transfer transportation benefits, even
• 3:01
  - housing,
• 3:02
  - But navigating those systems is genuinely complex.
• 3:05
  - People fall off not because they don't qualify,
• 3:07
  - but because the process just kinda defeats them.
• 3:11
  - So what we did was we built technology
• 3:13
  - and services that help health care organizations
• 3:16
  - specifically
• 3:17
  - identify eligibility,
• 3:19
  - complete applications for their for their patients, track
• 3:22
  - renewals,
• 3:23
  - and keep patients connected to their coverage and
• 3:26
  - benefits over time.
• 3:27
  - Today, we work with health systems, federally qualified
• 3:30
  - health centers,
• 3:31
  - CCBHCs,
• 3:32
  - other community organizations, and state Medicaid agencies.
• 3:36
  - And I think what makes our vantage point
• 3:39
  - unusual in this industry is that we sit
• 3:41
  - right at this intersection of three things that
• 3:43
  - usually live in separate rooms.
• 3:46
  - Health care deliveries, one,
• 3:48
  - Medicaid policy,
• 3:49
  - and then frontline patient care. So we get
• 3:52
  - to see what happens when a policy changes
• 3:54
  - on paper
• 3:55
  - and then how that translates to operational reality
• 3:59
  - at the front desk and at the bedside.
• 4:02
  - And that's become especially important right now
• 4:05
  - as,
• 4:06
  - hospitals get ready for Medicaid changes with HR
• 4:10
  - one, which I I know we're going to,
• 4:12
  - to dive into in a little bit.
• 4:15
  - Thank you. Talk to us a little bit
• 4:16
  - about
• 4:17
  - you do so many interesting things with with
• 4:19
  - so much compassion.
• 4:21
  - What are the trends you're watching in the
• 4:23
  - addiction medicine
• 4:25
  - world today?
• 4:26
  - What do you see out there?
• 4:28
  - And you you mentioned
• 4:31
  - working with street medicine, with homeless.
• 4:33
  - What are the what are the
• 4:35
  - what are you seeing out there in terms
• 4:37
  - of addiction
• 4:39
  - growing, accelerating,
• 4:41
  - specific types of issues that are driving a
• 4:43
  - lot of it? What are some of the
• 4:45
  - things that
• 4:47
  - that we should be thinking about or understand
• 4:49
  - about it?
• 4:50
  - I love that question.
• 4:52
  - I think among patients who have substance use
• 4:55
  - disorder, as I mentioned previously, they they tend
• 4:58
  - to be some of the most vulnerable
• 5:00
  - among us for a number of reasons.
• 5:02
  - One of those reasons is because
• 5:05
  - the challenge
• 5:06
  - with the substance they're using can often be,
• 5:09
  - entirely consuming
• 5:11
  - and can lead to other other needs dropping
• 5:14
  - off. And in in particular now with the
• 5:16
  - changes we're about to see with HR one
• 5:19
  - and Medicaid,
• 5:20
  - I'm incredibly worried that,
• 5:22
  - this group of people who often rely on
• 5:24
  - medications, like in the case of alcohol use
• 5:26
  - disorder,
• 5:27
  - naltrexone, or I'm Vivitrol. In the case of
• 5:30
  - opioid use disorder, Suboxone, methadone, these are life
• 5:33
  - saving medications. And without insurance, people won't be
• 5:36
  - able to afford them. And in fact, just
• 5:39
  - last month, there was a great evidence based,
• 5:41
  - peer reviewed paper that came out
• 5:43
  - demonstrating that this specific group of people is
• 5:45
  - at heightened risk of mortality, premature death, with
• 5:49
  - the changes that are that are coming with
• 5:51
  - HR one. And so to that end, the
• 5:53
  - trend I'm watching most closely,
• 5:55
  - I think, is also the the most misunderstood
• 5:58
  - part about the HR one law. So so
• 6:00
  - when people talk about HR one, the one
• 6:02
  - big beautiful bill passed last year with very
• 6:05
  - slim margins,
• 6:07
  - they tend to think about eligibility.
• 6:09
  - So so who qualifies
• 6:10
  - for Medicaid,
• 6:13
  - the biggest safety net program in American health
• 6:15
  - care? And yet
• 6:17
  - hospitals
• 6:18
  - don't experience
• 6:19
  - eligibility at all. What hospitals experience
• 6:22
  - is coverage,
• 6:23
  - and those two things are not the same.
