Fresh perspective
New Gateway Health CEO puts focus on ‘social determinants’ of poor health
No billing code exists, nor is reimbursement paid, for treating what Cain Hayes believes is a key to the health and well-being of the 550,000 members in the Gateway Health Plan that he now heads.
The popular term is “social determinants” — things such as housing, education, food and financial security that are not related to illness or injury but play critical roles in achieving and maintaining good health.
By Mr. Hayes’ estimate, those factors may be the primary reason why someone has, or lacks, good health. Their absence is also responsible for $250 billion or so of the nation’s annual $3.4 trillion health care bill, he said.
“I have a passion about the social determinants of health,” said Mr. Hayes, who in late November took over as president and CEO of Gateway Health Plan, succeeding Patricia Darnley, who left in August.
This is the third tour of duty in Pittsburgh for Mr. Hayes.
After college, he sold employee benefit programs locally in the 1990s, then left and returned in 2001 for a short time before moving out of state again.
Following a six-year stint in Connecticut with Aetna, eventually heading its national accounts division, Mr. Hayes, 49, most recently was president and COO of the health business for Blue Cross and Blue Shield of Minnesota.
Now he heads Gateway Health Plan, which specializes in Medicaid managed care and Medicare Advantage health insurance. Parent company Gateway Health Plan LP is owned by Pittsburgh-based
Highmark and the Michiganbased Trinity Health System.
Mr. Hayes quickly points out that Gateway Health Plan itself is a not-for-profit subsidiary whose 550,000 members make it one of the largest insurers specializing in health coverage for those on medical assistance.
Only Independence Blue Cross’ two Philadelphiaarea companies — AmeriHealth Caritas and Keystone Health Plan — and Pittsburgh-based UPMC have larger shares of that market statewide.
Although he’s still in his first 100 days at Gateway Health’s helm, one of Mr. Hayes’ early moves since moving into a corner office in Gateway 4, Downtown, was to withdraw the health plan from a joint venture in Arkansas beginning March 1.
The program, he explained, was moving into a new phase that would have required Gateway to take on a larger role under a different funding model.
“We just want to ensure that we’re able to meet the needs of the members that we have.”
The retreat raised some eyebrows, coming on the heels of turnover in the Csuite that saw the departure of Ms. Darnley and three other key executives last year.
Mr. Hayes said there’s no need for concern.
“The state of Gateway is good. We’re strong,” he said. “I feel really good about the future of this organization.”
Gateway Health still has a presence in Delaware, West Virginia, Ohio and North Carolina, although more than half of its members are Pennsylvania residents. Gateway Health Plan employs about 1,750 staff members.
Short term, Mr. Hayes said one focus will be lowering health care costs by, for example, making sure members have a primary care physician who can diagnose and treat small problems before they require a trip to the emergency room.
Emergency department use among those on medical
assistance is significantly higher than the general population, he said.
To be eligible for Medicaid, an adult under 65 must have annual income at or below 133 percent of the federal income poverty guidelines — about $16,000 in 2018. Those 65 and older who are blind or disabled are also eligible, as are families with children under 21 and people with significant physical or behavioral disabilities.
Mr. Hayes calls Gateway Health “a mission-driven organization” whose goal is to help those on medical assistance, 60 percent of whom hold full-time jobs.
“We don’t want members for life. We want people to be self-reliant. In an ideal world, we wouldn’t have the need for a Medicaid business.”