By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only true wisdom is to know that you know nothing.”

— Socrates

Wisdom of the Elders

Tribal community members often hold respect for elders as one of their core values. This respect is shown in many ways such as allowing elders to eat first at communal meals, valuing elders’ knowledge of native languages and traditions, and listening to their wisdom expressed through stories passed down for generations.

These demonstrations of respect were evident at a cultural event recently at the Karuk Kahtishraam Wellness Center in Yreka. Teenagers and young adults watched attentively as one elder taught them how to carve traditional wooden cooking paddles. Another elder displayed his tight-weave basket[1]making skills using willow twigs and aged spruce roots. When lunch was served, tasty frybread tacos and fruit, the elders were invited to serve themselves first. During lunch, several elders recounted stories from their lives, gently conveying the life lessons these stories contained.

Many in the United States use a different word to describe older residents: elderly. Although the difference is subtle, elderly is often used in association with a sense of responsibility to provide care, food, shelter, and entertainment. There is less of a sense respect for the wisdom of their life experiences, more of a sense that interacting with the elderly is necessary from time to time. This is a barrier to older adults feeling a sense of purpose as they age. Dr. Victoria Sweet’s excellent book, “God’s Hotel,” about San Francisco’s Laguna Honda Hospital elaborates on the evolution of modern American society’s conceptualization of our older residents.

Of course, there are exceptions to this. In his famous study of communities around the world where substantial populations live to over age 100, author Dan Buettner found that, in addition to a healthy diet, regular exercise, and six other factors, centenarians had an ongoing sense of purpose for their lives, usually including providing advice and support to the younger members of their families. The term “Blue Zones” is used to describe such communities in the Nuoro province of the Mediterranean island of Sardinia, the Nicoya Peninsula of Costa Rica, and Loma Linda, California.

In our early lives, our brains are wired for “fluid intelligence”: the ability to reason and think abstractly and flexibly. This allows us to learn everything from kinesthetic skills like sports or playing a musical instrument to mental reasoning skills involving creative solutions to mathematical or logical problems. As we age, the integration of what we have learned in our lifetimes — from books, other people and from our own experiences — can be manifested in “crystalized intelligence,” sometimes known as accumulated wisdom. Fluid intelligence generally peaks in our 20s and 30s and then declines steadily, whereas crystalized intelligence peaks in our later decades of life. Crystalized intelligence is helpful for teachers, with history professors actually reaching peak intellectual productivity in their 60s and 70s. Interestingly, our ability to learn new words and even new languages can persist well into our older years because the hippocampus, the seat of memory, continues to grow throughout life.

In his book, “From Strength to Strength: Finding Success, Happiness, and Deep Purpose in the Second Half of Life,” economics professor Arthur C. Brooks notes that high-achieving younger professionals who start to decline in their career should intentionally make the jump from the declining fluid intelligence curve to the rising crystalized intelligence curve.

American society celebrates the success of young entrepreneurs, young performing artists, and young scientists who make important breakthrough discoveries that require fluid intelligence. Success in early life, with its attendant public recognition, can make it hard to give it up to make the jump to the second, crystallized intelligence curve. Interestingly, societal belief systems that emphasize the idea that deceased ancestors support those who are living sometimes have more formal ways of recognizing the development of wisdom as a high goal in the second half of life. Confucian stages of life include the ideas of early education, social engagement with accumulation of wisdom in the middle of life, and tapping into the wisdom of elders, sages, and ancestors. As noted earlier, writings summarizing historic and current-day Tribal community values and beliefs include respect for the wisdom of the elders, and the important influence of one’s ancestors on those living today.

A more codified version of these stages is found in the ancient Hindu theory of Ashrama. Ashrama specifies that life should be lived in four stages, each lasting roughly 25 years:

• The first, in childhood and young adulthood, is devoted to learning.
• In the second phase, one focuses on working to build a career and financial stability, as well as to building a family and social connections.
• In the third phase, one retires from personal and professional duties to consolidate their wisdom through teaching and spiritual practices. Moving from the second phase to the third phase is analogous to the shift from the fluid intelligence curve to the crystallized intelligence curve, noted above.
• The fourth phase (if one lives long enough!) is devoted exclusively to spiritual understanding.

Clinician Wisdom

What are the implications of this framework to clinicians?

