Latest / Becker’s Healthcare Podcast / Dr. Ria Paul, Clinical Associate Professor, Stanford University School of Medicine; Chief Medical Officer, Santa Clara Family Health Plan

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Dr. Ria Paul, Clinical Associate Professor, Stanford University School of Medicine; Chief Medical Officer, Santa Clara Family Health Plan · Becker’s Healthcare Podcast

0:02
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Hi, everyone. This is Erica Carbajal with Becker's
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Hospital Review. Thank you so much for joining
0:37
us for this episode of the Becker's Healthcare
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Podcast.
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Today, we're joined by doctor Rhea Paul,
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clinical associate professor at Stanford University School of
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Medicine and chief medical officer of Santa Clara
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Family Health Plan. Doctor Paul, happy New Year.
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Honored to have you on today.
0:56
Thank you, Erica,
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and happy new year to you as well.
1:00
Yeah. Hard to believe we're in 2026.
1:02
Well,
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doctor Paul, would you start here by sharing
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a little bit about your background in health
1:08
care and your role today?
1:10
Absolutely.
1:12
So,
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as you mentioned,
1:15
I'm doctor Ria Paul. I'm an internist geriatrician.
1:19
I'm a practicing faculty at Stanford University School
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of Medicine,
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and I'm also the chief medical officer of
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Santa Clara Family Health Plan. A little bit
1:28
about Santa Clara Family Health Plan. Santa Clara
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Family Health Plan is the largest managed care
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plan of Santa Clara County in in California.
1:38
We provide health care services to around 350,000
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members in Santa Clara County, which is about
1:45
15%
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of the population of Santa Clara County
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through our two lines of business. One is
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our Medicaid line of business,
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and another one is our dual eligible
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or D SNP or Medicare Advantage line of
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business.
2:00
And D SNP, many folks don't know, so
2:03
that's why I mentioned it is a Medicare
2:06
Advantage Plan by CMS. So we have two
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product lines.
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One is, Medicaid,
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and one is,
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Medicare Advantage.
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And, we work very closely with our county
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health and hospital system. 50%
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of our membership
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are with Santa Clara County health and hospital
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system,
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and the other 50%
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is with other
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IPAs,
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medical groups.
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And,
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we provide holistic care, not only physical care,
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but also
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mental health and,
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other services
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through our CalAIM,
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resources through DHCS
2:45
from California
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State.
2:48
Alright. Thanks, doctor Paul. Helpful to hear that
2:50
overview
2:51
overview there
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and imagine
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a a lot you're accountable
2:55
for there, covering 15%
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of Santa Clara County as you mentioned.
3:00
Can you share what
3:02
the most important
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initiative is that you've led in the past
3:05
year? Tell us a bit about what that
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was and what the results some of the
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results that you're seeing now in early twenty
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twenty six.
3:13
Mhmm.
3:14
That's a very good question.
3:15
So last year, one of the major initiatives
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for us was to improve our
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our
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quality improvement
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scores for
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both for our line of business from Medicaid
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and our dual eligible or Medicare Advantage.
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As you know, for a health plan, our
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North Star is always our quality ratings because
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that's how we are perceived by,
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by ourselves and by others, how good of
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a care we are providing
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our members.
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So we focused heavily
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on our improvement of our quality ratings,
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like I said, for both of our line
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of businesses,
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Medicaid
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and,
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Medicare Advantage.
3:59
And few things that we did,
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intent
4:02
very deliberately
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is,
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focusing
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on the metrics, the specification of metrics,
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focusing on how the data is flowing from
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the various medical groups to the health plan.
4:15
And also, at the same time, doing
4:19
real time report outs to the medical groups,
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having,
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conversations with the medical group on a regular
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basis,
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making sure that they are aware of what
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their opportunities,
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what are their successes are, sharing best practices,
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evidence based guidelines,
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and also,
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at the same time, trying to see where
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we can help the medical groups because at
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the same because it is a collaborative effort
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that we feel
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is between a health plan and the care
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delivery side. So for example, that, when we
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identified that some medical groups
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had, some resource issues like,
5:00
the smaller medical groups needed a medical assistant
5:03
or a or,
5:05
coordinator
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to call patients for their appointments
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or their care coordination.
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So we actually provided resources
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for that and, which we really helped.
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We saw that it really helped the medical
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group's long term results.
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And, another thing that we did was,
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focusing on
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incentives.
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So not only on patient or member incentives,
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but also on provider incentives.
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The patient incentives,
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we deliberately
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selected measures that we felt was
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tougher
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to get done, for example, cervical cancer screening,
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for some immunizations,
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for, annual wellness visit, for our Medicare population.
