Examining the Social Determinants of Health: Measures, Evidence, and Policy Solutions
December 9, 2022
Despite significant investments to improve access to high-quality health care, health inequities in the United States persist by race, ethnicity, sexual orientation, gender identity, and disability, as well as by economic and community level factors such as geographic location, poverty status, and employment. While opportunities to advance health equity through clinical care continue to be important, addressing the ways in which SDOH increase or decrease the risk of poor health outcomes is critical to improving the nation’s health and wellbeing. Examining the root causes of SDOH is also critical for developing measures, evaluating data sources, assessing evidence and for formulating policy responses. This briefing: 1) Defined and evaluated the differences between SDOH, social drivers of health, social needs, and social risk factors; 2) Assessed the past and current SDOH policy landscape including metrics development and data source evaluation; 3) Discussed health care payor, provider, and community-based efforts; and 4) Outlined potential policy solutions at the federal, state, and local levels.
Speakers:
- Shantanu Agrawal, M.D., M.Phil., Chief Health Officer, Elevance Health
- Bryant Cameron Webb, M.D., J.D., Senior Advisor, White House COVID-19 Response Team
- Melinda Dutton, J.D., Partner, Manatt Health
- Ruqaiijah Yearby, J.D., MPH, Co-Founder & Faculty Affiliate, Institute for Healing Justice & Equity; Kara J. Trott Professor in Health Law, Moritz College of Law, The Ohio State University
- Rachel Nuzum, MPH, Vice President, Federal and State Health Policy, Commonwealth Fund (moderator)
This event was made possible with support from the Commonwealth Fund.
Presentation: Presentation
Event Resources
Key Resources
Additional Resources
Event Resources
Key Resources
(listed chronologically, beginning with the most recent)
“Health Care’s Increasing Focus on the Drivers of Health.” Seervai, S., Chen, A. The Commonwealth Fund. November 18, 2022. Available here.
“How the CMS Innovation Center’s Payment and Delivery Reform Models Seek to Address the Drivers of Health.” Horstman, C., Bryan, A., Lewis, C. The Commonwealth Fund. August 8, 2022. Available here.
“To Advance a National Health and Equity Infrastructure, Measure Drivers of Health.” Agrawal, S., Chen, A., Price, G., Perla, R. Health Affairs. July 1, 2022. Available here.
“Investing in Health: Seven Strategies for States Looking to Buy Health, Not Just Health Care.” Dutton, M., Ellis, K., Perla, R., Onie, R. Manatt Health. February 21, 2021. Available here.
“Structural Racism and Health Disparities: Reconfiguring the Social Determinants of Health Framework to Include the Root Cause.” Yearby, R. Journal of Law, Medicine & Ethics. January 1, 2021. Available here.
Additional Resources
(listed chronologically, beginning with the most recent)
“Federal Funding May Boost Social Determinants of Health Infrastructure.” Adetosoye, F., Khan, J., Baer, T., Leonard, S., Mandel, A. McKinsey & Company. November 1, 2022. Available here.
“Hospital Efforts to Tackle Social Determinants of Health Stall, Data Shows.” Kelly, S. Healthcare Dive. October 24, 2022. Available here.
“CDC’s Approach to Social Determinants of Health.” Hacker, K., Auerbach, J., Ikeda, R., Philip, C., Houry, D. Journal of Public Health Management and Practice. October 7, 2022. Available here.
“Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts.” Whitman, A., Lew, N., Chappel, A., Aysola, V., Zuckerman, R., Sommers, B. Assistant Secretary for Planning and Evaluation, Office of Health Policy. April 1, 2022. Available here.
“Medicaid Authorities and Options to Address Social Determinants of Health.” Hinton, E., Stolyar, L. KFF. August 5, 2021. Available here.
“What We Need to be Healthy—and How to Talk About it.” Lumpkin J., Perla, R., Onie, R., Seligson, R. Health Affairs. May 3, 2021. Available here.
“CMS Issues New Roadmap for States to Address the Social Determinants of Health to Improve Outcomes, Lower Costs, Support State Value-Based Care Strategies.” Centers for Medicare & Medicaid Services. January 7, 2021. Available here.
“Payment Structures that Support Social Care Integration with Clinical Care: Social Deprivation Indices and Novel Payment Models.” Huffstetler, A., Phillips, Jr., R. American Journal of Preventative Medicine. December 1, 2019. Available here.
“Healthy People 2030: Social Determinants of Health.” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available here.
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Experts
Speakers
Shantanu Agrawal, M.D., M.Phil.
Elevance Health, Chief Health Officer
shantanu.agrawal@anthem.com
Melinda Dutton, J.D.
Manatt Health, Partner
mdutton@manatt.com
Bryant Cameron Webb, M.D., J.D.
The White House, COVID-19 Response Team, Senior Advisor
bryant.c.webb@who.eop.gov
Rachel Nuzum, MPH (moderator)
The Commonwealth Fund, Vice President, Federal and State Health Policy
rn@cmwf.org
Ruqaiijah A. Yearby, J.D., MPH
Co-Founder & Faculty Affiliate, Institute for Healing Justice & Equity; Kara J. Trott Professor in Health Law, Moritz College of Law, The Ohio State University
ruqaiijah.yearby@slu.edu
Experts and Analysts
Genevieve M. Kenney, Ph.D., M.A.
Urban Institute, Senior Fellow and Vice President
jkenney@urban.org
Rebecca Onie, J.D.
The Health Initiative, Co-Founder
onie.rebecca@healthinitiativeusa.org
Rocco Perla, Ed.D.
The Health Initiative, Co-Founder
perla.roccoj@healthinitiativeusa.org
Government
Kelly Cronin, MPH, M.S.
U.S. Department of Health and Human Services, Deputy Administrator, Innovation and Partnership at HHS Administration for Community Living
kelly.cronin@acl.hhs.gov
Komal Bajaj, M.D., MS-HPEd
Agency for Healthcare Research and Quality, Chief Quality Officer and Clinical Director
komal.bajaj@nychhc.org
Alexandra Huttinger, M.S.
Health Resources and Services Administration, Deputy Associate Administrator
alexandra.huttinger@hrsa.hhs.gov
Eliseo J. Pérez-Stable, M.D.
National Institutes of Health, Director of the National Institute on Minority Health and Health Disparities
eliseo.perez-stable@nih.gov
Ellen-Marie Whelan, Ph.D., N.P., R.N.
Centers for Medicare and Medicaid Services, Chief Population Health Officer
ellenmarie.whelan@cms.hhs.gov
Stakeholders
Alice Hm Chen, M.D., MPH
Covered California, Chief Medical Officer
alice.chen@ucsf.edu
Debbie I. Chang, MPH
Blue Shield of California Foundation, President & Chief Executive Officer
debbie.chang@blueshieldcafoundation.org
Anand Parekh M.D., MPH
Bipartisan Policy Center, Chief Medical Advisor, Bipartisan Policy Center
aparekh@bipartisanpolicy.org
Ashley Perry, MPH
Socially Determined, Chief Strategy & Solutions Officer
ashley@sociallydetermined.com
Robin Rudowitz
Kaiser Family Foundation, Director, Program on Medicaid and the Uninsured
robinr@kff.org
Return to main event >>
Transcript
This is an unedited transcript.
0:05
Hello, everyone. Thank you for joining today’s briefing, Examining the Social Determinants of Health Measures, Evidence, and Policy Solutions.
0:14
I’m Devon Lata, Policy Associate at the Alliance for Health Policy.
0:18
For those who are not familiar with the Alliance, welcome.
0:21
We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.
0:30
We’d like to thank today’s sponsor, the Commonwealth Fund, for their generous support.
0:36
You can join today’s conversation on Twitter, using the hashtag all health live, and join our community at all health policy, as well as on Facebook and LinkedIn.
0:48
Today’s panel has a Q&A section at the end of the hour, We want you all to be active participants, so, please get your questions ready.
0:55
You should see a dashboard at the right of your web browser that has a speech bubble icon with a question mark.
1:01
You can use that speech bubble icon to submit questions you have for the panelists at any time.
1:07
We will collect these and address them during the broadcast.
1:11
Throughout the webinar, you can also chat about any technical issues you may be experiencing, and someone will attempt to help.
1:18
Now, I’m excited to introduce Rachel Nuzum.
1:22
Rachel is Senior Vice President for Federal and State Health Policy at the Commonwealth Fund.
1:27
Rachel works closely with policy makers at the state and federal level, and is responsible for developing and implementing the funds’ National Policy Strategy.
1:36
In addition to leading the Funds Federal and State Policy Program, she oversees the Funds Work on coven 19 and Public Health Modernization, and co leads the funds Behavioral Focus area.
1:47
Rachel has over 20 years of experience working in health policy at the federal, state, and local levels of government, as well as in the private sector.
1:54
Rachele, we’re excited to have you here with us, and I turn the stage over to you.
2:00
Thank you so much, Devon.
2:02
Thank you to everyone at the Alliance, and thanks to all of you for joining us for this important discussion around the social drivers of health, the economic and social factors that impact health outcomes and costs, as well as health inequities.