The scientific framework of evidence-based practice, where activities are tested objectively and rigorously, is at odds with a framework that draws on “ancient wisdom.” In fact, the current standard of care is evolving rapidly. The half-life of medical best practice is roughly five years. Put another way, half of today’s best practices for a given disease condition (e.g., which medication or surgical treatment is the safest and most effective) will no longer be the best practice in five years.

New graduates of physician residency programs, better trained than previous generations in evidence-based practice, will view some of the practices of older physicians as out-of-date. In some ways, though, the skills and experiences of older clinicians integrate knowledge that is not out of date and which younger clinicians would benefit from. Physical exam skills, for example, are becoming a bit of a lost art, resulting in over-use of radiology studies. Surgical skills for non-laparoscopic surgery of older physicians are often impressive, as they had a large volume of such cases before the newer surgical methods became available. Conversely, younger surgeons often have more robust experience with robotic surgery.

Clinicians need to track the evidence base for the conditions they commonly treat. Having a sense of curiosity and skepticism when reviewing the medical literature is key to critically evaluating new knowledge. As clinicians age, the wisdom reflected in their clinical judgement can continue to grow, if they systematically keep up with new knowledge.

Leadership Wisdom

This is also true for clinician leaders, although the nature of new knowledge related to leadership is very different.

Our understanding of the psychological and sociological aspects of human behavior is more scientific than previously, both through more advanced social science research methods, and with greater understanding of how this relates to underlying brain structure and function. The book, “Behave: The Biology of Humans at our Best and Worst,” by Robert Sapolsky is an impressive integration of these fields.

However, clinician leaders generally learn new leadership lessons more slowly, since we are often spending time maintaining our clinical knowledge while concurrently learning business operations and health care policy.

Fortunately, some core leadership wisdom is timeless, and so can be gained through literature, movies, and reading philosophy. An additional vital resource is the crystallized intelligence of our “medical elders,” experienced clinician leaders, such as Dr. Paul Farmer, Dr. Fitzhugh Mullen, and Dr. Anthony Fauci, as well as local clinical leaders in your communities.

To grow and age wisely as clinician leaders, we must embrace the opportunity to absorb the wisdom of elders even while we systematically strive to integrate new evidence-based knowledge!

By Robert L. Moore, MD, MPH, MPA, Chief Medical Officer

“The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.”

– Author Malcom Gladwell

Malcolm Gladwell’s first book, The Tipping Point: How Little Things Can Make a Big Difference, published in 2000, was one of the earliest popular books in the field now called behavioral economics. Classics that followed include Freakonomics, written by Steven Levitt and Stephen Dubner in 2005, Predictably Irrational, by Dan Ariely in 2008, Nudge by Nobel Laureate Richard Thaler and Cass Sunstein, and Thinking Fast and Slow, written by Nobel Laureate Daniel Kahneman in 2011. Collectively, these books combine elegant psychological experiments and data analysis using novel economic methods to dispel age-old assumptions about motivation and human behavior.

In his just-released eighth book, Revenge of the Tipping Point, Malcolm Gladwell examines the factors leading individuals to dramatically change their beliefs and values in response to the people around them. The many healthcare examples alone make it a worthwhile read for Medical Directors.

A particularly thought-provoking chapter is Chapter 4, The Magic Third. He presents a series of studies that show that 25-33% of a group of people can sway the rest of the group to the same set of beliefs/behaviors/values – the “Magic Third.” Examples include studies of the number of women on corporate boards, the number of Black children in mixed-race kindergarten classes, the percentage of Black residents in a neighborhood, and an elegant psychological experiment involving groups of people agreeing on names of random people in images. The “tipping point” in which major changes in the group cascaded rapidly was between 25 and 33 percent of the group. Gladwell goes as far as calling the Magic Third a “Universal Law,” a term social scientists and philosophers use in a way that is disconcerting to physicists.

One interesting experimental finding is that if 25-30% of a group are coordinated in trying to sway an entire group to their view (say on length of two lines, or the number of objects in a picture), they will generally be successful, even if the view they are agreeing on is demonstrably untrue! Social pressure is powerful!

On the other hand, the current political environment in Washington D.C. demonstrates that deeply held beliefs are not as susceptible to the “Universal Law” of the Magic Third.

