Congressional Briefing: What’s Next on Social Determinants of Health?

12:00 p.m. – 12:10 p.m.        Welcome and Introductions

• Sarah J. Dash, MPH, President and Chief Executive Officer, Alliance for Health Policy
  @AllHealthPolicy

• Courtney Christian, MPA
  Director, Policy and Research, Pharmaceutical Research and Manufacturers of America

12:10 p.m. – 12:30 p.m.        Fireside Chat

• Karen DeSalvo, M.D., MPH, M.Sc., Co-Convener, National Alliance to Impact the Social Determinants of Health; Professor of Medicine and Population Health, University of Texas at Austin Dell Medical School
  @kbdesalvo

12:30 p.m. – 2:00 p.m.          Panel Discussion

• William York, Executive Vice President, 2-1-1 San Diego
  @billyorksd

• Samuel Ross, M.D., M.S., Chief Community Health Officer, Bon Secours Mercy Health; President, Bon Secours Baltimore Health System
  @bonsecoursbalt

• Ana Novais, M.A., Deputy Director, Rhode Island Department of Health
  @RIHEALTH

• Kathy Stack, Chief Executive Officer, KB Stack Consulting

• Len M. Nichols, Ph.D., Director of the Center for Health Policy Research and Ethics, George Mason University
  @LenMNichols

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

SARAH DASH:  And I want to just say a couple words about this series before we kick off the program. Today is the last event in our 2019 Social Determinants of Health Signature Series, which is part of a broader effort we are doing this year around the theme of solving for health. We really created this series to highlight progress on persistent health policy issues and talk about tangible ways to move forward. Some of you might have joined us for our summit on Social Determinants of Health back in June and all of the materials for that event are on our website, and we explored a number of themes that we’re going to try to narrow in on today, in particular, one of the things that have consistently come up in our conversations around social determinants of health is the importance of aligning financial incentives and that’s come up over and over again so we’re going to try to take a little bit of a deeper dive into that issue today, and we have a fantastic panel to do that.

So one thing that’s a little different today about our briefing is it is two hours. Usually we’re 90 minutes, but we have a lot to cover and we have a special guest, Karen DeSalvo, today to have kind of a keynote opening, a Q&A with us, so we’re very excited about that, and then, we’ll move onto our more traditional panel discussion and throughout you’ll have plenty of time to ask your questions.

So before we officially kick it off, let me thank our sponsors for the entire Signature Series for making this possible, and I want to point out the importance of having such a broad cross-section of the healthcare sector represented because I think it really shows how important these questions are of social determinants of health across the public and private sectors. So I’d like to thank our Visionary Level sponsor, PhRMA; our Innovator Level sponsors, Anthem and Ascension; our Champion sponsors, Aetna, Blue Cross Blue Shield Association, Cambia Health Foundation, GlaxoSmithKline and Kaiser Permanente, as well as our Signature sponsor the Catholic Health Association of the United States.

So, with that, I’m going to turn it over, very briefly to Courtney Christian, the Director of Policy and Research at PhRMA to give some brief opening welcoming remarks.  Thank you.

COURTNEY CHRISTIAN:  Thank you, Sarah, and it’s lovely to see you all here today on this Friday the 13th, the full moon, and it’s raining so we’re going to make the best of it, right?

My name is Courtney Christian. I’m here from PhRMA. We’ve been happy to be a support of the Alliance as they, and many of you here today, have really been doing the forward-thinking on policy analysis around social determinants of health, doing a lot of the research, and opining on economic, budgetary, and infrastructure questions that could really move the needle on these issues.

The answers to these questions pose challenges because there’s not a one-size-fits-all approach to policymakers at each level of government in seeking to address social determinants of health. Every community is different and every community has its own unique set of needs. This work really requires an educational component of first framing what these determinants are and then meeting communities and patients where they are in a joint effort to improve health outcomes.

At PhRMA, we’re really being intentional and thoughtful about the ways in which our industry can work toward addressing social determinants of health. We recently convened and launched a health equity roundtable as we undertake this effort, and we really look forward to getting input and advice from many of you in this room as we move forward. We’re really also meeting communities and patients where they are with the mobile health fair program that we Road Map to Health, which brings educational tools, resources, and health screenings free of charge to communities in New York and pretty soon nationally.

So we look forward to the continued exchange of ideas here in the effort to bridge the gap on social determinants of health and improved health outcomes. The very impressive group of panelists you have here today will surely give us all perspective on how to do so. And lastly, I know, as a former Hill staffer, if we harness the power of everybody here in this room across all areas of government, across all healthcare sectors we can really do a lot to improve health outcomes for everyone and really make headway in the goal of doing more to address social determinants of health.

So thank you and enjoy.

[Applause]

SARAH DASH:  Great. Thank you. Well, now it’s my pleasure to welcome to the stage Dr. Karen DeSalvo, the former acting assistant secretary for health and the national coordinator for health information technology. She is currently a professor in the departments of medicine and population health at the University of Texas at Austin, Dell Medical School, and is Co-Convener of the National Alliance to Impact the Social Determinants of Health, NASDOH. She’s a nationally recognized health leader and I’m going to go sit down and let her talk. She’s going to be great. Karen, thank you so much for joining us today.

KAREN DeSALVO:  Good afternoon, everybody. I’m delighted to be here. Thank you. This is, as many people know, one of my very favorite topics for a lot of years running and so I’m excited to share some thoughts and hear from the panelists who have been doing really important work to help advance it.

SARAH DASH:  Thanks, Karen. So let me actually start off by asking you, I mean, you know so much about so many different topics and you’ve had so much experience across a broad array of health, healthcare, public health. What inspired you to focus your efforts now on social determinants of health and get involved and maybe you can tell us a little bit more about NASDOH and what that is.

KAREN DeSALVO:  Sure. You know, I talk a lot about my experience with Hurricane Katrina, which was now 14 years ago, as being really instrumental in crystalizing for me, as a doctor, how important the non-medical determinants were for the health of my patients in the community. It was an experience where the healthcare system went down across the board and when we were scrapping together a way to provide services for people, you know, literally on the street, stuff that was top of their mind was about housing, and when are the schools going to open, and when are the bus lines going to be back, and do you think my job is going to come back, and all my friends left and I’m lonely and scared, and there’s nowhere to buy food. I mean, these are all these social determinants and for them, it was more important than the diabetes or the hypertension management. And, in fact, you know, as a doctor, seeing somebody, for example, with diabetes and providing them just the right dose of insulin at just the right time for their care in that environment, and then realizing that they actually didn’t have a house or they didn’t have electricity in their house it was kind of for naught, right, because giving them the right medical care was only going to take them so far.

And so that was really, I think, an important time for me to realize that when we built back our community it had to be inclusive, not just of great medical care, but a social care system and integration that would support the people and community that we serve, but as I’ve reflected on this more and more over time, I think of so many experiences that I had across my life, particularly many of them in the exam room or the bedside where when I listened carefully what they were telling me was that it wasn’t that they didn’t understand what to eat or what they should be doing for their care or that sometimes even if we could get them the right care, there were so many other things happening to them in their lives that were barriers to their health and well-being.

So when I was at HHS, I used that opportunity to start to lift up a national conversation about the importance of social determinants of health, particularly in the context of how multi-sectoral collaboration needed to be part of the solution. This isn’t just for medicine. It’s not just for public health. It’s not just for social care. It’s not just for community. It’s about everyone coming together was certainly my experience in New Orleans of the way that we approached this, and especially when I was health commissioner. So Public Health 3.0, which is a report that we put out that talks about social determinants and what all the various actors in the ecosystem, the system can do to support people in communities and, frankly, what people in communities can do to empower themselves, was a focus of my work toward the end of the term. And I left, quite frankly, feeling so unsatisfied because there was so much more I wanted to do around social determinants, not only at the practice level but at the policy level.

And so, Mike Leavitt, who was former HHS Secretary and someone I’ve known since the time of Katrina when he was helping us to rebuild our system, asked what I was interested in working on and I said, I want to create a pragmatic approach to this national, understanding and finding a way to support social determinants not just downstream but also upstream and do that in a way that’s nonpartisan and that really supports all the great work that happens on communities on the front line. He said, “I’m in.” And he has lots of his own reasons for appreciating the sort of why and why now, much of which reflects in his time as governor, actually, and so NASDOH was born out of that shared interest to really think through a new paradigm for what health is in this country, not just about healthcare but also about the broader drivers of health. And we have pulled together a coalition of the willing—can I say that on the Hill? And folks who we knew were in the space or near to the space and this is now a couple of years ago, so we have this nice mix of consumers and public health and social care and health plans and healthcare systems and technology and business who have come to the table to think through a new pathway forward so that we can really drive health for the country.

SARAH DASH:  So, you’ve laid out some principles for kind of that pathway forward. You talked about shifting that paradigm or shifting that frame and obviously, this is something that folks have been talking about for a long time now. I think I remember talking about social determinants of health in public health school which was I won’t admit how long ago, but so the why, why now, and, like, what now?

KAREN DeSALVO:  Yes. This is an interesting dynamic a couple of years ago when social determinants of health lightbulb went off in the healthcare system and especially in the C-Suites and the board rooms and I spent a lot of time evangelizing around the country about social determinants in the last couple of years, but so have many other folks and I think through those of us who have been working on social determinants, particularly through a public health lens or through the social care system lens, initially it was, “Wait a minute.” Yeah, why are you all now with the party? Because this has been working on, but I think where the country has evolved pretty quickly is that the solution set is going to take more than the resources at hand or the approach that we’ve been trying historically, and that’s, for example, one of the reasons that we’re so excited to have interest from the business sector or from technology as they’re thinking through new design approaches and new solutions.

So our broad view on this is that there are places for common ground and there is work to be done that relates to not only shaping public and private sector policy but supporting data and technology and information flow, also creating a harmonized and rational system for assessing impact so that we can build upon what we learn and really spread and scale as quickly as possible, but do all of that not for but with people in community and be certain that whatever is being built really resonates with the cultural and other expectations on the ground. This is not straightforward stuff, but you being a public health person, know what I’ve just described is public health and it’s the way that we go about doing our business.

I think the why now, though, why others got involved and interested is to do with the value-based care push and this is I think philosophically incredibly important for us to understand, but in short, you know, when you begin to tell the big actor in driving health in this country, the healthcare system, that now it’s not just about doing things and getting paid, but you’re going to be accountable for total health and total cost. And when you have accountable entities like Medicare Advantage plans or Medicaid Managed Care plans, or systems like integrated delivery systems, as they get further on the journey to value and understand that they have some downside risk if they can’t reduce unnecessary use of the healthcare system, they start to peel back the layers to figure out why is grandma coming back to the ER all the time? Now, most clinicians could tell you why grandma is coming back to the ER all the time. She’s lonely, she’s hungry, she’s buying food for her pet dog that’s her only companion versus buying her medication. These are common clinical stories that we all see, but I think now we have big data that can tell us this pattern not just for one person but for populations. On the value journey, we’ve learned that people who are medically complicated are also socially complicated and so the solution set to being successful in value-based care has to be about more than clinical excellence. It has to also find a way to weave together social care for that person, for populations and then, more broadly, and so like many things in this nation, the driver has to do with the bottom line.

