Five Questions With: Dr. Marylou Buyse

Updated at 11:54 a.m.

Dr. Marylou Buyse joined Neighborhood Health Plan of Rhode Island in December 2018 as chief medical officer and senior vice president. Buyse’s past leadership roles in health care include being at the forefront of initiatives focused on population health and quality outcomes for Medicare and commercial plans, along with clinical leadership positions at Highmark, UnitedHealthcare of New England and Scott & White Health Plan of Texas.

PBN: What are your immediate goals in your first year at Neighborhood? 

BUYSE: First, let me say how proud I am to be one of the leaders of a managed care company providing access to high-quality, cost-effective health care that has served at-risk populations in Rhode Island for 25 years. I believe my role is to be sure our staff have the tools they need to best serve our members. As chief medical officer, my goals for Neighborhood are threefold: to be a 21st-century health plan, to work smarter not harder, and to support joy at work.

This requires we acknowledge that health insurance regulations and best practices for treatment are constantly changing. Therefore, my teams must have the appropriate technology to support delivering the right care management approaches. This is what it means to be a 21st-century health plan and have systems that work for us so we can work smarter.

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As soon as I joined Neighborhood, I began listening closely to my staff and collaborating with our Strategic Transformation Office to assess work flows and systems to evaluate how they are – or are not – supporting us in making sure our members are receiving the right care at the right time in the right place. I quickly learned we have an incredible team who go above and beyond to serve our members – even in the midst of change, which is important because change is synonymous with health care.

Change is also challenging and as such has the ability to distract us from our purpose and passion – which brings me to my third goal. I don’t want my staff to lose sight of why we chose to work in health care, more specifically to work at Neighborhood. We truly are a purpose-driven company, and I believe the joy and pride our employees experience delivering on that mission is what keeps us wholeheartedly engaged in our work. It’s important that while Neighborhood continues to evolve, we stay connected to the joy we feel working together to serve our members.

PBN: Is Neighborhood able to comfortably handle the needs of members who are on both Medicare and Medicaid?

BUYSE: As a not-for-profit HMO that has provided health insurance for 25 years to some of the most vulnerable people in Rhode Island, Neighborhood was well-positioned when it chose to become one of 13 Medicare-Medicaid demonstration plans a few years ago. As such, Neighborhood currently serves about half of the most at-risk people in the state and the care we provide is strongly tied to our mission of ensuring that individuals have access to high-quality, low-cost health care.

In fact, being able to once again serve members in government programs is one of the reasons I joined Neighborhood. I have extensive experience in care management, population health, quality, utilization management and medical policy development and find the work very gratifying. Neighborhood has a great reputation in these areas.

PBN: Amidst the struggle to keep health care costs down, how are insurance plans evolving along with providers?

BUYSE: At Neighborhood, we are continually looking at ways to improve quality and improve member experience at an affordable cost. We understand our provider network also embraces these important principles and we continually look for ways for both the plan and the providers to better coordinate and collaborate to improve health outcomes for all our members.

One of the ways we partner with providers is through our close relationships with Rhode Island’s federally qualified Community Health Centers, Neighborhood’s founders. We remain closely bonded, with CHCs represented on our board, and our teams regularly visit their facilities. We also co-create programs to better serve the approximately 50% of Neighborhood’s members who receive primary care at one of the 30 CHCs in the state. We firmly believe the CHCs are models for high-quality, cost-effective integrated medical and behavioral health services and are the building blocks of community health.

Another way that we work with providers is by sharing reports based on claims data with our Accountable Entities. The actionable information quickly illustrates such things as gaps in treatment, a series of visits to the emergency department, lapses in filling prescriptions and other key drivers of health outcomes. The information allows physicians and other providers to have meaningful conversations with their patients to help identify what barriers need to be addressed to support members achieving health and well-being.

PBN: How do you see Neighborhood working to improve health care for members?

BUYSE: Neighborhood works in many ways to improve the care of our members. From member services to marketing to medical management – we are all focused on keeping the member in the center of all we do. We work collaboratively and at all levels of the organization and with our external partners to improve the member experience.

One of the ways we improve health care for our members is to be strongly engaged in the community. This involvement not only shows our support for a diverse range of causes and organizations, it also affords us more touch points to reach our members. Through sponsorship of health-focused conferences such as the Partnership to Reduce Cancer in Rhode Island’s Annual Cancer Summit, information booths at cultural events [such as] the Dominican Festival, and staff involvement at charitable, community-focused initiatives [such as] the Back to School Celebration of Rhode Island, which provides backpacks and school supplies for children in need, we create additional opportunities to educate our members, answer their questions, and most importantly, get to know each other better – as people.

Another example of how Neighborhood works to improve health care for members is by ensuring our members have access to the medical treatment and community services they need in a culturally and linguistically appropriate setting. An extension of this is the makeup of our member services team who field incoming phone calls in a variety of languages. In fact, Neighborhood’s call center staff is as diverse as the community we serve and includes individuals who are especially empathetic and good problem-solvers because they were once members themselves.

We also develop collaborative partnerships across the health system to affect policies that impact our members. Last year, we co-hosted a policy conference with the Rhode Island Community Health Center Association on Neo-Natal Abstinence Syndrome with the goal of learning how to help pregnant women who are in recovery and women who are pregnant and would like to be in recovery have healthy babies.

We work closely with Rhode Island Kids Count to ensure we understand the unique needs of the children in the state’s foster program that we insure. We collaborate with the Executive Office of Health and Human Services to manage the medical and behavioral health care of those covered by Medicaid, including seeking ways to address food insecurity, housing issues and transportation, which are often barriers to health for this under-resourced group of the population.

PBN: Are there areas for improvement when it comes to quality outcomes for Neighborhood members?

BUYSE: Neighborhood is proud of our high quality rating and, in particular, of our nationally high rank for member satisfaction scores. We were one of the first CHC-affiliated plans in the country to receive “excellent” status from the National Committee for Quality Assurance and we have achieved NCQA excellence for 18 consecutive years. That being said, we are continually striving to improve our scores while also tackling the tough issues that are not always measured, such as understanding and acting on the social determinants of health that challenge our members.

Our high [Consumer Assessment of Healthcare Providers and Systems] scores reflect our members’ satisfaction with NHPRI and is another area that we work to continually approve. Let’s face it, like health, this is an ongoing journey and every day we are focused on being the best possible and making a member’s day just a little bit better than yesterday.

Elizabeth Graham is a PBN staff writer. She can be reached at

Editor’s Note: This story has been updated to reflect that Dr. Marylou Buyse joined Neighborhood Health Plan of Rhode Island in December 2018.