• 6:26
  - So let me put the scale on it
• 6:27
  - first. HR one is the largest Medicaid reduction
• 6:30
  - in US history, about $911,000,000,000
• 6:34
  - in federal Medicaid spending over the next decade
• 6:37
  - by the Congressional Budget Office's estimate.
• 6:40
  - And there are really two halves to the
• 6:41
  - law. There's the financing half. So we've got
• 6:43
  - changes to provider taxes, state directed payments,
• 6:46
  - and that hits hospital budgets directly. And that
• 6:49
  - honestly deserves its whole own conversation.
• 6:52
  - And then there's that coverage half, which is
• 6:54
  - where I spend my time because it's the
• 6:56
  - part hospitals can actually do something about.
• 7:00
  - Here's the key insight on the coverage side.
• 7:03
  - With a few exceptions,
• 7:05
  - the law does not change who is eligible
• 7:07
  - for Medicaid. What it actually changes is the
• 7:10
  - administrative
• 7:11
  - burden required to get and stay
• 7:13
  - covered. So there are four changes that hospitals
• 7:16
  - should really know about. One,
• 7:19
  - most eligibility renewals are gonna go from once
• 7:21
  - a year to every six months, and so
• 7:23
  - that's doubling the number of touch points where,
• 7:26
  - an individual can fall off coverage.
• 7:29
  - Two,
• 7:30
  - community engagement or work requirements. So most expansion
• 7:33
  - adults, so folks between the ages of 19
• 7:36
  - and 64,
• 7:37
  - now have to document eighty hours a month
• 7:39
  - of a qualifying activity.
• 7:41
  - Three,
• 7:42
  - the window for retroactive coverage gets narrowed. So
• 7:45
  - hospitals historically have really benefited from, you know,
• 7:48
  - someone newly enrolls on Medicaid. That coverage can
• 7:51
  - retro three months, and so that's covering claims
• 7:54
  - from the past few months. That's now gonna
• 7:56
  - reduce to, one month for the expansion population
• 7:59
  - and two months for other populations.
• 8:01
  - And finally, four,
• 8:03
  - eligibility tightens for certain lawfully present immigrant groups,
• 8:07
  - particularly folks who are refugees or seeking asylum.
• 8:10
  - And so these will all phase in starting
• 8:12
  - around October of this year and then finalize,
• 8:16
  - and become permanent in January '27.
• 8:19
  - So the real risk of HR one isn't
• 8:21
  - that millions of people are suddenly gonna become
• 8:24
  - ineligible. It's actually just that people who are
• 8:26
  - still eligible
• 8:27
  - are gonna lose coverage because the process becomes
• 8:30
  - too hard to navigate.
• 8:32
  - And that's the line I'd like everyone listening
• 8:34
  - today to hold on to, the fact that
• 8:36
  - coverage loss is not the same as eligibility
• 8:39
  - loss.
• 8:40
  - And and I think this will resonate with
• 8:42
  - a lot of people listening. So let me
• 8:43
  - explain it with a patient we all recognize.
• 8:45
  - So let's call her Maria. She's 52,
• 8:48
  - works part time at a grocery store, has
• 8:50
  - diabetes and depression, and she fully qualifies for
• 8:53
  - Medicaid.
• 8:54
  - Her renewal notice gets mailed to an old
• 8:56
  - address.
• 8:57
  - A deadline quietly lapses, and six months later,
• 9:00
  - she shows up in your emergency department with
• 9:02
  - uncontrolled diabetes. She's in DKA, sicker. Now she's
• 9:06
  - way more expensive to treat because she's uninsured.
• 9:09
  - Nothing about her health changed. Nothing about her
• 9:11
  - eligibility changed. She just lost coverage,
• 9:14
  - and that's really the entire law in one
• 9:16
  - patient.
• 9:18
  - And we're not speculating about this. Right? We
• 9:20
  - we've run a large experiment. So during the
• 9:23
  - Medicaid unwinding,
• 9:24
  - when the COVID public health emergency ended in
• 9:27
  - March '23,
• 9:28
  - there were three years from 2020, 2023 public
• 9:31
  - health emergency. Everyone stays on Medicaid continuously.
