How St. Charles Turned Clinical Quality into Payer Leverage: From Seven MA Payers to One

We dig into how St. Charles Health System, a four-hospital not-for-profit in Central Oregon and the sole major provider across a 32,000-square-mile service area, went from seven Medicare Advantage payers down to one and then turned a twenty-year track record of clinical quality into a negotiating tool that cut cancer treatment authorization times from weeks to a single day.

Matt Swafford, CFO, and Mark Hallett, Chief Clinical Officer, walk us through the decision to terminate contracts with six national MA payers, how they used NCCN concordance rates to negotiate instant authorization with PacificSource, and the CFO-CCO partnership model that enabled it all.

Transcript

Matt Swafford 0:00

we had one pair with 5,000 lives. 1200 denials in one 12 month period, of them were overturned.

Anika 0:07

Mm-hmm.

Matt Swafford 0:08

why are we doing this? the patient's important, the clinician's important, bend the system around it. And it's hard because the system isn't designed to be bent.

Anika (2) 0:23

Welcome to the Strategy Catalyst Dispatch, a podcast from the Strategy Catalyst team at the Health Management Academy. I'm your host, Anika Rashid Senior Analyst, and each episode we'll explore The trends and insights shaping healthcare strategy today. Let's dive in.

Anika 0:45

Today we're talking about how St. Charles health system went from seven Medicare advantage payers, down to one terminating contracts with six plans, that they felt weren't serving their community, and then use decades of clinical quality data to negotiate instant authorization with the payer that was willing to work with them. That cut the time from cancer diagnosis to treatment start in many cases from weeks to just a single day. What's special about this is that even though one of my guests today is a CFO of St. Charles, the payer strategy that you're gonna hear about wasn't really a finance play first and foremost, though, of course, that was also a motivator. It wasn't the primary one. This was a clinical quality play where the main goals were around safety experience for patients and clinicians and better care delivery for the community. That is what was at the heart of this So today we've got a CFO who says every single number in finance has something to do with people, and whose chief clinical officer calls him an uncommon CFO. You'll hear why. You'll also hear how the two of them think about their work. Their partnership is really special. the two of them in lockstep always acting as if the other was in the room with them. Matt and Mark presented on this work at T-H-M-A-C-F-O Circle, and we'll also touch on the just culture framework that they use to bring vacancy rates from over 20% down to single digits. So today I'm joined by Matt Swer, chief Financial Officer, and Mark Hallett, chief Clinical Officer at St. Charles Health System. Matt, mark, thanks so much for joining me today.

Mark Hallett 2:14

Good morning. Thank you for having us.

Matt Swafford 2:16

good morning. Thank you, Anika. This is Matt. and, as the Chief Financial Officer of St. Charles, Working with Mark, we're happy to be here to share our experience

Anika 2:24

So before we get into all of the moves you made, I wanna kind of set the stage. You terminated contracts with six of. Your seven MA payers. But before we get into how that happened, could you walk us through what inspired the termination of those contracts?

Mark Hallett 2:43

Maybe I'll step forward. This is Mark. St. Charles is not unusual in our patients experiencing delays and denials as part of the, MA process probably also not unusual. In our providers and staff having to jump through numerous hoops, trying to reverse denials and get pre-authorizations and so on. our initial work was focused on our cancer institute, despite the fact that. Our care at a very high and sustained level was conforming to national guidelines, the NCCN guidelines which are national guidelines for cancer care. if you imagine the frustration and the burden on, the providers and the staff, but more importantly. the cancer patients who were sitting waiting for these, hidden processes to, work themselves out. of that in the setting where what we're really trying to do is take, evidence-based, best practice, standard care of these cancer patients as quickly and as, low burden as possible. That was the impetus Now. that's easy for me to say as a clinician. And, the magic really had to do with what Matt and the, contracting team were able to work out. So, Matt's openness to that clinical frame, I think was part of the magic here,

Anika 4:11

So if I'm hearing correctly, this was a huge burden on your patients and then also administratively.

Mark Hallett 4:18

correct.

Matt Swafford 4:19

I think, one of the things that, that I'd like to, with is back in 2022, we had just, experienced one of the most challenging, periods, during COVID and had come out of, accelerating losses. Lost $16 million in 2021 lost $36 million in 2022. at the time we were about a billion, one in revenue. So $36 million in losses is a lot. We had negotiated some contracts, and improved our contracts from 22 into 23. That was primarily, stabilizing our financial picture so we could reinvest in people. And that was the critical theme, is that we're trying to make sure that we have the right people, the right programs and the right facilities to deliver exceptional care, for St. Charles in 2023, listening to the concerns of a very specific population in our cancer, program with three week delays to receive care. When we started our negotiations in 2023, we had seven plans in the Medicare Advantage market, and several of them were, national payers, Humana Health Net, WellCare. As an example, they proved to be very difficult to work with in prioritizing, the, improvement of prior authorization. And with that, we noted that it was going to be very difficult to bend the system to meet the needs of people receiving care and people delivering care. we chose to terminate those national plans.