2:16
We know that there’s a well established body of research that’s concerned that confirms that those experiencing social and economic or risk factors have worse health outcomes, increased use of healthcare, significantly higher healthcare costs for mental health, and are more likely to experience racism.
2:34
We also have evidence that shows that addressing social drivers of health can improve health outcomes more cost effectively and equitably in medical interventions.
2:44
You also know that efforts to move to traditional measures of value based care without addressing drivers of health and health equity could exacerbate access barriers and worsen racial disparities.
2:56
There have been significant policy developments around social drivers in the last few years, and it’s a really exciting time to talk about the progress we’ve made so far, and where we’re headed.
3:05
With the publication of the 2023 Physician Fee Schedule, Final Rule, we saw a major wins for drivers of health, measurement and payment across two major programs and CMS, the merit based Incentive Payment System, and the Medicare Shared Savings Program. These are the first ever Federal drivers of health measures focused on screening for food insecurity, housing instability. Transportation issues, utility needs an inter personal safety.
3:32
You’ve also seen CMS improving a number of new labor’s addressing health related social needs at the state level. We’ll hear more about those later today.
3:40
You’ve seen CMMI models that are increasingly examining and addressing drivers of health, and the National Committee on Quality Assurance just adopted its first social need screening and intervention measure.
3:51
The momentum is building, as policymakers at all levels, realize what is possible if we measuring pay for what we ultimately value, the health of all Americans.
4:01
Now, I’d like to quickly introduce our audience to today’s exciting lineup, of panelists who are going to help us walk through all these issues. Their full bios are included in the webinar materials.
4:10
First, we have doctor …, she’s the inaugural Kara Teach, Karen J Trap, Professor of Law at … College of Law, and the Faculty Affiliate, as it currently institute at the Ohio State University. She’s also a co-founder, and a faculty affiliate of The Institute for Health Healing Justice and Equity.
4:30
Next, we have doctor …, Chief Health Officer, an elephant house, where he oversees the enterprise Hulse Health Strategy, including medical policy, clinical quality, and delegation oversight, as well as industry leading work to address health related social needs and health equity.
4:48
Next, we’ll hear from Ms. Melinda Dunton partner at MassHealth.
4:52
Linda brings deep knowledge and experience in publicly financed healthcare, including Medicaid, chip, and the Affordable Health Care Act.
5:00
Coverage expansion, delivery system transformation and payment reform. Melinda Gates, federal and state regulators, local governments, providers, payers, life science companies, and foundations, Linden may not have been a longstanding partner and sent an expert in the area of social drivers.
5:16
Finally, we have doctor Cameron Lab, physician, attorney, and Political Candidate from Virginia, currently serves as the White House Senior Policy Advisor for co-ordinated Team Equity in the Biden Series. Again, all of the bios are available as part of the Webinar resources. So, now, let’s get started with the conversation. So, doctor Yuri, I’m going to turn it over to you.
5:40
And let’s go to the next slide.
5:43
Today, I’m going to talk about the social driver of ****, structural, racism and health justice. Next slide.
5:52
This is a roadmap. I’m going to give examples throughout my talk about neighborhood and built environment and economic stability and hopefully get to discussion of the ways that we can begin to address these health inequities. Next slide.
6:10
The saucer driver of health inequities, is structural discrimination, and that’s the ways that laws, policies, and practices, are used to structure systems. As I mentioned, I’m going to talk about neighborhood and built environment, and economic stability to advantage the majority and disadvantaged minority individuals, and also includes the ways that organizations work together to create separate and independent barriers to the neutral denial of equal treatment. That results from the normal operations of institutions in society. And I’m like, most of what we talk about in terms of discrimination, it does not require bad intent. Next slide.
6:53
Today, I’m going to focus, particularly on structural racism, but I want to highlight that social risk factors include all of the identities that we share, which includes race, sexual orientation, ability, disability status, class, gender identity. Today, I’m just going to focus on one because of the limited time that we have today to talk about these issues. Next slide.
7:22
When we look at predominantly black neighborhoods, they usually have less economic investment, fewer resources, such as places to exercise and play. Which is associated with higher rates of cardiovascular disease risk for black women. More pollution, noise in overcrowded housing stock. And this is, in part due to laws that allow for residential segregation. Many of those laws have been shrunk down. But we still see law gaps in the federal housing laws that allow neighborhoods to be disproportionately racially segregated. I’m not gonna go into those today. What I do want to focus on, however, is a lack of access to clean water for urban and rural areas that disproportionately harms racial and ethnic minorities. Next slide.
8:17
So, as you see here on this slide, it is a picture Amanda Larson, who is in Navajo Nation and what we see is that there is a lack of federal law addressing access to clean water. Not only does this impact people throughout rural and urban areas, but it disproportionately harms Native American Indigenous Americans because they are relying on the federal government to ensure that they have access to clean water, which is not happening. Next slide.
8:53
As I mentioned, there are gaps in the Federal law, when we talk about housing.
9:01
one of the main gaps is a failure to require safe and healthy housing as a result many, many, individuals’ racial and ethnic minorities as well as rule lack, access to clean water. This has been associated with increased rates of respiratory disease, as well as increased rates of covert 19, because if you can imagine, if you do not have clean water, you don’t have an opportunity to wash your hands or sanitary conditions. Next slide.
9:39
So, my summary is that, in terms of housing, because of laws, that allowed for residential segregation, because of the current gaps in Federal anti discrimination law, as well as State anti discrimination law, we still have increased rates of racial residential segregation.
10:02
Many of these neighborhoods, lack economic investment. There’s no federal laws regarding right to clean water and plumbing.
10:09
And there’s a failure to enforce the state laws regarding health and safe housing. This disproportionately impacts racial and ethnic minorities, as well as the core and the outcomes we see are racial inequities in health and well-being, particularly during the covert 19 pandemic. Next slide.
10:32
I want to turn now to economic stability. Today, I’m going to just focus on three laws in three areas of the law, but there are many gaps within employment discrimination laws. Title seven of the Civil Rights Act of 1964 prohibits among other things.
10:51
Race, *** discrimination, The Equal Pay Act of 1963 prohibits *** discrimination and state equal pay laws prohibit *** discrimination. Now, I want to start off by acknowledging that already gaps. In these laws, particularly under Title seven, because of how courts have interpreted, most of them will only allow you to bring a lawsuit for one form of discrimination. So, if you are a black woman, is very hard for you to bring a lawsuit under Title seven, claiming both race and *** discrimination. The Equal Pay Act is great. But, again, it prohibits black women from bringing a discrimination case based on race.
11:39
They would only be able to bring a case under *** discrimination, and be compared their pay to be compared with that of black men, which are often, also not paid as much as white men. Next slide.
11:56
So, as I mentioned, there, are gaps in these laws. And so, what does that look like in terms of employment? We see, for example, that based on employment salary, history, and hiring data, that many companies have used prior salary history to pay racial and ethnic minorities less than white men. The same is true for women. Even though racial and ethnic minority individuals were doing the same job as white men, and had the same qualifications evidence also show that companies channeled racial ethnic minorities into lower paying careers compared to white individuals, and we tend to see this happening in tech jobs. A 2018 study sound black job seekers were penalized for trying to negotiate equal or higher salaries than their white counterparts. And we saw studies that showed the same thing for women.
12:55
And so what I want to highlight is that law can be a tool for structural discrimination, which allows for employers to act collectively or individually. Lawyers, to be able to pay people less, even though they are doing the same work as white men, we see this associated with depression, and women, and higher rates of job stress, and post-traumatic stress, and ask, also has been associated with low birth weight babies for african american women, which has been one of the leading causes of infant mortality. Next slide.
13:39
Now, I do wanna pull out another group that is affected by these issues, and then as home health aides, they provide activities with Dave provide services for individuals with activities of daily living in their home. Almost two thirds of home health care workers are racial and ethnic minorities, Actually, additionally paid through Medicaid reimbursement. They are more likely to be in poverty.
14:07
They have higher rates of injury, the construction workers, and we tend to see that they are not covered by many of the health and safety protections offered, which includes workers’ comp, as well as paid sick leave. Next slide.
14:26
So, in summary, for employment, I want to highlight that employment laws allow employers to pay women and racial and ethnic minorities less than their white male counterparts. Even though they are doing the same job. Employment protections often do not apply to jobs. Racial and ethnic minority workers, such as home health care workers, disproportionately impacted racial and ethnic minority workers, including women of color. And what we tend to see is higher rates of inequities in health and well-being. As I mentioned, depression, higher rates of injuries, and we have also seen this during the Kobe 19 pandemic. Next slide.
15:07
And so, what I offer to you is just a brief discussion of the health justice framework that I have worked with others to create. And so, that requires that legal and policy responses must include truth and reconciliation process that acknowledges the existence of racism and provides a mechanism to overcome trauma. Impacted communities, like home healthcare workers, should be leading and driving the change, and that we must provide healthcare and financial support to be able to redress the harm that they suffered. Next slide.
15:43
They are going to share the slides, so you can see the specific center has provided for each neighborhood and built environment. Next slide.
