Improving Access and Transforming Healthcare Delivery with Rosemarie Day, President of Day Health Strategies

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: Welcome to the outcomes rocket podcast where we chat with today’s most successful and inspiring health leaders. I have an outstanding guest for you today. We have the privilege of welcoming Rosemary Day, president of Day Health Strategies. Rosemary has over twenty five years of health experience in the public private and non-profit sectors including 16 years of leadership experience in state government. Most notably Rosemary served as the founding deputy director and chief operating officer of the Massachusetts Health Connector where she played a significant role in launching the award winning organization that established the nation’s first state run health insurance exchange. In 2010 Rosemary founded day health strategies to focus on implementing national health reform. Her company now serves organizations across the entire country that want to transform their approach to offering or delivering health care. She also holds a faculty appointment at Northeastern D. A more McKim’s School of Business. Previously Rosemary was a chief of staff to the dean of Harvard Kennedy School. She also served as chief operating officer of Massachusetts Medicaid program and has held several senior leadership fiscal positions. She holds an MPP from Harvard Kennedy School and AB from Stanford University folks. She’s got an excellent background to be diving into policy government. And it’s our privilege to welcome Rosemary to the podcast. Welcome.

: Thank you very much Saul. I’m delighted to be here.

: So Rosemary anything that I left out there that maybe you want to fill in the guest on.

: Now actually I think he really covered it. I appreciate that great intro. Very thorough.

: Thank you very much. Thank you very much. Well it’s you’re definitely doing some impressive things when you go back to the genesis of it all. Rosemary what would you say was the catalyst that made you get into health care?

: Well I think I had always had an interest in kin of some of the inequities in our society. And the question was where would I actually apply my energy to because there’s so many opportunities where you could work on the issues and you could work on housing policy or you can work in healthcare any number of areas. And what happened was I entered state government and worked a lot of welfare reform initially. But the Medicaid opportunity actually kind of presented itself after I had different leadership. And I kind of left at it because I just saw that program size and importance and complexity as just being like the challenge. I wanted to take on. So I said yes.

: That’s awesome.

: That’s really where I got my start. And then it went from there. That’s how I took the plunge.

: That’s fascinating now. And so you took the plunge in a big way. You’ve obviously you’ve served in many different capacities. Today, Rosemary out of everything that should be on the agenda of medical leaders would you say that one thing is that can no longer be ignored?

: I really think it has to do with making sure that all Americans have access to affordable and quality health care. And I know that that can sound almost like a campaign ad but I don’t want it to. I just really fundamentally believe that the best way to improve our outcomes is to give people access to that health care coverage. And we have made some pretty significant gains frankly thanks to the Affordable Care Act. But those gains are at risk of eroding and while we’re starting piece with that. So I worry about how that will affect the whole system because if you are running any sort of business in the healthcare industry. You need customers and..

: Right.

: We need customers who can pay. And as we all know health care is expensive and not everyone can afford to pay for stuff out of pocket. So the fact that we’ve got no significant gap still today is something I think we need to continue trying to address.

: That’s a really interesting point. Rosemarie so what would you say some of the key areas of erosion that are happening?

: I see it in two ways. One is just that some people who had insurance are losing that coverage or are choosing to stay choosing with quote are choosing to drop that coverage because they find it to be too expensive. If they don’t have the benefit of employer sponsored insurance and they’re buying on their own for the open market and don’t qualify for subsidies, they’re going to find the cost will be increasing at rates that that could be unsustainable for them. So that will force some folks to drop coverage. The other is that people who do have health insurance coverage are really worried about whether they’re going to lose it if they lose their jobs and insurance that goes with that job. Could they afford to buy on their own or even even if they have employer sponsored coverage that’s facing a lot of cost pressures a lot of the time employers are moving more of that the cost sharing onto their employees will so they see you know higher deductible health plans in other ways. To kind of lean in and it again that could start to be a bridge too far for folks who are living from paycheck to paycheck.

: And there’s a lot more of folks that are living from paycheck to paycheck than we like to think. And this is a very real issue. Listeners, if you think outside of your day to day this pool of folks that are uninsured and are looking to be insured is a growing number. Most recently as I recall there is a sort of a shortening of the sign up window and a decrease in the marketing budget for the government insurance programs. I think he went from 100 million to 10 million. It went from I think five months to maybe 90 days or 60 days. So you know other things that Rosemary is referring to are very real. Rosemary what would you say right now like with the practices that you’re leading here with your firm is the key to making a positive change?

