Dr. Ria Paul, Clinical Associate Professor, Stanford University School of Medicine; Chief Medical Officer, Santa Clara Family Health Plan

Summary

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Podcast Summary

Episode Overview

Podcast: Becker’s Healthcare Podcast
Guest: Dr. Ria Paul, Clinical Associate Professor at Stanford University School of Medicine; Chief Medical Officer, Santa Clara Family Health Plan
Host: Erica Carbajal
Date: February 1, 2026
Theme: This episode features Dr. Ria Paul discussing her background, recent quality improvement initiatives, regulatory changes in Medicaid and Medicare, health plan-provider collaboration, and the integration of AI in member engagement. Dr. Paul brings deep insight from her dual roles in clinical leadership and health plan administration, shedding light on both operational strategy and frontline care delivery.

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Guest Background & Current Role

• Dr. Ria Paul’s Background:

  • Internist and geriatrician
  • Clinical Associate Professor at Stanford University School of Medicine
  • Chief Medical Officer (CMO) at Santa Clara Family Health Plan

• About the Health Plan:

  • Largest managed care plan in Santa Clara County, CA, covering ~15% of the county population (~350,000 members)
  • Two main product lines:
    • Medicaid
    • Medicare Advantage/DSNP (Dual Eligible Special Needs Plan, for frail elderly with complex needs)
  • Provides comprehensive services, including mental health, in partnership with county health systems and medical groups
  • Collaboration with public resources like California’s CalAIM

“We provide healthcare services to around 350,000 members... through two lines of business. One is our Medicaid line of business and another one is our dual eligible, our DSNP, our Medicare Advantage line of business.” — Dr. Paul [01:17]

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Key Initiatives & Quality Improvement (2025)

• Focus Area:

  • Improving quality metrics for both Medicaid and Medicare Advantage lines.

• Strategies Implemented:

  • Careful monitoring and specification of metrics
  • Real-time data sharing with medical groups
  • Regular performance conversations, sharing best practices
  • Resource support for under-resourced groups (e.g., medical assistants for smaller groups)
  • Introduction of both member and provider incentives to drive improvements in tougher clinical measures (e.g., cervical cancer screening, immunizations, annual wellness visits)
  • Shifting incentive focus yearly based on need and process maturity

• Results:

  • Across-the-board HEDIS measure improvements for Medicaid
  • Medicare Advantage/DSNP stars increased from 3.0 to 3.5 (noted as a “huge win”)
  • Pharmacy star rating reached 4.0

“We went from a three star rating to a 3.5 star rating, which we consider was a huge win for us. And our pharmacy star rating was actually four star. So we were very impressed by that.” — Dr. Paul [06:51]

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Incentive Program Design

• Member and Provider Incentives:
  • Monetary rewards, recalibrated annually
  • Focused on metrics needing extra push and those harder to achieve
  • When a metric becomes process-oriented and high-performing, incentives are reallocated to other areas needing attention
  • Both members and providers benefit—patients for attending screenings or wellness visits, providers for completing services that require more time or effort

“If we see that we are doing very good on a particular measure, we will kind of take away the incentive... then select a new metric which needs more focus.” — Dr. Paul [09:13]

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Regulatory Changes & 2026 Priorities

• Key Headwinds:

  • Upcoming regulatory changes affecting Medicaid (from DHCS, DMHC, CMS) and dual-eligible populations
  • HR1 legislation, redeterminations, and new work requirements beginning in 2026-2027

• Health Plan Response:

  • Diligent monitoring and rapid alignment with evolving requirements
  • Workflow reinvention to manage eligibility, redeterminations, and ensure coverage retention
  • Prioritizing member education to reduce disruption and anxiety

“At the end of the day we don’t want to scare our members but also we don’t want to have our heads buried in the sand as well. We are being very proactive.” — Dr. Paul [12:48]

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Opportunities for Organizational Growth

• Enhanced Collaboration:

