Interview with Joshua Crouch
Joshua Crouch is the Special Programs Manager at Inland Empire Health Plan (IEHP). This interview took place on October 9th, 2018.
Just to start off, it would be helpful if you quickly introduced yourself and talked about your role and the work you do that pertains to the opioid crisis.
Sure, I’ll include a little bit of my background. My name is Joshua Crouch, and I am a Special Programs Manager at Inland Empire Health Plan. We are a nonprofit organization that covers Medicaid in Southern California, specifically in Riverside and San Bernardino counties, which are about an hour outside of Los Angeles. We cover about 1.25 million individuals. All of our membership has Medicaid in Southern California, and there is a small percentage that’s called “dual choice”: they have both Medicare and Medicaid. We have 1.25 million members, so we cover about one in four people in Riverside and San Bernardino Counties. We’re a very large Medicaid and health plan.
As for my background, I have a Masters in Public Health and have been working at IEHP for about six and a half years. I started off as a Business Analyst and my current title is Special Programs Manager, so I’ve moved around in different departments and learned healthcare management in general. It’s been a really eye-opening and great experience learning about healthcare, especially working with the Medicaid population in Southern California. It’s been very fulfilling and I am very passionate about this work.
So, in your current role – you’ve been there for how long?
I’ve been here about six and a half years. I started as a Business Analyst in our Operations Department under Enrollment and Eligibility. We were in charge of receiving files because we’re not really enrolling people – we’re being told by the state who is enrolled. We are a nonprofit organization, but the state is giving us membership and then paying us to take care of those members. I was in the Enrollment and Eligibility Department, where we processed those files and made sure all of our membership matched with what the state had. Then I went over to Quality Management and became a project manager in that department, where we did a lot of quality-improvement projects and worked on a lot of quality-type programs to make sure that the care we and our network of providers are providing is high quality and that our hospitals, doctors, and physicians are taking care of our members appropriately. After a couple years there, I moved on to the Special Program Manager role. I work with our Health Services department and our Chief Medical Officer to make sure that all of the current programs we have for our high-utilizing population are functioning appropriately and that any new projects or programs are being implemented within a specific timeframe and following certain protocols.
In your time doing that work for six and-a-half years, what was the most memorable experience you had — what was something that jumped out at or stuck with you?
One of the key figures I like to tell people is that I’ve been here at IEHP about six and-a-half years. When I started, we had about 400,000 members and about probably 400 employees. I want to say our provider network was in the two or three thousands, including primary care physicians, specialists, everything. Within that six and-a-half years, we’ve grown to 1.25 million members, have about 2000 employees, and our provider network is over 6000 providers. We’ve grown exponentially and a lot of that growth is due to Obamacare and the expansion in California of Medicaid. California decided to expand Medi-Cal and allow individuals that are low income that maybe don’t have children, aren’t pregnant, or aren’t elderly to join Medicaid (called Medi-Cal in California). That really increased our growth and diversified our membership. Previously, before that expansion, our membership was like that of similar organizations in other states that chose to not expand Medicaid: families with small children, pregnant women, and the elderly. Individuals that don’t get coverage are those individuals that maybe don’t have children but are poor. So, you could be homeless, but if you don’t have young children or aren’t elderly, you might be out of luck and cannot get health insurance. Luckily, within California, we expanded and now a lot more people have insurance, so a smaller percentage of our population falls between the cracks.
As your membership expanded, what did your organization do to handle the massive increase in scale?
That’s a good question. We’ve had our growing pains; when you basically triple in size within five years, you’re going to have some growing pains. One of the biggest things that we implemented companywide and from chief executive level down was a Lean Six Sigma strategy: improving processes, making sure we’re reviewing our processes, and trying to get rid of wasted energy and manual power by automating as much as possible. Our whole plan was created twenty years ago; 1996 was our first year. There was a slow, steady growth for seventeen years and then that exponential growth at the end. A lot of the processes that have been weeded out were those manual processes that form when you start out small and then grow a company really quickly. It was really important to us to create an entire process improvement department, have these Lean Six Sigma strategies incorporated into our everyday workflows and making sure those processes are as succinct and improved as possible.
Over the years that you’ve been there, have you had any exposure to the effects of what’s been happening with the opioid crisis? Has that ever come up or has anything ever been noticeable?
IEHP is a health plan in the Inland Empire, which is Riverside and San Bernardino counties. The dual Inland Empire counties, obviously just like anywhere else in the United States, started to feel the effects of the opioid epidemic over the last couple years.
One of the strategies, which is more multidisciplinary and across multiple organizations, was actually originally formed by a group called HASC, which is the Hospital Association of Southern California. They formed a task force back in 2015 and called it the Inland Empire Safe Opioid Prescribing Medical Task Force. This was a very hospital focused, hospital centric strategy that worked on developing an emergency department tool kit – an entire toolkit for hospitals to implement within their emergency departments that would give recommendations, feedback, and answers to questions around how to deal with the opioid crisis at the emergency department. You know, you’re getting frequent fliers, people who are coming in for pain — what kind of prescription habits should you have? How should you treat the pain? It was all very focused on the ED. They developed this toolkit and then began implementing it in all the hospitals in the Inland Empire, which is about forty hospitals. They developed the toolkit throughout 2016 and began implementing it in 2017. Then HASC decided to take a step back from owning that taskforce because they wanted to focus their strategies on hospitals. So, the scope of the group started to expand a bit: there were pain specialists, primary care physicians, other organizations like first responders, and obviously the local health plan getting more involved.