5:50
So we provided,
5:52
member incentives.
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And
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at the same time, we provided,
5:57
incentives to our physician groups as well to
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help them navigate
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their their,
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whatever their
6:06
day was because we'd all know that annual
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wellness visits take a longer time. So we
6:11
wanted our our providers to do the annual
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wellness visits. But since it's a half an
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hour appointment,
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we try to incentivize the providers,
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to to do so.
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And, that's why we we saw that the
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incentives really, really help the provider.
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And at the end of the day, we
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definitely saw these all
6:32
helped our ratings for our medic Medicaid,
6:36
ratings. We we improved on all of our
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measures,
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all of our HEDIS measures. And for our
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Medicare Advantage or D SNP star ratings, we
6:46
actually
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improved as well. As you know, D SNP
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is a very tougher form of Medicare Advantage
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because the patients here are frail, elderly,
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and have multiple comorbid
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conditions.
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So,
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improvement
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of a star rating here in DSNF
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is it's actually
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a monumental effort, and kudos to our quality
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team at the health plan to do so.
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So we went from a three star rating
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to a 3.5 star rating, which we consider
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is, was was a huge win for us.
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And our pharmacy star rating was actually four
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star, so we were very impressed by that.
7:26
Yeah. Doctor Paul, congrats on those quality rating
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improvements. I know that's no small feat and
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certainly a lot of intentional coordinated work that
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went into that. I love what you mentioned
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as well just about
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the coordination and the partnership and the resources
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that you were providing to medical groups. I
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think it's such a great example of
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what that that collaboration actually looks like in
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practice because we hear a lot lot about
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that. And I know folks are interested in,
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like, what does that act actually look like?
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How does that happen in terms of the
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relationship between health plans and providers?
7:59
When you mentioned the incentives
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for patients and providers on the screening side
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and then both on the annual wellness visit
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side for physicians,
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can you share an example of what those
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incentives
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look like either for patients or providers?
8:15
Yes. These are all monetary incentives. So, every
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year, beginning of the year,
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we we have,
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we develop our incentive program. Usually, we replicate
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the incentive program from the year prior, but
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we always look at,
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the where our opportunities
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are and, then go ahead and select those
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metrics that we feel
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need an extra push both from the member
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side and both from the provider side. And
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that's how we select the metrics and
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how much,
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monetary,
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weightage we put on the particular metric also
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depends,
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what the what it was the year prior
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and, then decide whether to continue with the
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same
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same monetary met
9:07
monetary weighted for this year or should we
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go up
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this year as well? Another thing that we
9:15
do is that if we see that we
9:18
are
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doing very good on a particular measure, we
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will kind of take away the incentive on
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that measure because then we know that the
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patients and the providers have become very well
9:31
versed with that metric and that has become
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a very
9:36
it has become a very process oriented metric
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for the for the provider.
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So we will then take away the metric
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and then select a new metric,
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which needs more focus.
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And so, again, metrics we select
9:50
on a yearly basis. And also the monetary
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weightage, also we adjust on a yearly basis
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as well.
9:58
Yeah. No. That makes sense just based on
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really how how much
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improvements are happening in certain areas and where
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there are areas that still need that extra
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push.
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Well, doctor Paul, looking ahead, what are some
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of the biggest priorities and headwinds that you're
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focused on and and have on your radar
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in 2026?
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Mhmm.
10:20
Again, that is a very important question and
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very timely because we are just starting the
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year off.
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Definitely, we want to build on our gains
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from 2025,
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whatever we have built, done
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in, in 2025
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in terms of our quality improvement. We want
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to sustain and enhance on that.
10:41
At the same time, there has been a
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lot of regulatory changes coming
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down to us for our Medicaid line of
10:48
product from DHCS,
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DMHC,
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and from CMS for our dual eligible line
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of product.
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So,
10:57
we we have to align with that, And
10:59
so we are we are very, very, very
11:03
diligent
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in following up on these,
11:06
regulatory requirements, aligning with those.
11:09
And,
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the headwinds,
11:12
definitely for our Medicaid lineup product, as you
11:16
know, with HR one, there are a lot
11:19
of changes happening in the Medicaid arena. Some
11:23
are starting in 2026
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and some 2027,
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for example,
11:28
the redeterminations,
11:31
also the work requirement, and so forth. So
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all of these
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that we we were not really focusing on
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before,
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we
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are making changes
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in our workflows
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in making sure how we
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how are we are in alignment with all
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of these requirements
11:51
and also educating our members accordingly,
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helping our members through all these processes,
11:58
offering determinations,
12:00
work eligibility
12:01
because we want to make sure our members
12:03
are retaining the coverage
12:05
because that is
12:07
our
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priority at this time that our members
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retain their coverage
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and are continuing to receive the high quality
12:16
care that they deserve.
