Carmela Coyle is the incoming president of the California Hospital Association, a major player in the state’s intensifying debate over health care. Capitol Weekly caught up with Coyle recently in the midst of her hectic schedule relocating to Sacramento from Maryland.
Capitol Weekly: Tell me a little bit about your decision to come here to California. Why did you decide to make this move?
Carmela Coyle: Hospital association work is work that I know well. I have nearly 30 years of hospital association experience. Second, it’s work about which I am passionate. It’s work that I love to do. That’s why I’ve spent nearly my entire career working to help hospitals help people. Of course, California is very special. California, and the ability to do this work at scale, and the ability to help a state that is so diverse in terms of not only the hospital associations here but the communities that they serve–all three of those things are very important to me. Obviously, the ability to follow in Duane Dauner’s footsteps. Duane has been a friend for many, many years. He has left a terrific legacy in the state of California, and having the opportunity to be the one to carry that forward is also very special.
CW: What’s your vision for the California Hospital Association? How may it be different from your predecessor, Duane Dauner’s vision?
CC: I don’t know what will be different and what will be the same. I am looking forward to getting my feet on the ground, to getting to know a team that I understand is terrific, one of the best in the nation, and really getting to know the people and the politics of California. That’s going to be a full-time job for me right off the bat. I don’t know if it’s different or the same. Certainly, the objectives that I hold are of the entire California team, and that is, it is our job to represent our members in Sacramento and in Washington, D.C.. We’ll continue to do that work and do it well.
I expect that over time the issues will change and shift, as they do. But I think the work that we do, and the even the ways in which we do that work, will continue to press to make certain that we’re doing the best we can on behalf of our members, that we’re doing the best we can to educate elected officials about our issues, and that we’re really pushing for the right solutions for the patients that we care for.
CW: You just came from running the Maryland Hospital Association for nearly 10 years. How do you think the challenges you face in California will be different than the ones you faced there?
CC: Many of the challenges are the same. That is just all about our role as lead advocates for hospitals. I think doesn’t matter if you’re from the east coast or the west coast, that work remains the same.
Maryland is a very unique state in the nation. Maryland is the only state that has a waiver from the federal government for its Medicare program, and that led to a very unique system of hospital payments in the United States. In Maryland, hospitals are no longer paid per patient, they are paid based on a global budget, and what that means is that every year, a hospital gets one amount of money to treat all the patients that come through the door for the year. It is a national experiment, and it is an experiment for both affordability and quality improvement.
Certainly, what will be different is moving from that demonstration environment to an environment that remains largely fee-for-service. But I am hopeful that I will be able to bring some of the lessons learned from the Maryland payment model really focused on value and affordability and be helpful as California’s hospitals wrestle with the same issues.
CW: On that note, are there other innovations or lessons you’ll be bringing from your past experiences?
CC: I do hope that my experience in Maryland with state experimentation, in terms of policy, will be helpful in California. Obviously, the Trump administration and healthy Secretary Price have talked about the importance of state innovation. I’m hopeful that some of our lessons in Maryland will be helpful in California, as I believe we are going to continue to experiment with state innovation. I think our experience in Maryland working with the federal Medicare and Medicaid programs, how to actually implement new state experimentation ahead, will be helpful. And of course, just the nearly 30 years of hospital association work I hope will be helpful here in California.
CW: Are there lessons you are taking from your time working at the federal level for the American Hospital Association?
CC: I spent 20 years with the American Hospital Association, the last 11 of those as part of the executive management team, and obviously the American Hospital Association is the organization representing hospitals nationally. Really important lessons there, lessons around political timelines. Sometimes it takes longer to achieve the kinds of change at the national level that are needed. Timelines and political patience are important lessons.
Perhaps most important, having worked at the national level, I had an opportunity to help the nation’s hospitals, so to really do this work at scale. Moving now from the national level, where we focused on 5,000 hospitals, to Maryland, where we had significantly fewer, and now to California where we’ll have the opportunity to serve 400 hospitals, it’s an opportunity for me to use the skills that I acquired in terms of working for a number of large organizations to help our membership in California.