I have observed cases where less than one third of a group can sway the entire group. In the 1980s, vintners in different areas of California formed local trade groups to promote wines from their region. They sometimes held charity fundraisers, combining marketing of their products with philanthropy. In one case, the Napa Valley Vintners, the target of fundraising shifted substantially from supporting local hospitals to focus on supporting the farmworkers and their families who worked in the region. This change occurred when just two board members (former publisher John Shafer, owner of Shafer Vineyards, and Bill and Kathy Collins of Conn Creek Winery) worked together to sway the views of their fellow vintners. For approximately 30 years (even after the deaths of Shafer and the Collins’s), vintners throughout the valley would all say that the focus of their wine auction and other philanthropic activities was to care for the farmworkers who worked in the fields, making their wine possible. Vintner groups in surrounding counties did not develop the same shared goal.

A key lesson from the Napa Valley Vintners is that two charismatic leaders, working together, can shift the views of an entire group, even if they initially comprised less than 25% of the group. However, it takes a bit of effort and time to get to the tipping point and beyond.

A look at major public health initiatives in California and other major health policies find this pattern repeating: two passionate dedicated individuals focus their energy to changing the framing or narrative, gradually swaying the larger group (or even the whole population) to their frame/narrative.

If one person has an innovative policy idea, their first important task is to find a second charismatic person who will support the idea. Together, with time and attention, these two can often sway the rest of the group.

Patience and focus are key. Having too many priorities means that insufficient attention goes to any one of them, and success will be limited. Partnership HealthPlan of California tracks the public health priorities of all 24 of our counties. In some counties, there are so many priorities that the health officer cannot remember them all without looking them up. Lake County has adopted a different model inspired by a framework called Collective Impact. The health department is mobilizing all major county stakeholders to focus intensively on one high priority issue: nicotine consumption in youth. I have no doubt that this approach will have a substantial impact.

So, don’t make too many New Year’s Resolutions. Choose no more than one difficult-to-achieve goal and stick with it. If your goal requires changing the behavior or views of people around you, first find a partner to work with you.

As we look ahead to 2025, which may bring many changes, finding ways to make meaningful differences in our communities can provide resilience. We at Partnership look forward to working with you to make our local healthcare system as functional as we can, providing care and comfort to the communities we serve.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

 “I am often reminded of the adage, ‘If you are not at the table, then you could be on the menu.’ If I am not getting out and having my voice heard by those who make decisions, I am not doing my job.”

– Pat Rusk, elementary school teacher and former president of the Utah Education Association

In an energetic meeting marked by some controversy, California physicians debated priorities for supporting health care in rural parts of California and ensuring access to safe obstetrical services at the California Medical Association (CMA) House of Delegates (HOD) meeting in Sacramento, October 26-27, 2024.

CMA membership is dominated by physicians working in urban and large suburban areas, especially those working at large medical groups such as Kaiser and Sutter. Although the two issues under discussion were especially important for rural clinicians most CMA members expressed support for their colleagues who have chosen to practice in rural settings.

For rural health, 14 recommendations were adopted by the HOD, including:

• Supporting public health-funding allocation models to ensure adequate funding for small rural counties.
• Calling on congress to increase the number of visa waiver slots available in California for physicians practicing in rural areas.
• Calling on Department of Health Care Services (DHCS) to remedy the systematic undercounting of American Indians in Medi-Cal data.

One area of controversy was a proposal to create a Section of Rural Physicians with influence at the Board of Trustees level. The executive leadership and governance committees agreed to take up this topic at a future meeting.

To kick off the OB access topic, Surgeon General (OB/GYN) Dr. Diana Ramos presented up-to-date data on serious maternal morbidity and mortality in California and unveiled her pre-conception screening program, “Strong Start & Beyond.”

For obstetrical services, 18 recommendations were adopted by the HOD, including:

• Support for funding low volume hospitals using mechanisms such as standby capacity payments.
• Alignment with increasing the support for training clinician workforce to provide obstetrical care, including perinatal case managers.

The role of family physicians (FP) that are trained to provide operative obstetrical services in rural areas generated some controversy, with urban/academic OB/GYNs expressing skepticism that FP[1]OBs can provide safe care in rural areas, while family physicians working in rural areas spoke up to defend their role in providing rural obstetrical care. This is not a settled issue; continued advocacy is needed to educate urban OB/GYNs on how OB care is provided in rural areas.

The other important action of the HOD was that in a tight, three-way race, pediatrician Dr. Rene Bravo of San Luis Obispo won the election for president-elect. He presented an excellent understanding of rural issues and primary care; representatives from district X and XI were pleased with his election.

Many physicians from Partnership’s 24 counties enthusiastically participated in the activities, including seven Partnership medical directors. County medical societies in CMA districts X and XI represent 23 of Partnership’s counties (Marin is served by district VIII). These districts were especially active in presenting amendments and debating the proposals.