  • Deepening partnership with care delivery organizations—on both outpatient and inpatient sides
  • Embedding health plan nurses in hospitals to reduce readmissions and length of stay
  • Close work between care managers and ambulatory providers to improve scheduling, DME, and home health management

• AI & Member Engagement:

  • Launching AI-driven platforms (e.g., chatbots) to provide instant member information and reduce call burden
  • Plan for AI rollout to enhance engagement and rapid problem resolution

“Gone are the days where a member wants to be on the phone for the longest time... Using AI platforms, AI chatbots on how to engage our members and getting them answers for what they need... We are very seriously looking into that and will probably roll out something in this year or so.” — Dr. Paul [15:35]

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Notable Quotes & Memorable Moments

• On collaborative improvement:
  “It is a collaborative effort... between a health plan and the care delivery side.” — Dr. Paul [04:19]
• On member-centric adaptation:
  “Our priority at this time is that our members retain their coverage and are continuing to receive the high quality care that they deserve.” — Dr. Paul [11:33]
• On using technology:
  “Giving them more instantaneous information can be very helpful. That's where AI platforms can help us.” — Dr. Paul [16:15]

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Timestamps for Important Segments

• [01:10] — Dr. Paul’s background and health plan overview
• [03:13] — Key initiative: quality improvement efforts and partnership with providers
• [08:15] — Explanation of patient and provider incentives
• [10:20] — 2026 strategic priorities: regulatory adaptation and coverage retention
• [12:44] — Proactive outreach for member education on regulatory change
• [13:40] — Collaboration strategies and plans for organizational growth
• [15:35] — AI impact on member engagement

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Conclusion

This episode delivers a practical, high-level view of how a large regional health plan—under Dr. Paul’s leadership—is elevating quality, responding to regulatory headwinds, and innovating through inter-organizational partnership and technology. The discussion is candid, detailed, and rich in operational examples, making it valuable for anyone interested in managed care strategy, quality improvement, and the evolving payer-provider landscape.

Transcript

[A]

This is where healthcare leadership comes together. Becker's 16th annual meeting brings more than 3,500 hospital and health system executives and nearly 800 speakers to Chicago, April 13th through the 16th. This year's event includes keynote conversations with Dallas Cowboys legend Troy Aikman and former President George W. Bush. For the agenda and event details, visit Beckershospitalreview.com and click on the Events tab in the upper right. We're looking forward to hosting you in Chicago.

[B]

Hi everyone. This is Erica Carbajal with Becker's Hospital Review. Thank you so much for joining us for this episode of the Becker's Healthcare Podcast. Today we're joined by Dr. Rhea Paul, clinical Associate professor at Stanford University School of Medicine and chief Medical Officer of Santa Clara family health plan. Dr. Paul, happy new Year. Honored to have you on today.

[C]

Thank you, Erika. And Happy New Year to you as well.

[B]

Yeah, hard to believe in 2026. Well, Dr. Paul, would you start here by sharing a little bit about your background in health care and your role today?

[C]

Absolutely. So, as you mentioned, I'm Dr. Rio Paul. I'm an internist, geriatrician, I'm a practicing faculty at Stanford University School of Medicine, and I'm also the Chief Medical Officer of Santa Clara Family Health. A little bit about Santa Clara Family Health Plan. Santa Clara Family Health Plan is the largest managed care plan of Santa Clara county in California. We provide healthcare services to around 350,000 members in Santa Clara county, which is about 15% of the population of Santa Clara county through our two lines of business. One is our Medicaid line of business and another one is our dual eligible rdsnp, our Medicare Advantage line of business and D snp. Many folks don't know, so that's why I mentioned it is Medicare Advantage plan by cms. So we have two product lines. One is Medicaid and one is Medicare Advantage and we work very closely with our county health and hospital system. 50% of our membership are with Santa Clara County Health and Hospital System and the other 50% is with other IPAs medical groups. And we provide holistic care, not only physical care, but also mental health and other services through our Calaim resources through DHCS from California State.

