Social Determinants of Health

By Gregg Gordon

About me and why I’m here:

• Thank you for the opportunity to join you today.  The topic, as advertised, will focus on the social determinants of health and the operative word in that is social… which I tend to relate to community… and when I think about community, I often trace back to my first community, Ethical Culture.  But first, a little bit about me and how I arrived on at this podium. Very little traffic today; took Route 17, then Route 4, then got off on River Road…
• I’ve been in the health care space since I was an undergrad when I wrote my senior thesis on the birth of compulsory health insurance in Germany in the 1880s as championed by Otto von Bismarck.
• I have worked for major payor entities like HIP Health Plans and Health Net, and small Medicaid payors like NY Health Plan and Neighborhood Health Providers in a variety of administrative capacities.
• I have worked for a major health system, Northwell (formerly known as the North Shore – Long Island Jewish Health System), then a $4b health care system based on Long Island and now a behemoth $10b multi-regional player… and also for a specialty rehab hospital called The Kessler Institute.
• I have done some consulting and also worked in the tech sector for what felt like a hot minute helping to bring a cancer classification system to the market and the government.
• I spent 5 years working for MagnaCare, a mulit-state benefit plan administrator; essentially, their clients are companies and unions or funds who don’t want to buy insurance but want to take care of the claims that are incurred by their employees.  At MagnaCare, I held a Senior Vice President role and oversaw the development and maintenance of a network of providers that included 160+ hospitals and over 100,000 individual providers.
• I joined MVP aka the Mohawk Valley Plan in late 2016.  MVP is based in Schenectady, NY but they bought a Medicaid health plan in Westchester County a few years ago and now have a very significant footprint in the Hudson Valley.  I have been heavily involved in migrating traditional fee-for-service payments to providers to arrangements that are based on quality and value.

The Migration of Payments Methodologies and Medicaid Risk:

Traditionally, providers have been compensated based upon the volume of services that are provided… we call that Fee For Service.  In the current environment, this methodology has been supplemented with requirements for providers to be at risk for delivering better care and more importantly, proving it!  But, let’s be clear about the nomenclature. This may seem elementary, but I think it’s important to name the players.

• PAYORS can be traditional health insurance companies like Blue Cross Blue Shield, United HealthCare, Aetna, Cigna, Humana, etc… and they can be entities who self-insure, meaning that they do not buy a traditional health insurance product or plan; rather, they hire a company, like my former employer MagnaCare, to do all of the busy work of paying claims and doing medical management, but are ultimately personally responsible for paying the claims… thus, they too are payors.  And to be clear, Medicare and each state’s Medicaid agency are payors as well.
• PROVIDERS are simply defined as any person or place that provides a health care service.  Hospitals, primary care physicians, specialists like anesthesiologists, radiologists, surgeons… labs, physical therapy locations, ambulances, etc….  All of them are collectively providers.
• MEMBERS/PATIENTS are the same people.  In a sometimes impersonal way, health care industry folks will call them “consumers” as if to apply the traditional behaviors of consumerists to getting needed health care services.  But no, buying a car isn’t the same as finding a kidney specialist. All that we do in this business and our raison d’etre should start and end with patients. As you might imagine, that’s not always how my brethren always prioritize their motivations.

In New York, not unlike most states in this country, their Medicaid agency has long struggled with the rising costs of health care services that they reimburse, and the managing the reductions in revenue that come from state and federal funding.  If we think of this as a traditional business, they battle a binary formula of revenue and expenses where legislators, lobbyists, advocates, and citizens spend an inordinate amount of time on how and why funding this critical program should be paramount but they neither solve the looming deficit projections nor address the underlying root causes for the increases in health care expenses.  Like many other states, New York has determined that it’s days as a risk-taking payor are numbered.  They’ve determined that they need to essentially shed their risk and force others to assume that risk.

Coming back to the PAYOR definition, we remember that Medicaid, in its purest form, is a payor.  However, in the 90s, New York’s regulators made it a requirement that all Medicaid recipients join a health plan.  That is, if a person is eligible for Medicaid, they must enroll into one of the licensed NYS health plans or be auto-enrolled into one by the state.  Medicaid establishes premiums or funding amounts that pays to these health plans and pays them based on the volumes and types of members of enrolled. As health plans incur greater costs, NYS sometimes adjusts those premiums… but not all costs are absorbed by these licensed health plans.  Medicaid, is still a payor for a number of services… and it no longer wants to be in the payor business.