The medical directors at Partnership strongly encourage all physicians in our service area to join the CMA and their local medical society to ensure representation and a voice in CMA policy decisions. Ideally, the organizations hiring these physicians would support the membership dues because physician advocacy complements other mechanisms for influencing health policy in Sacramento, such as trade organizations and specialty organizations.

In addition to being a member of your local medical society, if you have interest in influencing health policy, the first step is to attend the county medical society events and executive committee meetings, volunteering to be a delegate or alternate delegate for the HOD.

The next HOD meeting will be on October 18-19, 2025, in downtown Los Angeles. If you want to learn more about how to influence our health care delivery system and support policies that support the health care system in rural California, we encourage you to consider attending!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The fact that we have the term “servant leadership” means to me that the definition of leadership is broken. To lead is to have a service orientation.”

–Stephen Shedletzky, author of Speak Up Culture

Job interviews for leadership positions often include the question, “what is your leadership style?” How does one answer such a question? Formal leadership training programs invariably include content on leadership styles which have been described and analyzed over the last few decades.

Before considering these, I will digress and note that there are centuries of writings in non-western cultures examining leadership frameworks with roots in the different cultural values in other societies. Descriptions of leadership are all frameworks that may ring true for some cultural and organizational settings, but are dependent on the place, time and mindset of the leaders being considered. This is an area of great interest to those working in companies with a multinational workforce. An excellent review article on this topic was written in 2019 by Vietnamese education scholar Nhung-Binh Ly.

The English-language leadership literature collectively includes more than 20 different leadership styles, although several are similar enough to be grouped together. Most authors select three to eight styles and describe these in more digestible comparisons. Here is a list of leadership styles that might apply to leaders of clinicians based in California:

1. Top-down Leadership: Autocratic, Authoritarian, Bureaucratic, Coercive, and Commanding

These styles are more common (but not universal) in military, veterans administration, and large, bureaucratic organizations. In these cases, leaders make decisions themselves with little input from anyone else. This works best if the leader’s knowledge and experience is much greater than that of their followers, when decisiveness is critical (such as emergency settings), and when following a hierarchy or dogma is highly valued. Downsides include stifling of innovation and feedback and disengaging of employees. In a setting of clinician shortages where clinicians are free to change jobs, this will lead to turnover in staff. Several years ago, a medical school classmate of mine had an autocratic leader of a community health center in Washington state; the entire clinical staff quit simultaneously.

Turnover is less likely when there is a significant penalty for a clinician to leave a position, such as a military enlistment contract, restrictions associated with immigrant visa status, a requirement to pay back a sizable advance or loan, or loss of large retirement benefits (sometimes called golden handcuffs). There is a cost to such binding covenants: those who stay in a position unwillingly will often be less efficient and empathetic towards patients.

2. Minimal Oversight: Laissez-faire, Delegative, or Absentee Leadership

These “hands-off” approaches assume that each clinician has their own way of practicing medicine and organizing their work which can be allowed to exist without interference. Many clinicians are partial to bosses who have this approach, feeling that their autonomy and expertise are being honored and respected. This comes with a cost, however: wide variation in practice styles leads to lower office productivity and office staff dissatisfaction associated with the mental gymnastics of meeting many different individual clinicians’ idiosyncratic “rules.” Similarly, improving quality of care across a practice requires standardization of processes, which is difficult in a delegative leadership environment.

3. Bottom-Up Leadership: Participative, Consensus-based, Collaborative and Democratic

Inspired by the ideals of egalitarianism, in these leadership styles, team members are encouraged to work together and give meaningful input into policies, decisions, and strategic direction. In the absence of consensus, the leader makes the final decision. This approach allows more engagement than the top-down leadership styles, but with more standardization than the minimal oversight styles. Ideally, decisions are made based on facts and quality of arguments presented by participants. In reality, there is often a social hierarchy at play with the participation process, with some participants having more sway than others not just due to the quality of the ideas presented, but by the social standing of each participant, and their desire to influence that social standing. If this social hierarchy is unchecked by a leader who is aware of these factors, the decisions made may be suboptimal.

