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.

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]

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]

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]

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]

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]

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]

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

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.