: You made some good points about places that were the you know the Affordable Care Act. It felt some pressure it certainly as you said the outreach period kind of shortening it was actually down to 6 weeks though. I think there had been a plan for that to happen over time anyway even if the Obama administration had still been in office that they didn’t want to get it closer to where commercial openable that periods are. But I think more significantly has been that the cost of insurance is going up so much because of a number of different things that have been decisions made by this administration to not support of the subsidies that existed under the original Affordable Care Act and also to kind of loosen some of the market standards. These are proposals that are imminently going to be coming out around short term health insurance policies that will kind of take have the effect of taking some of the healthier people out of the marketplace and leaving those in the exchanges probably the folks who need health insurance because of their health conditions a little more which can then increase the cost of that insurance. So there’s a bifurcated risk pool risk that we’re going to be facing and for a number of reasons a lot of uncertainty. Insurers say they find it hard to keep the prices down. And so that will hit folks harder. What I’m seeing though and this is what is so interesting in the world of of health policy is that state depends on always kind of swings and when the federal government is doing things that they felt like, they can look for ways to step up and kind of do some countervailing measures and that can happen with any kind of administration that. States will look attempted to counter what’s happening and I think we’re seeing some of the States stepping up to look at ways to shore up what was built in the individual insurance market. And that includes contemplating implementing a state based mandate and working with the state right now that is taking a serious look at that will came out last week with New Jersey just pass one and that’s to mitigate the effect of the mandate repeal mandate penalty repeal that happened last December under the Tax Act which will also have the effect of driving up insurance rate.

: Yeah that’s really interesting. So the effort of states is definitely you’re seeing it increase as far as trying to get the mandate back.

: The mandate is probably one of the most controversial aspects but there are other things that get into that whole world of insurance regulation where state insurance commissioners have an opportunity to take a look at their markets and set their own regulatory rules around things like the short term health plan.

: Yeah, that it’s interesting. I mean as we think about the health of communities and populations there’s no doubt Rosemary’s point is so true that you got to give people access. You just have to. So what would you think Rose-Marie is an example of maybe work that you’ve done that’s helping us get closer to that?

: So I’ll get to that with one second I want to make the point that you don’t want your only point of access for people to be the emergency room because that’s highly cost inefficient. And if you if your health condition is really a manageable chronic condition like diabetes, you don’t want to manage that to the E.R.. You want to be able to manage that through preventive care and that’s really where I think you make the case for coverage so that people can avoid those really acute conditions and be able to manage stuff at the front end. So that’s my plug there in terms of..

: Such a great point.

Yes. So the things we’ve worked out with organization is to help them to understand in this changing environment and there’s policy shifts. How do they strategize about what’s going to happen with their patient population and what’s the best way for them to proceed in this kind of very changing environment. So we’ve worked with a lot of organizations to look at those kind of major political and market force changes and strategize around that. And I also really like to work with organizations around how they actually develop what I like to call their own maturity to deal with these kinds of changes and so we have a model that we use that allows organizations to kind of see where their strengths and weaknesses are. And that way we can hone in on what are the areas that really will get the work done to bring them up the curve of managing and as we say ever changing environment.

: Well you’re definitely at the heart of our reform there. Rosemarie and what has been one of your biggest takeaways in the many years that you’ve been involved in and this type of health care reform that you want to share with the listeners?

: I think it’s amazing. It’s interesting that you can accomplish so much actually with very few people. And you know I had originally worked with very large government programs like Medicaid. But when we were launching the state health connector that first one out of the gate, we had a very small pool to begin with. And what we were able to accomplish with a small number of people but were extremely motivated to make something successful on a very tight timeframe. Having everybody energized and rolling the same direction it just kind of phenomenal what you can accomplish in that regard. And that that was for me kind of breathtaking to see where we didn’t have the usual kind of larger organization bureaucracy and we actually had bipartisan political support. You could just accomplish a great deal with relatively few resources. So that was a big left word for me like how back is the living how that can actually happen and it was very exciting.

: Now it’s inspiring. And so when you looked in the rearview mirror of that when you’re just like wow it doesn’t take many but it takes committed few.

: And not having people working at cross purposes.

: You know the alignment piece is key right?

: Yes, very.

: Love that. Now Rosemary you’ve had a lot of wins on your record. Can you tell the listeners of a time when you had a setback and what you learned from that setback?