We wanted to expand the scope and start coming up with other strategies: provider communication, community communication about the risk of opioids, discussion about naloxone and Narcan (medication-assisted treatment). The group wanted to start discussing and developing strategies like these, so HASC took a step back. My boss, Dr. Jennifer Sales, the chief medical officer for IEHP, stepped up to the plate and said IEHP will help with the administrative and organizational management responsibilities around the group, and that’s how I got pulled into it. My boss asked me to help with administrative duties, like making sure the work groups are getting formed and that they have developed, measurable objectives, making sure that we have the right individuals from the multidisciplinary organizations throughout the Inland Empire who are all participating, making sure there are flows and organizational charts. I’m responsible for a lot of that administrative burden.
We changed the name of the task force to the Inland Empire Opioid Crisis Coalition (IEOCC). IEHP has owned the responsibility for those organizational duties since about July 2017. It’s been close to a year-and a half now, and we’ve developed a vision and mission statement, trying to formalize the documentation behind it a little bit more. We have the overall coalition with the Steering Committee that leads the direction of the coalition and then six specific work groups. We expect everyone who is a part of the coalition to participate in the six work groups, where work is actually getting done. We have had the six work groups develop measurable Smart Goals for 2018, which we’re going to revisit for 2019. The gist of it is that we have been pretty integral in the development and responsibility for this, but we also really want as much external provider and community involvement as possible because we know that this can’t be health plan driven; it’s got to be multidisciplinary and involve other organizations, like the Public Health and Behavioral department, hospitals, pharmacists, and pain specialists throughout the community. If we’re developing a strategy but not including everyone, it’s not going to work.
What has your approach been in regards to medication-assisted treatment?
I’m speaking more as the representative of the IEOCC, but then obviously at IEHP, we have our own specific opioid and pain strategies. We’ve tried to align them as much as possible, but sometimes there’s a specific planned strategy that isn’t in perfect alignment with the IEOCC that we’re still going to implement. So, I’ll speak as a representative of the IEOCC, but keep in mind there may be other strategies. Maybe we won’t talk about them now; maybe it can be a future conversation more specific to the plan. Is that okay?
Medication-assisted treatment is something we’ve been working on implementing throughout the two counties for a while now. The six work groups that we’ve formed within the IEOCC are Access to Treatment, Engagement and Education, Naloxone and Overdoses, Reporting and Monitoring, Decreasing Prescription, and Emergency Department Toolkit Expansion. The strategy around medication-assisted treatment falls really nicely into our Access to Treatment work group, and we’ve been working on trying to expand not only the education — MAT providers need to go get licensed from the California Department of Healthcare Services and get certain licensure to prescribe MAT – but also linking members that need to utilize MAT to those providers and spreading the word that those providers exist and are within the network. It’s making sure we have the right number of providers with licenses but also that members are able to access that treatment. That has been our big push recently — getting more providers licensed but also getting the word out that these providers exist, that they’re within the network, and that we need to refer members to them for specific treatment.
I’ve heard that with Medi-Cal, when it comes to some kind of treatments, there’s something like a bureaucratic division, where one type of Medi-Cal covers it and another type doesn’t? Do you know anything about those bureaucratic issues?
I don’t know; that might be a good question for our Medi-Cal Director, who is really involved in the development of our MAT strategies. I have heard that there are some bureaucratic and regulatory issues, like members have to have specific diagnoses to get certain treatments. I don’t know the details on it for MAT. I know for something like naloxone, certain advocacy groups have pushed that anyone given a prescription for opioids should be given naloxone as well, just in case — especially if it’s above a certain milligram morphine equivalency (MME) – in case there’s an overdose. I don’t know the details on this as well, but I’ve heard there are certain regulatory requirements; someone has to have a specific diagnosis of substance abuse or opioid abuse in order to get that prescription paid for by the state. I think you’re right – there are certain bureaucratic regulatory issues that need to be worked out. I probably wouldn’t be able to give you any kind of detail, though.
In the news, they say that fentanyl has increasingly become an issue, particularly when it gets mixed in with other drugs without the end-user knowing. I was curious as to how your coalition sees that and what steps it thinks should be taken.
Most of our strategies have been around dealing with what we within the medical community can alleviate or respond to directly. You know, trying to develop MAT strategies and making sure our emergency departments and physicians are educated appropriately on prescribing habit; that members are educated appropriately on the usage of opioids. We’ve had some conversations around fentanyl use. But I believe, based on my background, that most of the fentanyl that’s getting mixed in with heroin and other drugs is synthetic, coming outside of what’s being prescribed. That has led to different conversations around naloxone and trying to expand its availability and use, where if someone has an overdose, they can quickly get naloxone given to them. They’ll have a much higher likelihood of surviving an overdose the earlier into the overdose the naloxone is administered. We’ve tried to incorporate first responders, so all of our paramedics and fire are carrying naloxone. We’re also trying to involve law enforcement: sheriffs, police, etc. It’s a little bit of a different conversation when you pull them in because it’s not necessarily co-providers and they’re looking at the issue from a different perspective; law enforcement is more trying to deal with the crime and illegal activity. But we’re pulling them in so we can try to have some conversations around what it would look like because, a lot of times, they are the first on the scene when there’s an overdose or when someone using fentanyl has an overdose.