I think the health systems are realizing that there’s more that they want to do. And I don’t mean to say that in a pejorative way because I do think that they’re, and I know that there are a lot of health system actors in this who are very motivated and driven by a mission to improve health of people in communities and that is really good, but it’s not as sustainable as a solid business model where it’s part of what the CFO believes, and that’s the place where, when we can feel like the CFO believes this is part of the core set of metrics, the core set of things that they’re following for whatever organization, that’s when I think we’ve hit the sweet spot. I often say the actuaries, but maybe that’s sort of the more proximate one, and once the actuaries believe it then maybe the Chief Financial Officers will believe it also.

So that’s why I think it’s the why now. I mentioned briefly the data, by the way, and I don’t want to pass over that too quickly because I think, you know, if you consider where we were even a decade ago, we didn’t have capabilities not only of analyzing data in the way that we do today but of mapping it, of looking at it, of presenting it in such a way that you can have hotspot maps, that you can show data on U.S. suicide rates by ZIP code and get a feeling for where there’s density of challenges or where the opioid challenges are and map that against other issues around social risks. So visually, I think, if you can put that on the front page of the Washington Post, it captures the imagination more than some tables and charts and I think that the analytics behind it, plus the way that we’re able to better present data, is helping the conversation to really move along.

SARAH DASH:  Great. Thank you. So I want to get to some of those specifics. I mean, this is such a big broad problem or can seem that way, so as you start to work with all of these different entities in the healthcare system, how do you start to think about are there specific roles, are there specific places to start? I mean, do you start with the data? Do you start with the community? You talked about kind of not for communities but with, you know, I mean, how do you being to define the problem in a way that’s really tangible that you can start to act on?

KAREN DeSALVO: I mean, I’ll be honest, I haven’t completely figured it out, but I’ll tell you the things that I’ve tried and, you know, the first thing that I would say to this group is that social determinants of health is big. It is life and how we live it and it is not for healthcare to solve alone or for policymakers. It’s not a purely public sector challenge, it’s our society’s challenge. And so my call to action here is not about specific legislation or a specific way that we interpret a rule. This is a failure of our appreciation as a country of what drives health and that we can’t just keep focusing on the 20 percent, we have to think about the 60 percent that drives health outcomes for people and communities. It’s about where they live and learn and work and play, the conditions in their communities. It could be air quality, it could be access to sidewalks, but it’s also the drivers that cause us to behave a certain way in a community. How do we make those choices in the moment about whether we’re going to take the stairs or the escalator? How do we find the kind of social connectivity that supports us when we’re feeling down or lonely? How do we have the kind of economic opportunity that’s really a job ladder?

So this is, again, back to sort of not just being a healthcare sector challenge, though healthcare has an incredibly important role to play for all kinds of obvious reasons. When people think of health they think of a stethoscope, you know, and so they go right to medicine and it’s great that medicine is interested and engaged, but they’re going to need partners to get this right for a bunch of reasons. And you mentioned it about community. I think this is where we’re still having a lot of tension.

So let’s say medicine wants to figure out what it can do. Data is usually where I recommend they start. Pull your data, figure out who are the highest-risk individuals that you have in your population and learn about them. There are structured questionnaires, there are ways that you can sit at the bedside in the hospital environment or in the dialysis unit or in the post-acute care environment and say, so we need to understand some things about your life, not just about your health. And then use what’s already available, sometimes publicly available, like the Aunt Bertha tool to find resources nearby.

Now, you can step up the sophistication of how you can identify high-risk populations and people and how you connect them with services and how you manage the care plan and the data. There are some very sophisticated approaches for companies that have been doing this a lot longer, like Kaiser Permanente. On the other hand, even small federally qualified health centers in rural Arkansas that I have visited are making good inroads because they’re learning that food insecurity is the biggest driver for social need in their population and they learned from the community this is about the width, but it wasn’t just about referring people to a food bank. That was an insult to their dignity. The patients were telling them they didn’t want to go and they didn’t have transportation so they made a food distribution center in the clinic so that now, when people go to get healthcare, they’re just going to the health care but they can leave with groceries. Modeled a little bit on like a big system like Geisinger did, building a food pharmacy, but nuanced in a way that works for that community.

So where I’m going with this is, it’s a really big problem but like any big problem, you know, you say you’ve got to eat that elephant one bite at a time and that’s what I’m finding in every time zone, every temperate zone across this country there’s a lot of innovation. That innovation is typically driven by an inspired leader in the right place at the right time who gets her hands on some good data. What we need to do is figure out how those are not one-off projects driven by charisma but actually become part of the mainstream of the way that we’re holding systems accountable, and I use that term broadly, for the health of people. And, again, we’re making some strong inroads to systematize that, but we have a long way to go for this to be a bunch of projects to being something that’s more of a national strategy in a way that we’re thinking about building sequentially upon the learnings of others and then weaving this into, again, the mainstream.

SARAH DASH:  Thanks. I want to give time to the audience for a question or two, so if you have a question there are mikes there, just raise your hand and someone will come around with a hand mike. We have time for maybe one or two questions, and while you’re thinking about your questions, let me kind of ask you, Karen, I mean, there is so much excitement about this issue right now. Are there any fault lines or unintended consequences that folks should be watching out for as people who want to really make progress can move forward?

KAREN DeSALVO:  I’m so crazy excited and optimistic about how the country said health is more than healthcare, and on the other hand, I’m so concerned and worried that the country has woken up and said health is more than healthcare because there is a lot of hype. And I think what you see is good intentions of presenting an effort that was done without a lot of scientific rigor so it’s really difficult to understand if that can be spread or scaled. You’re going to hear some good data today which I think is the kind of thing that we really need to be weighing into. You know, the National Academy of Medicine has a report coming out next week, the 25th, which is about integrating social care into healthcare and I hope you all will join us—and that’s my commercial—to hear a set of recommendations that point to the public and private sector about what could be done in a strategic fashion to enhance the downstream impacts around the social determinants of health and try to filter through some of the hype.

I might just raise a couple of big points about worries, and one is that we’re going to medicalize the social determinants of health and turn this into part of a benefits package or a new thing that doctors have to click on the electronic health record, or some other manifestation. And, in reality, though healthcare has an important role to play and they should have some shared accountability, we should be thinking about how to strengthen the public health and social care sectors so that they can be partners to healthcare and not just expect healthcare, Medicaid, Medicare, whatever to take over it all.

And I think the other one I would just mention since sometimes in healthcare we’re not as attuned to it, is that we might harm the people we want most to help. And that could manifest as, for example, asking a grandmother if she has electricity and her revealing that she doesn’t and then having to call child protective services because she’s been taking care of grandkids in the home. And really, what you were trying to do is help her get electricity, but then you’ve kind of run into a situation where now she’s having to worry about keeping her grandkids.

There are other problems about exacerbating disparities and I’m hearing stories about this already on the ground, that the social care organizations, because they feel overwhelmed, are learning to cherry-pick in just the way the healthcare system learned and try to take the healthier people who have social needs because they don’t have the resources to help folks and then that just further marginalizes those who have more need. So this is part of my hope that we develop a national strategy around social determinants because we could be off on a pathway that either won’t show benefit because we haven’t done the science right and we haven’t shared information, or we’ve harmed people without realizing it because we haven’t been transparent, or we’ve gone way too far to make this something medical and not really thought about how it’s a shared responsibility.

SARAH DASH:  Thank you so much. Alright, there’s a question back there. Yes, just someone will come around with the mike. Thank you.

HENRY:  Thank you very much. I’m Henry Pretta (phonetic), I’m a healthcare IT consultant and I work with Medicaid plans a lot. Quick question. I think you just touched on this topic, but, in your travels, have you witnessed any best practices in terms of how, for example, a health plan comes to know about the SDOH needs of a person. For example, in some states, the states will try to have the FQHC’s file a prepared form or something like that. It kind of interrupts in their flow, but have you seen any other ways that one might come to know about situations like that?

KAREN DeSALVO:  Okay. I have 12 seconds.

SARAH DASH:  You can go a couple more.

KAREN DeSALVO:  Thank you for the question because the knowing is, I think, one of the unintended consequences. We’re on the precipice of asking people to prove to us over and over again that they’re hungry or have housing challenges because we’re asking them to fill out a lot of long questionnaires and we need to avoid that at all costs as a country and get to the business of helping people.

And so the solution set for this, actually there is a stream of work going on through an effort called Gravity, which is now a formal project supported by the standards body HL7. And everyone is on board, hundreds of organizations to create a more transparent, interoperable way to define a social profile, but there is some important work that we’re going to do at NASDOH which is about leveraging modern open standards to—and when I say “standards” I mean technology standards for those of you who are not tech folks—to use APIs to better connect not only care plan data but administrative data. And I’m not sure I’ve seen a best practice quite yet, but here’s what I would say is a really optimistic view is that all the digital platforms, tools that are being developed in social determinants are using open standards. They’re approaching this challenge as they want an interoperable system which is a far cry from how we did this in healthcare. So I’m very optimistic that this is going to serve people better in the future.

But I’d love to talk to you afterward specifically about some stuff we’re doing because we’re working on building a best practice model.

SARAH DASH:  I think we have one more question. Yes, ma’am.

LESLIE RITTER:  Hi. Thank you. I’m Leslie Ritter. I’m with the National MS Society. You mentioned a lot around needing the data to do this and we know that our public health infrastructure is not what we need it to be in terms of data collection, surveillance data that we would need. So, for those of us in the room, what advice would you give us to kind of help build support for that kind of infrastructure.

KAREN DeSALVO:  God bless you. Thank you for the question and we didn’t have time to talk about things that the Hill could do and maybe this is my chance to quickly say that.

I think one important lesson for folks on the Hill, one thing is start where you are, which is learning, and learn in your own members’ districts because there is going to be work happening and if we can be helpful, I’m more than happy to do that. Know that there is a lot of existing statutory authority already for Medicaid and Medicare Advantage, in particular, the latter thanks to what Congress did even just recently and the administration and states are working within that regulatory authority to sort out how to not only do their own work but also how to build partnerships in the community, which gets to your question.

