Introduction

Inland Empire Health Plan, or IEHP as it is commonly known, is a large not for profit health plan serving now over 1.5 million low-income, high risk Medi-Cal members in the Inland Empire. Started in 1996, it grew to be one of the largest Medicaid/Medi-Cal health plans in the nation with over 2000 employees. It is governed by a public Board and has strong ties within the community it serves.

Given the nature of the members that it served, it was critical that a positive, member and provider focused Team Culture was established and maintained to ensure that members and providers who served them received the highest level of customer service, and that medical decisions and policies always focused on “doing the right thing”. Balancing available funds and the need to provide accessible, high quality care for the members needed to always result in members getting the care they needed, and providers being paid as much as possible within the financial constraints of the premiums from the state.

I joined IEHP in March 1996 as employee #10 and helped create and improve the health plan. I served as the Medical Director, Chief Medical Officer and for the last 10 years of my 23 years with IEHP I was the Chief Executive Officer. I retired in July 2019.

This case study focuses on those last ten years I served as the CEO and describes how a positive Team Culture was nurtured and improved over that time.

Top Leadership Critical

Clarity and rigorous adherence to our Mission, Values and consistent, positive macro and micro decision making had to be done by all top leaders. Whether it was making macro financial decisions or making critical individual decisions about members’ health care, our mantra was “Do the Right Thing”. That meant that all decisions had to be weighed against what was the best for members and providers in general, but also in individual cases. Two illustrative real scenarios:

  • During a state budget downturn, the Department of Health Care Services implemented a 10% cut in most provider payments, with a subsequent lowering of the premium paid by the state to IEHP. Medi-Cal payments were already some of the lowest in the nation, and a further 10% cut would have been very difficult for our providers. We made the decision to not implement the reduction and absorb the premium reduction using our reserves. That would not have worked in the long run, but we assumed that the state finances would improve over time and the cut would be rescinded, which it was a few years later. It did impact our bottom line for those years, but we survived financially and accrued very good will from our providers. The decision was made by the CFO and CEO with permission from our Governing Board.

  • At one point we had a 12-year-old boy with neurofibromatosis (Elephant Man syndrome) who needed a very high end specialty consultation. The tumors with this syndrome are usually benign, but in his case he had a rare malignant tumor. We investigated the best place for his consultation and determined it was Johns Hopkins University in Baltimore Maryland. We flew him and his family out there, paid for hotel costs and of course the diagnostic and treatment costs- which, due to their unwillingness to contract at reasonable rates, cost us over $500,000. It was the right thing to do, and he had a good outcome. Care within our system, by specialists that were not as familiar with his rare condition would have cost much less but might not have had the same good outcome. The decision was made by the CMO and CEO.

Staff Engagement Crucial

“Top down” even with good leadership does not always work to fully engage staff and drive positive culture; it was necessary to have bottom up engagement and staff initiative for “Doing the Right Thing”. Engagement with the staff, managers and directors was accomplished in the following ways:

  • For the last 5 years of my CEO role, we implemented a company wide LEAN strategy. The focus was operational excellence and decision making at the lowest level possible. The effort included Managing for Daily Improvement (MDI) huddles throughout the organization, both specific to the unit and cross department joint huddles. At any one time there were 40+ huddles occurring daily across the company, led by staff, supported by supervisors, managers, and directors. This encouraged staff to create experiments to improve processes, to make decisions on direction within scope and engaged them in determining needed changes across departments. We also did multiple Value Streams and literally hundreds of Rapid Improvement Events. Those events further engaged staff to have input to operations, processes, and decisions to best serve our members and providers.

  • High level of engagement with staff by top leadership- all senior leadership were encouraged to do “walk arounds” (our building was only two stories with a huge footprint so easy to walk the entire building or parts of it reasonably quickly) to see and engage with staff. I made a point of learning hundreds of staff names- early on I knew the vast majority; that became more difficult as we grew (it was a company legend that I literally knew everyone’s name). In addition to walk arounds which I did frequently, I and senior leadership would schedule time to sit with staff as they did their jobs- member services, claims, care management, and many other units. This was a combination of “connecting” but also doing the Gemba- going to where the work was done to watch. Almost every time I did it, the staff and I would think about potential improvements to processes that could be then presented to the supervisors and managers for review. That encouraged staff to bring ideas forward in the future.

  • Job interviews - during my tenure I required senior staff on a rotating basis to interview all final candidates for all levels of positions, I interviewed all finalists unless away from the office. This accomplished two goals: making sure we were selecting candidates that were not only qualified but fit with our mission, as well as giving myself and senior staff the opportunity to make clear our expectations around our mission and values. Many employees remembered their interview with me and senior staff and said it made a significant impression compared to other companies- where in many cases they never met senior staff or the CEO.

  • Personal connections - part of my personality and being a physician, I would personally connect with any Team Member that had something adverse happening in their life- medical or personal issue, or other difficulty that was known by their supervisor and okay for them to talk to me about. I would go to their desk or office, be private as needed, but make sure they were okay and if the company needed to do anything for them. This was very visible to the Team, and much appreciated by staff.

