​ interview

Addressing the opportunity gap

Nathan Chomilo, MD, FAAP

Department of Human Services

DHS recently restructured Medical Directorship to now include two individuals. Please tell us about this shift.

The move allows DHS to bring on regularly practicing physicians and providers who also have demonstrated experience in addressing health equity, health access, and better statewide integration of care. It is in line with the state’s commitment to address health disparities, particularly around substance use treatment, mental health access, and child and maternal health outcomes. Having a director focused on behavioral health and familiar with the nuances of care delivery as well as a director who is a practicing physician taking care of Medicaid patients regularly will allow these policy discussions to be more grounded in the impact on patients and their families.

What are some of the things that appealed to you about taking this new position?

Much of my early career focused on advocacy around early childhood, racial and health equity, and how health care systems can address the opportunity gap and structural racism. We have to shift how our health care system talks about disparities, how we structure payment and quality measurements, and how health care becomes a more just and equitable force. Medicaid plays a huge role by serving some of our most under-resourced communities. As one of the largest payers, it often sets policy that is followed by others.

Roughly 50% of my patient panel is served by Medicaid or MinnesotaCare. I had been interested in how I could utilize my experience with early childhood advocacy, Reach Out and Read Minnesota, and Minnesota Doctors Health Equity to help inform state policy—but I was not ready to move into a full-time policy position and give up my clinical practice. This opportunity aligned with many of my goals and existing efforts. In addition, our Governor, Lieutenant Governor, and Commissioner have been very clear about addressing racial disparities in Minnesota, recognizing the importance of early childhood, and making equity a focus across all efforts.

What were some of your initial priorities and goals?

Prior to COVID, my goals were:

• Working to address the racial and geographic disparities we see in our state, particularly regarding maternal health outcomes;
• Continuing the work my predecessor pioneered on addressing the opioid crisis through the opioid prescribing improvement program; and
• Using Medicaid’s role throughout early childhood to better support the early childhood infrastructure and help decrease opportunity gaps that start as early as 18 months and lead to many of the disparities we see throughout life.

I also have taught and given several Grand Rounds about structural racism within medicine. I aim to help facilitate similar conversations within DHS and to support efforts to make DHS an agency that not only values equity but specifically anti-racism. The pandemic has allowed conversations about the importance of a racial equity lens to be applied to all policy discussions and for decisions to be accelerated.

​Leaders should seek to understand first before being understood.

Please tell us more about what your day-to-day activities are like now.

Before accepting this role, I split my time as an internal medicine hospitalist and a clinic pediatrician. My schedule was one week of hospital medicine and one week of clinic pediatrics. I’ve now moved to a casual position with the hospitalist group and I’m doing one week of clinic pediatrics, then one week with DHS.

As Medicaid medical director, my days are a mix of reading to stay abreast of the ever-changing policy landscape and medical literature; meetings with my DHS colleagues and with other state agency colleagues, health plans, provider groups, and patient advocates; and preparing and delivering talks to help inform the broader public about the work I do and the work of Minnesota’s Medicaid agency.

What surprised you most about your first six months?

The easy answer is COVID-19. There were few within public health or health care policy who saw in January the dramatic impact this would have. My initial plan was to spend a good chunk of the first six months getting to better understand our Medicaid agency functions at the state level, getting to know my colleagues at DHS and the work they are doing, and then starting to build toward my goals and the changes I hope to impact. COVID-19 accelerated some of my work and postponed other parts. It has been difficult to connect with and get to know all of the other leaders within the Medicaid agency due to both the difficulties of working from home and the extraordinary time and effort needed to address COVID-19—challenges that our whole agency has had to undertake.

What are some examples of how the pandemic has impacted your work or changed your priorities?

It has given me the platform to push for an “equity first” lens in all of our work earlier than I had planned. One of my mentors gave me some great advice before I took this role: Leaders should seek to understand first before being understood. I continue to try to take that approach, but with COVID-19 I am more comfortable pushing first for a focus on equity, and for racial equity in particular.

I’ve heard the analogy that the COVID-19 response has been an exercise in building the airplane while you fly it. I’ve consistently pointed out that we need to build equity into the walls and core structure of our airplane rather than waiting to add it. As we are fundamentally restructuring parts of our health care system and society in ways unexpected just six months ago, it is important to recognize that we can’t simply go back to normal. Normal wasn’t working for so many communities in our state, so this moment requires a new normal committed to addressing the racial inequities that have persisted for much too long.

What are some of the DHS programs physicians should be more aware of?

I hope all physicians who care for children are aware of our Child and Teen Checkup program and the numerous benefits it provides for families to get childhood immunizations, developmental screening, and a healthy foundation.

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I particularly want to highlight our integrated health partnerships (IHPs) and our integrated care for high-risk pregnancies (ICHRP). IHPs are an innovative way to support the delivery of health care by allowing providers to develop models that support Medicaid enrollees in the clinic/hospital as well as the social drivers that impact the health of enrollees and their communities. IHPs are in their second iteration (IHPs 2.0) and there are currently 25 IHPs throughout the state addressing issues such as food and housing insecurity, as well as transportation barriers. We continue to explore and develop this model and I am interested in how this can help us address some of the social drivers of health and decrease some of the racial and geographic disparities.

Our ICHRP program is an innovative way to address the maternal health outcome disparities we’ve seen in African American and American Indian populations in Minnesota. It is a community-led and community-driven model. DHS entrusts the communities, who know what resources they need, to help identify the problem and co-create the structure for them to be the stewards of those resources. This shared power is often where talk about equity and addressing structural racism has lagged in big health care systems. This model could be scaled up to be the standard of care for all Black and American Indian mothers in Minnesota, as well as an example of how we can share power with communities to address some of the deep inequities stemming from structural racism.

Lastly, DHS helps our neighbors in need of housing, income, childcare, and nutrition support.  These social drivers of health greatly impact our patients’ overall health, so I hope that physicians are aware of these resources and how to connect their patients to them, especially given the economic and health impact of COVID-19.

Nathan Chomilo, MD, FAAP, is medical director for Medicaid and MinnesotaCare at the Minnesota Department of Human Services. A pediatrician and internist, Dr. Chomilo is a founding member of Minnesota Doctors for Health Equity, a statewide coalition of physicians. He serves as medical director for Reach Out and Read, Minnesota, and as an Early Childhood Champion for the Minnesota chapter of the American Academy of Pediatrics.