The partner, you’re only as strong as your weakest link, and my work in Public Health 3.0 was to call out that public health was not strong enough to be a partner in all kinds of ways, including its opportunity around workforce data infrastructure. And we did do some work on that which shows that we’re short about $12 a person a year in this country to fund a public health infrastructure to be able to provide the services that everyone should expect in the country. I’m happy to send some more information about that. We did it in partnership with many others and just published a paper in the American Journal of Public Health on it this month.

The other sector which I would like us to pay an awful lot more attention to is the social care sector. They are really struggling on the front lines to meet not only the current expectations but this rush of people that are about to come at them. Many of those organizations are working off of paper or IT systems that can’t meet cybersecurity expectations to be a part of this broader interoperability world and their workforce isn’t quite ready for it and their business model isn’t quite there. There are good efforts to try to advance that but this is going to take something on a scale of what we did to transform healthcare. The billions of dollars that we spent to get healthcare ready for value is the kind of thing we’re going to think about needing to do for their partners to get them ready for value. Thank you.

SARAH DASH:  Thank you so much. Thank you, Karen. I want to thank you so much for joining us. I know we could go on and on probably and talk much more about this. You pointed to some great resources which we’ll make sure are also on the Alliance website as well, and we’ll now have time for our next panel. Thank you so much.

KAREN DeSALVO:  Thank you guys so much.

[Applause]

SARAH DASH:  I’m now going to ask our panelists to come and join us up on the stage, please. Alright. And I’m just going to wait just one moment until everyone is seated and then go ahead and start introducing them.

By the way, while we’re taking a moment to transition and, again, just as a reminder, we will go to 2:00 today for the briefing, so if you think of questions to ask you have some green pieces of paper at your table so be thinking about your questions. We’ll be collecting those during the Q&A session, and we also have a blue evaluation form in your packet and we hope you’ll take a minute to fill that out as well before you leave.

So that was a great conversation with Karen DeSalvo and I would now like to introduce our panel. We’re going to go in the order of the panel discussion. So you have longer bios in your folders, as well.

So, first, I’m really pleased to introduce Bill York. Bill is the Executive Vice President of 2-1-1 San Diego, one of the most successful 2-1-1 providers in the nation, and he has dedicated his focus and leadership to developing strong teams to manage the many operational hubs of 2-1-1 San Diego as well as the region’s community information exchange and his stewardship has really gained national recognition so we’re excited to hear what’s going on on the ground in San Diego and thanks for coming all the way across the country to be with us today.

We will then hear from Dr. Samuel Ross, who is Chief Community Health Officer for Bon Secours Mercy Health and the President of Bon Secours Baltimore Health System. Along with managing an acute care hospital in the heart of West Baltimore, Dr. Ross is also responsible for a vast network of community outreach divisions that focus on positively impacting outcomes that influence the social determinants of health including affordable housing, education, job skills, behavioral health substance abuse, and rehabilitation.

We are next delighted to hear from Ana Novais, the Deputy Director of the Rhode Island Department of Health. She’s worked in public health for more than 30 years, including in countries other than the United States, in Africa, Portugal, and beyond. She’s worked with the Rhode Island Department of Health since 1998 focusing on achieving health equity throughout areas of health disparities and access to care and chronic disease management and prevention environmental health and maternal-child health. So thank you so much for being here.

And then, on the other side here to my left, we have the Chief Executive Officer of KB Stack Consulting. A one-woman operation, awesome. Kathy Stack. She has a distinguished career in the federal government including 27 years at the White House Office of Management and Budget where she served under five presidents focusing on improving the design and implementation of innovative, evidence-focused initiatives that require coordination across agencies and levels of government and played a central role in the development of some things that Kathy is going to talk about today, including paper success and performance partnership pilots for disconnect youth, so we’re excited to hear more about that.

And then, last but not least, we’re delighted to have joining us today Len Nichols, Director of the Center for Health Policy Research and Ethics at George Mason University, having served as a senior advisor for health policy at the Office of Management and Budget in the Clinton Administration to being an innovation advisor to the Center for Medicare and Medicaid, innovation at CMS, he has been deeply involved in health reform debates, policy development, and communication with the media and policymakers for a number of years. We’re delighted to have you, Len.

So we’re going to now turn it over to Bill York to kick it off and tell us what’s going on on the ground in San Diego.

BILL YORK:  Great. Thank you and thank you for having me here. We’re honored for 2-1-1 San Diego and CIE to actually attend, so I thank the Alliance for inviting us. Oftentimes regional approaches don’t get kicked up to national conversation. We have had, because of some of our awareness through Robert Wood Johnson, Data Across Sectors, and I worked with SIREN, so I appreciate that we were able to come and talk a little bit about it. What’s happening for sort of our boots-on-the-ground look at things and from our 2-1-1 CIE perspective.

To give you a little background of San Diego, and a lot of times we are in different rooms where people don’t understand what the 2-1-1 system is, we’re always amazed that people are not aware that there’s 248 2-1-1’s across the country, 50 percent of those run by United Way and 50 percent standalone, but if you’ve seen one 2-1-1 you’ve seen one 2-1-1 and how they might operate and it’s really according to the way that the community might embrace them and support them.

We’ve been lucky enough in San Diego that, with the county of San Diego, we were once part of United Way and left in the early 2000s and became our own 2-1-1 and quickly realized that the model of information and referral was not working. We were also thought about as heretics in the 2-1-1 world for a long time, of saying that we needed to have a more client record versus a call record system, that we needed to track outcomes, we needed to know whether services were actually being delivered, and it’s taken us over ten years to get to that point.

On top of that, our local San Diego County has had a 10-year plan of the Live Well initiative that actually was to build a better service delivery system and the three components of that were building better health, living safely, and thriving. And so many of our nonprofits worked that into the systems that they were working, as well as other community organizations came together and said our systems around social services are broken. We have 3.3 million people in San Diego County. We’re one of the largest, you know, as large as 19 states and we realized people were bouncing around programs and services that we didn’t know, making seven to ten calls before they found services.

So 2-1-1 started its transition to its own personal record many years ago and then our communities started on a Community Information Exchange which, to us, has defining components to that. So it’s a systems change that fostered true collaboration across networks and it’s really moving to person-centered interactions and from healthcare, and to human services. And it goes from approving health and wellness for individuals and for populations.

So right now, from 2-1-1’s perspective, we have over 70 partners in our Community Information Exchange that share data across systems. They are able to share their outcome data, their referral data, and so we are actively, and we’re also actively working with communities across the country, so a lot of pieces I’m going to share with you today are not just our learnings, but from eight to ten other communities that we’re learning and so my last few slides are really around the funding barriers in some of the partnership things that we’re seeing that really needs to move forward because of the many silos that are really happening in social services organizations and I’ll talk about that for a moment.

On the Community Information Exchange, and this is a really important piece because we’re seeing Community Information Exchange come up in many different ways and we have a very, you know, capital CIE information exchange versus creating a community information exchange. It is no longer just a technology or a network of providers. It really is an ecosystem and it’s a multi-disciplinary network of providers with a shared language, with a resource database, an integrated technology platform, and really the community care planning. So we have learned a lot in the last five years since we have launched this new system. It has evolved from, again, being just a technology of providers and shifted to really a systems change.

So 2-1-1 San Diego has had the opportunity to be put at that backbone role, but it is a community partnership of over 70 organizations that really, again, from bridging health, social services, and it’s really moving away from being reactive to proactive into a person-centered model. So right now we have over 75 cross-sector partnerships that actually agree to the same business association agreements, to partnership agreements, clients’ consents, authorizations, screenings, which we’d prefer deeper assessments specifically around food, transportation, and housing versus a few questions, and it really does incorporate the 2-1-1 database which I will tell you I think is valuable at different levels across the country as a national resource that 2-1-1 does have a science of knowing where programs and services exist and actually the eligibility to get there all at different levels that I think are valuable to the national conversation.

So the functionality allows us and all our network partners to actually directly see information, sort of, we like to call it a golden record across social services, that now integrates other data systems. That’s what’s the difference between what’s happening, you know, people calling that they have a community information exchange versus a data exchange bidirectionally for all care coordination.

Some of our sectors that we actually have in our CIE and, again, we’ve been working on this a long time. It was a lot more work than we expected. A lot more cost than we expected, but we have housing providers, we have our multi-service agencies that are often offering hundreds of programs, many that include transportation, housing, food banks. Our multi-service aging, legal, employment agencies and, of course, nutrition. San Diego Food Bank alone and their system represents 442 pantries, anything from church, you know, from faith-based to actually a larger pantry at healthcare organizations that are also integrated into our system.

In the healthcare section, we have health plans, Blue Shield, CareFirst, again, Molina. We have hospitals that are now sharing data directly from the EHR. Emergency medical services allowing us to see transport data to the emergency rooms. Healthcare centers, FQHC’s, and we’re very proud of our San Diego Health Information Exchange. It’s award-winning that integrates a health and exchange from seven different healthcare systems. Yes, we have seven different health plan systems and seven managed Medicaid plans in San Diego. And then we have behavioral health data, as well as public health all integrated into our CIE.

In our government sector, we’re proud of San Diego as we went on a journey they also took a system and built what they call “ConnectWell” integrating several of their disparate systems from their foster care to probation to their eligibility benefit system to child welfare services and connected a large system of ConnectWell that also connects to our CIE, again, with data use agreements of what should be able to be seen, who can see that, role-based permissions for, again, to do care coordination across a population.

One of the things that is something that we’re proud of that we built as a component of CIE is the ability to measure and track the change over time. Before 2-1-1 and CIE actually had a longitudinal record, we saw that clients were sitting in systems and as they entered or left programs there was no long-term tracking of their progress and exactly what happened to them before and after. And I give the example of HMIS systems. Fantastic HMIS systems out there when you enter homelessness and when you leave it. So what are the pre-indicators that are happening? And already we’re seeing a lot of data that shows us what steps it’s taking for a person and how many calls and how many accesses to other agencies does it actually take for them to enter homelessness? A recent report we put out on Thursday in housing stability is that one out of the four of our callers, within four months of them calling us for a housing or a utility need, are entering homelessness. So being able to move upstream. That’s not just with the 2-1-1 data, that’s with HMIS data, that’s with other data from those other multiservice agencies. And so we’re actually, in our CIE and because of that risk-rating scale, being able to see what happens over time, use that data, other agencies and care coordination, and seeing the other care plans are able to do interventions.  We’ve seen reductions in return to homelessness. We’ve seen reductions in emergency room visits.

I mentioned the resource database and the bi-directional referrals. I think this is very important to highlight is that the 2-1-1, although they are different places and scopes out there and sizes, they are a valuable resource. There are 60 years of expertise around the Alliance information referral systems. Not all the same, but do understand agency programs, services, and where they’re rendered and understand eligibility requirements. So we think they’re part of the conversation that people should be having. Can they do what we have done? Not all. Some are moving into those conversations. Most of those other aided communities to 12 that we’re working with are not 2-1-1’s.

