Welcome to the Fall 2020 newsletter. You can find past newsletters with additional background materials, and different stories and initiatives on my website and in my LinkedIn articles or posts. Join me in identifying and coordinating initiatives that advance health, health equity and community and healthcare redesign.
Shannah’s Insights and Reflections
This newsletter covers September, October and part of November 2020. It proves that if you wait long enough there is new hope and a new potential framework for addressing growing U.S. challenges. COVID19 and our needed racial reckoning have been magnifiers for health disparities and inequities that have always existed. They are driven by inadequate living conditions for a majority of our country that have gotten worse due to COVID19 and the economic downturn.
We currently have an administration that gave up on addressing the pandemic and the drivers of disparities. The Biden Harris administration (B-H) is already taking on the critical challenges we face for everyone in the US regardless of race, ethnicity or political affiliation.
My greatest fear is that a divided Congress and country will make it hard to move ahead quickly, but I anticipate that B-H will take a page from the current administration and use executive orders to leverage the full breadth of the executive branch’s administrative powers.
My overall takeaway from this extended period of time is Community, Community, Community, whatever we do it has to empower and invest at the community level in a way that acknowledges, eliminates and makes amends for discriminant and disparate services, treatment and opportunity. It should also strive for improvements and solutions that pool investments at the community level, rather than those driven by individual health systems or plans.
This concept is embraced and explored in the Health Affairs blog on the new PPE – Public health, Primary care and health Equity. The authors have created a community PPE index to estimate “capacity to respond to and recover from the impacts of the pandemic.” The authors note that score on the three core metric areas will help educate the community and inform policy. I believe it is akin to their suggestion to other countries – it is a framework that has to be rooted in local context, capacity and engagement all limited or enabled through resources that each community may or may not have.
Healthcare systems and plans are investing in community organizations that serve their members distinct from the entire community. This is a patchwork, siloed, seed funding approach that is too focused on near term health system outcomes and not the upstream challenges that underly health disparities. We need to shift sustained investment to the communities and community services outside of the care delivery system.
An article about the devastating effects of the pandemic on the Micronesian population highlights how interwoven structural racism and violence are to the disparate health outcomes for low-income underserved populations. This is the same systemic drivers of disparities for people of color throughout the US that clearly identifies what is broken in the health systems and its payment structure.
I’m including a rather lengthy quote from a World Medical & Health Policy article on what the pandemic has revealed in terms of disparities and what that means for policy. The article goes on to emphasize research, but this is one of those moment when I think we have to use radical common sense. The basic needs of individuals and communities are not mysteries and fundamental change can start today! Some communities started back in the early days of COVID19.
“The systemic nature of the disease and its impact means that effective public health policies cannot be considered in isolation from broader social consequences. Doing so could mean not only ineffectual policies, but also dire outcomes in terms of health, education, nutrition, employment, and general well‐being for society. Innovative policies aimed at closing gaps in access and treatment—not to mention overall well‐being and life chances—must be developed and implemented in ways that speak to inclusion and fairness as a matter of course. Regarding racism as a determinant of health, its effect is significantly related to adverse health outcomes, over and above factors such as age, sex, birthplace, and education (Paradies et al., 2015; Williams et al., 2019). However, research also suggests that the adverse consequences of racism on health can be reduced through policies that “maximize the health‐enhancing capacities of medical care, address the social factors that initiate and sustain risk behaviors, and empower individuals and communities to take control of their lives and health” (Williams & Mohammed, 2013, p. 1200).”
The Institute for Health Justice and Equity has published a report with recommendations on how to respond to Racism as a Public Crisis. This is a great framework to move from declaration to action.
A recent article relating to top factors underlying COVID19 disparities, highlights the importance of prioritizing vaccines, once they are proven safe and effective to higher risk populations. This quote from doctor Rhonda Meadows President of population Health at Providence St. Joseph should guide the new Administration’s Pandemic task force:
“The whole idea that we make sure that we prioritize the people who we know are at higher risk with mobility and mortality. That includes not only protecting our frontline, but make sure people in nursing homes, people of color with high morbidity and mortality are in the front to receive the vaccine because they are more likely to suffer a more severe illness and death.”
Recent survey findings from NPR, RWJF and Harvard’s T.H. Chan School of Public Health reminds us of how the current frail environment is putting families that have historically lived comfortably at risk. Close to 50% of household face serious financial challenges during the pandemic and it is worse for Latino and Black households.
It appears health insurers have fully embraced the need to focus outside of clinical care. The Annual Payer Index survey from Altruista Health indicates plan leaders see “managing and predicting Social Determinants of Health” among members as their greatest concern for 2021 outweighing COVID19. Second on the list is interoperability under the 21st Century Cures Act, also ahead of COVID19. The Survey also shows the usual SDOH suspects having the greatest impact: transportation, food insecurity and housing. Poverty is next on the list and there is no mention and perhaps no option to choose racism. Also interesting is that SDOH comes in 4th on the responses to your top three care management priorities after — improving member outcomes, complex care management and integration of behavioral/medical health and before — member engagement, improving quality and compliance and provider engagement. Arguably it is a driver of the first three priorities.
Humana’s report of an estimated $4 billion in savings resulting from value-based care that incorporated addressing social needs may be an example of why health plans are sold. Many large delivery systems are acquiring home care service providers and expanding services to the home. To what extent are the savings attributable to SDOH and do the arrangements have risk sharing to share in the profits?