: Yeah, it actually is kind of the other side of the when. So I would say the launch of our of the state’s Health Connector here in Massachusetts and what that begat was with very exciting for somebody who started out as a policy student and thinks about the state of a laboratory of democracy and being able to seethat it had the potential to go even beyond our state which I didn’t even imagine when I first took the job. But I think during the really rough and tumble of startup stage that we had and I was there for the first four years we got to a more stabilized place. And what was interesting in the arc of that of getting out of that crazy first year start out and more into like the way a real organization should run. Not putting out fires every second but trying to get a more sustainable low. I learned that there were people who were absolute that we brought onto the team who were just superstars in that very hectic kind of crazy stage of the year one startup and then when you got to a place where the organization started to run more and more I would call normally the way I was used to much more established organizations running. Some people were not as good of a player in that stage. Some people could make the transition and some people couldn’t. And I it took me a little bit to understand that because I hadn’t been through that transition before. And usually when you’re giving people reviews you’re thinking well they’re so great at. Like they got us through year one but now we’re like in year three. And you say, huh, OK. You know people can can be great at multiple stages but some people are really probably better for year one day. That was a real lesson learned for me.

: And that’s a really interesting thought too, right because if we’re as we’re thinking about these types of transitions you know health leaders wearing our hat. We’ve got to deliver on a certain metric or a project and Rosemary’s point is interesting right because the person that could help you in startup mode really may not be the one that gets you through the next step. How do you plan for that Rosemarie. Like what suggestion would you offer listeners that are maybe potentially going through that change right now?

: Yeah well I should also mention the flip side was there were a lot of people I tried to recruit who I knew were really great producers who didn’t want to take the risk of coming to a startup and yet keep them in your contacts list because they may be the ones who are great for when you’re more established right that they just weren’t comfortable at the super risky stage and then kind of that Converse is what I was you know the other point I made which I think is just being aware that you need to kind of think about that risk takerness and it’s been almost like a personality inventory and I’m not going to recommend one product or another but that at least in the back of your mind keeping out awareness of like it’s not just the expertise around a particular knowledge set. Of course we needed that too. But that appetite to lead and manage through change that you’re looking for and then naturally to sustain change. And I think it’s OK to say well you know what. I’m glad we hired who we hired in the beginning because we needed them for the launch. There were a lot of people who just give or take that kind of thing on but understanding that you’re going to need more and more for your leadership team and your need change.

: Such a great call out and personally a big fan of doing personality and aptitude assessments when forming teams whether it be the Myers Briggs or shrink’s finders whatever it may be. It definitely helps. And they always say always be closing but I always tell my my team always be interviewing and the Rosemary’s point right if it doesn’t work like you got that year three person and you’re at the beginning keep them in your Rolodex.

: And I think we are one. Yeah as got to say Rolodex not to date myself here but thank you for saying that.

: I am old school.

: I get it. I think that as you get to know people over time you get more you’re able to kind of gauge whether somebody is just a really strong individual contributor or they’re a really strong team player. And I think when you’re doing crazy days in start u,p it was OK to have really strong individual contributors there wasn’t even time and time to do really as a team. But over time you need to. So that’s a quick gauge.

: I think that’s so great so great Rosemary great notes for our listeners that are leading organizations and building teams and businesses. So that’s a great callout. How about one of your proudest Healthcare Leadership moments that you’ve experienced today?

: I think it’s really been the fact that we were able to successfully launch you know the Health Connector in a bipartisan fashion. And one day and that framework became a model that can be used across the nation. I wish it had been launched in a more flexible way so that states can really tailor it more because I do think there’s such tremendous variation across states and we do respect that and have some national standards but not necessarily superimpose all that. So I do wish there’d been a little more of that flexibility but because you know Massachusetts Well we set out a framework. We can’t speak for the nation on everything. I get that. So I’m proud of it. But I would be a kind of a man that asterisk say hey wish we could have made a little more flexible.

: Yeah in retrospect but you guys did a great job obviously served as a as a template for the rest of the nation to follow. So you’ve left a really really great fingerprint on the way that things are done. Health coverage is obtained at the state level so kudos to you. Thank you so Rosemary. What’s an exciting project. Our focus that you’re working on today?

: So you know there’s a couple of things. One is that we have as a firm been looking at how to really help folks once they do have coverage. And I’m really excited about the Accountable Care Organization World and really trying to get care to be very patient centered and tool oriented and all those good things the collaboration to help patients manage their care across specialist and their primary care provider. We’re excited to be doing that in Massachusetts actually to the state Medicaid program and that’s just like this year. So that’s been a base project we’re working on and I think it’s the life extension of get you know once people have coverage and really tried to help them use that coverage effectively to improve health. My also alleged to have two things the other project on a personal level that I really want to try to encapsulate what we learned from launching the prototype for the ACA and what we’ve learned and kind of this whole debate about in our country about health care coverage and really try to get this book together that will give people an action guide of how we can continue to make progress.