So it is a great repository that is actually well known for its process, and I do want to say I’m a 2-1-1 fan as a way in. We take over 500 unique calls a year. We have 250,000 unique records of clients in our system and we have over 125 that share their data through the CIE system across those 75 agencies.

I love this slide just so I can just wow you with our technology. And why I really wanted to share this is that we feel that it’s very important to not talk about an off-the-shelf referral product. And I think, in the conversation we’re having, linking healthcare to get them a referral for food, transportation, and housing when each community is complicated, it is different, resources are different, housing inventories are low, shelters are low. And so, we believe a list is just a list and so just a simple referral directory versus data interaction is very important. We have deployed an enterprise-wide solution with a sales force. We laid over an Informatica system that it can adjust anything from CSV to Excel, API’s. Again, I think Karen mentioned that the nonprofit systems are all at different places in their technology. Steve and Connie Ballmer, just last year, invested $59 million in a nonprofit saying that most social services in data outcomes are 20 years behind. And we are seeing that in San Diego throughout the country in the technology they have in order to share this data and measure outcomes.

And then, we integrate from all kinds of different data systems. I mentioned already that we’ve integrated a HUD-funded HMIS system. We have our HSS repository, ConnectWell, our Health Information Exchange, and we’ve connected with three FQHC’s. Our foodbank system, which represents those 442 pantries, our local Workforce Partnership, which is our employment, and then several of the local EMS and ambulance transport so we can actually get when someone is transported to an emergency room.

We also, which is an interesting hurdle as well as something that’s valuable, are able to get Who’s in Jail data. It’s sad that we can’t get who’s getting out of jail data so we could actually have a real reentry program so some of the things that work as a barrier. We like to look at our system as the micro-mezzo – I don’t know, I’m going over time? A minute or so, alright.

I’m going to jump a couple of slides because this is really what I wanted to get to, and it was really notes from the field in four parts of where we were talking about barriers to access. You know, current funding really does hinder innovation for systems change. Change is slow and the state of the field tells us time is now and interoperability is key. And let me tell you about a few of those things.

The funding structures, particularly for social service providers, do not foster growth. They do not foster technology. They do not foster innovation. It is so competitive. It’s a patchwork of social services out there that are chasing competitive funding and reimbursement contracts and they’re still expected to be providing the safety net. And I think that’s the conversation between healthcare is are there actually resources available to refer to in an overwhelmed system already and what does that look like?

We’ve heard from many places why would we pay for a referral to a program that exists from different parts of healthcare, government, as well as even business? There are dozens of silos across multiple systems. Some of that has to do with where the funding comes from. Transportation wants a transportation data network? Food wants a food network. Behavioral health wants a behavioral health network. So it’s difficult to connect all of those systems and then we actually have found that the backbone support funding is not there as supportive. So our own philanthropy and our own funding sustainability comes into question each year and, actually, the components of research are actually not supported as well. We get several grants that actually they think it’s a great idea and they cut out the research component completely.

We know that change takes time. Meaningful partnerships, not just collaborations, are important. One of the biggest last things I’m going to jump to is that technology is the easiest part but the people and the partners are the glue. After the initial build, it’s our staff that is most costly. I think Karen mentioned is actually working with integrating into the way that services are built in the community. If you’re working with social service providers, they have ways that they’ve worked that are required to work with them. We now have to embed ourselves into those agencies and look at their workflow in order for it to be successful to work in CIE.

So we know that change takes time. Interoperability, I heard it already I think twice today, that lack of data stands around social services and I think you were referring to meaningful use and the things that happen with HIEs and electronic health records if there was something that you could standardize around social services. We are underrepresented and often underrepresented or misunderstood or even minimized in the value system, but everybody wants to connect to that wellness. So I think those are some of the challenges. And, again, there is no voice. I saw there are many associations and American associations of different things in the room, and there isn’t a national association that’s representing a wide breadth of social service programs here. And we go to many rooms where we have to represent our community for those programs.

So, in closing, and again, I apologize that I go over, I wish we had an instructional manual for how to do this. As an operations guy at heart, I would’ve loved to have just implemented something and said give me the book and I’ll follow it. So we’ve been partially writing it and sharing it, but also keeping ourselves out of the bubble, bringing best practices in. And the last few years has been quite a whirlwind of what we’ve done. We see that we’ve actually hit a great stride that we have more partners joining. Healthcare is joining. Healthcare is starting to pay for it. They see the values. We’re seeing the outcomes, but I will tell you it came at a cost with new privacy and security officers, new attorneys, the new chief medical officer, with all those things that we didn’t really expect when we thought we were building an integrated technology to share data.

So, we’ve even selfishly created our own Community Information Exchange summit where we bring 500 leaders in this to discuss, in the spring, about what this looks like and where it’s going. So I skipped over a few things. Interoperability, I don’t want to go over time, but – so hopefully this was, again, I tried to put my context in there with what we’re doing, but again, thank you for allowing me to come and talk.

SARAH DASH:  Thanks so much, Bill, and I think we’ll get into some really interesting Q&A and thanks for sharing that very on the ground example of just how challenging it is in one town.

So Dr. Ross, could you share an example from another town across the country? Bon Secours Mercy Health in Baltimore. Thanks.

SAMUEL ROSS:  So thank you. You were worried about time? Don’t worry about time. I’m also the son of a Baptist minister, so how much time do you-all have? [Laughter]. It’s all good.

So one of the things I would say, you know, hearing what’s been said and what Karen said earlier, as well, you know everybody is here from a different perspective and so I tell our team a lot of times unlike the western movies, the cavalry ain’t coming. [Phone rings.] Well, maybe I was wrong. [Laughter]. Maybe the cavalry is coming.

The other thing I tell them is that, you know, we are the ones we have been waiting for because this is the choir and when we come to these meetings we preach to one another and we have a pep rally and we leave feeling good but there are a lot of other people outside of these walls that we need to be converting to the mission. And then, the third thing I’ll say before I get into my slides, and I’ll stay on time. I won’t do the preacher thing. Being a son of a Baptist preacher I’m going to make three points then I’m going to pass the collection plate.

So the first point, again, because we all come from diverse areas, and this actually came from a minister’s sermon years ago was to start where you are because we’re all in different places with our organizations, our resources, so start where you are. The second point is, in doing that use what you have because, again, we all have different resources available to us. And then, the third point is, to do what you can with those resources that you have available to you. So Bon Secours Mercy Health, we merged a year ago. Bon Secours, which is based on the East Coast, and Mercy which was Ohio so we became what most of us were like $3.5 billion organizations and we’re now $8-plus billion organization, and we just added Bon Secours Ireland, so we’ve crossed the pond and have gone international.

But our mission is our why. I think Karen mentioned something earlier about why everybody does this organizationally, but being Catholic healthcare and the sisters who came to this country over 100 years ago, they came to provide service and to care for those who had needs. So that has been our why throughout this process.

Some of the challenges we have are terminology. We tend to use community health, population health, public health kind of all interchangeably. And, quite honestly, the community doesn’t care because that’s not how they refer to themselves. And so, we may feel good about it. It may help us understand. It may help to educate us. But, as we go out among the community, let’s just be aware that they don’t know what we’re saying when we say these three different things. And sometimes we don’t know what we’re saying when we say these three different things.

But our focus has really been, and my new job over the last year, has been community health for our system across seven states and it really is about focusing our efforts in a different way. And there is an intersection with Pop health because population health primarily has been around value-based purchasing. But that’s only a subset of a community because not all the people in the community are members of Medicare Advantage or some commercial plan that has these benefits. So we just need to understand what we’re dealing with.

The other thing we talk about is social determinants of health. How many of you-all have been to a community meeting where someone who is grassroots in the community stood up and said, “I want to talk about social determinants of health.” Anybody? That’s our terminology and we feel good about it and we hang onto it. There is literature now that says it’s not social determinants, it’s social influencers of health because you say “determinants” that means that if I’m born in that community, I have no choice but to end up a certain way. But we know that these factors—housing, education, transportation, et cetera—influence our outcomes because not everybody you grew up with, regardless of the resources that exist in your community, ended up the same way.

The other thing I wanted to say briefly is community benefit versus community investments and this gets to the funding issue and particularly in healthcare. Community benefits are defined by the Affordable Care Act and how we maintain our not-for-profit status and so, the long list that you see there is really what’s required for us to report and how we track that number. The smaller number, which is where we all have to do a better job in partnership is on the investment side. What are the dollars, discretionary dollars, that exist in our organizations that we can invest in social determinants? So most large systems have community direct investment funds. They have foundation budgets and they have operating budgets. So those, in your communities, just think about your health systems and those opportunities that they have.

The driver for what we decide to invest in should be our community of needs assessments. And, again, mandated through the Affordable Care Act and what we need to do every three years, so the priorities that exist where we decide what’s important in a community—is it housing, is it behavioral health, is it transportation—should come from the community health needs assessment. And we often say it has to be community-led and community-driven otherwise it’s just us making up stuff again.

This is just briefly kind of our model, but the four points here in this model is that you identify your community and then, with your community, you diagnose what the issues are; then, with your community, you implement interventions; and then, with your community, you continue to measure and monitor what those outcomes are.

One of the frameworks that we’re moving to, and there are actually 45 other health systems in this country now, over the last two or three years, that have adopted the Healthcare Anchor Network strategy. Being the largest employers typically in our environments, the major focus areas are local hiring, local sourcing on the supply chain side, and then place-based investing. And the place-based investing would be around any of those areas of the social determinants. So we, along with Geisinger and Kaiser and University of Pittsburgh Medical Center and Dignity and now CommonSpirit, and just a number of healthcare institutions across this nation now that say this is how we’re going to address social determinants. This is not where we end, but this is where we start. And the request is that you donate up to 1 percent of your investment dollars that are available to these kinds of activities. I’m fortunate that my system just, really in the last two weeks, put $50 million into our foundation that’s restricted funds for community health initiatives. Not to spend it all at once, but to use it as leverage to bring other people to the table in order to do this.

I think this is my last side. We also not just want to do things but how do we measure the impact, and all struggle with this, you know, the outcomes because nothing happens quickly. And so I think as we move forward, you know, with future direction is understanding that there is a return on investment. It’s not your typical financial return on investment, but there is a social return on investment. And I did mention earlier when we were talking that we’ve been working with an MPH student from Hopkins School of Public Health and she did a logic model on our housing initiatives to determine what the return was. And using that logic model for every dollar we spent on housing, the return could be 1.3 all the way up to three dollars as a return based on how you measure that.

So I’ll stop there and we’ll have Q&A later.