[B]

Great. Thanks, Dr. Paul. Helpful to hear that overview there and imagine a lot you're accountable for there covering 15% of Santa Clara county. As you mentioned. Can you share what the most important initiative is that you've led in the past year? Tell us a bit about what that was and what the results, some of the results that you're seeing now in early 2026.

[C]

That's a very good question. So last year one of the major initiatives for us was to improve our quality improvement scores both for our line of business for Medicaid and our dual eligible or Medicare Advantage as you know, health plan. Our North Star is always our quality ratings because that's how we are perceived by ourselves and by others, how good of a care we are providing our members. So we focused heavily on our improvement offer, quality ratings like I said for both of our line of businesses, Medicaid and Medicare Advantage and few things that we did in 10 very deliberately is focusing on the metrics, the specification of metrics, focusing on how the data is flowing from the various medical groups to the health plan and also at the same time doing real time report outs to the medical groups, having conversations with the medical group on a regular basis, making sure that they are aware of what their opportunities, what are their successes, are sharing best practices, evidence based guidelines and also at the same time trying to see where we can help the medical groups. Because at the same, because it is a collaborative effort that we feel is between a health plan and the care delivery side. So for example that when we identified that some medical groups had some resource issues like the smaller medical groups needed a medical assistant or coordinator to call patients for their appointments or their care coordination. So we actually provided resources for that and which we really helped, we saw that it really helped the medical group's long term results. And another thing that we did was focusing on incentives. So not only on patient or member incentives, but also on provider incentives, the patient incentives we deliberately selected measures that we felt was tougher to get done. For example, cervical cancer screening for some immunizations for annual wellness visit for our Medicare population. So we provided member incentives and at the same time we provided incentives to our physician groups as well to help them navigate their whatever their day was. Because we all know that annual wellness visits take a longer time. So we wanted our providers to do the annual wellness visits but since it's a half an hour appointment, we tried to incentivize the providers to do so. And that's why we saw that the incentives really, really helped the provider. And at the end of the day we definitely saw these all helped our ratings. For our medic Medicaid ratings we improved on all of our measures, all of our HEDIS measures and for our Medicare Advantage or D SNP star ratings we actually improved as well. As you know, D SNP is a very tougher form of Medicare Advantage because the Patients here are frail, elderly and have multiple comorbid conditions. So improvement of a star rating here in D. SNP it's actually a monumental effort and kudos to our quality team at the health plan to do so. So we went from a three star rating to a 3.5 star rating, which we consider was a huge win for us. And our pharmacy star rating was actually four star. So we were very impressed by that.

[B]

Yeah. Dr. Paul, congrats on those quality rating improvements. I know that's no small feat and certainly a lot of intentional coordinated work that went into that. I love what you mentioned as well, just about the coordination and the partnership and the resources that you are providing to medical groups. I think it's such a great example of what that that collaboration actually looks like in practice because we hear a lot, lot about that and I know folks are interested in like, what does that actually look like? How does that happen in terms of the relationship between health plans and providers? When you mentioned the incentives for patients and providers on the screening side and then both on the annual wellness visit side for physicians, can you share an example those incentives look like either for patients or providers?

[C]

Yes, these are all monetary incentives. So every year, beginning of the year, we develop our incentive program. Usually we replicate the incentive program from the year prior, but we always look at where our opportunities are and then go ahead and select those metrics that we feel need and extra push both from the member side and both from the provider side. And that's how we select the metrics and how much monetary weightage we put on the particular metric also depends what it was the year prior and then decide whether to continue with the same monetary weightage for this year or should we go up this year as well. Another thing that we do is that if we see that we are doing very good on a particular measure, we will kind of take away the incentive on that measure because then we know that the patients and the providers have become very well versed with that metric and that has become very, it has become a very process oriented metric for the, for the provider. So we will then take away the metric, then select a new metric which needs more focus. And so again, metrics we select on a yearly basis. And also the monetary weightage also we adjust on a yearly basis as well.