15:51
And economic stability. Next slide. But I want to leave you with just a couple of citations to articles that you can go ahead and pull. And feel free to e-mail me if you want more information. Thank you.
16:06
Thank you so much for, that was. That was really, really invaluable background, we’re going to turn it over to you.
16:17
OK, well, thank you very much, I hope you can hear me OK, and I really appreciate the opportunity to be here, and to be joined, to join these other panelists.
16:27
So in many respects, I’m going to pick up from the perspective that you’re just hearing about, but, sorry, hopefully now you can also see me, uh, In many respects, I’m going to pick up, on the perspective you were just hearing, and try to discuss how an organization, like elephants health really thinks about addressing social drivers of health and what we feel like we are capable of doing to address these needs.
16:58
Next slide please.
17:00
First one thing I’ll say for some context, in case viewers are not aware, listeners are not aware, is just one element of healthcare. So we were formerly known as Anthem.
17:11
We are a health benefits and health services company.
17:15
We serve about 47 million or so people around the country across numerous different populations, including employer sponsored insurance, Medicare, Medicaid, and the individual marketplace.
17:28
And, you know, we certainly view strategically addressing whole health to be a major pillar of ours.
17:35
And so that means addressing the physical health needs of our members, their behavioral or mental health needs, and, equally importantly, their social health needs.
17:45
Next slide, please.
17:46
So, what that has really meant for us is first, better understanding the social needs of our members.
17:53
Know, oftentimes you will hear in this field that there’s a certain amount, a good amount of social risk data that that the ecosystem has access to, and certainly there is access to data, but it is generally at the environmental or population level. So, you know, oftentimes you can think about the area deprivation index or the Social Vulnerability Index, these are publicly available.
18:18
Data that have occur at various population levels, whether it’s a zip code or a neighborhood error or otherwise.
18:26
Um, you know, in our perspective, certainly, that is not sufficient in order to be able to address the individual needs of our members, and to really know what the individual needs are.
18:36
In many respects, I often compare addressing social needs of population level data, being like addressing hypertension with population level data. It is not sufficient.
18:47
It can help you target your interventions or approaches by first identifying the overall neighborhood of the population that may face various social vulnerabilities.
19:00
But then you really do have to get at that individual level and really be able to address their hypertension or their social needs doing otherwise, might actually be insufficient or perhaps even dangerous.
19:12
So, one way that we have sought to understand the individual needs of our members is to conduct a a statistical survey.
19:21
And this was a first initiative that we rolled out at the end of last year, and it continued well into this here. What I’m actually sharing on this slide is data with you from a survey of our Medicare Advantage and commercially insured members.
19:37
We are actually in the midst of conducting a similar survey for Medicaid member, but there are a few finding here that I think are very interesting.
19:45
First, in this population, both in Indiana, in Georgia, we found that there were a number of members who reported having at least one social need, and, you know, roughly the equivalent between the commercially insured and Medicare advantage. So, about 70% of all the members that we spoke with, reported having at least one need, and then, oftentimes, more than one.
20:09
And we divided those needs up into nine different areas that are shown on the slide. You can see how common some of the needs are.
20:18
So, healthcare insecurity, for example, not being able to afford their healthcare or getting access to sufficient care, while less frequently highlighted, other aspects of financial strain were, frequently highlight it as was food insecurity.
20:34
And we did compare our survey findings to nationally available data, and, in many respects, it was quite similar, although, you know, there were some needs that, I think, rose to the top in our sample. And we also did see some differences by geography.
20:49
And so, what that really held up is, again, I think reinforces the notion that you really have to lift that needs, at an individual level, that they can very, for a variety of reasons, and what we are still very interested in. And, I don’t think we’ve got a great answer to it.
21:03
How often needs change, so how often does a member population have to be re surrogate in order to update and understand what their needs are?
21:12
I will also say, you know, once we had access to the kind of data, we could, of course, analyze it against the other kinds of data that we have, like, claims and access the registries, and other information. And, of course, found that with every report reported. Social need there was a, an association with Worsened, Mental, and Physical Health and Association, with changing healthcare utilization, for example.
21:37
More use of the emergency department and higher health care spending.
21:41
We actually saw that each need add an incremental impact in each of these areas with a particular inflection point once a member reported having three or more need.
21:53
And so, this work is definitely started informing our thinking deeply, and we have taken various steps, because, you know, conducting a statistical sample is actually quite challenging.
22:03
And so, what we’re really working towards is being able to get this data at a member level more routinely, working through our standard processes and operations, as we engage with members, for example, through case management, but also working really closely with providers.
22:19
And we have actually created a provider incentive program for them to be able to conduct social screening on our behalf and get that data back to us.
22:27
Next slide, please.
22:30
So, you know, obviously, then, the question becomes, well, once we have this information, what can we do about it?
22:35
And, again, I think we really created a strong case internally that these social needs are highly related to, or health outcomes, or quality outcome to poorer value for our span and indeed, higher spend.
22:49
And so, it is very addressing social needs, I would certainly argue, is extremely good with the line.
22:55
I think addressing health equity, overall is extremely busy with the line, for a variety of reasons, that is yet another reason why all organizations, and, frankly, all organizations should address these areas.
23:07
Um, and so, what we have work to do is to create what we’re calling the community connected care, dilution.
23:15
Both at the most elemental level, but this solution seeks to do it, again, combine social with information and data, have the member level.
23:23
And at the population level, there clearly is a role for population data to help target and focus needs and identify priorities.
23:30
But again, we want to drill that down to the individual member level, and really understand the health impact of social need.
23:39
And, you know, I already discussed the variety of data points that we’re trying to gather.
23:43
We did, I should just say, we didn’t want to create our own social needs survey. We really looked outside at validated surveys.
23:53
Basically adopted one of them throughout our enterprise, in order to gather that social data, and make sure that it is consistent across profits.
24:01
Using that information, then, we, of course, work directly with the member.
24:05
And, you know, I think it’s really important to conduct a, know, an assessment alongside the member using the validated survey. But then, also, go beyond your, really understand what’s driving their social needs.
24:19
And then, once we have that information, we can, of course, want the member to solution, so we can point them first, internally, to our own benefit.
24:28
You know, across many of our products, we offer supplemental benefits, value added benefits, which are, are quite often geared towards addressing social needs. And so, that really is the first place to make sure the member using the benefit that they already have access.
24:42
Second, we think about sending them to a variety of external solutions, And I’ll get into some of what those are in the next slide, And finally, I’ll and I’ll actually address that later in the talk. We have created solutions called Life Essential Kits for our own associates that we can actually utilize once we have a better understanding of what the member or associate social needs are. And then, finally, as I briefly mentioned earlier, we are actually curating a network of providers to assess social needs and get them addressed in the community.
25:12
And this is quite often where a community based organization come in.
25:17
And so, you know, again, argue it, we have to assess and address these social needs in order to meet the whole health needs of our members, and that when we do that, we actually make it more feasible for their health to be improved in the behavioral dimension and in the physical health dimension. And that’s ultimately where we get the highest value care for all of our members.
25:38
Next slide, please.
25:40
So, this is just a little bit more detail on the various steps that I laid out. I won’t go into all the details here, but, again, no, data is a really important driver of what we do, because it helps us in the right direction and get this, we hope, in front of the right members. There are a variety of approaches we take to getting NSF and somebody’s social history.
26:03
And, of course, with the other data that we have at our disposal of the health benefits company, we can then combine that data in predictive analytics models and other approaches. So, again, we are trying to prioritize.
26:15
and work with the right set of members. And then, you know, quite often, we have other processes that are already engaging with members. For example, case management processes or health risk assessment that we’re doing other customer service processes.
26:29
And so, we are working to create the right linkages so that if any of those elegant help employees get the sense that a member has a social need, they can either kick off a screening or do a warm handoff to one of our social counselors and get that screening done.
26:46
We also created a tool called The Whole Health Index that we’re actually working to publish on externally so that we’re being transparent about it. But that seeks to bring together information, Had an individual member level show what their needs may be on a physical dimension, on a behavioral, health dimension, and on the social dimension.
27:05
So, again, moving in the middle column, there’s a variety of engagement approaches that we have. So, we are embedding social screening and referral in our digital platform, that’s called Sydney. And that the standard mobile app that all of our members have access to. We have telephonic counseling resources, and we’re actually working to create more virtual and face-to-face counseling resources, as well.
27:27
Then, once we have that understanding at a member level, we can, of course, get them connected to a variety of resources, as I previously discussed.
27:38
Next slide, please.
27:41
So, actually, let me in. I mean, the Community Connected Care Program is relatively new of how we actually build it, earlier this year. We’ve been scaling it. We started in Medicaid, or probably Query, then. That solution is currently rolled out in 13 of our Medicaid market. And we’ve gone from, essentially, conducting very few risk screening.
28:05
Now, having conducted over 100,000 social screens in this year alone, we will be working to expand that solution into all of our Medicaid market for the remainder next year, working to expand it in Medicare, and, of course, looking at other population segments like our individual marketplace members, as well.