• 9:35
  - Then that ends in March '23. And starting
• 9:37
  - in April, states have to recertify everyone's Medicaid
• 9:40
  - eligibility. During that time over the over the
• 9:43
  - ensuing year, more than twenty five million people
• 9:46
  - lost coverage.
• 9:48
  - And and when you look at why, a
• 9:50
  - huge share of that was procedural.
• 9:52
  - So people who are still eligible
• 9:54
  - but couldn't get through the renewal. They moved.
• 9:57
  - The mail went to the wrong place. The
• 9:59
  - online portal didn't work. The documentation was confusing.
• 10:02
  - And then when you follow that up with
• 10:04
  - work requirements, which is that second piece of
• 10:06
  - the law we talked about, We have data
• 10:08
  - around that too. We ran a big study
• 10:10
  - out of Arkansas.
• 10:11
  - So Arkansas tried work requirements back in 2018.
• 10:14
  - After seven months, a judge halted it because
• 10:18
  - more than 18,000
• 10:19
  - people had lost coverage in that seven month
• 10:22
  - period,
• 10:23
  - and most of them actually were working and
• 10:25
  - fulfilling the work requirement, but, again, just couldn't
• 10:28
  - complete the bureaucratic process of turning in paperwork,
• 10:31
  - etcetera.
• 10:32
  - Similarly, we saw Georgia stand up a work
• 10:34
  - requirement program. And in the first year,
• 10:37
  - they thought over 240,000
• 10:39
  - people would be eligible,
• 10:41
  - and yet fewer than 10,000
• 10:43
  - actually ended up enrolling. So, again, that administrative
• 10:46
  - complexity was exceptionally high.
• 10:48
  - And so that's really the reason why I
• 10:50
  - think this is the trend to watch right
• 10:52
  - now because it's no longer theoretical.
• 10:56
  - Nebraska
• 10:56
  - turned its work requirements on in May, actually,
• 10:59
  - so earlier than the rest of the nation.
• 11:01
  - They're the first state in the country to
• 11:02
  - do it. And the first existing enrollees will
• 11:05
  - get checked at the end of July,
• 11:07
  - and then it'll phase out over the year.
• 11:09
  - We've also got Montana, Arkansas, Iowa, all coming
• 11:12
  - online this year.
• 11:14
  - And just two days ago, the federal government
• 11:16
  - released its nationwide framework for how states will
• 11:19
  - have to implement all of this. It was
• 11:20
  - a a CMS document published on June 1.
• 11:23
  - So over the next few few months, we're
• 11:25
  - gonna get this real world data on how
• 11:27
  - big this administrative coverage loss is gonna be.
• 11:30
  - And so if I'm a hospital leader, I'm
• 11:32
  - watching Nebraska like a hawk because it's a
• 11:35
  - preview of what's gonna happen to me in
• 11:37
  - my hospital
• 11:38
  - in January
• 11:39
  - 2027.
• 11:41
  - As you look at this and trying to
• 11:43
  - take care of people with addiction issues and
• 11:45
  - challenges and so many,
• 11:47
  - And so many revolve back to social determinants
• 11:50
  - of health.
• 11:52
  - What are you most focused on, and and
• 11:53
  - and where are you most focused in what
• 11:55
  - you can do
• 11:57
  - in in trying to have impact?
• 11:59
  - For me, the focus is really on helping
• 12:03
  - leaders
• 12:04
  - reframe this from a from a threat
• 12:07
  - that they brace for into a problem they
• 12:09
  - can actually solve. And
• 12:12
  - many have said it over the course of
• 12:13
  - history, but if if we set up our
• 12:15
  - systems to care for the most marginalized among
• 12:18
  - us, then then we're actually
• 12:20
  - providing better care to everyone in our society.
• 12:23
  - And I think HR one really mandates this,
• 12:27
  - because, again, each individual who lose coverage who
• 12:30
  - loses coverage isn't just now getting having worse
• 12:33
  - outcomes and less access to care. That also
• 12:36
  - has bottom line implications for for payers and
• 12:39
  - for for health care providers.
• 12:41
  - And so here's the distinction that I think
• 12:43
  - is is very freeing for leaders today.