ANA NOVAIS:  Hi. Good afternoon. My name is Ana Novais. I come from Rhode Island Department of Health and, as I was listening to the conversations and dialog prior to me, one of the things that came to mind was how did we get where we are in Rhode Island right now? And we all have those moments in our professional lives where something happens and we believe that we take pause and we look back and we assess where we are. In Rhode Island, we did that pause and that assessing of where we were around ten years ago. At the time, I was doing, among many things that I was in charge of, I was looking at our healthy people, 2010, back then, indicators and really trying to see how we were and how we compared with the rest of the nation. And, as everybody else, most likely we made progress in some indicators. We went in the wrong direction in some others and we were not moving. But most important for us and what gave us pause was the fact that when you really did a deep dive in the data the fact that the next generation, my children’s generation, your children’s generation, your children for those of you who have children, and for those of you in the room that are young enough to be that generation, had a lower life expectancy. How is that right and how is that acceptable? Where did we, as a system, as a state, as a nation get it so wrong?

And I think it has to do with some of the things that we’ve talked about, the things that really impact, influence, determine our health beyond what happens in the healthcare system. And so if we truly believe that that was at the root cause of that nonacceptable trend in data, in population health data, we needed to do something different and there was no book or no instructions on how to do that and there was no funding that tells us how to do that, but if you truly believe and we install this framework from then CDC director Dr. Frieden, if you truly believe that a comprehensive public health program that achieves population health outcomes needs to have all of those levels of intervention and if you, any other health department back then, did an assessment, put this framework on top of their programs, they will realize that most of their investments were on that level 1, telling people what to do. We are so good at doing that in public health and that’s the approach that has the lowest impact from a population health perspective.

But we had almost no investments at the bottom of that pyramid where it’s truly what we’ve been talking about. So we needed to change and the health equities own the model that I want to talk to you about, it’s how, in Rhode Island, we decided that back then we needed to change. We needed to move from a silo to disease-specific approach and investment to more of a place-based approach that was trying to get at the root causes of the disparities and inequalities in health outcomes.

And so our Health Equity Zones, we pulled funding together because, as I said, there is no funding that comes from the federal government or even from the state in our perspective to do this work, but at the core we wanted communities, we wanted to elevate the voice of the communities. We have data. Some said not, as was pointed out, sometimes not the most perfect data, but I truly believe that there is a story and a knowledge at the community level that if you truly elevate that voice and integrate it in the data that you already have gives you a more complete story.

And so we asked our communities to come together to draw a line on a map and really define their zone of intervention, to build, maintain, expand whatever collaborative they already had or to start a new one. We required them to truly be multi-sector collaborative that integrated residents of the place that they were proposing their interventions, and then we asked them to conduct a baseline assessment, not a needs assessment, but truly an assessment of everything that happened at the community level, through a community prioritization process, define a plan of action and we implemented that plan of action, supported the implementation of that plan of action. We had broad goals that were traditional public health goals because we are accountable to the funding streams, but we needed to truly come up with the funding stream and it was through a braided model. We braided funding from all of those different funding streams that you are seeing there because we truly believed that if we had a sustainable investment with flexible funding, we’ll be able to achieve outcomes that truly move the needle.

So this is a slide that I’m not going to go through. It’s the mechanics of how we do this, but I wanted you to have it because if you click on those links you will see exactly how we were able to mix all of that funding and keep the integrity of the funding intact because that’s what braided funding does, and these are some of the priorities identified by our communities; some of them traditional public health outcomes and expected priorities, some of them not so. Things that you’d say we have no funding to address, but here is how it worked four years later. We had 63 percent decrease in school absenteeism, or 44 percent decrease in childhood lead poisoning prevention, or a 24 percent decrease in teen pregnancy. Those are real outcomes, change from a population health perspective. We saw 36 percent increase in access to fruits and vegetables. Those things don’t happen overnight and those were results that we had never achieved before.

And so some of the outcomes and lessons learned outside of the specific changes in terms of population health, we had so much more increased collaboration both internally and externally. We had an opportunity to leverage resources that has never before happened in our state. We started with that list of funding streams that you saw and now, today, five years later, we have funding that comes from Medicaid within our state, from the Department of Transportation, from the Department of Mental Health and Behavioral Health we were able to bring all of those different threads and continue to support those community priorities because there was a community infrastructure that was built and that was ready to be invested in.

Is this easy? Absolutely not. It required so much change in terms of financial processes and financial accountability that we needed to build at the Health Department’s level. Dealing with the federal funders’ anxiety both at our program’s level and with the federal level because we were asking them to do something that is not written in the books according to them, that was not allowed according to known or perceived regulations. But we did pass two financial audits with no findings so I guess we did figure out how to do it right.

And I want to stress, as my final slide, part of the dealing with the anxiety both from our program but also from the Feds has to do with what we talked about, partnerships. Taking the time to really build the partnerships, build the trust of our different programs, build the trust of our federal partners, of our state agencies to believe that change was, indeed, possible and to believe that the only way for you to truly change and impact those determinants, not one by one, not at the individual level, but at the community level it’s for us together to take responsibility, for us together to agree on a common vision and then, for us together, to invest in that vision. That’s what we’ve been able to achieve in Rhode Island and I think it doesn’t matter that we are the smallest state in the nation. I do believe that whenever there is a will and there is a recognition of our social responsibility toward the people that we serve we find a way to make it work. So thank you.

[Applause]

SARAH DASH:  Thank you so much and that’s a perfect segue to the more federal budget perspective. Let me just ask you kind of a quick question because it really sparked a question, something you said. You talked about building that community infrastructure and then that’s what enabled you to use the Medicaid, transportation, public health, behavioral health kind of funding. So which comes first? Do you have to blend the funding first to make it possible for that community infrastructure, or was it the fact that you just decided, nope, we’re going to come together build this infrastructure, and that’s what has enabled you to create these outcomes?

ANA NOVAIS:  It was more of deciding first we needed to do something different, and then we did an assessment of the kind of funding that we had and making it clear for the community that we had funding to support infrastructure, but in terms of implementing the plan of action, it will depend on the funding that we had and the priorities that they had and we tried to match, that’s why it’s braided. We then matched, at the activity level from their work plans, the different funding streams based on what they had.

SARAH DASH:  Thank you so much. Alright, well Kathy Stack, take it away.

KATHY STACK:  That was a great setup. So I just want to remind everyone here that these guys are really atypical. I think awesome people in D.C. say, oh, well, they’ve done it there, why isn’t everybody doing it? And it’s just really, really hard.

My experience, my 28 years at OMB, I was not in health I was in education, labor, and the non-health social services and it was my job to enforce all those budget rules that make sure that every dollar that Congress appropriated is only used for the authorized purposes and that sets in motion a whole set of things that make it really hard to do this kind of work.

During the Obama Administration, I had the privilege of working on some initiatives, Pay for Success and Performance partnership pilots that were intended to liberate and help state and local communities do innovations to overcome all of these struggles and so I want to just share some lessons from those experiences.

First, just an overview for budget infrastructure challenges, very quickly. The program silos that originate in statute are further prescribed by agency regulations on what’s allowable with funds. There are allowable activities, there are eligible entities, there are periods of availability where certain dollars can only be used during a certain period. And there are two main kinds of funding. We have mandatory funds through authorizing committees that provide permanent authority like TANF, Medicaid, SNAP, and there is some certainty there because the statutes are multi-year and state and local grantees understand how much money is going to be coming under what conditions. Then there are discretionary appropriations where the authorizing statutes are provided in an authorizing bill and the appropriators, on an annual basis, decide how much money to spend. In both cases, mandatory and discretionary, there is a period of availability that is set up that requires dollars to be recorded against the right year.

There is a vast bureaucracy in the federal government, at OMB, at GAO, and the agencies, and then down at the state and local level making sure that the dollars are properly accounted for so that you can show that they are only being used for allowable costs. There is an army of auditors who go out to make sure that the documentation is proper and that all the dollars are being used for allowable costs. And there is an amazing fear at the grantee level that if you don’t have that documentation you may have to turn back that money and it really creates a very risk-averse culture where people are focused on how do I comply with the rules rather than how do I step back, think about how all the dollars coming into my community could be used more effectively and we could do some creative work like Rhode Island is doing?

The two models that I was involved in, one was Pay for Success and the other was Performance Partnership Pilots for Disconnected Youth. These were both things that were sort of done midway through the Obama Administration. They were bipartisan. They got congressional support. And we learned a lot from them. First, on Pay for Success. These were projects that were set up to fund effective social services through outcomes-based financing contracts. If service providers achieved the predetermined outcomes that they had contracted for, they were then able to get payments from the government based on those outcomes and those outcomes were usually associated with things that would save costs because these were prevention activities that would reduce downstream government costs. So the major projects, there are, frankly, only about 30 that have happened so far in the United States. The SIPPRA legislation, Social Impact Partnerships for Results Act that Congress passed in 2018 is setting up a new pipeline of more projects, but most of the projects were in maternal and child health, homelessness, recidivism, and early childhood.

But we’ve learned that while we’d all hoped for lots of transformational initiatives, it turns out to be really, really hard to put together a Pay for Success deal. And the challenges were, first of all, there is a very weak evidence base and that’s something that we have in the area of social determinants of health, too. We want to believe that these prevention strategies are going to improve outcomes and save money, but we don’t have a body of rigorous research that tells us exactly what those are and how to do them and what population they worked for.

There were a few jurisdictions that had the resources to take on the complicated resource-intensive design of Pay for Success projects with external partners. You almost always needed philanthropic partners to fill the gap and the biggest thing that we’ve heard over and over again is the data. Few jurisdictions had the data, the ability to integrate their data across programs and the analytics capacity to really understand who were those high super-utilizers we should be targeting and how are we going to measure the results we get? Also, with Pay for Success, these were like innovative projects that were developed outside the system and many of them, no matter how successful they are, there is not a path to scale because they were so different than the way we normally run programs that people don’t know how you would take that and use existing program streams to fund scale-up.

Performance Partnership Pilots. This was an authority that was enacted in 2014 in appropriations language. It’s still around. It’s been there for five years now. It allows youth-serving programs in labor, HHS, education, justice, and HUD.  State and local governments can take those funding streams and pool them, blend them, and get waivers from program requirements in order to test out more effective interventions for at-risk youth and improve education, employment, and other well-being outcomes. It’s up to ten pilots a year and the Department of Education has been the lead, but there is an interagency group that runs the program. Here, again, the intent was we want transformational initiatives but the results have really fallen far short of that because of implementation challenges.