[B]

Yeah, no, that makes sense just based on really how much improvements are happening in certain areas and where there are areas that still need that extra push. Well, Dr. Paul, looking ahead, what are some of the biggest priorities and headwinds that you're focused on and have on your radar in 2026.

[C]

Again that is a very important question and very timely because we are just starting the year off. Definitely we want to build on our gains from 2025. Whatever we have built done in 2025 in terms of our quality improvement, want to sustain and enhance on that. At the same time there has been a lot of regulatory changes coming down to Medicaid line of product from dhcs, DMHC and from CMS for our dual eligible line of product. So we, we have to align with that and so we are, we are very, very very diligent in following up on these regulatory requirements, aligning with those and the headwinds definitely for our Medicaid line of product. As you know, with HR1 there are a changes happening in the Medicaid arena. Some are starting in 2026 and some 2027. For example, the redeterminations, also the work requirement and so forth. So all of these that we were not really focusing on before, we are making changes in our workflows in making sure how we how we are in alignment with all of these requirements and also educating our members accordingly, helping our members through all these processes, offering determinations, work eligibility because we want to make sure our members are retaining the coverage because that is our priority at this time, that our members retain their coverage and are continuing to receive the high quality care that they deserve.

[B]

Yeah, absolutely. There's so many changes coming ahead and it sounds like the health plan is sort of looking at them in phases and prioritizing that way of what's happening, what's going to start being put into place in 2026, what's going to start be put into place in 2027 and working on it in that way. Has the health plan already started really shoring up and getting proactive about the patient education and the outreach there?

[C]

Absolutely. We are going all out and educating our members regarding the changes that is coming down at the pipeline. At the end of the day we don't want to scare our members but also we don't want to have our heads buried in the sand as well. We are being very proactive. We have developed teams for not only the education part but also how to roll out the strategies or to help our members with redeterminations, the work eligibility or even educating them with any of the changes that is coming down in terms of co pay benefits and things like that.

[B]

Yeah, thanks Dr. Paul. Where do you see some of the best opportunities for organizational growth in the year ahead?

[C]

Well again that is very Exciting for me, I feel, because again for me, in my previous role as a CMO of the Stanford Health Plans, I've worked very closely with the care delivery side and I saw how important it is for a health plan to work in tandem with the care delivery side and not in silos. And that is what I'm focusing here in the managed care, the Spanish care plan at Santa Cara Family Health Plan that working in very close collaboration with the care delivery side, focusing not only on the outpatient side, but also on the inpatient side. For example, I have set of processes where our um, nurses are actually in the hospitals and then they are working closely with the discharge nurses in the hospital, which really helps reduce length of stay readmissions and so forth. And also our care managers on the health plan side are working very closely with our providers on the ambulatory side to help them in various scheduling appointments, getting dme, home health and so forth. So there is a lot of collaboration between the health plan and the care delivery side on multiple angles. And that's what I see that that is how we can have a better outcome for our patients. Another thing that looking at and we have started slowly is integration of AI in our member engagement. And because I do feel that gone are the days where a member wants to be on the phone for the longest time and so they do want instant information and that is the most effic efficient way of engaging a member instead of them being on the phone for five, 10 or 15 minutes. So, so using AI platforms, AI chatbots on how to engage our members and getting them answers for what they need. And if there are escalations then it can be escalated to a live person. But giving them more instantaneous information can be very helpful. And that's where looking how AI platforms can help us in this area. We are very seriously looking into that and we'll probably roll out something in this year or so.

[B]

Yeah, a lot to look forward to and I think so many great points what you mentioned about collaboration and really focusing on that. It really sounds like for that to be effective between health plans and providers really has to be on the ground partnerships and support, as you mentioned with having nurses even work in tandem and lots to look forward to on the AI side as well with member engagement. Dr. Paul, thank you so much for your time today. It's a pleasure to have you on the podcast.

[C]

Oh, thank you so much, Erica.