• 12:47
  - The financing cuts in HR one
• 12:50
  - are outside of any single hospital's control. We
• 12:53
  - can't, like, vote on that to get a
• 12:55
  - provider tax change. But the administrative coverage loss
• 12:58
  - is totally different. It's it's preventable. It's completely
• 13:01
  - preventable.
• 13:02
  - So if a patient is still eligible and
• 13:04
  - we help them get through the renewal and
• 13:07
  - the reporting,
• 13:08
  - they keep that coverage
• 13:10
  - full stop.
• 13:11
  - And that's really a problem where hospitals can
• 13:14
  - get their hands dirty.
• 13:15
  - The reason this should matter to a hospital
• 13:17
  - leader and not just to, you know, frontline
• 13:19
  - clinicians like me is because
• 13:22
  - coverage preservation
• 13:24
  - is simultaneously
• 13:25
  - population health and its revenue protection.
• 13:29
  - It's really the same activity. So every every
• 13:31
  - patient we keep covered has better outcomes, lower
• 13:34
  - bad debt, lower uncompensated care, more stable revenue.
• 13:38
  - And, you know, as we all know, and
• 13:40
  - I'm I'm a primary care physician. I've seen
• 13:42
  - patients come in and out of coverage over
• 13:44
  - time. I can say that no matter what
• 13:46
  - happens to their coverage,
• 13:48
  - their cancer, their diabetes, those things don't don't
• 13:51
  - go away.
• 13:53
  - A common misconception here that I wanna flag
• 13:55
  - is that
• 13:57
  - sometimes,
• 13:58
  - some of my colleagues,
• 13:59
  - leaders at at hospitals and other sub health
• 14:01
  - systems,
• 14:02
  - assume that those patients will just shift to
• 14:05
  - other coverage,
• 14:06
  - but mostly they won't. We actually have pretty
• 14:08
  - good evidence out of the Commonwealth Fund and
• 14:10
  - other places, KFF, Kaiser Family Foundation, that
• 14:13
  - employer coverage or coverage on the exchange really
• 14:16
  - isn't available to part time and low wage
• 14:18
  - workers.
• 14:20
  - And that's the reason they're on Medicaid. Right?
• 14:21
  - So let's say a state's Medicaid income threshold
• 14:24
  - is $1,800
• 14:25
  - per month, and now someone gets, like, a
• 14:28
  - 1 or $2 raise at work, and all
• 14:30
  - of a sudden they're making, let's say, even
• 14:32
  - $2,300
• 14:34
  - a month. As as we all know
• 14:36
  - that there's this huge coverage desert between, let's
• 14:40
  - say, like, making 18 or $1,900
• 14:43
  - a month where you you might qualify for
• 14:45
  - Medicaid based on the state you're in and
• 14:47
  - making, like, you know, 3,500
• 14:49
  - or $4,000
• 14:50
  - a month, which is probably the amount you
• 14:52
  - need to afford the premiums and deductibles on
• 14:55
  - the exchange or through employer sponsored
• 14:58
  - insurance. And so the most realistic destination for
• 15:01
  - these folks is that coverage desert of being
• 15:05
  - insured. And in rural parts of our country,
• 15:08
  - that that's that's really where it lands the
• 15:10
  - hardest because
• 15:11
  - that hospital is the only source of care
• 15:13
  - for Miles. It has older patients, higher Medicaid
• 15:16
  - reliance, razor thin margin, sometimes just a week
• 15:19
  - of cash on hand.
• 15:21
  - And so it's it's even more important to
• 15:23
  - be thinking about this in those areas.
• 15:25
  - So what I'm what I'm excited about, and
• 15:27
  - and that's sort of weird to say, but
• 15:29
  - what I'm excited about is that this is
• 15:31
  - one of the few places in HR one
• 15:33
  - where a hospital can genuinely change the outcome
• 15:35
  - for its own patients and its own bottom
• 15:37
  - line at the same time. Everything's aligned, and
• 15:40
  - that's very rare in health policy. So when
• 15:43
  - I think about the work we've done at
• 15:44
  - ItoHealth over the past year to get ahead
• 15:47
  - of this, a big piece has been
• 15:49
  - education,
• 15:50
  - talks like this,
• 15:52
  - to to hospital associations, to primary care trade
• 15:55
  - associations,
• 15:56
  - and then the work we're doing with our
• 15:57
  - technology,
• 15:59
  - to support these organizations and keeping people on
• 16:01
  - Medicaid.