28:26
Results are still quite early, So, I completely agree with the earlier discussion that a variety of publications in peer review publications have shown that assessing and addressing social needs truly are valued driving, and, and help improving.
28:41
We will be collecting that data internally, and reporting it, externally, as well.
28:47
I thought, though, I would tell you about a program that we built specifically for our own associates, because that’s been in place for longer, and actually have gotten to the stage of, being able to show clear results, which I think are really exciting.
29:01
So, about a year and a half to two years ago, we actually conducted a social screening of our own associates using, again, validated tools and really sought to understand what their needs were. This was obviously in the midst of the pandemic.
29:15
And we knew as a leadership team that social needs were no no doubt, worsening and changing.
29:21
And what we found is that a significant number of our associates reporting were put in having needs in three major dimensions First, know, Craig, quite critically. They did reflect national averages and and did express that really concerning food insecurity.
29:39
A second need that they express was playing the role of a caretaker a caregiver for either elderly parents or children. And so they needed more support as a caregiver. And third, they also reported transportation insecurity and again, that’s pretty typical when you look at national social risk data.
29:58
And so, what we did to address their needs is created, what we call it, like a central kit.
30:03
So, there’s three LEAs, one in each of these dimensions, that offered a specific benefit.
30:08
So the nutrition paid, for example, offered a monthly grocery allowance that the associate could use in a variety of stores in order to supplement.
30:19
Yeah, they’re their grocery buying power and be able to supplement their nutrition at home.
30:25
We had similar approaches for the other two domains, and I will tell you that even when what they transportation security was reported by the associate, they are the vast majority of our associates actually shows the nutrition light potential kit.
30:42
So that became the overwhelming choice of over 9% of the associates to qualify.
30:47
And next slide, please.
30:48
And so, what we did is we actually followed these associate and what you see on this slide and beta hat for about one year of following them. We now have data for two years.
30:58
And we’ve submitted that data for publication in a peer reviewed journal that’s currently under review.
31:04
So just to share with you, the first year of finding what we actually did first is constructed a control group, working with our employer sponsored insurance customers, and looking at other employers.
31:16
We found similarly matched associate and actually track survey data, where we, you know, regularly surveyed all of the involved associates, both in the intervention arm and in the control arm.
31:30
And we, of course, track healthcare claims, another utilization pattern.
31:34
And what we found is that this intervention was really led to remarkably significant results.
31:40
We saw in the intervention population A, and these are all statistically significant, finding a decrease in overall medical expenses, a decrease in emergency department visits and hospitalizations.
31:52
We also found an increase in outpatient clinical appointments, an increase in the use of virtual care.
32:02
And even among the outpatient appointments, we found that a skewed toward regular outpatient visits, not urgent care visits.
32:10
And then of course at the same time we were gathering the survey data that were reported by the associate.
32:16
And therewith a difficult statistically significant rise in reporting mental health and well-being. A decrease in anxiety, a tweet, decreasing, depression. And so, we have really package that, at this point, in a, in a publication, and is currently under review. And you can see some of the quotes that we got from the survey on the right.
32:36
We are continuing to work in this area with our own associates.
32:40
We’re actually building onto the life essential kit, nutrition counseling for next year. And then we’re also working to create another program that can get associates connected to social resources that they need really bringing together the community connected care program, with what we’re also doing for our associates.
32:58
So thank you again for the opportunity to talk about our work, and I’ll be happy to engage in discussion and take questions.
33:05
Thank you much, so much. Knew that was really terrific and now we’re going to turn it over to Melinda.
33:14
Hi, and thank you. That really was terrific.
33:17
And I feel like that there’s a great kind of continuing conversation happening here and starting with the very broad structural issues, structural racism, environmental structural issues, moving towards the more tactical in terms of how one leading health plan is addressing the issues within the healthcare system and bridging over to the social services system. And then, what I’m going to talk about today is how that’s playing out for State Medicaid programs.
33:45
Then in my work, I work a lot over my 30 year career.
33:50
I’ve really focused on the Medicaid program and and related government financed healthcare programs. And I work a lot with state governments, as well as other stakeholders who are trying to improve the care for people who are, receive coverage under Medicaid and chip and related programs. And, increasingly, that work has been focused on addressing drivers of health. And if we could go to the next slide, that’s great.
34:17
I’m going to be clear, I’m going to be a little tactical in terms of what we are seeing states doing and lift up, where we see some trends that are promising, and also where there remains some challenges in integrating and efforts to address drivers of health into the healthcare continuum. Medicaid is a Health Care program.
34:41
Under its Federal Authority, It is two, provide access to coverage and care, health care, and improve health for people enrolled in Medicaid. And, historically, the assumption has been that, that the program is very much focused on health care delivery of health care services.
34:58
And increasingly based on the growing body of research that both speakers have talked about, there is a focus on how do we not just improve health care delivery, improve access to healthcare, but improve health.
35:14
And for Medicaid, which is a program, that’s a means tested program, by definition, people enrolled in Medicaid have low or moderate incomes, and, or higher health care needs.
35:28
That is a population that disproportionately vulnerable to drivers of health that can negatively impact their health outcome and, and even life expectancy, So.
35:40
And as we work with Medicaid programs and other stakeholders to think about how do we bridge between the health care delivery system and the social services system and, and environmental factors that impact health, we think about kind of three different legs of the stool here.
36:02
one is measurement, what, how do we find out what we’re doing? What, what, what people’s needs are, how we are to what extent we’re meeting those needs to is payment. How are the incentives aligned within Medicaid financing and other sources of funding to facilitate efforts to address drivers of health. And then finally, infrastructure. And this is recognizing this gap that exists between our healthcare delivery system and our human services or social services delivery systems within communities. And so I’m going to talk a little bit about what we’re seeing in terms of faith effort, to address the three legs of the stool across the country. Let’s go to the next slide, please.
36:54
This is just a very high level frame framework for organizing some of the emerging practices across the country. And I’m gonna go in a little bit more deeply into each of these in a moment, but just to orient ourselves, You know, as I said before, because Medicaid is a nice, means tested program.
37:14
It covering 80 million people in this country.
37:16
That includes half of birth, half of all children, and it is disproportionately the coverage vehicle for people of color in this country.
37:28
One fifth of our national health expenditures, It’s an enormously important program. And, and it’s also a program that the joint State and Federal program.
37:39
So while there are federal parameters related to its implementation, states have flexibility in terms of how they want to implement the program within their state, the long as they’re within those parameters.
37:50
They have a fair amount of flexibility, so it’s different than Medicare or even commercial insurance, in that we have these very large number of folks receiving coverage within the states, and we have the flexibility and State policy lever to try to craft programs to address social needs.
38:08
We’ve seen a dive into that, too, addressing social needs across kind of these three areas.
38:15
First, in terms of identifying reporting on social needs, I’m gonna get to it in a second, but it, over 30 states right now, are screening or assessing people for social, already.
38:26
So that, people see that it’s enormously important priority for states for a variety of reasons. What happens after that is it is more merchant in terms of what do we do with that information. How to respond to those needs. We do see that it’s very common, and, frankly, historically, has been built in for certain types of programs and services within Medicaid to integrate social needs into efforts to care management.
38:50
And, increasingly, we’re seeing efforts, particularly through Managed Care, to grow the workforce, who bring skills to bridge between health and human services, and to increase access to Human Services beyond the traditional health, traditional healthcare environment, Including through the use of community health workers, and partnerships with community based organizations.
39:14
All the way over to the right. This is the area that I think is that it’s the hardest and the biggest left and where efforts are most emergent.
39:21
Um, but we are also seeing efforts primarily through 11 15 waivers, which I’m going to talk about in a moment.
39:28
To invest in and engage in the community, and to create the, kind of infrastructure that we need to create sustainable bridging across our Health and Human Services system.
39:38
So, at its most basic form, we’re seeing Medicaid increasingly paying for services that are, delivered in the community, non traditional, non medical services, that have an evidence base, showing that they can improve health.
39:53
And we’re also seeing Medicaid programs, investing in infrastructure, like data exchanges, on capacity building for community based organizations to expand the range of services that they’re able to offer, to help facilitate health improvements within, among Medicaid populations.
40:12
I’m gonna go into each of these in a little bit more detail. So let’s go to the next slide.
40:17
I’m going to start with screening. And, and doctor …
40:20
talked about the screening efforts within elegance and similarly, states are really prioritizing, screening. This map reflects the review of Medicaid managed care contracts across the country.
40:33
And the bright colors mean that, that state is, in some way, requiring screening for their Medicaid populations, for drivers of health.
40:43
How they’re doing? It varies. You can see in the, in the blue, those states have said, we want screening within specific domains. For example, how you can see in the gold those states that have said, we want specific screening instruments use this instrument to do it. So, there’s some variation in how they’re doing the screening. But, you can see, overwhelmingly, states are moving towards requiring screening as part of a baseline assessment.
41:10
People enrolled in Medicaid and to help ideally inform their care plan and potentially provide population level information that can help states and their partners, plans and providers improve the delivery of care to their population.
41:26
A challenge that we have here, as you can see, that the gold boxes are around the States where there are, where reporting is required related to the screen.