So first, we learned from this, that myths reign supreme at the state and local level. To apply for a pilot, a state or local government had to document the barriers that were getting in their way at the federal level and then write justifications for waivers. Well, that 80 percent of the waiver requests that came in were for things that they did not need waivers for and Rhode Island is perfect as an example. So many people thought in order to braid money across programs you need a waiver. Well, there are other ways to do it, but that information is not out there.

There was very poor knowledge about available funding streams. A lot of communities wanted to apply and they said, “Can you tell us what money comes into our community because we really don’t know.” That information is so siloed at the federal level, well, it’s siloed at the state and local level as well, and, like Pay for Success, very low data and analytics capacity. Another problem with this program is it is kind of below the radar and, frankly, it wasn’t a priority for the federal staff because Congress wasn’t on their case saying make this a priority to help state and local governments. So it became so bureaucratic and slow that a lot of potential grantees just walked away and said, not worth it.

How many people here have heard about the HR 4004, which is the Social Determinants Accelerator Act? It’s been introduced in the House on a bipartisan basis. Cheri Bustos, Representatives Cole, McGovern, and McMorris-Rodgers were the primary sponsors and it’s small. It’s $25 million. It has two main components, but there are design features here that, if implemented well, could really take the lessons from Pay for Success and Performance Partnerships and do something to move the ball so that more jurisdictions can do this kind of thing. It sets up grants for state and local governments to develop social determinants accelerator plans and the components of those plans are very similar to the components that were in Performance Partnership pilots or Pay for Success. You identified a high need population, high cost, what are those measurable health and social outcomes that the project would achieve, look for interventions that are informed by research, but also you’re going to build new research by embedding strong evaluations in whatever you set up, making sure that you have the capacity to link data across programs so that you can both coordinate care and do evaluations. And, unlike Pay for Success, these plans would require a strategy for scaling with existing resources. Again, going back to the Rhode Island example, like you figured out how to take these dollars and leverage them. And, in this case, you’d be also looking for plans that are going to leverage existing waiver authorities. Right now we often do waivers like within a program, but this could be a chance to work with the Feds to figure out how do you take the multiple waiver authorities that exist across a range of programs and put them together to do something much more impactful.

The other piece of it is there is a council. It’s an interagency council with the usual sort of health and social services agencies, but it also has state and local representatives and experts in policy and research that would be helpful additions. And the council is charged with providing coordinated technical assistance to state and local governments to help them understand how to leverage existing resources. Right now, in the federal government, it is nobody’s job to think about how to help jurisdictions pull all these resources together to do the innovative stuff that these guys are doing. It’s no one’s job. It would be the council’s job and there would be accountability in terms of an annual report to Congress on the progress and activities. There is also a provision in there that requires the council to survey the state and local governments to say how are we doing on our technical assistance and how could we improve? Too often federal agencies treat state and local governments as distant doers. You do this, rather than as partners that together we’re going to do this.

So my hope, again, I’m a silver lining person; if implemented well, what could you get out of this? You would have a new, hopefully, more effective model for intergovernmental cross-agency collaboration where both sides are accepting responsibility for co-creating better solutions for using existing resources to go back to our point over here. You’d have ready to implement strategies coming out of these plans for high interventions with high return on investment, integrated data and analytics capacity, and rigorous evaluation plans that are developed with researchers from the beginning so you  know how, at the end of the day, you’re going to learn whether these strategies are better than the status quo. And then, if these projects are launched, you get proof points. You get a range of proof points that vary by community and state on how to make these existing resources work more effectively. And those become models that a lot of jurisdictions can follow because they can find sister organizations, sister jurisdictions that look like them. But the reality here, if not implemented well, well, at least we get more lessons about the shortcomings of federal innovation initiatives and what to do better next time. But you’ve got it all figured out.

SARAH DASH:  Thanks, Kathy. Len?

LEN NICHOLS:  Hi, Sarah.

SARAH DASH:  How are you?

LEN NICHOLS:  So, you know, when you started your conversation with Karen, Sarah, I was impressed with the question sort of why now? How come everybody’s already into social determinants of health and I would say, yeah, it’s true. The whole world has discovered social determinants of health, even economists have discovered social determinants of health and, of course, when economists discover something we think we invented it and so we’re bringing the math to it, but I’ll just say, you know, at the end of the day, it’s really true that social workers have known this stuff for about 120 years and so it imparts a bit of humility to economists which is rare. I’ll just observe it and go on and say here’s how I got to this place.

About five years ago, I can honestly say I couldn’t spell social determinants of health. I didn’t know what it meant. I thought it was this touchy-feely thing upstream from where life mattered with, you know, payment reform, insurance reform and then I heard my incredible co-author, Lauren Taylor, give a talk. How many of you have heard of Elizabeth Bradley? Bradley was the woman who, when she was at the Yale School of Public Health, figured out that the United States spends way less on social services and way more on health and most of the OECD countries do exactly the opposite, spend less on health and more on social – and she figured out that it’s the ratio of social to health that may actually matter. And Lauren was her undergraduate research assistant. And Betsy figured out how smart Lauren was and figured out how to cheat and get her an MPH in one year, and then Lauren’s boyfriend, uncharacteristically, was big and fast enough as a Yale football player, got drafted by the Kansas City Chiefs, so Lauren goes to Kansas City and pretends to be an NFL wife while she edits Betsy’s book, which became the American Healthcare Paradox, which explains all this social health stuff. And basically did such a good job Betsy made her co-author so Lauren had a book at 24. Then Shane got cut but he lasted two years more than me so I’m still impressed.

They come back to the East Coast and Lauren does what she wanted to do, which was change the world. So she goes to Harvard Divinity School. Turns out she finished Harvard Divinity School, she can marry you and bury you, but it turns out there is no pulpit at the end of Harvard Divinity School. You’re just sort of supposed to go off and change the world. So what does she really care about? She cares about health policy so now she’s in the Ph.D. program in the Medical School which Joe Newhouse created after finishing the RAND experiment called Healthcare Policy. She’s going to finish in a year. I saw her speak for Betsy at a conference about three years ago and I said, wow, I’ve got to meet this one and I just went up and said, hi, you know, I’d like to get to know you a little bit and learn what you’re up to. Two years ago, I said, if you will teach me this social determinants stuff, I will find us an economic model to incentivize investment upstream.

I was bullshitting. I had no idea. I figured, you know, I’d make something up. How hard could this be? So she did her job in about a month and then I went, woo, I’ve got to go do this. So I started digging, digging, digging, digging, digging and we wrote this paper a year ago and, you know, stuff happened.

Let me just say that I promised Sarah I wouldn’t use equations so I have pictures here, and here’s the deal. Okay. If you think about investing in housing, in food, in transportation, in complex case management that’s going to help people. It’s going to help a lot of people individually, but it’s also going to help a lot of people what we call downstream, right? It’s going to make them healthier, maybe even better able to participate in their society and even go to work and create tax revenue. Maybe get arrested less often. Go to healthcare providers way less often, save healthcare money, also save city hall money because a lot of the homeless, for example, get arrested a lot. And if you figure out a way to contain the chaos in their lives you can actually save enough money to pay for the housing. So that’s what that’s about. This is about the sort of notion that, look, giving the right stuff to the right people at the right time benefits many, many players downstream and that turns out to be what we call an economics of public good. It benefits multiple people downstream.

Turns out, when you have a public good situation, all these different beneficiaries, no one creature is going to want to invest enough because it can’t capture the return on the investment and that creates what we call a free-rider problem. Turns out, it took a while to find this, but it turns out my profession, God bless it, invented a solution to the free-rider problem in the 1970s, and it kind of got buried in highly mathematical General Equilibrium Theory and forgotten once Reagan won because it really was designed to sort of substitute for government. People were worried about too much government. Once Reagan won people quit worrying about too much government. Now the problem is too little government, but the point is, it got buried in this highly mathematical corner of the universe. But I went to grad school in the ’70s. I can read that shit. It’s amazing. I had no idea. I could remember and so I found it, oh, my God.

So there are two conditions that make this thing work. One is, there’s got to be a local stakeholder group, we call it a coalition, it could be a working group, that recognizes simultaneously there’s a potential collective benefit and individual benefit. Maybe that benefit is financial, maybe it’s not, but it’s a benefit nevertheless that flows to these multiple players. That group has to exist. Number two, there has to be a trusted broker. I’ll talk more about that in a moment, but let me just say these conditions, particularly this coalition of stakeholders looking upstream exists in our nation. Karen has talked to most of them. They’re all out there. Why are they out there? I think three reasons.

Number 1, readmissions penalties. Readmissions Penalty says that if I have a patient that’s discharged from hospital A and goes into hospital B, hospital A gets dinged, which meant, oh, my God, we have to collaborate and they started to do that all over the country. Number 2, opioids. Opioids brought criminal justice, family services, ER docs in the same room trying to solve a family’s problem. Once you get in the [Indiscernible] spread around, all the solutions are upstream, all of them. Because it’s all about the family and where they live and work. And a third condition that made this turbocharged activity out there is Medicaid Expansion, because Medicaid Expansion put, for the first time, the homeless on the rolls of Medicaid Managed Care Organizations. And so suddenly you had this powerful incentive to figure out so who are these community health workers and how can they help us? How can we learn to talk to the homeless in a much more efficient way and try to manage the situation?

So those three things created these conditions, therefore, let me tell you, there is a hunger out there for upstream solutions that I have never ever, ever seen. And finally, here is how the model works. Basically, think about it this way, the problem with the free-rider problem is no individual that’s going to benefit wants to reveal what they’re willing to pay. Why? Because I would rather have the other hospital pay for it. I’d rather have the health plan pay for it. I’d rather have somebody, the government should do – somebody should do it, not me. Certainly not. So what if you had a trusted broker, someone to whom you might be willing to reveal what you’re actually willing to pay if you could keep that knowledge private? United Way, by the way, is a pretty classic case of somebody who can play this role in about an hour, so could a local philanthropy, so could a local academic if they were trusted enough. But the point is, you’ve got to have someone to whom you will whisper it. So the trusted broker takes all the individual willingnesses to pay, adds them up in secret. If the sum of the willingness to pay exceeds the cost of the program, then, sports fans, you’ve got a project worth doing. Also, here’s the real trick, if you’ve got a project worth doing, that is to say you’ve got a surplus, you can develop prices for everybody to pay such that no one pays as much as they bid. Everyone gets to share in the surplus therefore, it generates an ROI, therefore, it is sustainable because it’s based on self-interest. The economist has entered the room. And that’s why it might actually work.