4. Transactional Leadership

In this leadership style, tangible rewards and punishments are used to achieve goals. In the realm of leading clinicians, the tangible rewards may be financial (e.g. productivity incentives or quality incentives), or non-financial, such as allowing clinicians more flexible schedules or non-clinical administrative roles. Behavioral economic studies show that punishments are twice as effective at eliciting changed behavior than rewards of equivalent value but using punishments on individual clinicians often leads to turnover, so it is less likely to be useful in a setting of clinician scarcity.

5. Evangelical Leadership: Visionary, Charismatic, and Pacesetter

These focus on the leader themselves convincingly connecting the clinician work to a larger cause. Visionary leaders focus on the future state of the organization, and may or may not be able to connect that vision with the operational steps and staff motivation needed achieve that vision. Charismatic leaders tap into the human-mirror neuron system, building an unconscious desire to please the leader. Pacesetting leadership involves a hard-driving leader pushing followers to ever higher levels of excellence with no tolerance for mediocre effort or results.

6. Positive Leadership: Affiliative, Coaching, and Servant

These are hands-on styles that seek to promote longevity and performance by being supportive of clinicians. There are some important differences in the three subtypes. Affiliative leaders seek to create emotional bonds with followers, which can lead to hesitancy to have difficult conversations about performance and lack of feedback to leaders about organizational challenges. Coaching is important for new clinicians, but experienced clinicians may not see their boss as having the experience to be worthy of being a coach. Servant leaders attend to the needs of their high-performing staff, yet can give constructive feedback and have difficult conversations. Servant leadership was first described in 1970 in an essay by Robert Greenleaf, and many books have subsequently described and celebrated it. It has become so popular that author Stephen Shedletzgy implies in the quote above that all effective leaders are servant leaders.

7. Integrating Leadership: Adaptive, Situational, and Transformational

In real life, clinician leaders use elements of several of the above leadership styles, depending on the situation and the characteristics of the clinician they are supervising. Having an awareness of the usefulness and limitations of each style can help a leader of clinicians choose the best leadership style for a given situation. Transformational leaders use the best elements of several of the earlier leadership styles simultaneously, conveying the vision effectively, taking input from the team, using charisma to build trust and buy-in, while serving their employees and setting an expectation of excellence.

Returning to the quote by Stephen Shedletzgy, does all leadership require a service orientation? Not necessarily, although effective clinical leaders are more likely to choose to leverage a servant leadership style, much of the time.

I close with two questions for clinician leaders to reflect upon:
•   Which leadership style do you most see yourself using?
•   Which leadership style do you want to strive to use more often?

By Dr. Ashley Sens, CMO Woodland Healthcare

“Teaching is more than imparting knowledge; it is inspiring change. Learning is more than absorbing facts; it is acquiring understanding.”

– William Arthur Ward, Author

In my role as Chief Medical Officer for Woodland Memorial Hospital, I am sometimes asked to meet with patients whom physicians and nurses are concerned may decide to leave the hospital prior to the treating team feeling they are safe to discharge. When I get involved, it is typically because the team is concerned a patient-directed discharge could lead to the patient’s death. The stakes are very high for everyone.

I want to share with you an encounter I had with such a patient who taught me one of the most important lessons of my career.

Typically, the treating team and I would emphasize with these patients the dangers to them if they leave the hospital: “You are making an unsafe choice.” “You could die.”

However, this particular patient (we will call her Rose) helped me hear what those words sound like and feel like from the perspective of someone who has lived a life of severe trauma. The “aha” moment I experienced with Rose came when I realized Rose did not feel she was worthy of the care we were providing to her. All the threats to her safety and wellbeing were actually feeding into her impulse to leave – to run away, because, after all, what we were threatening is what she felt she deserved.

This insight did not happen because Rose told me explicitly she was not worthy of our care. The “aha” happened when I listened to her talk about her life and watched her squirm in the hospital bed. That was when I realized just how uncomfortable she must feel. For those who have lived a life of repeated and ongoing trauma, the trauma itself can feel more comfortable than safety, care, concern, or love – because it is familiar, and because their life experiences tell them they are not worthy of love.

So I stopped telling her she could die. I told her how much we care about her. I told her she was worthy of our care, that she deserved to be safe, and that she deserved to be well.

“We care about you.”

“You are worthy of our care.”

“Please stay with us and allow us to care for you. You deserve this.”

“You are worthy. You deserve to be well.”

Rose stayed.

— Dr. Ashley Sens, CMO, Woodland Memorial Hospital

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“We didn’t stratify the data by American Indian/Alaska Native, because the numbers were too small.”