Anika 6:02

Matt, can you give me a sense of scale of what you were dealing with?

Matt Swafford 6:06

you know, we had one pair with 5,000 lives. 1200 denials in one 12 month period, of them were overturned.

Anika 6:15

Mm-hmm.

Matt Swafford 6:15

why are we doing this?

Anika 6:17

So you walked away from six of those seven plans.

Matt Swafford 6:21

We did find some traction with local not-for-profit plans in particular, PacificSource. and what we oriented with PacificSource around was a specific instant authorization program for our cancer patients. And we started with cancer because of the high quality and performance, work done by that particular Clinical area at St. Charles, and due to the fact that patients were receiving, delays of up to three weeks, And what we decided to look at was how do we get an instant authorization process in place for those patients where it's really clear. Their clinical needs could be met readily. distinct from a gold card approach, which is based on a 98 or 95% approval rate by a payer. We were really trying to orient around guidelines that would be payer agnostic. Both PacificSource St. Charles used the NCCN guidelines, that's where we initiated the primary negotiation. And Mark, maybe you can describe a little bit of what the NCCN guidelines meant in terms of, the instant off versus, non-instant off part of that.

Mark Hallett 7:36

Sure. just briefly. NCCN guidelines are category one, category two, A and B. In category three, category one guidelines are standard of care. Very well established two A are just a notch down below that when you get to two B and three you get more. I'll say, research based, if you will, meaning there's less evidence based for those. So the problem we are trying to solve is for, testing or treatments that were category one. I can think of a specific time when different oncologists needed to, appeal just to get approval for NCCN category one treatment. So that was the sort of the impetus.

Anika 8:27

That's the, that's that's the standard of care treatment, and they were still having to do that.

Mark Hallett 8:31

Absolutely. this is really unnecessary and not serving the patients and putting additional burden on the physicians and staff. what's curious about that is, sometimes cancer comes back, sometimes cancers, Fail different treatments, and in some cases what you actually need is a more rapid denial so that patients who fall into that category can be treated, with a research trial. So in, in the vast majority of cases, when it's guideline conforming, we want speed, in return for that high quality, evidence-based practice. Treatment and evaluation in that other case, we actually want a rapid denial so we can enroll, patients in trials to try to, treat their cancer.

Anika 9:23

so I think what I'm hearing is that there was. Immense burden and delays for patients. And then also that was frustrating the clinical teams. And so you had this vision of how things should be, and not every payer was open to that vision, but Pacific Source was because you were able to use, the NCCN concordance rates as a little bit of a lever to pull there. Is that kind of, would you

Matt Swafford 9:52

when you look at a system that is designed based on denial, we wanted to flip that and say, the patient is able to get care immediately because the standard of care designates it, do we orient around that? where this program came from. So it flew in. The face of the larger dynamics of authorization is important for however anybody might describe it. This is the patient's important, the clinician's important, bend the system around it. And it's hard because the system isn't designed to be bent.

Anika 10:29

What does the instant authorization experience look like for a patient now?

Mark Hallett 10:35

Very quickly. Our meantime to begin treatment, which when you're a cancer patient, every day that goes by that you're not on treatment is a day that, you're worried about the cancer getting worse or spreading. So that's a really meaningful patient facing metric. that meantime to begin treatment was roughly around two weeks, and once we began this, it rapidly came down to one day. and if you're the staff or the providers, you can see more cancer patients, because you're not taking time to get pre-ops and denial appeals and that sort of thing.

Anika 11:13

So better experience for everyone around and also peace of mind.

Mark Hallett 11:17

yes,

Anika 11:18

Yeah.

Matt Swafford 11:19

in the larger population for, PacificSource, I think 33% of patients had a wait time that was greater than 10 days. Now it's less than 10%.

Anika 11:30

Wow.

Matt Swafford 11:31

that's the overall population. Mark is describing those that were subject to the instant off, the entire population, those that were a little bit more complicated and required that direct appeal, peer-to-peer appeal. so we have really improved the experience of patients and clinicians very directly in this program. and that is, an excellent outcome.

Anika 11:54

So it sounds like it had far reaching implications in terms of access. Also

Mark Hallett 11:59

Yes, and actually We're in early conversations to try and duplicate this in our next area. so we continue to try and build this.