Okay. So we have this little project. You know it’s a crazy idea; I agree, and so we went to foundations and they said, Len’s crazy idea, okay, but let’s teach it, and that’s what we’re doing. We’re teaching it to the country. You, too, can come and join. We’re halfway through, three-fourths of the way through our little webinar. The project’s called Capgi. You can get all that stuff. But the point is, usually when you write a paper with economic content, I’ll just say, in 40 years of experience, you typically get four e-mails. Okay. The first one says, “You should just go ahead and retire and coach football.” That’s actually applicable in my case. The second one says, “You should have used a different dataset. You should have used a different mathematical technique, a different way of proving this thing.” You know, it’s just crazy. Economists are nasty people. And, in this case, we had 20 communities come to us and say, “Can we do this here?”

Our third webinar was yesterday. We had people on there from 29 states, 171 different ZIP codes, 95 counties from Hawaii to Massachusetts, from San Diego to Tidewater, Virginia. I have never seen anything like this, and the paper is clever. It ain’t that clever, okay? It has to do with the urgency that people feel on how to solve these common upstream problems.

Okay. So what are we doing here? Well, basically, we’re looking at communities, taking all the data we can pull, taking what they can provide. We’ll pull the CHNAs and all that stuff from the local community and they will assess, as they’re going through this, might this model work for them? Might this be a way to use local collective financing in such a way that you can essentially braid and blend and make the world work? We’re going to assess their capabilities and they’ll assess whether they want to do this. We’ll go visit some of these communities and we’ll do this in sort of late ’19 and early ’20, and then we’ll help them write proposals to do the TA, the technical assistance, to implement the thing.

So here are the big questions. Everything moves at the speed of trust. This thing doesn’t work unless there is a trusted broker. This thing doesn’t work unless each individual stakeholder is willing to acknowledge, A) there is a personal benefit for them; and, B) that they’re willing to put some of their skin in the game and some other money on the table. We don’t know for sure that that can be nurtured enough and channeled. We don’t really need government to step in and solve this problem. We do need government to get out of the way and, by that I mean, to do a lot of what Kathy was just describing. Make clear what you can do now and maybe, just maybe, grant a little waiver around the edges here, there, and yon so that you can let people do what they want to do. It’s in their self-interest but they feel like they can’t and they’re terrified of the auditors coming and preventing them from doing it. And also, there’s a little problem of Medicaid being somewhat, shall we say, solicitous of getting their savings back because they’re strained, everybody knows that. Well, if what Medicaid does, after allowing creative things to happen, is come in the next year and cut the rates to take the healthcare savings out, then suddenly you’ve lost the funding for the upstream work. So we’ve got to work all that out.

Will the CFOs in the real big healthcare institutions actually believe what the literature says? Literature is not great. Karen just reviewed a bunch of it. You’re going to see it in a couple of weeks. It’s not that bad, but it is targeted, right? So you can show how housing first can save money for specific populations. Not for the homeless in general, okay, so stuff can be oversold, but you can also target it and be very smart about it. Will the CFOs believe any of this? I don’t know. We’re still working on that. Will fundamentally people believe they can collaborate again? At the end of the day, this solution was created to get around government, to go around, to avoid the need to increase taxation to solve collective problems. It’s using existing resources to solve those problems in a way that the locals want to collaborate. Our tool to make this happen, right?

The question is, can they believe that it’s possible to collaborate again because we’ve lost faith. The reason government can’t do it, one of the reasons Pay for Success didn’t work, government doesn’t have money to write the check. Doesn’t have money to write the check because people have lost faith in government, which means people really have lost faith in the ability to do collaborative things together. So we have to help them believe again. We are the change we need. Thank you.

[Applause]

SARAH DASH:  Thank you so much to all of you. So we have time for some questions and it is freezing in here so we need your energy. We need your questions. We’re sorry it’s so cold in here. Write your questions down or stand up or raise your hand. I want to kind of warm us up with a question, though, so I mean, wow. So many important topics that we’ve covered and I want to, you know, there has been so much focus on the state and local level and what state and local governments can do and like what the federal government can or cannot do to help and so I want to start there which is, you know, how important is it that the state and local governments get this help because so often, I think, at the federal level and kind of having come from the Hill, we think of things as like either Medicaid policy or Medicare policy or, you know, private coverage or, you know, appropriations and we kind of think about things in this like Balkanized way so how do you square that circle? How do you get the help where it’s needed, where it’s going to be the most effective use of taxpayer dollars and have the most effective outcomes? Len, can I start with you, since you ended?

LEN NICHOLS:  So I would say everything that we are doing, and one reason I’m very excited, you may be able to tell, about this work is precisely because the focus is local. That doesn’t mean exclusively local, but it means you start at the local level because what I’ve observed, basically, is that our national politics are broken, our state politics are somewhat but not always better, but at the local level, it doesn’t matter how you vote. Everybody wants it to work where they live and work and play and pray. And so, fundamentally, it’s a much more fun place to be.

Second, I think it’s true, the focus there identifies what elements of a state and federal need to be at the table to cooperate. Like I said, this isn’t going to – my thing is not going to work, no one’s is going to work unless Medicaid gives the freedom to the MCOs to do what they’re going to want to do in their own self-interest and same thing for Medicare Advantage. There is a lot of the target populations here, frail elderly come to mind, duals or natural, you need Medicare Advantage – they both made, I will say, the Trump Administration has made great progress of late in granting more and more freedom for both of those actors, but by the way, it’s not identical and it’s not enough. So what I want is the conversation to center on the local, have the locals tell the state and the Fed what they need and have Kathy Stack help them navigate that waiver through the bureaucracy.

SARAH DASH:  Thank you. Alright. Let me ask one of our state and local experts to take a stab at that question. Ana, do you want to start?

ANA NOVAIS:  Absolutely. I think definitely there are barriers at the federal level. More flexibility, less siloed granting would be appreciated. At the same time, I believe sometimes those barriers are more perceived by the states than real barriers and so if you look at any federal grant that comes from the agencies, they all refer to achieving equity. They all say that they want to address the social determinants of health. They all say that they need to eliminate disparities. It’s there. So it’s for us to say, to tell our story, and put on that grant application response the things that you believe are going to facilitate your processes. I tell the story of HEZ in every single application that I submit to the federal government. It doesn’t matter if it’s obesity, if it’s tobacco, if it’s diabetes, whatever is the topic I tell the story of HEZ as this is how I’m going to address that problem. When they approve my grant application, they automatically approve the use of that funding into that infrastructure into that way.

So I think we states, we cannot expect or wait for the perfect solution. We can challenge ourselves and, at the same time, challenge our federal government and extract all of that relationship so you do get to a practical solution. I call myself a practitioner of public health and, as such, I do not waste time trying to figure out the perfect approach, the perfect full understanding of the rules. I challenge those on a daily basis and then I engage in that conversation from a perspective of a trusted partnership.

SARAH DASH:  So, Kathy, you mentioned, I think you’re both kind of singing from the same page here. I mean, what could the federal government do, just from the get-go, you know, within even existing authority help the state and local folks to understand better what they can and can’t do or is that impossible?

KATHY STACK:  I’m just going to offer an example, an anecdote actually, from July. I was part of the National Academy of Public Administration and we set up sort of a problem-solving forum around ways to improve grants accountability, to focus more on outcomes and less on compliance. And we had a conversation that involved the head of human services for the state of Virginia, the head of the family services department for Fairfax County, and the federal OMB team that oversees all of the grants and financial management compliance rules. And from the Virginia folks, state and county, they told us what are the things that they’re doing to be more outcome-focused. It was varied data-focused, trying to bring down the data, together the data to understand the population and measure outcomes. And then they listed a set of things that they wanted to do but they couldn’t do because of federal requirements.

Well, the OMB folks in the room said, “You know, I think probably most of the things you want to do you can already do.” So that was illuminating. It’s like everybody, whoa, really? But to really get clarity on that you’ve got to have the people from OMB at the table who set the policy on grants management compliance, and the programmatic staff from the agencies and the attorneys from the agencies who know what the statutes allow. It’s very hard to get that group of people together unless there is someone at a very high level in the White House or OMB saying this should be a priority. That it’s your job to create those forums so that you can be responsive to what state and local governments are facing, and that’s where Congress potentially could try to create an imperative for the Executive Branch to organize itself that way, or leadership out of the White House could do the same.

SARAH DASH:  Thank you. So we have a couple of questions here about the return on investment, and that’s something that I think just about everyone on the panel talked about and whether it be financial return on investment or social or, you know, health return on investment so one question here is: How do you talk about, and best describe return on investment, or think about it when it seems like billions of dollars are going to be needed to invest in social care networks first? So, Len, you had one very concrete way of answering that, and then I want to see if maybe Bill and Dr. Ross have a thought on that.

LEN NICHOLS:  So I would start with looking at what’s happening now and look at something or a phenomenon as disparate as watching Centene, which is the nation’s largest for-profit MCO company. They’re building a thing they call a social bridge which is their version of connecting social and healthcare sectors that 2-1-1 in San Diego has created. So they’re doing this as a for-profit company because they think there is going to be value in managing their Medicaid patients. Kaiser Permanente is doing the exact same thing with a platform called Unite Us and they’re going to put their little Unite Us stamp everywhere. Kaiser has a big number of enrollees. Exact same concept, connecting, because both of these healthcare for-profit, nonprofit, big institutions think if they came to know more about where people are going now, they will understand better how to manage their own patients.

So the truth is, these services are being delivered now, they’re just not being delivered at scale and are not being delivered necessarily in a tailored way. People going to the food back, but not getting medically tailored meals, and so there is a lot of sort of tweaking that can happen that can help you. But the key, and it comes back to Karen’s point and everybody’s point, really, if you don’t have data to track the impact of the intervention on people you cannot generate the ROI and that’s why, for us, the data is a prerequisite for us to go in. Everything you heard today from your incredible panel, I will say, I’ve been doing these a long time, this is the best one I’ve ever seen, except for me. But anyway, I’ll just say, you know, I’ve learned a lot. I was writing down. So they’ve already figured out how to track data where they are and that’s absolutely central to prove anything to any CFO.

SARAH DASH:  Thank you. Bill, you started off talking about the data and how you created this system, so can you shed some light on this?

BILL YORK:  Yes, and there are a couple things because I appreciate Kaiser’s venture into the INS wanting an enterprise-wide solution. We work closely with them actually in most of their regions, making sure that they connect to that social service system. So that is often the underrepresented, the underserved and so making sure the medicalization of social services doesn’t happen and that’s my point and we’ve been working with them around that. A referral doesn’t mean an outcome and an eligibility – I mean, there are a plethora of programs that exist out there, that doesn’t mean members, clients, patients will receive those services, so that outcome. And we’ve seen that ourselves. So thankfully, we’re involved in that project throughout several places in San Diego and applaud what they’re trying to do because they are thinking it from the social service infrastructure in what they need to do to boost that.