12:18
Yeah. Absolutely. And it's there's so many changes
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coming ahead, and it sounds like the health
12:23
plan is sort of looking at them in
12:24
phases and prioritizing that way of what's happening,
12:27
what's gonna start being put into place in
12:28
2026, what's gonna start be put into place
12:31
in 2027,
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and,
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working on it in that way. Has the
12:36
health plan already started
12:38
really shoring up and getting proactive about the
12:41
patient education and the outreach there?
12:44
Absolutely.
12:46
We are,
12:47
we are
12:48
going all out and educating our members regarding
12:51
the changes that is coming down at the
12:53
pipeline.
12:54
At the end of the day, we don't
12:56
want to scare our members, but at but
12:59
also we don't want
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to have our heads buried in the sand
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as well.
13:04
So we are being very proactive. We we
13:07
have developed teams
13:08
in,
13:09
for not only the education part, but also
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how to
13:14
roll out the strategies
13:15
for to help our members
13:17
with redeterminations,
13:19
the work eligibility,
13:21
or even educating them
13:23
with any of the changes that is coming
13:25
down in terms of co pay, benefits,
13:28
and things like that.
13:31
Yeah. Thanks, doctor Paul.
13:33
Where do you see some of the best
13:35
opportunities
13:36
for organizational
13:37
growth in the year ahead?
13:40
Well, again, that is very exciting for me,
13:43
I feel, because, again,
13:46
for me,
13:47
in my previous role as a CMO of
13:50
the Stanford Health Plans, I've worked very closely
13:53
with,
13:55
with the care delivery side, and I saw
13:58
how how important it is for a health
14:00
plan to work
14:02
in tandem with the care delivery side and
14:04
not in silos.
14:06
And that is what I'm focusing here in
14:08
the managed care the Spanish care plan at
14:10
Santa Clara Family Health Plan that working in
14:14
very close collaboration with the care delivery side,
14:17
focusing not only in the out on the
14:20
outpatient side, but also on the inpatient side.
14:24
For example,
14:25
we I have set up processes where,
14:28
our
14:28
nurses are actually in the hospitals,
14:31
and then they are working closely with the
14:34
discharge nurses in the hospital,
14:37
which really helps
14:38
reduce length of stay, readmissions, and so forth.
14:41
And also our care managers
14:44
are, on the helpline side are working very
14:46
closely with the,
14:48
with the,
14:50
with our providers
14:51
on the ambulatory side to help them in
14:54
various,
14:56
scheduling appointments, getting DMEs,
14:58
home health, and so forth. So there is
15:01
a lot of collaboration
15:03
between the between the health plan and the
15:07
care delivery side on multiple,
15:10
angles.
15:11
And,
15:12
and I that's what I see that that
15:14
is how we can have a better outcome
15:18
for our patients.
15:19
Another thing that looking at, and we have
15:22
started slowly,
15:24
is,
15:25
integration
15:25
of AI
15:27
in our member engagement.
15:29
And because,
15:31
I do feel that gone are the days
15:33
where a member wants to be on the
15:35
phone for the longest time,
15:37
and, so they do want instant,
15:40
information.
15:41
And that is the most efficient way
15:44
of engaging a member instead of them being
15:47
on the phone for five, ten, or fifteen
15:49
minutes. So in, so
15:52
using AI platforms, AI chatbots
15:55
on how to
15:56
engage our members and,
15:59
getting them answers for what they need. And
16:02
if there are escalations, then it can be
16:05
escalated to a live person.
16:07
But,
16:09
giving them more instantaneous
16:11
information can be very helpful.
16:13
And, that's where looking at how AI platforms
16:17
can help us in this area.
16:19
We are very seriously looking into that, and
16:22
we'll probably roll out something in the net
16:25
in this year or so.
16:27
Yeah. A lot to look forward to, and
16:29
I think so many great points, which you
16:31
mentioned about collaboration and really focusing on that.
16:34
It really sounds like for that to be
16:36
effective between
16:38
health plans and and providers, it really has
16:40
to be on the ground partnerships
16:42
and support, as you mentioned, with have having
16:45
nurses even work in tandem.
16:48
And lots to look forward to on the
16:49
AI side as well with member engagement.
16:52
Doctor Paul, thank you so much for your
16:53
time today. It's a pleasure to have you
16:55
on the podcast.
16:56
Oh, thank you so much, Erica.