Communication

Constant communication and reinforcement of our mission, values and “do the right thing” mantra was very important in maintaining those ideals front and center for staff. Channels for communication included:

  • CEO emails - I would do emails every one to two weeks, informing staff of significant issues or events that could impact IEHP or the staff. Non-ideological political information, state budget or other updates, changes in federal or state law, organizational changes or just commenting on current events all served to keep the staff updated and feeling informed. I would continually reinforce our mission, values, and our mantra in those communications.

  • Monthly All staff meeting - we would use a large open area in the middle of the building that could seat 600 people and do multiple shifts. I would be the Master of Ceremonies (often sharing pictures of my grandchildren to warm up the crowd) and then a unit or department would do a more in-depth presentation of work they were doing, our quality metric results, or a key policy issue that we wanted to discuss with the team. We would take questions on any subject and thus engage around any concerns from staff. This always made me a bit nervous given the crowd, but ultimately it was positive.

  • Staff meetings - senior leadership and I would attend staff meetings to listen and be available for questions or concerns from staff, supervisors, etc. As an example, I would frequently attend the monthly 7am Member Services staff meeting and be available for questions from our front line staff that took member phone calls.

  • Walking around and personal connections - as mentioned above I and senior leadership would do walk arounds to engage staff and be visible. I was often stopped for a conversation about a member, or other issue that I could then interact directly with a nurse or other staff member and reinforce our “do the right thing” approach by discussing the specific issue or concern raised. As a physician, I could interact around clinical issues as well.

  • Open Door policy - all senior staff were encouraged to have an “Open Door” policy to encourage staff to make an appointment or literally stop by to discuss concerns or questions. As expected, I did not have frequent encounters in my office with staff, but when they happened I made sure the team member felt heard and would follow up as appropriate on the issue or concern raised.

Fun and Being “Human”

IEHP organized multiple events during the year for Team Members, including a very engaged and competitive Halloween costume competition, BBQs for the team, Thanksgiving pumpkin carving competitions, Christmas unit area decoration contests and many potlucks for any reason. Participation was very high at these events with senior leadership including myself as servers at food events, judges at the competition and as a group doing a themed costume dress up. These events were fun and appreciated by staff as well as reinforcing the positive connection between leadership and the Team.

Personally I worked hard to connect with staff on a personal level, sharing pictures of my grandchildren at the all staff meetings, joking about how my psychiatrist wife was responsible for who I am and telling personal anecdotes from my time as a primary care physician to reinforce the needs of our members- my entire practicing physician career was caring for low income, at risk populations including jail medicine, substance use and mental health co-morbidities, etc. I feel this connected me to the team on a deeper level and was a model for my senior leadership.

Results

So, the key question is: did all of the above work? How best to measure it? Here are some results below:

  • Employee Engagement Surveys by national organizations:

    • 2017 - The Advisory Board - participation rate = 96.8% Engagement = 92nd percentile

    • 2018 - Advisory Board - participation rate = 95.8%/Engagement = 89th percentile

    • 2019 - Press Gainey - participation rate = 96%/Engagement = 92nd percentile

    • Our survey was compared to the vendors national book of business

    • Our participation rate was well above their average

  • There were units and departments that were better than others, but the commitment to our Mission and Values was very high across the board. We had an extensive follow up process with the results down to the staff meeting level. As just one example, our Credentialing Unit went from one of the lowest scoring units to 100% engaged within one year, by focusing on engaging the staff in the LEAN process to get their input and implementation of improved processes for their unit. In addition to improving the engagement, the time for a full credentialing process and the inventory of credentialing packets both went down substantially.

  • Provider Surveys by national organizations:

    • In summary, our provider surveys consistently ranged from the 95th to 99th percentile for provider satisfaction overall and “recommending us to other providers” when compared nationally to other Medicaid/Medi-Cal plans. When the surveys asked the providers to compare us to other health plans they worked with in the Inland Empire, we scored the highest.

  • Member Surveys- on an annual basis we administered the Consumer Assessment of HealthCare Providers and Systems (CAHPS) survey, which is a validated, standardized, anonymous member survey used by all health plans that are National Committee for Quality Assurance accredited. Our results were mixed, but consistently we were in the 90th percentile nationwide for Customer Service which included any contact with health plan staff by the member. That measure was the most “controllable” by us in terms of our Member Services, Care Management, or other clinical staff that talked directly with members. We did not do as well for our members’ satisfaction with our doctors or other parts of the healthcare delivery system- which is true for most California Medi-Cal plans.

Conclusion

Given our responsibility for organizing the care for over 1 million low-income, at-risk members, IEHP was very focused on developing, maintaining, and improving a positive Team Culture that was focused on “doing the right thing” for our members, providers, and our Team Members. I believe we accomplished that goal through a combination of “top down” and “bottom up” leadership and engagement. Our results of externally implemented surveys with national comparisons demonstrated strong engagement by the Team, and positive responses by our members and providers. We were known as the “Health Plan with a Heart” and that was demonstrated by leadership and staff on a daily basis.