For us, in San Diego, matching our CIE technology and then working with our hospital systems, Sharp being one of them, and I think it was Len that talked about community health benefit dollars, is we were able to make some pilot projects around readmissions penalties, but for the first few years that didn’t really translate to a payment model. It was community benefit dollars that did finally transition to operational dollars. So it’s an ongoing project both involved in two parts. Our Community Information Exchange having that data across sectors that Sharp, that CIE and other partners can work in, and a navigation around that coordination of when the resources weren’t working. So, in that project, we were able to take a certain population that the healthcare system was working for and what we were working for and actually bring down the admissions so we were able to make a case for it. So I think there is a movement to that more value-base that it’s more than just the penalties and moving into the operational that this is working. So that’s part of our model and selling why this works. But I do think Kaiser Permanente is on the forefront because our thinking of the nonprofit infrastructure too in those communities and what they’ll need to be successful.

SARAH DASH:  Thank you. So, Dr. Ross, we’ve actually heard about readmissions penalties a few times. We’ve talked about community benefit investment and you had some thoughts on that. So can you share how do you think about investing in what’s going to create the best outcomes and how do you think about those measures of success and how to tie that to the investments?

SAMUEL ROSS:  You know, when you were asking earlier about the role of the, I guess, federal government versus state government, and the way grants typically get allocated I would say those become catalysts or accelerators for a lot of the work that we want to do. But the sustainable part ties to the points that Len was making where you have to have, what did you say, the local stakeholder coalition and the trusted broker. In our world, particularly with the healthcare network framework, it’s about the health system becoming that trusted broker in bringing others to the table whether that’s public or private or other philanthropic funders, as well, in order to do that because that, over the long haul, makes it sustainable. You know, grants run out and the well runs dry, but the ROI piece that we’ve demonstrated time and time again, we had a similar Health Enterprise Zone initiative in Maryland and we were able to demonstrate in five regions of the state that we reduced ER visits, reduced avoidable admissions and readmissions, and addressed chronic disease states in that population.

The challenge with ROI is that if you have an attributed or assigned population, you can track and follow those things, but if you’re trying to do that for a community or a public where you don’t have access to those kinds of data and tracking, then it’s much harder to define that return on investment. But I think, you know, we’ve shown in healthcare that addressing the social determinants really does make a difference in what I would say all of our previous—you know, David Letterman used to have a segment called Stupid Human Tricks—all of our previous stupid human tricks around just medicine really didn’t make that kind of difference.

And I just want to comment on one other thing because a couple of times we’ve said, or it’s been commented about CFOs. I don’t leave this to our CFOs, you know, Studer, who has written a lot, you know, he had a phrase in there that said “the fish rots from the head.” And the point is that if the CEOs or presidents aren’t really out front in driving the need for addressing social determinants and the impact that it has, not just on their organizations but communities, then it also won’t be sustainable. But it’s not a CFO issue from my perspective, it’s a CEO issue.

SARAH DASH: Thank you so much. So we let me give Joyce a chance to ask a question. While we’re getting the mike to her, we’ve got a couple of questions on evidence and I want to get to those as well. So, go ahead.

JOYCE FRIEDEN:  Hi. Joyce Frieden, MedPage Today. A lot of you have talked about collecting data, particularly tracking individual people within the system and I wondered if privacy concerns had come up and how those were addressed.

BILL YORK:  So as we ventured into what we thought was going to be our own client management system and then a shared community system, I would say that was sort of my last comments of like the whirlwind of the investment we’ve needed to make in consulting and, again, there is no standardization around social service data. I have heard the strangest things from the strangest people saying there isn’t – you don’t need to have any. There is no privacy around housing information if you’re entering this system. You don’t need a consent. These are things that we heard a long time. You know, we decided in San Diego, because of the influence of our county and our own health exchange, to go to the highest standard we could. So we have a consent that is a social consent that is the client that owns that that can participate at an agency or even through 2-1-1. We have authorizations that then allow us, because of our interactions with healthcare systems and EHRs, that are higher level of actual authorizations and we’re working on even a higher level of behavioral health authorizations in very small pockets of where that’s needed but I would say one of the things of working so long was the expense, the number of people when I mentioned the, you know, we have a privacy, a security officer, the amount of controls that we’ve had to put in place, the additional kind of software for security, the checks and balances of not only our staff system, salesforce, and so HIPAA controls, but every person with a role-based permission from every one of those agencies that enters, that is our responsibility.

The insurance requirements on that. The risk around any type of data breach. So it’s an ongoing – and, in California, now, with our HIEs and counties is, you know, consent management pureed and consent management repositories and at what level do you put that back in the hands of – it can always be revoked but, you know, there should be several levels of consent. Social consent and authorization are a behavioral health consent that expands that. So I would say it’s not knowing what we’re completely into with the eight years ago mark that it’s probably our biggest investment in the ongoing conversation. And one more piece to it is the identity management across systems. So I mentioned we used an Informatica and ETL that takes this data and matches Billy York, William York, William Lester York, Huckleberry Finn from systems and brings you together. That always doesn’t confirm identity and so another piece that we’re investing dollars in think-tanking is identity management across multiple systems.

So for us, that’s the number one conversation that we have in our community every day.

SARAH DASH:  Thank you.

KATHY STACK:  I just want to add that states and counties are all over the map on privacy right now and there are the outliers like San Diego, Washington State, South Carolina that have figured out how to comply with all the privacy rules. Some are using consent, some are using data warehouses that strip identifiers, but there are technology solutions that allow you to comply with privacy rules and bring the data together to do all kinds of analytics and targeting and even care coordination. But the vast majority of jurisdictions are confused. We have different privacy laws coming from different agencies. It’s no one’s job, again, at the federal level to say here’s how you bring all this data together and do it in a way that won’t get you in trouble, but it is possible.

SARAH DASH:  Thanks. Well, we have only a few minutes left. We have a few questions that I’m going to try to kind of combine and hopefully, we can do like a quickfire challenge, lightning round.

So let’s talk about measures of success, how are we going to know we’ve succeeded and there was a really good question here about the evidence base and kind of the short term versus the long term. We always want quick results but it’s not always possible. So how are we going to know that we have succeeded with good evidence? Who would like to start?

ANA NOVAIS:  Well, I can tell you that, in Rhode Island, one of the ways that you are able to bring the funding was making sure that every categorical funding that we used we select evidence-based initiatives and we created a menu of activities that were evidence-based for the community to choose from so that gave us that accountability that is needed from a funding perspective.

The other thing, it’s really collecting the data to be able to demonstrate results. We have two levels of results. At the community level according to their workplace with the kind of data that I’ve shown, and then we also have, at the state level, where we aggregate the data to tell the success story of the HEZ at the state level and that’s also some of the data that we have. So those are the two that we do.

BILL YORK:  I think there is some great work being done. Somebody mentioned the Gravity Project. I think that by Gravity, Robert Wood Johnson’s data cross-sectors for health and there are many groups of collaboration that are working there. The UCSF SIREN, which is the Social Interventions Research and Evaluation Network, is doing great work. But, again, what we’re seeing in collaborative, this is – in San Diego 2-1-1 CIE has done nothing on their own, so it’s great to be able to talk up here and represent that, but this has been a collaboration and bringing in experts from all over the country.

It is really interesting on the grant applications and in philanthropy where the research gets crossed out and unfunded so to either vet or continue to vet, you know, different parts of these things, there are a lot of great evidence-based practices already, but we’re seeing a trend where that, no, don’t do that, just stay and do this which is not exactly moving the innovation of this data sharing and outcomes forward and that’s not just us seeing that. We are part of many collaborative applications throughout the state and even with those other partners across the country and it seems like that’s just exed out and they’ll fund a part of the program so it needs a little bit more, and it’s mostly philanthropy that seems interested, but it seems to be moving that out of the funding.

SARAH DASH:  Thank you. Dr. Ross, how will we know?

SAMUEL ROSS:  I would just say, for health systems, any healthcare system in your area you should be able to go online and see their community of needs assessment, but it’s not just the needs assessment. There is an implementation plan required. So you should be able to monitor, year to year, to see what they said they were going to implement and the outcomes they were looking to achieve and whether or not they did. So that should be public information that allows you to track that, as well.

Internally, it’s part of our key performance indicators so our leadership, we’re incentivized around our KPIs for things that are related to social determinants and so there is a short-term piece that’s really operational and then there’s a longer-term piece around our CHNAs and things like the Robert Wood Johnson, County Health, you know, indicators, et cetera. But those are much longer-term and a lot of people have to be playing together to really get those outcomes.

SARAH DASH:  Thank you. Kathy?

KATHY STACK:  One of the things in the Obama Administration that I and others worked on was how to improve the quality of rigorous research and lower the costs. And there, for a long time, was this perception that randomized control trials were impossible or unethical or too costly and what we did is we tried to create incentives and partnerships for people at the state and local level to recognize that, first of all, our CTs are not that costly if you use administrative data and to the extent that you’re building capacity, like San Diego is building, to link data sets it becomes much less costly for researchers to come in and partner with government. There are researchers, academic researchers that would die to be part of an exciting study on how to increase the return on investment. And when you’re playing in this social determinant space, there is potential for huge return. You know, maternal and child health, things that cost $75,000 a day to keep a kid in the neonatal unit. If you can avoid that with upstream prevention and you can demonstrate that with a control and a treatment group it doesn’t mean you’re being unethical to deny services to a control group. It means what you’re doing is say, as we start a strategy, let’s test it out with a subpopulation of those and find a comparable comparison group so we really can have a rigorous test. And when you get that evidence with an RCT there’s nothing more powerful as far as changing the minds of policymakers that they need to invest in those things that have been demonstrated to work.

LEN NICHOLS:  The coolest thing along those lines is this notion of stepped wedge. And this stepped wedge is a way to do a randomized trial where it may be unethical to deny the services forever. It was invented by epidemiologists when they figured out a drug was working so well, they thought they should give it to everybody in the trial as opposed to wait, you know, for cancer and stuff that really matters. Well, same thing in social determinant space. You start in one neighborhood; you start in one building and if you prove it with a rigorous control group then you’ve got the justification to expand it to everybody and you just phase it in in a way that actually makes sense.

But I want to go back to Ana’s point. If you don’t collect the data you have no hope. And so, at the end of the day, you are only going to get this done where people have come to the state of Nirvana to understand they need to have these data. And I think that’s expanding and I think it’s growing and these technology tools are going to make it more possible over time and the examples that you-all demonstrate. As long as you got Kathy’s memo how to get the Feds to bless it.

SARAH DASH:  Great. Well, thank you so much to all of you on our panel. Thank you to Karen DeSalvo for joining us earlier and for sticking with us. Thank you all for sticking with us and hope you learned a lot and certainly got a lot of ideas for follow-up conversations. Fill out your evaluation forms before you leave and have a great weekend. Thanks.

[Applause]