Introduction
Welcome to my January 2022 Living Conditions and Health 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.
A New Direction
This is my last Living Conditions and Health newsletter. It has been four years and time flies even during COVID! I have decided to concentrate my future posting and blogging on advancing multistakeholder investment and engagement in upstream efforts to improve living conditions AKA Social Determinants of Health (SDoH). I still dislike this term. It is one more mouthful acronym that doesn’t resonate with the people outside of the healthcare bubble, including the people we are trying to help.
I see the need for broader stakeholder engagement as the greatest gap in advancing sustained health equity, supporting underserved individuals and communities, and dismantling racism. These efforts need to be pursued in tandem with improvement in living conditions for health and sustainable living. Broad stakeholder engagement is needed to focus on the full landscape of barriers and benefits to greater equity and opportunity. These efforts must also be led by the individuals and communities we seek to support and non-health stakeholders in the communities including employers, investors, infrastructure businesses and community-based organizations. Often health care providers and payers are anchor institutions in communities and will still play a key role in the multi-stakeholder support. As I start to shift my focus, I wonder if the public health perspective would bring a more balanced view to this worthy task. The pandemic has taught us that public health brings a broader perspective that enables change when given the resources.
If you have been following my newsletters you know I strongly support changes that are not unduly tied to discrete healthcare outcomes and instead focus on basic human needs of individuals, families, and communities. The best part of having tracked SDOH over the past 4 years is the broad acknowledgement that circumstances in which people live, work and play is the greatest driver of health outcomes (40-60%) while clinical care effects only 20% of health outcomes. However, most of the healthcare industry investments are heavily focused on target members or patients of each organization rather than looking at the collective needs of the people in the communities with inadequate resources for basic daily living needs. I’m getting ahead of my first official post for this new direction but rest assured, or with trepidation, that I will still be engaged. I will be seeking out like minded colleagues and friends to help advance this approach locally and nationally, and my focus will still be directly related to living conditions and health.
The inequities laid bare by the pandemic and discussed at the JP Morgan Health Equity conference mentioned below are what excite me about taking a new direction in my efforts to help advance change. I also admit freely that this new direction my have unduly influenced this final newsletter. Apologies if you were expecting something different.
Shannah’s Insights and Reflections
January 21, 2022 marked the one-year anniversary of the Biden Administration and the Executive Order on Advancing Racial Equity and Supporting Underserved Communities through the Federal Government. Race Forward and Policy Link Published a report Advancing Equity in Year 2 of the Biden Administration. They also hosted an event on February 3rd to discuss the way forward that included: Congresswoman Ayanna Pressley, Nse Ufot of the New Georgia Project and Chiraag Bains Deputy Assistant to the President & Deputy Director of DPC for Racial Justice and Equity. The event is well worth your time to hear what has been accomplished and what is still ahead.
As part of the 40th JP Morgan Health Care Conference there was an inaugural event called Real Health Equity 2022: Changing Outloud. The JP Morgan conferences have historically been all about the big investments and acquisition deals in healthcare, pharma, biotech and more recently Health IT, but this event felt different. There were many great examples of grass roots initiatives that are being scaled. However, for all the talk of engaging the individuals and communities we’re seeking to support with more equitable health access, services and social supports, there was not one consumer panel or participant. Perhaps next year’s event will add this crucial element.
At the annual U.S. Conference of Mayors, 143 mayors signed the Mayor’s Compact on Racial Equity indicating they believe systemic discrimination exists and commit to pursue 8 goals “…to dismantle institutional racism and systemic inequities in measurable and sustainable ways.” The Route Fifty article went on to say that during panel discussions mayors said they would use funding from the American Rescue Plan Act (the infrastructure act) to address racial inequality. Some Republican mayors signed the compact and some support the goals but worry about the political backlash and have not yet signed on.
The Health and well-Being Matter monthly blog from the Director of the Office of Disease Prevention and Health Promotion (ODPHP) discusses 7 conditions vital to well-being and needed for longterm resilience: Meaningful work and wealth; Reliable transportation; lifelong learning; belonging and civic muscle; humane housing, basic needs for health and safety; and a thriving natural world. The blog highlights the importance of equity and a voice at the table under belonging and civic muscle and calls out the need for individual and community action.
Kaiser Family Foundation updated a broad range of charts looking at measures of racial and ethnic disparities. If you need metrics to help educate people on these disparities this could be a great resource. Except for the Asian population, all other race and ethnicities demonstrate disparities on most metrics. Some striking examples include:
Family median net worth: White $189,100, Black $24,100 Hispanic $36,050
Percent of Adults with food insecurity: White 6%, Black16%, Hispanic 13% Asian 4% American Indian Alaskan Native (AIAN) 20%
Out of 16 measures of SDOH the number for which the population fared worse than the white population: Black 14, Hispanic 15, Asian 7 (Asian’s also fared better on 7 measures), AIAN 10 and Native Hawaiian or other Pacific Islanders 8
An article about Texas Health Resources joining the National Health Equity Collaborative established by the American Hospital Association’s Center for Health Innovation highlights the importance of moving upstream to really impact improved health and engage the community. This reminds me of the Hospital Toolkit on Investing in Community that highlighted the broad range of assets (e.g., land, financial resources, relationships expertise) that hospitals, and arguably all businesses, can harness to support community investment.