This is the backdrop to the current environment.

Payor Methodologies

As I shared, most providers are paid purely and simply on a fee-for-service basis.  The more a physician does in a patient visit, and the more he or she bills for, the more he or she gets paid.  It’s a volume game and it invites unnecessary care or duplicative testing and sometimes fraud. Moreover, there hasn’t been a reliable way to determine who is a “good” provider and who isn’t as good.  We have long relied on word of mouth and the bedside manner of our doctors.

Most people rely on their family physician.  In health care speak, that’s your primary care physician or PCP.  This person is responsible for coordinating your care, for doing preventative screenings and testing, for recommending downstream specialists for conditions that are beyond the training or expertise of the PCP.  How do you know if your PCP is doing all that he or she can to ensure that you are being tested for the things that you should be tested for… and at the proper intervals… and that you will be referred to a high quality specialist… who is also participating in your payor’s network?

There are now effective data-driven tools today that are fascinatingly revealing and which enable a payor to determine “good” from “not so good” and sometimes even “bad”.  To be clear, a bad doctor kills patients, commits fraud, and has multiple malpractice losses.  Very few are bad. The majority doctors run the scale of good to really good, but it’s amorphous and ambiguous.  How can we differentiate physicians?

Here is an example: if you want to compare the cervical screening rates of females aged 21 and older, and you are comparing two doctors in this metric… and Doctor Jones refers far fewer patients for the test than Doctor Smith, Doctor Smith is clearly better because more patients are getting appropriate preventative care. No, it’s clearly not this simple as comparisons can be made across any number of factors and variables such that the lay person no longer has to rely on word of mouth or bedside manner.

In NY, Medicaid created what’s known as the Road Map.  It requires a licensed health plan to enter into value-based agreements with the providers who participate with that plan.  That means, instead of solely relying on reimbursing providers on a fee-for-service volume-based methodology, that payor must include “value” elements.  They have to require that their provider partner (and I want to come back to this concept of “partner”) become more efficient cost-wise, provide higher quality care, and ensure the long-term health of their members.  It is based on a primary care model. The theory is that a PCP who was selected by a member as their PCP needs to coordinate all of the care that the member will consume whether or not the PCP provides that care.  For instance, if I am a diabetic, my PCP should be ensuring that I am getting eye exams and am routinely being seen even if I’m somewhat loathe to seeing doctors in general. If I am aged 50 and should be getting a routine colonoscopy, the PCP should ensure that I get it and don’t just shrug off the recommendation.  If I am a frequent visitor to hospital emergency rooms, the PCP should spend the requisite time to figure out what’s causing me to go there so frequently… and if there is perhaps just an educational element that may reduce the frequency.

What’s the motivation to A) force the payor to set forth these requirements from its participating providers, and B) force the providers to comply with such requirements?  Of course… MONEY.  I spoke earlier of Medicaid funding health plans through premiums; in the NYS Road Map, the state has ability to materially reduce those premiums if the health plan does not migrate enough of its participating providers to value-based arrangements.  So, naturally, payors have introduced similar monetary incentives to its participating providers… and to be clear, we’re talking about large physician groups, not solo or small practices who lack the business scale or sophistication to do this.

These value-based agreements essentially work like this:

1. Payors compare the costs of a large group from year to year with the goal of seeing those costs reduce.  Contrary to propagandized ideas of rationing or death panels, the focus is to reduce waste such as duplicate testing, administrative inefficiencies, and the like.  Just do a better job managing your practice and be efficient. Those are easy wins for all sides. 
2. A practice is asked to intervene with the patients who have the greatest health care needs.  Hire care coordinators who will focus their efforts on these individuals, manage their care needs, keep them out of the ER, ensure that they take their medications, etc. 
3. Focus on preventative care.  There are a number of tests that clinical associations, state and federal agencies, and industry groups all agree should be performed on certain types of individuals.  I gave examples of diabetes eye exams and cervical cancer screenings and colonoscopies… and there are many others. If the practice doesn’t do those things, partner with another practice that does… and if you need help identifying who else can do it at an affordable price and with high quality, ask your payor partner for help.
4. Create solutions for the obstacles that keep people away from your practice.  Some are practical and some are exceptionally challenging. These are… drumroll please… the social elements.  Bet you thought I’d never get here!