41:36
So, we are screening, doing a lot of screening.
41:41
We aren’t sure exactly what is coming from that screening, and to what extent the, our interventions are impacting the outcomes for, for individuals who have been impacted by drivers of health that put their health at risk, and that’s largely driven by a lack of standardization. At this point, Rachel mentioned at the top of the call, we’ve seen some real progress in the last year. In efforts to create more standardized measurement tools for screening, identifying positive screens, and then taking action on those positive experience related to drivers of health.
42:18
They are not standardized measures, though, yet, in Medicaid programs. And so, we have some states creating home-grown measures, other states looking at the new NCQA measure that was just released in the last year. But this is an area that is the hamstring state’s efforts to bone structure interventions on an individual level, and also be responsive on a population health level to what we’re learning from these screenings that are happening.
42:45
Let’s go to the next slide, please.
42:49
Um, common for states to specify in their effort, populations and, or domain, that State Medicaid programs want to prioritize in terms of making an impact? And, this is, in part because a desire to not try to boil the ocean. The process of addressing drivers of health within the Medicaid program is complex, and requires investment and policy change. And so, we see states often prioritizing a month specific populations and domains, particularly, where there’s an evidenced based or reason to believe that those interventions can be successful.
43:27
You can see on the left-hand side, women and pregnant or parenting people, children, members with high needs, behavioral health conditions, homeless numbers, Those are among the most common populations that states have focused on in their efforts to address drivers of health. On the right-hand side, housing and food always rank at the top.
43:48
And housing is an area where there is, it’s among has among the strongest evidence base for showing that housing interventions can actually improve health outcomes. Of course, it’s also one of the hardest things to solve, from, in terms of the use of Medicaid resources.
44:04
Food is, it also has a very strong evidence base, and is a very common domain that states have prioritized in their Medicaid effort. Go to the next slide, please.
44:18
So we’ve screened someone, we’ve identified that they have a need, potentially, we’ve even assessed to get underneath the hood of that need and understand what assistance they might need, Then what happens. And this, I think, is what, in many conversations with providers, community based organizations, with others. And the concern is we’re screening, but then sending folks on a road to nowhere. We don’t have the infrastructure, or the services, or the payment mechanisms in order to do something about the information that we get through those screenings.
44:53
And there are some pretty serious barrier in, in this regard, that we have a cultural does that divide between our health and human services system. We don’t, We both are. So, that they, their priorities, and, and mission, 10, can be different, and create difficulty in communication and aligning on effort.
45:18
There’s limited data sharing across the two health and human services, and systems funding streams, and the way organizations get paid are completely different. They speak different languages.
45:31
And then, really, critically, there’s a lack of investment. I mean, our social Safety net is frayed. And I’m sure folks are well, aware of the documentation of the under resourcing of our social safety net in the United States, compared to other countries.
45:49
And that lopsidedness create structural inequities within the, even the negotiation processes between health organizations and and CBOs.
46:01
And, and create lots of barriers to bridging and enabling there to be a support system, to intervene and provide assistance to individuals who are identified as needing social supports to address their health related social needs.
46:17
Let’s go to the next slide.
46:19
Um, states are taking a variety of, or maybe using a variety of strategies to try to help create this bridge. Some are very simple, some are, you know, within their Managed Care contracts.
46:32
I’m just requiring the plans to create partnerships.
46:37
I’m sure many of us have heard about closed loop referral platforms that has, there are a number of them that have emerged and are helping to provide common data exchange for referral, to from healthcare organizations, social service organizations, and then the closing of that loop, reporting back on what those findings are.
46:59
And all of those are incrementally helpful.
47:03
As we’re also seeing emerging, what I’m calling here, community care hubs. And we recently released a report that talks about this more broadly, but basically community based organizations coming together and sharing and centralizing administrative and operational infrastructure.
47:19
But also, putting together networks of social services that then can be made available to help partners, whether those be plan to provider organizations and to credit, to help accelerate the ability of organizations CBOs to participate in these types of collaborations.
47:40
And we’re seeing that North Carolina’s waiver as an example of where they’ve deployed that strategy. But we know that that’s happening in other parts of the country, as well. And so that’s one way that we’re seeing some states start to seek to create more infrastructure in order to be able to address social needs once they’re identified. Next slide, please.
48:05
I’ve mentioned waivers a couple of times.
48:07
And I’m gonna, after this slide, I’m going to talk about, there are a variety of the port authority under Medicaid to address social needs outside of waivers, but certainly on the Olympic team waivers, addressing drivers of health, are the headline get hurt? And that’s because there are limitations within the Federal Authority, Federal Medicaid Authority, in order and into limitations on the ability to make the investments that are needed to address drivers of health.
48:36
11, 15 is a provision in the Medicaid statute that allows the federal government to waive certain aspects, certain limitations within federal law, to give states and flexibility to test new models, and where those new models can improve health.
48:54
And, further that, the purpose of the Medicaid statute, we’ve highlighted a bunch of states here that have had 11, 15 waivers. I want to note that these waivers require a partnership and agreement between CMS, the federal government, federal regulators, and and the state Medicaid programs. North Carolina is a state I’ve worked a lot with. Their 11, 15 approval came from the prior administration, The Trump administration is.
49:20
they were authorized to use up to $650 million in Medicaid funding over five years to launch pilots around the state, where the Medicaid program is paying for 27 different health related social services, food boxes, and support for people experiencing interpersonal violence on housing assistance.
49:48
And, and a whole other range of services. And, and the, through that pilot Medicaid dollars are being set aside and provided to health plans who are responsible for managing the care of people enrolled in Medicaid and to insure them access to those services. And, as I said before, using community care, how to do that. Most.
50:10
recently, just this past year, we’ve seen just a flood of new approvals, Oregon, Arizona, Massachusetts, California of mine.
50:21
I don’t have Arkansas on here, there, another recent one.
50:24
New York has a waiver renewal, where they’re seeking to implement the hub model that IHS I mentioned. And kind of a North Carolina style.
50:33
And we have other states like Washington and Rhode Island that have existing waivers focused on addressing drivers of health.
50:43
So, the 115 waiver demonstrations have really accelerated the ability of a new model, Um, and, I think, will increasingly be of interest to other states.
50:56
Given their potential, to enable states to use dollars in ways to, for example, fund infrastructure for building that community capacity, which, normally would not be a way that Medicaid dollars could be used, and, also to fund certain types of services that would not be possible on, under the Medicaid statute.
51:18
Then, finally, having said that, I want to acknowledge that next slide, please, beyond what the waiver Medicaid does, as I started out saying, Medicaid has states have flexibility and implementation of their, of their Medicaid programs to use Medicaid dollars.
51:36
In a variety of ways, They can address drivers of health, and on the left-hand side, you see the word State plan.
51:43
And that just means that there are a lot for, you know, the history of the Medicaid Program has given enough flexibility for states to fund things like the cost, the cost associated with care management, and inclusive of linking people to social services programs, to help people find housing, to provide assistance in finding and retaining employment.
52:06
Those are our services that the State Medicaid programs can provide without any waiver, under their existing authority, at their, at their discretion.
52:15
Managed care often also gets even additional flexibility and you can see that with the context of withhold and incentive payments in lieu of services, those are all strategies within managed care that can enable plans to have more flexibility to pay for interventions that addressed drivers of health.
52:41
And then over to the right hand side.
52:46
Also within Managed Care, you can see, you know, things like adjust, we’re doing risk adjustment for social factors at this point.
52:54
I think only Massachusetts is doing that in the context of their Medicaid program, but where they’re actually taking into consideration social factors in determining what the capitation rates are, what are being paid for individual Medicaid beneficiaries, there’s a long history of adjusting risk based on health needs. This is an innovative effort to say, well, let’s also look at social needs.
53:18
Because, we know that those social needs dramatically impact that, the, the interventions that individuals need, and therefore the cost of their care.
53:28
And, so, these are all strategies here that A tab, or tools authority, that they have to implement efforts to address drivers of health without eating special federal authority. And, and, so, I would just conclude by saying, I do think both leveraging the 15 waiver authority and these other state authorities. We’re going to continue to see states really pushing the envelope and seeking to be creative in their efforts to improve health, improve health equity, and reduce costs through by addressing drivers of health.
54:01
And I would just encourage everyone to continue to think about how we can bring the innovation that we’re seeing across all payer systems into our Medicaid space.
54:11
Where on there such opportunities and where the population really stand on, so much to benefit from it.
54:19
Thank you.
54:22
Thanks so much, Melinda. That was terrific and I’ll turn it over to you as our final speaker.
54:28
Fantastic, Well, thanks so much for having me today. Again, I’m Kimberly Web. I’m a senior advisor on the White House. Coburn 19 Response Team. And in the context of today’s conversation as we talk about, examining the social determinants of health really wanted to take a different angle on this, the unique moment that the pandemic created it as a crisis as it created a really unique policymaking environments. So you’ve heard from previous presenters, elegance and from and not talk about really more about about the specific dynamics from a payer perspective and how that intersects states and even the federal government and access side of things. But even more broadly, our ability to navigate social interprets else. We can really lean into a lot of their policy strategies as well.