The National Alliance of Healthcare Purchaser Coalitions published Leading by Example and Moving Upstream Together Two regional coalitions in Kentucky and Pennsylvania recruited 3 employer members to develop ways to locally address social needs and social determinants of the workforce. Working with the health and community stakeholders revealed a broad spectrum of initiatives that would help their employees and the community when contemplating a broader definition of health and social factors.
One of the most read Health Affairs articles from its grants watch series is about Finding Effective Ways to Address SDOH. The following quote from this article reinforces my new direction.
“But until we can deepen the evidence base on how to address social determinants of health, and sift out what works and how it works, we cannot expect big health organizations, systems, and, above all, payers to shift their resources toward funding such integration (between health care and social services), says a report funded by a large foundation in Texas.”
My firm belief is we do not want the shift in resources unless it isn’t skewed by clinical outcomes. The health system has enough to fix without trying to bolt on addressing adverse SDOH that they are ill equipped to handle and for which there are broader reasons and outcomes to consider beyond health. The conclusion suggests we need all funders of healthcare and social services. I believe we need a much broader set of investors.
A study on the impact of the sex of the surgeons on the outcome of patients by sex, showed women have 15% worse outcomes when the surgeon is male and are 32% more likely to die! Conversely women had better outcomes when the surgeon was female. This is the kind of health equity that should be front and center for providers and payers, and it is much more closely tied to the need for institutional and professional change.
Similarly, a range of programs discussed at a session during a recent Health Equity Summit emphasized fixing structural barriers to improve health equity. Note the interventions and targeted outcomes are tied to clinical care. Three experts underscored the need for addressing structural barriers and gave suggestions or examples of improvements. The populations and examples were: American Indians living in tribal communities are often without physical infrastructure like electricity, plumbing or technology and needed structural change includes access to insurance, clinicians and better visibility into the health of the population; Black, indigenous and other people of color were disproportionately affected by COVID and the state of Vermont gave them access to COVID Vaccines ahead of expanding it to residents 16 and older; Latinx, Filipino and LGBTQ residents of Solano County CA were substantially underserved with respect to behavioral health services even though they represent 45% of the county, providing training on culturally and linguistically appropriate services resulted in substantial increases to the populations seeking services. (All of the stated population terminology was used in the article.)
One article and one research report were focused on ROI for investing in SDOH. An article on ways to assess SDOH programs return on investment, discusses a NORC case study report that looks at best practices from Medicare Advantage SDOH programs. It discusses some softer metrics including beneficiary surveys. For example, SummaCare partnered with Papa on its companionship program and surveyed beneficiaries using the UCLA Loneliness Scale. The article also discusses the Special Needs Program alliance report from 2021 highlighting how members are using SDOH data. The Commonwealth fund reported on research using an ROI tool for community based organizations and health care organization (HCOs) to facilitate partnerships. There were benefits and challenges to use of the tool, but it appears to be weighted towards improved health outcomes that have ROI to HCOs vs ROI to the communities and the local organizations. The narrower focus of research also makes it less viable given likely broader community and individual needs.
Finally, an article about a healthcare system and a network of foodbanks in Ohio highlights the challenges HIPAA can present when trying to coordinate needed food access and stability services. Here’s an excerpt on the problem and the added solution costs due to administrative and access requirements.
“Although HIPAA allows for data sharing of PHI (protected health Information) between covered and noncovered entities for the purpose of coordinating patient care (eg, as in the Mid-Ohio Farmacy (MOF)) through a business associate agreement (BAA), Food Collective interviewees expressed concerns regarding what specifically is allowable under HIPAA and whether partner food pantries could be HIPAA compliant, ultimately resulting in their reluctance to enter into a BAA,” the study authors explained.
The organizations resolved these concerns by requiring patients to consent to the release of information. However, this decision entailed significant legal discussion between entities which presented an initial hurdle to the partnership’s creation.
The release of information also created a more detailed clinical workflow and an additional potential barrier to patient participation in the MOF, as individuals may be hesitant to share their PHI with external organizations.
Additionally, the organizations had to create a unique, partnership-specific patient identifier in order to link patients across entities.”
SIREN picks
The research entry that caught my eye in keeping with my new direction was:
“It’s Not Just the Right Thing . . . It’s a Survival Tactic”: Disentangling Leaders’ Motivations and Worries on Social Care This research using semi-structured interviews with health care organization administrators talks about why they are taking actions and the concerns they have in terms of their role. Their concerns dove tail with the need for a different framework in which Healthcare delivery and payment have a role, but perhaps should not be the lead.
You’ll find the January SIREN research round up here.
RECENT & UPCOMING EVENTS AND RESOURCES
Virtual event “Investing in Health: The Intersection of Business, Public Health, and Community Development.” Hosted by the Federal reserve Bank of New York and New York City’s Department of Health and Mental Hygiene The 90-minute event focused on prioritizing investments to meet local health needs equitably and seeking to boost more private investment and market opportunities in underserved communities. There should be a recording available.
RISE Summit on Social Determinants, March 20-22, 2022, Nashville TN
AHA Community Health Improvement: Accelerating Health Equity Conference 2022– May 10-12, 2022 | Cleveland, OH
On Wednesday, January 19, 2022, the Federal Reserve Bank of New York and New York City’s Department of Health and Mental Hygiene hosted a virtual event, “Investing in Health: The Intersection of Business, Public Health, and Community Development.”
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