Anika 12:08

That's amazing. so I think understand the impetus on to make the experience better for clinicians and also patients, how the system should be right and bending it to fit that vision of what it should be. walk us through that decision to terminate those contracts. How did you weigh the revenue you might lose against the cost, financial or otherwise of keeping those relationships?

Matt Swafford 12:33

Yeah, I think the biggest challenge with that whole, analysis was starting with what is gonna be the impact on our community. And, and the impact of a program, Medicare Advantage, that is designed to offer, private insurers an opportunity to provide benefits that, would often take resources away from the acute care system in favor of benefits like dental or others that might not be included in traditional Medicare. So you can see the appeal. the challenge that we noted is that when it's time to actually receive acute care and Medicare advantage, there were a lot of barriers, sometimes denials and inability receive, significant interventions because of the way, Medicare Advantage, is managed and frankly diverting. Resources from the acute care system towards these other benefits. not all community members know that. Part of what we had to do was provide education to the community and support organizations that help seniors understand the choices that they make. and for St. Charles coming out of the post COVID financial challenges, we needed to make sure that we had stabilized the financial picture, so that was really what we were trying to get to is I would say make Medicare Advantage and traditional Medicare competitive, make them similar in terms of the financial outcome. So it did have a financially beneficial impact to St. Charles from a stabilization perspective, really started with. What is the impact on people receiving the care and people providing the care? and then the financial impact was secondary to that.

Anika 14:29

I would love for you to talk me through How did you manage the transition? What was the community reaction? Talk me through that.

Matt Swafford 14:38

mark, you and I had the opportunity to be, in the press, sometimes with, the challenge of having the actual message get through and, in favor of sometimes the preference for media to. Tell the story they'd prefer to have told.

Anika 14:54

What was that story?

Matt Swafford 14:56

that anytime there is a dispute between an insurance company and an hospital system, very easy to villainize one or the other. And about the outrage of the conflict rather than the substance of the challenge at hand. and you get it. It's a very upsetting and emotional, thing to have your coverage changed a contract terminated. That was a challenge to just know that you can be grounding it in the facts that you have. You can be really clear, you can be trying to keep it about, um, the substance of what is the issue, gets wrapped up and a very emotional. reaction that is also completely understandable.

Mark Hallett 15:40

I think you're getting, at the essence of. Sort of how Matt and I collaborate and the reason is that we were completely aligned about the framing that, this is not good for patients. This is not good for providers and staff and financially The hidden cost of this is really hurting the business model. So that

Anika 16:07

That story.

Mark Hallett 16:07

Matt needed to do all the negotiations and, between ourselves, even though we were shoulder to shoulder, we agreed that the clinical face should be outward facing, telling the clinical storytelling about what's actually happening to patients and that. that was pretty complex from the standpoint that people who are not on Medicare Advantage don't really understand how it's different than, than fee for service Medicare, even our provider. So we actually had to start out with the change management internally with our physician providers and staff, and then work with our community partners. Because Matt's absolutely right it. The idea of, wait a minute, we're gonna terminate. something with Medicare in its name was pretty frightening and intimidating, and we had to make sure we were leading with people understand that this system isn't working for anybody right now. we were talking with our, Senior medical director, physician leader for cancer yesterday, and she said this program has been outstanding for patients, outstanding for providers and staff, and has actually led to, growth and, commercial success of our cancer institute as well. So I, I think it, it was a big change management lift, but we led with the, the clinical side and backed it up with the financial side.

Anika 17:46

Gotcha. So it sounds through any period of change, there's going to be, a period of discomfort, right? so it sounds like it was about being resilient through that, and then also about the messaging piece and making sure that you have the right face behind that messaging piece, and then eventually, the impact and the results speak for themselves. Does that sound right?

Matt Swafford 18:09

It does.

Anika 18:10

since we're already getting at it, the partnership between, both of you. What would you say is really inherent to that partnership? What makes that partnership work and what are some things that you both do that other pairs might not?

Mark Hallett 18:23

You wanna start Matt?

Matt Swafford 18:25

No, I'm curious to hear how you would start, mark.

Mark Hallett 18:29

Matt is a, an uncommon CFO in my experience, in that he understands that healthcare begins with, patient care, by nurses and doctors and providers, the rest of us are in support of that. So I think there's a certain humility. that along with shared vision that allows me to, be shoulder to shoulder, lead, as if Matt was in the room. he does a similar thing, meaning, There's no finger pointing. this all has to work. The clinical care and the business model has to work, and it's on us to make it work the way we lead. So what it's led to is, example we talked about earlier, with negotiations and trying to bend the Medicare advantage. Contracting world so that it's better for patients and providers and staff. And at the same time, we did some work on, just culture, what we call culture of Excellence. And Matt as a CFO was trained, as a, culture of Excellence champion. So one of, one of 40 that we trained, system wide. So there's very much of a, A collaborative leading as if the other person, was right off your shoulder. because if we don't get it right, in the organization will get it. Right.

