IMI Signature Series: Karen Dale

The Institute for Medicaid Innovation (IMI) Signature Series profiles IMI volunteers about their work, passions, and experiences.

Interview with Karen Dale, IMI Board Member.

The interview has been edited for brevity and clarity.

Can you provide background on your work and how it led you to your involvement with IMI?

I have well over three decades of working in health care and its related components. In each space where I’ve worked, I’ve had a focus on positive, sustainable gains and improvement. While we can simply guess at the way to make these gains, it’s important to make sure the right voices are present to inform our work and ensure it is more rigorous as we are studying, understanding, quantifying, and evaluating.

When I met [IMI founding executive director, Dr.] Jennifer [Moore, PhD, RN, FAAN], way back when, I was struck by the rigor that she brings to all of this work. It strengthens the work to take that time to gather information in a very scientific way, to evaluate data, to come up with recommendations, to test, to gather all the appropriate voices. When I saw that, that’s when I said, “Yep, I’m in it for the long haul.”

That’s how we create sustainable change. Change can happen in peaks and valleys, but when we are in the valleys, it can actually be harming communities. We’ve got to spend the time on the rigor to ensure that we’ve given the change the best chance of doing the good we intend.

It’s interesting that you mention those valleys. There’s been a recent study that found that in the field of women’s health, individuals covered by Medicaid faced, on average, 44% longer wait times than individuals covered by commercial insurance. From your standpoint, what implications does this have for eliminating disparities and creating the sustainable change you spoke of?

It is a full indication of how bias and racism is embedded in the fabric of our nation, and it is something that must be tackled. It is actively harming individuals. This is not something that just happens with no ill effect.

I’ve also observed that the person who is harmed is then also blamed.  They are said to be noncompliant; they won’t come in for their visit, expectant moms are told they are coming in too late. That may be factual, but we have to understand the “why.”

I’ve always been puzzled that, in health care, we do not treat the members as consumers. In any other business, if you go to a website, people know what you clicked on first, and if you clicked that first, the next time you come back, there’s an update based on that behavior. We are using all these analytics to understand and make things easier for customers. Amazon says they are “customer obsessed.” It’s beyond saying just “we care about our customers.” They say, “I’m going to make your life so easy, that you will be freed up to do other things.”

If I need air filters—and we’re talking air filters, not my health—and I order them with a determined frequency, they are going to set up a nice reminder telling me it may be time to order again. They make it easy. They pull it up and all you have to do is click. But in health care, we’ve decided that it does not require that same level of customer obsession.

So, here’s what would look really great to me: these women would be able to make an appointment at a time that is convenient to them.  If I have young children and I work—which is often the case in the District of Columbia—there are essentially no late afternoon or evening appointments, or even appointments on Saturdays. So, we’ve not leaned into the idea of what access really means. Access means I can conveniently get the care I need; that means how far I have to go, when I go, and the kind of practitioner.

I was speaking at an event for the [Centers for Medicare and Medicaid Services] CMS recently, and I was talking about the twofold definition of what access really means. It’s all the things I just mentioned, as well as the culturally responsive component. The culturally responsive component would say that if I am a Muslim woman, don’t assign me a bunch of male clinicians, because I can’t go see them. We need to pay attention. If we remove these implicit biases, not only do you have access to care in the ways I said before, but when you go to the appointment, you’re treated with dignity and respect.

I talk to our members, and I hear repeated stories like this. There’s an assumption that if you’re on Medicaid, you must not be so smart. I’ve spoken to members who have called multiple friends of theirs who have commercial insurance—they’re doing their own study—and they tell me, “Ms. Karen, they get an appointment so much faster.” So, the members have spoken, but now we have it fully documented as research.

It has terrible implications for the health and well-being of who we serve, who we know are often of higher risk for a whole host of lived experience reasons, and then you’re going to make it harder for them to get an appointment when they are trying to get the help they need? Not good.

The study only focuses on women’s health. It does take into account race or ethnicity, though all of those obviously play into this as well.

Oh, I can tell you right now if you look at it by race and ethnicity–and it’s interesting the excuses people make for not looking at that. They say, “oh we don’t have enough information; we have too small a size.” Self-report works just fine.

It’s so interesting to hear that when you talk to community members and you listen and learn about what’s really happening, you know what’s really going on, but of course it takes a study to get people talking about it.

I wanted to ask if you would like to speak to how your training as a nurse has helped in your work addressing disparities in Medicaid.

It starts with systems thinking and not believing that there’s one component that will address what’s needed. Just like our bodies function as full systems, this idea that we can treat someone for behavioral health because it’s here to here [gestures to head], and a heart condition because it’s from here to here [gestures to heart], and a stomach ailment because it’s from here to here [gestures to stomach and laughs].

You know what I mean? When, in fact, they could all be connected. For example, if I have anxiety, it may or may not require medication, and if there’s a panic attack, there’s a physiological response, too. I may be  more likely to have a certain headache, and heart disease may also run in my family. We are human beings in all of our wholeness and complexity.

When we think about public health or how we approach creating delivery systems and being responsive to the needs of human beings, all that needs to come into play. I believe that nursing school is a great place to learn about systems.

If you’ve ever worked in a hospital, it’s all those cooperative components that need to come together in order to make it work. And now they are even rethinking what happens in hospitals. They are no longer the place. How does it become more of an extension so there’s more of a handoff. There are now discussions of hospital-at-home concepts. What if discharge wasn’t just giving someone a piece of paper and instead follow up happened in a better continuum with the same information following the person?

This idea of systems thinking and applying the principles of human centered design, now we are talking. I feel like I learned a lot about that and applied that thinking in a systems way to inform how we lead, how we focus on and measure goals, and how we design things. I feel like nurses often bring that to the table.

I like to wrap up these interviews by asking if there’s one thing or project, big or small, that you’re working on right now that you’re excited about and would like to share?

I co-chair the health equity advisory team for the innovation unit in CMS, [Center for Medicare & Medicaid Innovation] (CMMI), and Jennifer is on that committee, as well. Why that excites me, is that’s the area that can affect all the other things I care about: maternal health, child health, behavioral health.

Those things have very high, predictable potential to improve the lives of people served by Medicaid, but we have to have a system to pay for it. So, all the work we do is focused on alternative payment models. How do we structure things, whether it’s bundled payments, or a type of capitation tied to quality? We’ve got a wonderful theory of change we are working through.

One of the things I’m so excited about is working with community-based organizations. We have this wonderful asset that has the trust of the community, except insurers often say, “we have to do it all.” When we lean on the community-based organizations, we’re not reimbursing them in a way that acknowledges the work they do, and we can come up with an alternative payment method for that.

It’s not the be-all, end-all, but even if we make medium-sized, incremental steps in that direction, that could have an enormous ripple effect on improving care delivery and having us have a better system design to create better outcomes.

The reason we are including this with equity is that, in Medicaid, there’s often much higher levels of clinical and social complexity, and both need to be addressed with equal attention. Think about someone who is insulin dependent, diagnosed with diabetes, but who does not have stable and reliable healthy food sources. You can make sure they are taking their insulin, but there’s going to be a problem when their blood sugar is off because of the available food.

So, I am so excited about this work. We are deliberately being informed by stakeholders around this work to ensure more alternative payment methods are utilized, especially in areas where equity matters in order to improve health and outcomes.