: Very cool. Say a book on the horizon. I do love it. And you have a launch date or publish date?

: Well it needs to happen in 2019 at some point. That’s my goal. I can’t pinpoint the day but it’s an aggressive deadline and I’m just trying to find more hours in the day.

: Well Rosemarie I would pick that book up. So when you launch it and I know the listeners would too. So let’s make sure we get you back on because we want to hear about it right?

: Fabulous thank you.

: Absolutely. Definitely some some great learnings here folks. If you haven’t had a chance again we’re talking to Rosemarie Day. She’s the president at Day Health Strategies. Very experienced leader in health care and also government health projects. You want to hit the rewind button if you missed the beginning of this because we definitely have been talking about some really value added things that you could be considering for building organizations and even the impact of the things that are going on with the ACA. Getting close to the end here. Rosemarie let’s pretend that you and I are building a medical leadership course on what it takes to be successful. Let’s just call it health policy today. The 101 of Rose-Marie day so four questions lightning round style followed by your favorite book that you recommend to the listeners.

: Great, sure.

: All right. What’s the best way to improve health care outcomes?

: Coverage.

: Love the brevity. Haha. Love it. What’s the biggest mistake or pitfalls to avoid?

: Making it to pass work and confusing complicated and throwing in like skimpy coverage. People need adequate health care coverage, not stuff that’s masquerading as that.

: Love that. How do you stay relevant as an organization despite constant change?

: You know I’m going to say people need to embrace change and I know some people are more change averse. But you’ve got to have a critical mass of folks on your team who are excited about change and want to learn so that you can truly create that learning organization environment. That’s how you can be really successful.

: What’s one area of focus that should drive everything in a health organization?

: I think the mission orientation to really truly improve health care whether that’s a patient centered perspective or making it more affordable and accessible more efficient, better solutions through technology. Any of those kind of things that stay focused on that mission because you’ll attract great talent folks who really do want to make a difference.

: What book would you recommend to the listeners Rosemary?

: So I know you originally said to many about your all time favorite book which is a super hard question to answer. I’m just going to focus it on a really great non-fiction book that has been on the bestseller list for a while now for good reason and that’s called being mortal by Atul Gawande. And I don’t know if he’s had a lot of other interviewees mentioned this book but I highly recommend it. Atul Gawande has written a book that I think has gotten us out of the kind of unhelpful rhetoric around death panels and really into a place where we can have a conversation about what should be happening at the end of life. From a personal and you know a policy or societal perspective. And he was courageous enough to put it in the frame of the story that he could tell them not to her world practice but his actual personal life be to be his father. And I think when people are willing to personalize things like that who are you know as smart and informed about the broader issues packaging that into one book it’s very accessible for people and it opens up the door for a lot more conversations both at your own family level and in a more systemic level.

: But a great summary Rosemarie and yeah you know the book’s been recommended by a few I guess but nevertheless the recommendation here from you cements it as a must read. So listeners if you haven’t gotten to On Being Mortal by Atul Gawandi, you have to. This is this. Yeah. So if you want more information the transcript, links to the book that Rosemary suggested, links to her work and her site. Go to outcomesrocket.health/day, as in Rosemarie day, D A Y. You’ll be able to find all the show notes and transcript there. Rose-Marie, before we conclude. I’d love if you could just share a closing thought. And then the best place where the listeners can get in touch with you or follow you.

: All right well to find me and you can send me your link and my name Rosemarie Day and I’m also fairly active on Twitter both through my company and personally so @DayHealthStrat or @Rosemarie_Day1. So just a closing thought. I’m very struck by I think the power we have if we want to improve our health care outcomes and as I said I think coverage is a big key step to doing that. I think we can achieve that with the power of collective action and if the people understand how it pertains to all of us that will individually and collectively as a society benefit from putting more in that direction. I think that’s really what I’d like to leave people with as a thought.

: Some great shares there Rosemary and inspiration you left us with to not settle and find those people like minded that are willing to do what it takes to make these programs succeed. So really again just want to say a big thank you to you. Thanks for carving out the time for us. And we’ll be in touch for when your book launches.

: And thanks so much, I really enjoyed it.

Thanks tuning in to the outcomes rocket podcast. If you want the show notes, inspiration, transcripts, and everything that we talked about on this episode just go to outcomesrocket.health. And again don’t forget to check out the amazing healthcare thinkathon where we could get together to form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is implementation is innovation. Just go to outcomesrocket.health/conference that’s outcomesrocket.health/conference and be one of the 200 that will participate. Looking forward to seeing you there.

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