No single organization can solve health equity alone, says Point32Health CEO Cain Hayes

Point32Health CEO Cain Hayes says there are "tremendous opportunities" to advance health equity in 2023. 

Mr. Hayes took the helm of the Canton, Mass.-based payer in 2021. Point32Health formed in 2021 when Harvard Pilgrim Health Care and Tufts Health Plan combined. 

Mr. Hayes sat down with Becker's to talk about the company's approach to health equity, Medicare Advantage and more. 


Question: Health equity is one of your big focus areas at Point32Health. What's a recent achievement in this space you're proud of?

Cain Hayes: There's so many it's hard to pick one. As one of the top-20 health plans in the United States, health equity is a significant focus for Point32Health. We're proud of the fact that we're the only health plan in Massachusetts that provides coverage for every segment of the population. For members that have Medicaid, Medicare, Medicare Advantage as well as the ACA exchange and commercial segments, because we believe that everyone should have the opportunity to achieve their best health. Determinants of health equity are so important as it relates to that.  

We're also proud of the fact that we're the first health plan in New England to receive the NCQA Health Equity accreditation. It truly is a testament to all the great work of so many of our colleagues that are focused on access and helping people in our communities get access to quality, affordable healthcare. 

Colleagues at every level really have this as a significant focus. Last year, we launched what we call the Point32Health corporate health equity program. We have over 70 initiatives focused on health equity throughout the organization, so it's hard to choose just one. We created this program to really drive broader impact to really drive better overall outcomes. 

The way we think about health equity is that no one organization can solve it alone. It requires collaboration and public and, frankly, private partnerships. 

Q: You serve every segment of the market. How do you tailor your health equity approaches in different populations?

CH: We believe there's not a one-size-fits-all solution to health equity. For example, in our Medicaid population, we recognize that there can be more challenges with the social determinants of health, which include safe housing, healthy food, transportation, language barriers. For that population, we really zero in to truly do an assessment of our members to understand where there's gaps and where their needs are, and then connect those members to the resources that are in the community that can help serve those needs. Whether it's partnering with the food bank for food insecurity, those are some examples of how we tailor programs specific to those populations. 

Q: What is the biggest challenge payers face when addressing health equity?

CH: The biggest challenge, I would say, is around the tracking of comprehensive data, inconsistent data, related to health inequities. This is getting better, I have to say, because it's been a focus for several years. For several years, gaps existed in [the data on] access, cost and quality for patients based on race, ethnicity, gender, age, sexual orientation and other demographic factors. These inequities meant that gaps were often unaddressed. At Point32, we remain laser focused on continuing to work diligently and providing up-to-date and in-depth data to our providers. We believe that's very important. The data is crucial to advancing health equity by identifying health disparities, and developing interventions to address them, and measuring the success of our health equity initiatives. 

Q: Tufts Health Medicare Advantage plan has earned a five-star rating eight years in a row. How do you maintain these quality standards, even as CMS has shifted its methodology for calculating ratings? 

CH: First is just to continue to guide and empower our Medicare members to live their healthiest lives. I'd also say that we want to ensure that our Medicare members have access to high quality health benefits and services. We need to continue to have strong collaborations and partnerships with the provider community, and comprehensive programs and initiatives, including our care management programs. We want to help members manage chronic health conditions for better health outcomes. 

Lastly, I'd just say to continue to provide members with excellent, personalized customer services to help them navigate health and well-being in this healthcare system. 

Q: Point32Health was formed by two plans joining forces. Other nonprofit payers have made moves to combine recently. From your position as a nonprofit plan leader, do you think further consolidation is the way plans are headed? 

CH: No, I don't necessarily believe consolidation is the way forward for nonprofit payers. There are many state and regional nonprofit health plans across the country that are doing some great work at delivering innovative programs and initiatives, and delivering great value to their members, and to the community, which is really key. 

Now of course, through the combination of Harvard Pilgrim Healthcare and Tufts Health plan, we created our parent company Point32Health, and we're able to deliver greater value to our members and the communities that we serve. We've had a number of successes over the last two years as a combined organization in terms of strengthening our position of providing access to quality, affordable healthcare to our members in an easy-to-navigate experience. 

Q: What's the biggest challenge on your mind in 2023? 

CH: From a general healthcare landscape perspective, I believe there are a number of challenges that the industry is facing now and will continue to face. First, the last several years have been incredibly challenging for the healthcare system. Doctors, nurses and other clinicians are stretched to the brink. There are significant staffing shortages at healthcare systems, and health systems are really being forced to be creative to fill those clinician gaps to care for patients — outsourcing firms, et cetera, which can come at a higher cost. I expect there will be an overall impact in healthcare costs in 2023 as a result of this. While not close to the staff shortages of health systems, we're also facing some challenges as it relates to open positions across the country. 

The next thing I would say is affordability of healthcare is a challenge. Providers are looking for, certainly, higher rates given COVID-19 costs. That kind of leads to the next piece, which is where I believe COVID-19 will continue to be a factor in 2023. Like many other healthcare companies, Point32Health experienced higher medical trends in 2023, including the cost of COVID-19 vaccine administration, treatment, et cetera, as well as the cost of deferred care as a result of the pandemic. As you can imagine, the impact of COVID is difficult to forget, but we believe that there will be an ongoing impact. 

I'll say that while I don't necessarily see it as a challenge, but more of an opportunity, I believe there's tremendous opportunities to develop new healthcare initiatives, programs and measures to advance health equity across the New England region and, frankly, the country. 

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