My characterization of the lopsided investments in improved health outcomes. The stick figure is by an unknown author and is licensed under CC BY-SA
Welcome to my February 2021 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
February is the shortest and coldest month (in much of the U.S.) and did not bring enough relief to the scourge of the pandemic. A recent article about the approaching “milestone” of 500,000 deaths in the US emphasizes the scope as many people continue to marginalize the true impacts. It is almost the equivalent of the total Wyoming population or major city populations like Atlanta, Raleigh, Minneapolis, Kansas City, or most major cities west of the Mississippi river and east of the Rockies.
We continue to see poor and inequitable distribution of the vaccine. People with means and technology access are navigating the complexities of finding a vaccine better than underserved populations. A Forbes article highlights how extreme weather shows the importance of living conditions in Texas and disrupts vaccine distribution throughout the country.
There is growing momentum for adoption of a digital vaccine passport to allow all businesses and services to validate vaccine status and be able to safely open and operate. This may make disparities worse regarding COVID and healthcare because of mixed vaccine access and the risk of discrimination based on the haves and have nots of passports. If we are determined to go down this route as a country, then we should enable this digital passport to also serve as identity authentication for patient access to their own health information.
A new rule on consumer access to our electronic health information goes into effect on April 5, 2021. Somewhat like state IDs for people who do not have a license, people should be able to get the passport for purposes of unique digital credentials without having received the vaccine. It would not be proof of the vaccine in that instance, but it could ensure the passport investment has sustained and more equitable value.
A quote from a recent Journal of Public Health Management and Practice article shows how contact tracing discriminates or forces impossible choices:
“Tough choices presented a sort of “catch-22”: Do good and honestly name all known close contacts and risk a “snitch” label; or avoid the label, yet leave friends, neighbors, or coworkers in the dark, … and let the avoidable spread of disease continue. When identified as a close contact or COVID-19 positive, many low-income families had to make the tough choice between conforming to COVID-19 restrictions or losing income, and worse yet, risking job loss or antagonizing their employers by reporting that they got infected at work. Some had to choose between strictly quarantining and meeting basic needs–food on the table, the roof over their heads, utilities intact, and so forth.”
Life expectancy analysis of the first 6 months of 2020 shows an average 1-year drop due to COVID19 combined with worsening living conditions. Sadly, and predictably, the reduction is much worse for people of color. Black male life expectancy dropped 3 years, for Hispanic males 2.4 years, black females 2.3 years and in truth, non-Hispanic white female and males only dropped 0.7 and 0.8 respectively. The RAC monitor article discusses drug overdoses as one of the added SDOH causes, likely all of the poorer conditions in which underserved populations live and work contributed.
A Lancet article on Avoiding a legacy of unequal non-communicable disease (NCD) burden after the COVID-19 pandemic emphasizes the risk of worsening health disparities for these diseases including heart disease, diabetes, cancers as a result of COVID-19 because of a spiraling effect on economics and no corresponding plan to systematically prioritize underserved vulnerable populations. This quote captures the fundamental need now and in the future:
“It therefore seems clear that the social determinants of health must be considered as foundational to NCD prevention and centrally embedded in government policy at all levels.” This aligns with the EO on advancing race equity and underserved communities discussed last month. Let’s hope it is the start of a growing trend.
Why Business and Public Health? de Beaumont foundation partners with Johns Hopkins school of public health on 7 Ways Businesses can Align with Public Health. The report advocates for the alignment benefits to businesses, communities and improved public health. The high-level recommendations are:
1) “Put out the fire” of COVID-19 by following advice of credible public health experts.
2) Improve the health and well-being of employees.
3) Promote healthy communities.
4) Become a “force multiplier” by leveraging expertise, staff, and other resources to collaborate with local and state public health departments to be better prepared for future public health emergencies.
5) Actively facilitate public-private partnerships in the community.
6) Advocate for development of accountability dashboards that track and monitor progress toward achieving key economic and public health outcomes in a community.
7) Advocate for a rebuilding and expansion of a national public health workforce supported by a modern information technology infrastructure.
If you’d like to hear some of the leaders in public health and business discuss these changes in the context of COVID19 watch this Washington Post event
In line with these concepts is Dayton Daily News project the Path Forward: Race and Equity, the start of their journey to understand the problems in their community and identify solutions.