– DHCS webinar, reviewing quality data stratified by race

Two years ago, Partnership first stratified Quality Outcome data based on the race/ethnicity we received from DHCS. As noted in prior newsletters, this data showed that outcomes were much worse for the self-identified American Indian/Alaska Native (AI/AN) population than for any other racial group. This prompted Partnership to launch a Tribal Engagement Strategy to build relationships with the 21 Tribal Health Centers and their associated 51 individual tribes, so that we can work together on improving health and wellness for our Tribal communities.

Two months ago, while preparing a presentation for the Medi-Cal Managed Care Advisory Group about Partnership’s Tribal Health Liaison Yolanda Latham, I was looking through race/ethnicity data on our members, and comparing it to the official California Census data, and discovered something very concerning: The number of AI/AN members enrolled in Partnership seemed very low. After a little digging (details below), I discovered that the magnitude of the undercounting is somewhere between 213% and 900%, and maybe even higher.

The reason for this is the way DHCS takes the race/ethnicity/tribal affiliation data from the official Medi-Cal application and uses an algorithm to assign a single race. The Medi-Cal application encourages individuals to choose all races that apply, in accordance with federal recommendations going back to 2000.

Page 4 of the Medi-Cal application:Page 20 of the Medi-Cal application:

The mechanism that DHCS uses to convey membership information to Partnership and other Medi[1]Cal managed care plans is a file called the 834 file or membership file. This file lists just one single race-ethnicity category per enrollee. DHCS uses an algorithm to translate the application race and ethnicity responses to this single category.

While the exact algorithm is not publicly posted, it seems likely that if an AI/AN member also identifies as Hispanic or Latino, this trumped their AI/AN status, and they were assigned a Latino ethnicity. Additionally, if an enrollee identified as both AI/AN and any other racial status, they were classified as “other” or “mixed race,” a category with poor outcomes similar to the AI/AN population, but as it is mixed with all other mixed-race individuals is completely non-actionable.

Here are three mechanisms used to estimate the scope of this undercounting:

1. Census Data

One way to estimate the scope of undercounting is to compare the proportion the Medi-Cal enrolled population identified as AI/AN compared to California census data on AI/AN ethnicity.

Official Medi-Cal statistics show a total of 55,302 (only 0.4% of all beneficiaries) AI/AN individuals enrolled in Medi-Cal as of July 2023. (Medi-Cal Fast Facts).

In contrast, in the 2020 census, 1.6% of the California population identified as American Indian and Alaska Native race alone, and an additional 2% of the population identified as American Indian or Alaska Native in combination with some other race, for a total of 3.6% of the population categorized at AI/AN alone or in combination. Even if we assume that the proportion of the AI/AN population of California with Medi-Cal is the same as the non-Medi-Cal population (a highly unlikely assumption), Medi-Cal is undercounting the AI/AN population by as much as nine-fold. Put another way, the true number is 900% higher.

Extrapolating the scope of the undercounting based on census data, as many as 495,000 Medi-Cal beneficiaries would be categorized as AI/AN alone or in combination, instead of just 55,302.

2. American Community Survey

An analysis of the 2018 American Community Survey conducted by the National Indian Health Board estimated the California Medi-Cal population to be 242,813. An updated estimate from 2021 put the number at 330,959, or 600% higher than the official state data.

3. Tribal Health Centers

Confirmatory evidence of racial mis-categorization comes from the subset of Tribal health centers, which only allow enrolled Tribally-affiliated members to be served. Of those Medi-Cal members served at these Tribal health centers, 53% were categorized by Medi-Cal 834 data as not being AI/AN. Meaning that the true number is 213% greater than the identified AI/AN at Native-run health centers.

Extrapolating this underestimate would mean that the actual number of AI/AN members receiving Medi-Cal is about 118,000 individuals.

Why such a broad range?

The range of undercounting (from 213% to 900%) is so large, partly because the U.S. Census groups together indigenous populations from Central America (such as the Maya and Aztec), South America and Canada into its totals. Of these groups, those who identify as indigenous from Central America are large and growing, resulting in a shift from the Latino category to the indigenous/AI/AN category. In contrast, Indigenous persons from outside of the United States are not generally eligible to receive care at Tribal health centers that are limited to Tribal members.

The American Community Survey assesses race and ethnicity differently, in a way that likely does not include Indigenous individuals from Central America in the AI/AN count, which lowers that count relative to the census estimate.