55:10
So, wanted to to use the pandemic and kind of my role on the covert Response Team to illustrate ways that we were able to take social determinants approach. And some of the aspects of the pandemic response also make the case that we can can and should continue to support these types of investments and expand them far beyond. Cause at 19, 19 is a lens, so we can talk about how to move towards more of these policy solutions and strategies to address the drivers of health. So when it comes to Covert 19, you know, we started off and go back a couple of years really early on, we realize that disproportionality in terms of covert outcomes. And as you all know, that wasn’t tied to any new genetic predispositions to bad outcomes with Code. You know, really was tied to the, the aggregate impact of social drivers. The aggregate impact of a kind of a burden of chronic disease. That is also connected to social drivers. And so we put all that together.
56:04
We knew that certain communities who are going to be harder hit stays higher risk with regard to the pandemic. And there are a lot of different factors that went into that, and if we’re talking, in terms of social drivers, that we could start off by, talking about, access to, healthcare being one of the key ones, but also, we can talk about employment. The risks that really impose on some folks. In terms of being frontline workers, are essential workers. We can talk about, you know, housing density in the likelihood of folks who are working outside the home, or using public transportation now, Bringing that back into households with more individuals. And less ability to socially, or physically distance within the household lead to more transmission within certain communities. All those things came together, and layer them on top of each other at disproportionate rates three times, four times the rates obligations.
56:54
And that’s often in communities of color, so, you know. When this administration started in January 21, we really wanted to center this idea of equity in addressing the … pandemic, and inherited that. It wasn’t just the measuring of disparities of the measuring of inequities. It was also what is the lens of the approach that we have to take to drive equity and decidedly as a social determinants approach decidedly, that’s. That’s kinda tapping into some of those different societal dynamics that drive the inequities. So we started off with a couple of things.
57:27
one of the first things that the President did was we had a health equity task force that was pulled together, doctor Marcelo Smith’s this leading this, will pull together experts from around the country. And not only did they give advice on some of the key machinations of the coat response, but also how we can connect these two different efforts across agencies in the federal government to really address some of those underlying social determinants that impacted the pandemic. And so, you know, that task force made over 300 different recommendations. They made a final list of 55 recommendations. And even at the time that they transmitted that report to us, we had been taking their advice all along. By November of last year. We started a X naught over 80% of those recommendations. And, even today, we continue to look back to that, those task force recommendations, as a key mechanism for us to engage around those social determinants.
58:19
The second piece I want to talk about is these Executive Order 1985, which was advancing equity and racial justice to the federal government. This was an executive order that the President put forward very early on in the administration. But, really calling on all executive agencies to center this idea of equity. And, I raised that here in a social determinants conversation because the equity work and the Department of Education, or our Housing And Urban Development, or HUD, HHS, Health and Human Services, you know, the work across these. Different agencies is inherently social determinants of health work, is kind of at that core. And so by having equity action plans by really having this approach through the agencies to drive equity, You know, that’s also helping in the 19 pandemic, because we have concurrent policy that’s being created to help create more equitable environments. And then, finally, I want to talk about one of the tools that we use pretty regularly in our policy approaches, And I’ll dive deeper on that in a couple of seconds.
59:15
But we used pretty readily the social vulnerability index, and a lot of you are familiar with that.
59:21
But SPI, as it’s known, it’s typically a county based metric. It measures social vulnerability, but it’s looking at socioeconomic status, it’s looking at various household characteristics, like the age of the individuals in the household, disability status, language proficiency, is looking at race, Ethnicity, is looking at housing type. It’s looking at transportation dynamics. It’s pulling those together to get a sense of who’s most likely to be negatively impacted by something like a pandemic, and by using SDI. In our approach to the pandemic, we were able to incorporate a lot of those different drivers of health in the allocation of resources, in the places where we really wait first was a lot of our tools to address the pain and mix.
1:00:00
So when you when, you know, go to those resources and you talk about when the rubber hits the road, how did we do it? They’ll start off talking about the vaccination effort, which, you know, as of next week it’s gonna be two year though. It was at two years of this vaccination effort are really important and critical tool to keep people safe in the pandemic.
1:00:18
But it’s built on top of these dynamics of a lack of access to care and a lot of communities, the ideas, the reality of discrimination, and also perceptions of discrimination, and how that’s going to layer on top. There is also a lot of dynamics, tens of immigration enforcement that I think a lot of you were concerned up early on. We can list all the different factors that drove the anticipation that we’re going to have gaps in terms of vaccinations, and there are others that I think are more directly tied to two. So the social sciences we’ve been talking about today, think about employment and paid time off as being one of the big drivers. That’s something we were able to navigate through funding that Congress appropriated to ensure that people have the ability to get paid time off from work if they’re getting vaccinated for Copenhagen. We can talk about child care. The lack of childcare and how that created that people couldn’t go to get back to them because they didn’t have space.
1:01:08
So, we worked in partner at the private sector to find childcare entities nationally, who were able to provide free childcare for folks as they’re going to get vaccinated. Transportation was a huge issue. So, you know, states and localities really led the way on this by making sure that public transportation was taking people directly to vaccination sites. But then we worked with Uber and Lyft to also give people free rides to vaccination sites to try to navigate those social drivers. And then finally, a lot of the work that I was doing early on that’s going to different communities talking to folks about vaccines, about pandemic more broadly.
1:01:45
We created this, We call it … series where we’re going into communities, whether virtually or in person.
1:01:50
And talking about the issues that already exist. The social determinants that we’re really top of mind, oftentimes mental health challenges, gun violence, whatever it may be, food access and we’re talking about those how they’ve been exacerbated by the pandemic and how the vaccines were part of the past to address those core issues as well. Again, taking that lens was really helpful when we’re able to close the gaps and inequities in terms of … vaccinations by November of last year. We see those gaps re-emerged with boosters and we’ve been able to close those again with over 6550 to 64, but the reason they re-emerges because the structures of the dynamics across our society continue. They haven’t been addressed. Those underlying causes of those inequities has not been adequately addressed, and that’s where, really the work has to continue. I know we’re a little running over time, so I want to go a little bit faster. But, but in terms of testing, that’s another area where I really wanted to talk about some of the dynamics in terms of social drivers that impacted token testing. And, yes, access to care, again, being key there.
1:02:52
But health literacy is important to address linguistic appropriateness, housing density being another one. Yeah. We created a program where we’re sitting tests to every single household, But we couldn’t just send the same number of test every household, because, again, there’s differences in terms of housing density, so we had to find ways to make sure we’re getting the right number of tests to the right individuals. And sometimes that was challenging when you have kind of a, I would say, a crude tools from government to ship tests out. But at the same time, we’re trying to make sure it’s adaptable and augmented by other programs. And so, in terms of strategies, when they’ve been able to partner with housing and urban development to get testing into public housing spaces, we’ve been able to work with the banks to get testing of those spaces, where people regularly go, folks who maybe more income sensitive and more likely to have some threats from that standard tests to schools, so families can get those. And so, again, those are all strategies. We also worked closely with community health workers and promotoras.
1:03:47
This we worked with the National Association doing health workers. We did priority sending of tests to people from the highest SDI, so most socially vulnerable zip codes in the country. They were prioritized for the shipping of their tests. We even had a reserve allocation. That was, that was reserved specifically for ISPI’s. So, those are some of the things we’re able to do. You’ll continue to see that in our conversations around treatments, like packs of it, the oral antiviral that can reduce the risk of hospitalization and death by 90%, that, you know, again, access to health care became a big challenge. Their health literacy paid time off. Those are all some of the dynamics that make it hard for people to get access to treatment. And so, we work to expand prescribers. We work to ensure that they’re free.
1:04:32
But I want to close by talking a little bit about the threats, because even though we’ve been able to mobilize a lot of resources and tools in the context of pandemic those dollars are theory anymore. Right. The funding from Congress has dried up. We’ve made several requests that haven’t been honored, and so at this point, that lack of funding from Congress, it’s gonna make it harder for us to continue, as a lot of these community based strategies, those investments, and kind of navigating this. social drivers of health. And then you add, on top of that, the unwinding of the Public Health Emergency, whenever that is, the impact it’s going to have on access to healthcare specifically through Medicaid, the impact it’s going to have. You know, when you have that, that continuous enrollment requirements that goes away, you’re seeing those determinations. Yeah, there’s a really strong likelihood people are going to lose. Some people are gonna lose their coverage and what impact does that have on their ability to access these tools, these resources and others and that’s where, you know, our work in kind of the commercialization of the pandemic is inherently equity.
1:05:28
We’re trying to make sure that we can navigate some of this factors already described to you. So I’ll close by saying this. You know, two weeks ago, we held a White House summit on … equity. And what Works symposium. We brought community based organizations, local public health leaders, lots of folks from all over the country, to share promising and best practices. And Kevin’s a thread through those conversations was the navigation of the social drivers, the social determinants of health. And so that’s going to continue to be really important. Just today, actually, HRSA is mobilizing $350 million to federally qualified health centers all over the country, so that they can partner with community based organizations in their communities to help get people connected to the vaccines, the new updated vaccines that are going to be really important in the event of a winter searches. So, the work continues. You know, we continue to work on the broader equity mission, but I think that the key takeaway I want you all to have is that there are levers, we can pull from a federal perspective.