Black Maternal Momnibus Act – “12 Bills to Save Moms’ Lives and End Racial and Ethnic Disparities in Maternal Health Outcomes” Includes bills to address basic living needs and community resources as well as needed changes in health care and services. It appears thus far it is exclusively a democratic initiative in both congressional houses. The bills take the needed more inclusive approach to change, but we will see if it can maintain traction and stay reasonably intact. Similar to the executive order discussion in last months newsletter. The upstream investments in communities are the same infrastructure and resource needs that impact many disparities and ideally should look at the overall investment needs.
Mount Sinai’s Mobile Health Clinic to address access to urology care for Black prostate cancer disparities, in contrast to the Momnibus effort, may be a welcome improvement for Black men in some communities of NYC. Unfortunately, it doesn’t look at the root causes of the disparities and is a sad example of how our health systems and financing has caused this day-late dollar-short focus. It is philanthropically funded to the tune of $3.8 million. Addressing the result of historic neglect falls to the entire health system not just Mount Sinai. Addressing the living conditions and broad systemic racism that underly not just prostate cancer disparities, but all race and ethnic health disparities, is the responsibility of all industries as the de Beaumont report is advocating.
The first report on the Centers for Medicare and Medicaid Innovation Accountable Health Communities showed a 9% ED reduction. It is a start, but It makes me wonder about the gating metric. The following quote, with emphasis added, notes the narrow target population (a portions or which will always gravitate back to the mean):
“Beneficiaries are eligible for navigation services via the AHC Model if they have one or more of the five core health-related social needs targeted by the model—housing instability, food insecurity, transportation problems, utility difficulties, and interpersonal violence—and self-reported having two or more ED visits in the 12 months before screening.”
There are important initial lessons learned including: addressing challenges in closing navigation to needed services; seeing differences in the two AHC models, the assistance track verses the alignment track in which the community worked to build up available services to meet social resource needs; race and ethnic groups were overrepresented among the eligible population; differences in rural and urban resources; and, meeting needs and closing the referral loop requires more than the available resources. A quote from the report identifies further navigation challenges: “It also requires that beneficiaries can access CSP organizations; meet eligibility requirements to use the services; and find resources that are medically, linguistically, and culturally appropriate.”
HIMSS article on Digital health literacy as an SDOH highlights the digital divide and states that payment parity across mechanisms for services e.g., phone verses video visits is necessary if increases in digital services are going to allow for equitable access and care. The article also emphasizes the need for software and apps that address language and cultural differences.
Technology can be a facilitator and a barrier to improved living conditions. Health Current, Arizona’s health information exchange selected Now Pow as a means to support referrals to address social determinants of health throughout the state. The design and approach is reaching beyond the health systems to community-based organizations and community stakeholders. Partnering with 211 Arizona expands the goals of the solution beyond just health outcomes. Let’s watch this initiative and cross our fingers that it expands the vision for addressing upstream community needs regardless of the individual’s or family’s relationship to a particular health system or plan.
A number of investments in equity and SDOH were highlighted this month below are a few. However, it is always important to keep these in perspective to total healthcare expenditures.
The American Heart Association is committing $230 Million to SDOH & equity over 4 years to research, expanding diversity, addressing community health equity barriers and a partnered program with HHS on hypertension initiative for Black, Hispanic and Indigenous communities.
Health Affairs Article discusses research that quantified health system spending on upstream social determinants of health for almost 3 years (2017-2019) that estimates $2.5 billion in spending, $1.6 billion of which was housing focused. Total US healthcare expenditures over the same time period were greater than $10 trillion, thus spending was 0.025%
CVS housing investment reached $114 million, but, CVS’s annual revenue is >$250 billion, remember this is a pharmacy chain, with clinics and a national health plan. Yes, this is better than no investment, yes small in comparison to the health dollars they receive and the cost to the health system for the lack of housing. It is almost double the percentage just mentioned for upstream spending. I can’t have it both ways, but I would like them to consider a larger investment with partners in communities of need that aren’t tied to insured seniors in their health plans or targeted pharmacy patients.
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RECENT & UPCOMING EVENTS
Health Disparities Research Institute (HDRI) virtually August 9-13, 202, Applications will be accepted from February 1 – March 8, 2021! Designed to help aspiring early-career minority health and health disparities research scientists. Go to the website for more information.
The Root Cause Coalition National Summit on Social Determinants of Health is being held virtually October 4-6, proposals to speak or lead a breakout session are being excepted until March 15th.
The RISE Summit on Social Determinants of Health June 13-15 live and virtual.
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