Impact of Undercounting

Official methods of categorizing race have a centuries-long history of being built on racist assumptions and bias. While I would like to think that the algorithm decisions that led to the undercounting of the AI/AN population in Medi-Cal were not intended to harm the AI/AN population, such large-scale undercounting has several important impacts.

First, it reinforces the perception that American Indians are no longer present in California; “erasure” is the term used by American Indian scholars and activists. In fact, in the past century, erasure was an official U.S. government policy, as tribes were “terminated” in the 1950s and 1960s, children kidnapped and taken away to boarding schools to indoctrinate them into American culture. The residual evidence of erasure reflects a lack of acknowledgment and sensitivity of this historical trauma.

Second, such profoundly faulty data leads to faulty analysis of health inequities. If the racial data used to calculate rates of quality indicators is biased and faulty, then the inferences drawn by stratifying data by race are hints of the underlying reality, but any sanctions or penalties tied to reducing such inequities by any specified quantity are statistically invalid.

Lastly, such significant undercounting impacts public health prioritization based on population affected, and thus potentially impacts funding allocated proportional to the AI/AN population affected.

What should be done?

Major Tribal organizations representing health and public health policy issues have raised the problematic nature of categorization of AI/AN persons in multiple settings and give input into the newly updated 2024 OMB standards.

National organizations, especially the National Indian Health Board, have raised the issue of data incompleteness and undercounting. Some shorthand terms for the lack of sharing of accurate data about the AI/AN population is “data sovereignty” and the need to “decolonize data systems.” The National Council on Urban Indian Health issued an analysis of undercounting among Urban Indians. Other organizations that have weighed in on undercounting of AI/AN population data include the 12 regional Tribal Epidemiology Centers, and the state Tribal health organizations like the California Rural Indian Health Board.

Major changes in the new U.S. Office of Management and Budget (OMB) Standards

The Updated 2024 OMB Standards for categorizing race/ethnicity move Latino/Hispanic to be a co-equal race/ethnicity category, instead of a carved-out ethnicity category. The Middle-eastern/north African population was carved out of the White category, so there will now be 7 major race/ethnicity categories. One of which is American Indian or Alaska Native, with a box to fill in details with the following language: “Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya etc.”

The most concerning aspect of the new OMB standard is the list of options for handling individuals who identify more than one race/ethnicity category. The three options identified are (see page 22195):

• The “alone or in combination” approach mentioned earlier related to census data. There is some complexity to using this approach, but it substantially resolves the undercounting of the AI/AN population and should be the starting point of data sharing and equity analysis. A key feature of this approach is that the total of all categories is greater than 100%, as one individual maybe two or more categories; this requires special statistical methods to avoid errors.
• The “most frequent multiple responses” approach, in which the top combined categories are each presented with individual data. For example, in addition to each race ethnicity category alone, each combination is listed with the number of individuals. Some may be simple two-race categories (like Black-Asian), but more complex combinations are possible (like Latino-Black[1]White). This allows the most granular data analysis, and the numbers can be folded into the “alone or in combination” category. The sum of all individuals in all categories will total 100%.
• The “multiracial” approach in which any individual who chooses more than one race/ethnicity category is categorized as either “other” or “mixed.” This grouped category is impossible to analyze, so the “pure” race/ethnicity categories end up being the only way to look for health disparities. This appears to be the method currently used by DHCS, and it should be abandoned as soon as possible.

What Can DHCS Do Now?

First and foremost, DCHS should share the current detailed enrollment race/ethnicity/tribal affiliation data with all Medi-Cal Managed Care plans so they can better analyze and understand the inequities faced by their members. This could be done with a separate monthly report from DHCS and it could also be integrated into the new Medi-Cal Connect platform that DHCS is building to feed assorted supplemental data to health plans. In addition, if DHCS has separate member-level internal flags indicating Tribal affiliation or AI/AN status, from other sources, this should also be conveyed to the plans with the more complete enrollment demographic data.

This granular race/ethnicity/Tribal affiliation data will allow managed care plans to re-run our disparity analyses and release an analysis of our findings. In addition, we can pass on this information to primary care practices to give them the complete and accurate data they need to identify and address health inequities.

As DHCS plans its implementation of the new OMB race-ethnicity standards, they should convene a workgroup with representatives from the California Tribal Epidemiology Center, the California Department of Public Health, the California Rural Indian Board, the California Consortium of Urban Indian Health, and Region IX of US HHS to review the options for categorization of data, strongly considering either the “alone or in combination” approach or the “most frequent multiple responses” approach, which can be combined to create “alone or in combination” groups. These two approaches would stop the undercounting of the AI/AN population.

