Theresa Blanco, DO, does more managing in a day than most of us do in a month. And it’s only partly because she’s the director of medical affairs for Molina Healthcare of Florida. The 39-year-old Blanco is also the mother of six, her children ranging in ages from nearly 2 to 12. Her home life strengthens some of the skills needed for her job. “It helps me multitask,” jokes Blanco, who’s been in her present position at Molina since 2015. Then, seriously: “I can review cases, and get into a meeting, get insight, give advice to our nurses. [Being a mother] helped me become very patient.” She’s the first doctor in her family and, yes, of course, her parents Manuel, a CPA, and Maria, a retired national sales trainer for a pharmaceutical company, are very proud. (Her husband, Miguel, does promotions and marketing for radio. He’s proud as well.)
Part of a team
Blanco works with three other medical directors. Three (including Blanco) are stationed in the company’s Doral, Fla., office (outside of Miami; Blanco went to Tennessee when Hurricane Irma hit), while one is out in the field visiting hospitals, physician practices, social service organizations, and government offices. Blanco’s team reports to the Florida health plan’s chief medical officer, Mark Bloom, MD.
Most of Molina’s members are either Medicaid beneficiaries or people getting insurance on the ACA exchanges. Because of its background in Medicaid, Molina—at least initially—turned a profit on the ACA exchanges, though it’s gone through some tougher financial times recently.
One of the attractions of working for Molina, Blanco says, is that the company very much keeps in mind employees’ desire for work-life balance. Hers is an eight-hour day, but it’s a full and hectic eight hours.
“We work from beginning to end,” says Blanco. “I mean, just before this call, I was on a peer-to-peer that was taking a bit longer than it usually does, which is why I had to postpone our interview for a few minutes.” Peer-to-peer consultations involve discussing possible courses of action for a patient with the treating physicians.
Blanco earned a bachelor’s degree in science at the University of Miami, and her medical degree from Nova Southeastern University in Fort Lauderdale. She interned at Westchester General Hospital in Miami, where she also completed her residency.
Her job at Molina consists mainly in making coverage decisions, anything from pediatrics to hospice to oncology. “Anything that comes to our desk,” she says, “whether it be a long-term care member who needs extra hours for home health, to whether or not a pediatric case needs a CT of the brain.” Blanco makes the final decisions, but they can be appealed by a member, doctor, or hospital.
Blanco’s job also entails making prior authorization rulings, asking physicians why certain tests were ordered, deciding whether treatment criteria should be overridden, making sure that patients are seen by the appropriate specialists, and that they are prescribed the right medications at the right time. In addition, she speaks to hospitalists to discuss whether certain admissions were necessary, and to relay information about patients that the hospitals may not have on record.
This sounds somewhat like her job entails saying “no” a lot, an assumption Blanco takes pains to dispel. “We do think about what’s best for our members,” she says. “It’s not so black-and-white. We have things that we have to review, and there are a lot of gray areas.”
For instance, say something a patient needs is not covered by Medicaid or an ACA plan. Blanco helps members find what they need by working with Molina’s Community Connectors (community health workers) who help connect members to local community and not-for-profit organizations. “We help them find it, whether it’s a bedside commode or home care visits or transportation. That’s what we do on a daily basis.”
Keeping track of costs
On the other hand, “Absolutely, cost is taken into account. That’s another reason we’re here.”
For instance, Blanco will determine whether the care a patient might seek at a hospital can be delivered in a less expensive venue, such as an urgent care center. “We do daily rounds here, so we go through all of our patient admissions on a daily basis, and we review for medical necessity,” she says. “We also, most importantly, prepare and help our members with discharge planning.”
These decisions come with a lot of input; the insurer’s interdisciplinary teams get together once a week. They are composed of nurses, case managers, community health workers, health coaches, supervisors, pharmacists, and medical directors.
Tough year for Molina
In sum, “We’re very much on top of our members and their needs, and we’re trying to make sure that they have everything they need before they are discharged, and that no one is missing anything.”
It’s been a rocky year at Molina. In May, the board fired the CEO, J. Mario Molina, and the CFO, John Molina. They are sons of the founder of the company. In July, the company announced it was laying off 10% of its workforce.
Blanco says her job hasn’t changed. “I was drawn to Molina in large part because of its mission to provide quality health care to people receiving government assistance, and that mission remains the same today.”