1:06:24
We just need to continue to add the wherewithal from our legislative spaces to provide the resources so that we can partner really efficiently across government and continue to have that kind of.
1:06:33
So with that, I’ll turn it back and looking forward to the questions.
1:06:38
You so much.
1:06:39
I’d like to just thank all of our panelists again and ask everybody to turn your videos back on as we come into the question and answer portion of the conversation. This is also a time for you, the attendees, to participate. So you can go into the question does the goto Webinar platform and put your questions in. We already have a few questions to get us started, but this is a great opportunity to be thinking about that. I want to start with Linda directly from the audience.
1:07:13
Clearly, everything that you commented on, I think, addresses it, but this is such a high level, overarching question. I thought it was good to race for all of the ad. For all of the participants. They say, we’ve done a good job of collecting data, and implementing … studies.
1:07:30
You keep getting the same results to highlight the existence and impact of structural racism and discrimination. And that proves the impact of interventions on CLAS, an outline the impact of upstream efforts on long term savings.
1:07:43
So, they have a question about how do we make this shift some continued evaluation in theoretical conversations to actually restructuring policies and implementing efforts that can affect change? What will it take to make this shift? Who’s doing the work, and where is the hope? That’s the whole purpose of this conversation today.
1:08:02
So, just really simple questions to kind of get us started, but Can I ask you to start us off, who, what will it take to make the shift? Who’s doing the work, and where’s their hope?
1:08:18
Thank you. So, one of the key components of addressing structural discrimination and in particular, structural racism is to name it and to name it and to actually require some action steps that will address it. As I mentioned, regarding the health, Justice Framework, that is one of the parts of it to actually name that. structure. Dissemination is key. So that means, as we take a look at Healthy People 2030.
1:08:49
Yeah, we revise that framework to show that structural discrimination is a root cause and not just have the circle, which has the five key factors, is if they’re separate from structural discrimination.
1:09:02
It means that when we adapt regulations, rules, practices, that we take that into consideration, which I think the current administration is trying to do.
1:09:14
That means that when we look at some of our insurers, that they ask about structural discrimination. That they try to provide additional support from people who are suffering from that. That means that when we use the SPI, that we are intentional about who we are trying to track and what they actually need.
1:09:37
And that, it is not just about increasing the access, perhaps, to healthy foods, and we understand that this is a generational issue and so that we provide additional money and supports for individuals who have been harmed for this four decades.
1:09:58
And I am going to stop there, but I think it’s just a more intentional focus, explicit focus.
1:10:08
Let me add one other thing about, about this. I think the last point that I really want to highlight is that we cannot just have the same people who have been doing this work continue to do the work because part of the problem is that the communities who have suffered the most are not actually leading and driving the change. So, to me, that is key. So, what does that mean, explicitly? That means that if you have me talking about these issues, you should also have a community member talking about how they have suffered and what they need and what they want to address this change and so, requiring the federal government and any funding that they give. It has to be a community partnership part of that, and lead community people leading that, as what happened in the late 19 vaccine rollout for many states that they were required to work with communities.
1:11:09
To me, that is, is a key.
1:11:15
So much, I see a lot of nodding going on on the screen to New Melinda, can do you want to make any additions to that?
1:11:31
I’ll maybe I’ll go, OK, I’m just going to say quickly, you know, the comments that, um, know, we’ve been collecting and navel gazing, staring at data for a long time, that’s very true, right, I mean this, you know, the the inequities this isn’t a WEB. Du Bois is the Philadelphia Negro, and you have to write. This doesn’t start with, you know, the Heckler Report in 19 85. This doesn’t stop with unequal treatment in 2000. And this has been around, right? We know these data. So I think it’s, it’s just a fallacy for people to suggest that we still need to collect data. And the action, the time is now. And actually, we’re speaking with, CDC director will ask you just the other day. And she said, We have what we need to move on it. Now. It’s just the time for action. I think that’s that’s absolutely the case. And if anybody suggest otherwise, I think that we just need to really press it all spaces, to tell people to walk and chew gum at the same time. click what you need. But act on whichever.
1:12:24
That thank you go headshots.
1:12:28
Actually, I really agree with what’s been said. I do think there’s a lot of data that’s been collected.
1:12:35
You know, I think, as we take actions to address social needs, to improve health equity, we are also collecting data along the way to make sure those actions are having the right impact.
1:12:46
To me, I, I think the public sector has taken a strong leadership role, and, and I would certainly encourage that continuing, I think, state, various, they’ve been really proactive, as Melinda pointed out, on these issues, I think, raising the bar, raising accountability and expectations, whether they do it through payment policies, through quality measurement. You know, my view is, we should be taking in all of the above approach.
1:13:11
You know, CMS is now doing this in the Medicare program.
1:13:13
I think, I think that will have tremendous impact, where I’d love to see, and maybe policy can play a role here, but no significant number of Americans are insured under employer sponsored insurance.
1:13:26
I think getting into that market is really important. We have those conversations with our employer customers, and partly why, I think, it’s important to talk about the work that we can do with our own associates, is to influence those customers.
1:13:41
two units word, adopting similar approach, you know, setting up a model for what they can do. But, I think, I think that market is really critical, because so many Americans get their insurance.
1:13:54
Thank you so much. Go ahead, Melinda. Go ahead.
1:14:02
Melinda, are you muted?
1:14:10
Sorry, I was just saying that, I think that I think the observation about the importance of naming it is so important then, and one, um, issue or one.
1:14:23
A challenge that I see is that, as we look at integrating community voices and community based organizations, and a different, that services and types of intervention intervention, to address and improve health, adress drivers of health, and improve health, and improve health equity.
1:14:41
The standards that we often apply to that, um, don’t acknowledge the, the opportunity and the challenge at hand.
1:14:50
And what I mean by that is, you know, frequently, we, we talk about this in terms of ROI.
1:14:56
Whereas, you know, if we had a cure for, you know, cancer, we wouldn’t say, Well, what’s the ROI on that?
1:15:04
If we can see that what we can do is improve health and improve health equity, the roi is gravy on that, but improving health and improving health equity is a value into itself, and part of the mission and purpose of the Medicaid program and other Public Finance Healthcare Program, as well. So, being really clear about why, why are we doing this? Is it purely about saving money or are we actually furthering the purpose of the program, which is to improve health and improve health equity?
1:15:32
Um, then, second, and a second example of where, you know, I be frustrated.
1:15:39
We often, then, kind of with that ROI lens, say, Well, we think about our investments in those community resources, in the kind of old fee for service, health care, context, where we’re, like, Well, we’ll pay someone for food box. And that’s kind of as much as we can do, to form the solution, as opposed to thinking about, you know, or will just refer someone to a food bank. And that’s kind of the end of our job, as a healthcare organization, when we know that that food bank is already over tack, when we know that in order for that organization CBO to be a true partner. They’re gonna need a different kind of set of capabilities and IT and financial wherewithal and.
1:16:26
no expertise then and voice in negotiating terms and that sort of thing.
1:16:32
And know, I think about the journey on value based payment and how, you know, we are investment in the primary care infrastructure. I think that our social services sector we should be thinking about in those same terms.
1:16:45
It’s going to require upfront investment. This isn’t going to just magically happen by focusing on an ROI at the end of the day. And and that’s a very technical, long winded way of saying I think that starts with the naming it that Professor Yogi with what was referencing.
1:17:05
Do so much, Kim. I love your quote Collect what you need, act on, what you have.
1:17:13
I think that could just be another motto for today. And so, just on that topic, as measurement, because, you know, there’s a lot of attention and progress in this space.
1:17:25
Should we be concerned about duplication of effort and lack of co-ordination among the range of entities, whether it’s state health plans, providers, Federal government, all aiming to identify, and address drivers of health, Social Drivers of Health, in kind of their own, unique way? How concerned are you about that?
1:17:47
You know, the different approaches there out there, Melinda, maybe I’ll start with you just given the measurement work, but if others want to comment on that, I’ll open it up.
1:18:00
I wrote down Cameron statement, and I’m gonna use that constantly. I mean, I think there’s gonna be some amount of chaos for awhile, right?
1:18:11
Where it’s going to take awhile for us all to converge around common tools and common measures And it and in no circumstance in healthcare, do we sit back and wait until we think we have everything perfectly aligned across.
1:18:24
All players before Report forge ahead with trying to create incremental progress and you know, in my slides on them. That was kind of my point on that screening.
1:18:33
It looks a little bit like chaos right now, but it is movement and I think we need federal leadership to help guide that movement and partnership between state and federal regulators to help guide that movement, but we can’t sit back and wait for us all to come to consensus about a single approach when we need some of that chaos to inform and create momentum towards that convergence.
1:19:03
Sorry, Go ahead, Kim.