On the technology and data fronts, this article about the expansion of Nebraska Health Information Initiative (NEHII), Nebraska’s statewide health information exchange (HIE) highlights an important social support technology to some of the hardest hit COVID19 states. “NEHII announced the expansion of its behavioral health data platform, that includes social determinants of health (SDOH) data, to six additional states: Iowa, Kansas, Minnesota, Missouri, North Dakota, and South Dakota.” It will help hospitals anticipate utilization and communities address service support gaps. It will also assist with the data uncertainties tied to clinical care received across state lines.
Lyft tool integrated into Epic EHR to help address transportation barriers. Other examples of integrating social needs support is the virtual solutions enabled during COVID shut downs like Blue Shield promise and LA Care. Their efforts included virtual visits and support for Wifi/needed data access to engage with the virtual tools.
Blue Shield of CA is making social determinant of health data in California available to everyone with the Neighborhood Health Dashboard. One of the goals is to help stakeholders across industry segments perhaps to aggregate community investments.
BU and Sharecare released their Community Well-Being Index state rankings report using SDOH to measure community wellness
In July I responded to a post about Joy Buolamwini and the underlying biases of Artificial intelligence…. I now follow Algorithmic Justice League United on Instagram a feat in itself for someone who is feeling social media is also part of our societal problems. In all of our data activities these bias needs to be examined every time we create a solution that relies on standard data that too often has inherent biases.
This story about Hometown Health combining house calls and telemedicine caught my eye, because it is an old concept combined with new technology that confirms, bringing the broader scope of health to where patients live can have added health and social determinant benefits. This aligns with a renewed push for making in-home primary care mainstream. Heal’s doctor on demand model and Clover Health, a Medicare Advantage Insurer, seem to have adopted adjacent models that can collaborate with other homecare providers. This coincides with trends in plan acquisition of home care and long term services and supports.
An article about mitigating the COVID19 impact on Medicare risk scores also highlights using some of these enhanced home services to help along with encouraging patients to return to normal utilization rates. The problem is that plans will get lower risk scores as consumers avoid going to their providers for fear of getting COVID. CMS initially bumped up the rate but may look to reduce compensation in 2021. The article doesn’t discuss alternative policy options that perhaps might hold rates steady until we are past the challenges of the pandemic.
CDC started a quarterly Health Equity Matters Newsletter in Summer 2020 and the Fall newsletter came out on September 24th referencing the Health equity strategy and Healthy People 2030 both of which I mentioned in my last newsletter. You can sign up for the newsletter on the website in the link.
Study shows COVID19 has taken a greater toll on mental health than prior national trauma’s including 9/11. The impact is again more severe for low-income populations given the combined trauma of the pandemic and economic consequences. Healio article underscores the importance of “societal efforts to support people with fewer resources.”
New Interim guidance from the American Academy of Pediatrics on evaluating and supporting children, adolescents and families struggling with emotional and behavioral health during COVID 19 highlights added risks inherent in social isolation and how it is complicated by social media. Today’s environment adds new complications to what were already challenging situations. Pediatricians, if/when they are able to see patients may be the only external touch point for children and adolescents who are struggling including potential abusive situations and added burdens for patients already trying to manage emotional and behavioral stress. More evidence of disparities, the need is greater for underserved populations and the services are more limited.
This guidance may be some of the focus for Thriving Families, Safer Children: A National Commitment to Well-Being – a program launched by U.S. Children’s Bureau, Casey family Programs, The Annie E. Case Foundation and Prevent Child Abuse America to rethink Child Welfare by supporting families to help “…break harmful intergenerational cycles of trauma and poverty.” The program will start in four states CA (LA county), CO, NE and SC. “The multiyear initiative will provide resources and support to help move jurisdictions from traditional, reactive child protection systems to systems that proactively support child and family well-being and prevent child maltreatment and unnecessary family separation.”
Two other service delivery models are worth mentioning. First, community health workers (CHWs) the bridge between communities and systems of care, are featured in a perspective piece in NEJM. It highlights CHWs as the way to address social determinants during and after the pandemic. Training and leveraging community health workers in a sustainable way will be critical. Unfortunately, I recently learned that the American Cancer Society heavily scaled back their Nurse navigator program due to COVID19, we can only hope this is temporary.
Second, are medical-legal partnerships part of the solution for equitable access to needed services? There is no question that underlying racists and services barriers are legal impediments, but what should this help look like and is it perhaps the one other services component that is not where substantial investment is needed? Aren’t our health and legal systems already garnering more investments/revenue distinct from community services (depends on the model, Mount Sinai’s program leverages pro bono services of local legal firms) traditional affordable legal aid has always been underfunded, consider the Cares Act $50 million verses billions for airlines, or Boeing, pick your big corporations that needed assistance?
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RECENT & UPCOMING EVENTS
Modern Healthcare’s Social Determinants of Health Symposium December 8, 2020
Background and Definition
I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible. This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020
I participated in a center for popular democracy training and they shared this MLK jr. quote “Power without love is reckless and abusive, and love without power is sentimental and anemic. Power at its best is love implementing the demands of justice, and justice at its best is power correcting everything that stands against love.” Perhaps a wish for Thanksgiving.