CW: You moved from the AHA to the MHA right around the beginning of the Obama Administration, so you’ve been on the state level since the Affordable Care Act was implemented. How have you seen the ACA change or affect hospitals?
CC: The impact of the Affordable Care Act has been one of the most important changes in health care in a very long time. Obviously, at its core, it is a law about ensuring that people have greater access to health care coverage. We saw that very, very clearly in the state of Maryland, where we saw health care organizations largely serving the homeless population, literally, within a handful of months got coverage and had access to the wide range of services that they need. That’s just one example.
Our ability as a nation to provide coverage to millions and millions of people has changed the way in which we can think about health care, and I believe allows us to make health care ultimately more affordable.
Prior to the Affordable Care Act, it was often the hospital emergency department that was the only point of access for somebody that did not have health insurance coverage. What we’re able to do now at hospital organizations is to, make certain we’re treating people in the hospital when they need that higher, more expensive level of care, but actually refer them back into the community. We can now create a clear care pathway for people back into the community to see a primary care physician, to get the follow-up care that they need, to get the medication that they need. That was simply not possible prior to the Affordable Care Act.
I will say that the Affordable Care Act in providing health care coverage is a necessary but not sufficient condition. By that I mean we can create access to coverage, but if we don’t have the right health care professionals available and out there in the community, right now the shortage of primary care providers are quite traumatic in California and across the United States. We can give you a card that says you’re covered, but what we’re really working towards is to make sure that people have timely access to the care that they need.
CW: What policy changes would you like to see at the state or even federal level?
CC: Coverage is the critically important first step, but now we’ve got to figure out what the right complement of workforce needs are. We do have an opportunity at the state and the national level to begin to prepare and train more in primary care as an example. We should be looking at payment models that incentivize organizations like hospitals, nursing homes, primary care physician offices, to work together to better connect and coordinate patients with the care they need along their journey.
It used to be we would look at a patient in the segments of care that they needed, so the hospitals would focus on the acute care piece and then hand off and sometimes not so smoothly to the next type of provider, say the post-acute provider. Then maybe there was a hand-off to a primary care provider, but often not. This is an opportunity for organizations to really work together to coordinate the care, as you would want done for your family, as I would want done for my family, and for providers to really step up to be that quarterback of care, to help people really move through the process.
But you can’t do any of that if you don’t have coverage first and foremost.
CW: Are you concerned about policy changes–like attempted ACA repeals–coming out of Washington?
CC: We all need to remain concerned. We dodged a deadly bullet with the repeal and replace discussion and the fact that that was not repealed, but it could come back. I think there could be opportunities for the congress to revisit the repeal of that legislation, and we’ll have to fight as hard as we all collectively did the first time to make sure that we don’t backtrack on coverage for Americans.
I also think that we have to be hypervigilant in the upcoming federal budget discussions, where issues around Medicaid funding cutbacks will certainly be in play. Not only this year but I expect in future years as well. Much of what Congress is talking about, in terms of moving the Medicaid program to a block grant or applying per capita caps, is all really shorthand for significant federal funding cutbacks and we’re gonna have to remain hypervigilant in making sure that that doesn’t happen, year after year after year.
CW: You don’t start until Oct. 23. What are you doing between now and then to prep for the big move to California? Not just professional things: Have you found the best grocery store?
CC: I’m standing in Sacramento right now up to the ceiling in moving boxes. I head back to Maryland on Wednesday. I’m not kidding — up to the ceiling. My husband and son are here. My son has just started high school in the area, so we wanted to get them moved in and settled, so you’re absolutely right, I’ve been wrestling with boxes and paper and things I haven’t seen in many years, items that we’ve uncovered in the move.
As soon as I can get my family settled and learn my way around, that’s step number one. Obviously, they next most important one is to really get to know this terrific California Hospital Association team. We’ve already begun to do some of that virtually, but I look forward to it. Also, meeting with and listening to our California hospital members, and obviously getting to know the elected officials here in the state, I look very much forward to the opportunity to serve.
Ed’s Note: This interview also appeared in Capitol Weekly’s special fall print edition on health care.