• 16:02
  - Because we know that the organizations that wait
• 16:05
  - until 2027,
• 16:07
  - are gonna be behind on day one. And
• 16:09
  - so at Eto, we've been building the infrastructure
• 16:12
  - to do this at scale,
• 16:13
  - proactively identifying Medicaid patients, tracking renewal dates, helping
• 16:17
  - with documenting
• 16:19
  - exemptions, keeping people connected to coverage
• 16:21
  - through new and innovative touch points.
• 16:24
  - And we're watching that go from sort of
• 16:28
  - a, like, a a warning on a slide
• 16:30
  - to something
• 16:31
  - operational that really protects real patients, and and
• 16:34
  - we're seeing that live now with with our
• 16:36
  - many customers, and that's what I'm exceptionally proud
• 16:39
  - of.
• 16:40
  - How did you become
• 16:42
  - so
• 16:43
  - focused and passionate about addiction medicine?
• 16:46
  - I mean, obviously, your knowledge of this and
• 16:48
  - what's going on is incredible.
• 16:50
  - How did this become your passion? How did
• 16:52
  - you grow into this area?
• 16:54
  - Well, I I I went to med school
• 16:55
  - in in Washington, DC, and, while there,
• 16:59
  - helped run our student run clinic, which was
• 17:02
  - in, Southeast Washington DC at a federally qualified
• 17:05
  - health center.
• 17:06
  - And it was there that I made the
• 17:08
  - decision to pursue primary care. And so,
• 17:11
  - when I went on,
• 17:13
  - to to residency in in New York City,
• 17:15
  - I was I was at Columbia at this
• 17:17
  - wonderful primary care clinic in Washington Heights
• 17:19
  - taking care of people,
• 17:22
  - and,
• 17:22
  - it was there. And then at my first
• 17:24
  - job out of residency, which was on, death
• 17:26
  - row at the San Quentin State Prison, where
• 17:28
  - I saw that there was this incredible
• 17:30
  - overlap
• 17:31
  - of sort of people
• 17:33
  - who,
• 17:35
  - low income,
• 17:36
  - receiving
• 17:37
  - Medicaid,
• 17:38
  - but also struggling with an incredible amount of
• 17:41
  - trauma,
• 17:42
  - substance use and addiction,
• 17:44
  - and cycling in and out of the carceral
• 17:46
  - system.
• 17:47
  - And so I think it's those experiences that
• 17:50
  - really brought me to a place where I
• 17:52
  - wanted to incorporate addiction medicine and psychiatry into
• 17:55
  - my primary care practice so that I could
• 17:58
  - provide more holistic care to people.
• 18:00
  - And it it,
• 18:02
  - it also sort of led me down this
• 18:04
  - path of thinking more about
• 18:06
  - people who,
• 18:07
  - are struggling with things like cycling in and
• 18:10
  - out of hospitals and prison settings and and
• 18:12
  - the street. Like, you know, there's that trifecta
• 18:14
  - that we're all aware of, all of us
• 18:16
  - who have worked in safety net settings, where
• 18:18
  - patients just kinda flow between the emergency department,
• 18:21
  - the jail or prison, and the street.
• 18:23
  - And so, much of my career,
• 18:26
  - I've thought about that. I've taken care of
• 18:28
  - people who are struggling with that. And and
• 18:30
  - my goal, I think, with this company is
• 18:32
  - to think through how we, at a high
• 18:34
  - level,
• 18:35
  - begin to change that and interrupt that cycle.
• 18:38
  - And I think addressing people's basic social needs
• 18:41
  - is one of the most foundational ways to
• 18:43
  - do
• 18:44
  - that. Thank you so much, doctor Vanjiani. It's
• 18:46
  - it's remarkable what you do and how you
• 18:49
  - do it in your knowledge base of HR
• 18:51
  - one, addiction, and so many areas.
• 18:53
  - I wanna thank you for taking the time
• 18:55
  - to visit with us today on the Becker
• 18:57
  - Healthcare podcast.
• 18:58
  - Just incredible what you do, and thank you
• 19:00
  - for joining us very much.
• 19:02
  - Likewise. I love this podcast, and thank you
• 19:04
  - so much for what you do as well.
• 19:05
  - And thanks for having me.