Finally, to stop presenting incomplete and inaccurate data about the AI/AN population, DHCS should create an internal team to review all presentations of data that is stratified by race/ethnicity to identify, correct and/or put into context the data as it relates to American Indian population. This team should be empowered to raise concerns anonymously to the DHCS Chief Health Equity officer if their concerns are not addressed.

As unintentional as it may be, the DHCS racial categorization algorithm is an example of structural racism that deserves to be addressed. With the increased emphasis on Health Equity at DHCS and CDPH, there should be a heightened sense of urgency to definitively address this issue. DHCS alignment with the OMB’s updated race and ethnicity data standards creates an opportunity to correct an issue that obscures Tribal communities and other small populations from the data.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Today we have gathered and see that the cycles of life continue. We have been given the duty to live in balance and harmony with each other and all living things. So now, we bring our minds together as one as we give greetings and thanks to each other as a people.
Now our minds are one.”

– Beginning of the Mohawk Address of Thanks and Greeting to the Natural World.

Much of the health care delivery system in Partnership’s 24-county service area is composed of not-for-profit organizations. Only two of 50 hospitals in our service region are for-profit. Our primary care network is now largely made up of not-for-profit Federally Qualified Health Centers, Tribal Health Centers, and hospital-affiliated Rural Health Centers. Many ambulance providers, hospice and home care agencies, and community-based organizations that we work with are also not-for-profit.

While private physicians, especially specialists, are theoretically for-profit entities, stagnant Medicare and Medi-Cal rates for the last 25-40 years have led those physicians who have not retired or joined a larger group, to not have much profit left. So they are functioning like not-for-profits, staying in business to serve their patients and their community.

Notable exceptions to this trend is ownership of skilled nursing facilities (SNFs) and dialysis centers. Many are privately owned, and a notable number are owned by private equity firms. In the case of small dialysis centers, for-profit entities take over these entities to create a positive cash flow by improving efficiency and leveraging economies of scale. In other cases (SNFs and some specialty groups in our region, hospitals other regions), these firms use their financial strength to gain control of organizations, work to extract value from property/buildings, and then leave town when low quality leads to facility closure, with a net loss of SNF beds in our region. In the Partnership region, private equity owned SNFs have the poorest quality scores.

On June 11, the Corporate Crimes Against Health Care Act bill was introduced in the U.S. Senate. This bill would hold corporate executives personally criminally liable for patient deaths resulting from looting of health resources by private equity firms.

It is hard to know if this punitive approach will have its intended impact on health facility ownership, or behavior of private equity firms. A softer approach in California is to require the state attorney general sign off on any proposed private equity purchase of a health care facility. Any effort in reducing the negative impact of private equity firms on health outcomes is certainly worthwhile.

The not-for-profit sector is not uniform in its focus on improving outcomes for the community. “Not-for-profit” is a tax category, not a reflection of mission or corporate culture. As a result, some corporate not-for-profits are deeply connected to their communities in a way that promotes interdependent and synergistic activities to improve health outcomes. Others may have a mission statement related to health status, but their leadership is more focused on financial returns and growth than on community engagement.

What sets community-based and community-focused organizations apart from other not-for-profits? In her book, Braiding Sweatgrass, Indigenous Wisdom, Scientific Knowledge, and the Teachings of Plants, Robin Wall Kimmerer, a botany/ecology Professor and citizen of the Potawatomi Nation, gives a series of essays on the reciprocity that’s inherent in the cultural frameworks of Tribal communities. People support the Earth/nature, and nature and the Earth supports us.

People living in communities support each other, and the community supports each of us. Community-based health plans support the clinicians, hospitals, county health departments, and other health care providers, and those community-based health centers, specialists, hospitals etc. support the health of the health plan.

When we are in tune with our mutual interdependence, then our relationship is not one of trying to extract concessions in a zero-sum-game frame-of-mind, but that of how we can help each other grow and thrive while the patients we serve also grow and thrive.

In many schools in Tribal communities, each day starts with an address expressing gratitude for our fellow human beings, all living beings, the earth around us and the sun and moon that make life possible on Earth. Although not related to the American Thanksgiving holiday, this address is often referred to as the Thanksgiving Address, and includes the repeated phrase, “Now our minds are one.”

I thank all of you for your commitment to your community and to the interdependent health care delivery system we are all nurturing together.