1:19:06
And then, sometimes, I was just gonna add, from, from my perspective, in federal government doing this work, you know, I can’t tell you how many times a week, I say there are things that we can do from the federal government, And there are things that don’t make sense for us to do. And oftentimes, I engage with community based organizations who say, we got a way that we can do this. In this community, in North Birmingham, Alabama, you know, how can the federal government support us? And, what I say is, you know, it shouldn’t necessarily be the role of the federal government. To decide exactly what CBO and what neighborhood and what community. We just have to create the environment to help make that possible, right? We need to lift those examples in satellite on those and say, look at what’s happening in North Birmingham, Alabama. How can we rally local public health leaders, state leaders, and also, the federal government, also, our partners across agencies to help get the job done? So I think a lot of it is. Making sure that, you know. Yeah, I think, I think is absolutely. Right. You know, everybody needs to be doing work with all deliberate speed.
1:20:05
I think that what happens from here, though, is that, as we continue to go, we continue to iterate, and we find the different spaces, the different roles for everybody within the work. But as, you know, I engage with a lot of community organizations in this work. And I don’t think a single one of them would tell any of us to sit back and wait, and plan, and figure out who should be doing what. They need all hands on deck.
1:20:32
I’ll add to that, I agree with Cameron and Melinda said, so, you know, first of all, make sure that your question, it, healthcare can naturally, it’s fragmented, and there’s duplication of effort, that’s kind of what we do.
1:20:44
But I think what’s what’s great is there is an infrastructure for bringing more consistency and uniformity to use the infrastructure. So, I’ll put in a plug for my former organization, National Quality Forum.
1:20:55
Let’s use the NQF to help decide what the best measures are NCQA, obviously the leader in this and can play an important role.
1:21:03
So, you know, there’s an existing infrastructure. I think we do tend to underutilized that we don’t align around consistent solutions when we have the opportunity to do so.
1:21:12
At the same time, I agree with what’s been said.
1:21:15
We have to start solving issues, We have to, you know, sort of put our programs in motion, and let perhaps, some of these solutions catch up to them.
1:21:25
The one Yeah, so I agree with what’s been said. The one thing, maybe, I’ll say a few words about it.
1:21:33
In working with a variety of CBOs, as you all know, they are in really different places. They have a vastly different levels of resourcing and staffing, et cetera.
1:21:42
I think as we bring bring the gigantic machinery of healthcare into this space, we have to be really thoughtful, Not to adversely armed ecosystem. And so, we come with accreditation requirements and measurement requirements, and reporting requirements, and HIPAA and other things.
1:22:00
I would just add policymakers to really think about the intersection of our existing infrastructure with CBOs, and other social resources so that we don’t accidentally crush these really important actors that have been working in this space for a long time. Let’s bring a light touch approach, figure out how we resource them, certainly, how we get members and patients to be able to access their, their resources.
1:22:27
But without unnecessary oversight and requirement.
1:22:34
With that, to say that, to me, it means that there is going to need to be a different way of grant making, and a different way of Sunday. And so, what we have prides ourselves on is competition instead of collaboration.
1:22:51
And so one of the things that we have done at The Institute for Healing Justice, we are working with … Johnson to help them in grant making. And we did so by creating a consortium of experts. So then you’re not competing, You’re bringing expertise together, and you’re finding a group to work together to do these issues. The same should be done with community based organizations. one of the things that … has done is to find an organization to provide support for the community groups so that they can do the work, that they are not responsible for the requirement of reporting back and things like that. So I think what we need to do, if we are serious about community led change, is to change the model, son, now, to collaboratively work together and sundown, so that they can have some administrative support to continue to do the amazing work that they are doing.
1:23:50
That’s great.
1:23:51
Really, really critical component, especially as we hear more emphasis on involving the community and community based organizations, where we’re quickly running out of time, And then when I wanna get it, this one, I’m also from the audience, and we’ve talked a lot about screening, and how essential that is to understand the services and supports are needed.
1:24:14
However, to be screened, one really needs to be connected and successfully navigating the healthcare or social services system, right? So, how are those without ties to the healthcare infrastructure or social service system? Being accommodated and, you know, in other cases such as limited English proficiency, proficiency or hearing loss of vision loss.
1:24:38
There’s a lot of other no issues and factors. people may be bringing to the table that could complicate.
1:24:46
You know, again, what looks on paper like a very exciting, you know, losing the right direction on screening. How are we kind of taking a holistic approach and making sure that that is really inclusive of the populations that are most likely to get missed if we’re, if we’re not thoughtful about that. And, I’ll open that up to whoever wants to start.
1:25:11
I will say I think this is another example of advantage that community based organizations can can bring our strength that they bring in terms of, you know, when I was the legal services attorney.
1:25:23
Um, people came to me when they didn’t have proven their cupboards when they were under threat of eviction. When they were fearful of losing their children their far, Those are moments of crisis that far outweigh. whether I’m getting my primary, keeping up with my primary care visits.
1:25:38
And the community based organizations that, I think, a lot of times, we think about, well, we find them here in the health care environments. And then we will ask the community based organization to come in and deliver the food box. As opposed to thinking about the ecosystem within which people are moving. and, and there, you know, priorities in terms of their own, managing their own lives. And community based organizations can help us identify people who are also experiencing health crises or chronic conditions that are going untreated or, you know, they can be a doorway through which we’re bringing, bridging between health and human services to get to help people improve their lives.
1:26:16
And so, I think it brings us back to the conversation before about, so, how do we do that in ways that don’t medicalized our partners?
1:26:27
And, and how does the financing work, and, and, you know, how do we structurally ensured that?
1:26:34
there’s that systems, information, systems, et cetera, to enable that to happen? But I, I, I view that as kind of a core part of the problem that we’re trying to solve.
1:26:48
Melinda? We are, at our time. I’m going to ask one final question and give everyone the opportunity for final comments. Given that the audience that we have today, and, again, thanks to everyone for taking a Friday lunch to join us, and predominantly focused on federal policy, working for Federal policymakers, assisting them advising.
1:27:15
I would love just to hear from all of you as we close.
1:27:21
What’s the most critical stuff a federal policy maker could take today to accelerate action and social drivers of health, and to really enhance health of all Americans and get at some of these issues that we’ve been talking about? And Sam, you’re sitting in a hub, does a lot of activity. So maybe I’ll start with you. What’s the one thing that you would love to see federal policymakers accelerates? and we’ll go around the screen?
1:27:51
I can do this all day, but we could start with pass a budget. Let’s do that. And so, I think that’s a, that’s a good start. And a comprehensive one, Right? We’ve been doing a lot of continuing resolutions. Let’s get an omnibus go. And let’s let’s make sure we’re funding a lot of aspects of government. So we can fund access to health care in a thoughtful and meaningful way. As a foundational part of all this work, you know that the dollars are going to be a big part of this as, think that, um, that, you know, our legislators have a big role to play in, making sure that this ecosystem is well supported from a funding standpoint.
1:28:27
Thank you, Sandy.
1:28:30
Thank you. I’d say probably broadly incentivize shifting resources to addressing this area. So it with all sort of available lovers.
1:28:41
Right? So I think somebody mentioned earlier, risk adjustment. Maybe it was Melinda. Risk adjustment. I think you can certainly think about risk adjusting payments, risk adjusting measurement, but put more measurement against that.
1:28:54
Let rejigger the medical loss ratio so that literally every actor in the eco system, payer provider, and otherwise is it. You know, the incentives are clearly aligned to address social needs to address health equity.
1:29:10
I think that’s a major leverage point about the only one, but I think that’s really critical.
1:29:16
Thank you.
1:29:21
Sorry, it took me a second to unmute to me, because a majority of workers, Reese Wintery of individuals in the United States receive health insurance health access to employment that we really have to ensure that everybody has access to health insurance. And, I, when, I mean, when I say access, I mean that they can actually pay for it and use it, particularly for those who are working in the health care system, providing access to health care, And they cannot get access to health care of themselves. So, I think employment changes, so everybody can have to access.
1:30:06
So, I want to say, All of the above.
1:30:09
And I guess just to add one more piece on this, on the financing piece of it, and I think also, at the federal level, helping to develop mechanisms to solve for the wrong pocket problem, and that this goes back to, it, goes beyond that.
1:30:26
I completely agree with what John was saying about aligning financial incentives and mechanisms within our healthcare system, but bridging them across.
1:30:35
Because, particularly as we think about our populations, children, people experiencing homelessness, justice involved populations, that wrong pocket problem is a huge barrier for us to, to do that alignment, and make the change we need.
1:30:52
You so much, and just to find those, thank you for all of our speakers. This has been a really terrific conversation and I also could keep going all afternoon, but I think we would eventually run out of our run out of our time with goto Webinar. So thank you again for all of our attendees that have been with us over the course of this conversation. Please take time to complete the recent evaluation survey that you will receive immediately after the broadcast, as well as by e-mail later today. And keep an eye out on the Alliance website for details about future upcoming events, and, know that a recording of this webinar, and all of the materials size, background, readings will also be made available. So with that, thank you, again, to our presenters, is a terrific conversation. And thanks to all of you for joining us. Have a great weekend.