Anika 20:02

Matt, I would love to hear your perspective on this and then as well, what your experience participating in the cultural work was.

Matt Swafford 20:09

so I do lead with Mark's voice, in the back of my mind, in large part because the numbers that we assemble in finance the interactions of people every single number has something to do with people. And if you, start there, then in my view a finance leader, your insights. Your, work, your negotiations, all the aspects of what you do are centered around that. If the rest of the system understands that Mark and I as respective leaders in our areas, see eye to eye there's no daylight, and the disagreements we handle that's meaningful, as an example to the rest of the system, that we aren't, Prioritizing one area over another, that we listen to one another. And so that creates the basis of, in my view, trust, and understanding. raised my hand for the Culture of excellence work, in part because of the inspiration of Mark's leadership since he joined and knowing that. If I don't show as a system services leader, and system services being the part of the system that enables the provision of care but isn't necessarily at the front line, what example, will be provided to those who are, in system services If someone in my position hasn't stepped up, plus, I firmly believe that in our Culture of excellence work. you can have values written on a piece of paper or on your website, but your values mean nothing until they're challenged and you don't wanna wait for them to be challenged in the of just patient, interactions. You need to create some training where those case studies of how your values appear and how you address them, especially when there's a conflict and practice that. there's a powerful example if you have leaders at St. Charles leading that work rather than a consultant. I learn about the cases that people run into, I understand. Oh. This is the actual work that goes on. These are the actual values, conflicts that people have. This is what I need to be mindful of, and understanding the insights of the performance of the system from a numbers perspective as well.

Anika 22:34

That makes a lot of sense I mean, culture isn't really culture if it just lives in the HR pillar, right? it has to expand beyond that to everyone. And I really like what you said about, The values point doesn't mean much until it's challenged. And then what you said earlier about your partnership, I think that really resonates with, a quote from your presentations. I think it's, I think it's yours, Matt, that your decisions are grounded and Together Choices grounded in shared math rather than just finance says no. would love it if you could give me an example of how that plays out in practice

Mark Hallett 23:07

from my standpoint, you heard Matt's. and humility. Because, culture of excellence, just culture is high level holding individuals accountable for the quality of their choices. While at the same time leaders are responsible for how, the quality of how we judge those choices in the moment. And more importantly, the quality of system design. nothing that we're doing is hard. It's just, we make it hard through some of our mindsets, some of our attitudes the fact that I lead as if Matt was in the room. I never ever point to as the people of, no. I take responsibility, for having tough conversations, as if Matt were in the room and at the same time you've heard that he looks at patient care in a way that understands the complexity. of patient care I know executive teams collaborate. I've been part of many of those, but we've just taken it to another level I think.

Matt Swafford 24:20

as we push further and further the understanding of what it means to have a strong business case that matches safety, quality, financial sustainability, and growth, everybody is thinking in that balanced scorecard. There are degrees of emphasis, but we all own quality. We all own safety. We all own sustainability. We all own growth. In one way, shape, or form. And the advantage of a smaller rural focused system like St. Charles is in one conference room, you can have the entire leadership and you can look each other in the eye. So one of the things about collaboration that I think is important is do you create that level of connection regardless of the scale of your organization. If somebody believes that the chief strategy officer owns strategy and that's it, if somebody believes that for the Chief clinical Officer, chief Financial Officer, that's not a recipe for success. there is a co-ownership of the challenge. It's too big allow the silos to, evident at the top, and certainly, unfortunately, that would inspire the same level of silos all the way through.

Anika (2) 25:40

I think that's a great one to end on. So, thank you so much to both of you for joining me today.

Anika 25:46

the shared ownership piece is, is really what ties this whole conversation together. the payer moves the culture work. None of that happens if the leaders are operating in separate lanes.

Anika (2) 25:57

obviously, you have your niches, but it's really important to find that common ground and that common ownership over things to really establish that, Impactful and efficient partnership.

Anika 26:08

Matt, mark, I'd like to thank you so much for joining me today.

Mark Hallett 26:12

Thanks for having us.

Matt Swafford 26:13

Thank you Ika. Appreciate the opportunity.

Anika (2) 26:17

That wraps up this episode of the Strategy Catalyst Dispatch. If you found this episode valuable, please like and subscribe on your podcast platform of choice and leave us a comment. If you have other thoughts or questions, we'd love to hear them. Email us at Strategy catalyst@hmacademy.com. You can also find more of our resources on HM academy.com/strategy-catalyst. That's it for this dispatch. Thanks for listening.