• This element in value-based agreements requires a practice to partner with a community based organization, or CBO.  What is a CBO? It is an organization that provides support to Medicaid and uninsured populations at the individual level such that they deliver services that are culturally responsive and address an individual’s social determinants of health.  These social determinants are fundamental to supporting medical interventions and improving health outcomes.
• There are five general areas of social determinants of health.  They include
  • Economic stability
  • Education
  • Social and community context
  • Health and health care
  • Neighborhood and environment

Empirically, relative to safety, we think about food, safe housing, affordable public transit, clean water, non-polluted air, and very basic elements to a person’s dignified existence in the community.  If any one or more of these is problematic and a hindrance to a person seeing their PCP, they won’t see their PCP. Many of us might take for granted that we can read English, that we can drive a car, or easily get to public transportation… that we can wake up in the morning in a peaceful environment and make a plan for the day… that we can choose which clean shirt to wear and eat the type of food that we crave at that moment… that we can socially interact amongst those in our community without fear of persecution, intimidation, or fear… both physical and psychological.

Preventative health care, in this context, is neither a priority nor an option.  It is a luxury. If you can’t leave your home to go to the store, you’re not going to your doctor.  If you are unable to access any reliable, safe, or affordable mode of transportation, you’re not going to your doctor.  If you are stigmatized by your accent, your attire, your immigration status, etc., you’re not going to your doctor. Add 100 other reasons that the collective “we” would judge as rational or irrational where neither label matters… and that person doesn’t get their needed and necessary health care access.

What happens then to that person when they get sick?  Where do they go? [PAUSE]…  The emergency room.  Where is the most expensive place that any of us could possibly go to for health care?  The emergency room. Who else goes to the emergency room? People with gunshots, heart attacks, strokes, etc… and people who have indigestion, need their stitches taken out, have a headache…  So, that Medicaid person who didn’t see their PCP because of any of the aforementioned reasons has to compete with serious and non-serious patients… and wait their turn for hour and hours. They then see clinicians whose job it is to perform triage quickly and determine if the condition requires a surgical intervention, diagnostic testing, on-call specialist visits, or more.  It’s harried, somewhat organized but frenetic, and in no way contemplates the very unique characteristics of the patient and his or her needs. It isn’t a coordinated visit of a multi-disciplinary team that manages the complex interplay of medical, psychological, behavioral, and economic variables.

Taking a step back to the economics of health care access, let’s remember that Medicaid recipients do not have to contribute to the costs of their health care, thus the motivations that some of us with traditional health insurance plans have to go to an “in-network” provider do not exist with this population.  So, who pays the hospital for the ER visit? The payor. Who funds the payor? Medicaid, through the payment of premiums. Who funds Medicaid? All of us through our taxes. Let’s extrapolate this to the uninsured population; who pays the hospital? Well, they may be billed and may pay a small portion, but in most states, there exists some form of a pool or money that is intended to pay hospitals for what is called “bad debt” which is another way of saying that hospitals get some portion of uncollected patient revenues.  Who funds these state pools? All of us through our taxes. What does this mean? It means that we are all responsible for how the least served and most challenged people in our community access health care. Please, pause for a moment and put this big picture into focus. The proverbial “can” that some may decide to kick down the street still lands on our property.

So what’s the end result?  We have the neediest population getting the least amount of attention.  We have the most expensive setting for health care delivery utilized at high and unnecessary levels.  We have poor data gathering to measure the health of population cohorts, thus we fail to fully understand them, develop programs to address them, develop funding solutions to help them, and more.  We essentially have a disenfranchised segment of our community.

So what do we do?  The Community Based Organizations, or CBOs, aren’t based upon a new idea.  We have had similar but differently nomenclated groups to help the needy for a long time.  What is different, I believe, is the scale of impact to the affected population. Through focused efforts in New York and throughout the country to financially motivate the stakeholders… meaning the PAYORS and PROVIDERS… and applying a narrative that seeks to depoliticize and humanize the problem, progress can be made.

I spent some time over the last year with an organization called the Sharing Shelf.  They are in Port Chester, NY and their mission is simple: provide free clothing wardrobes for kids and teens.  The idea is this: families of very limited means have very small margins for aesthetics. A family completes a questionnaire that gathers information on the child or children.  The questionnaire is received by The Sharing Shelf, and they put together an entire wardrobe that is seasonal and complete, meaning shoes, under garments, and matching sets of outfits.  All of the clothing is donated… from individuals, from stores getting rid of inventory, and from manufacturers. The clothing must be in near-perfect condition, cannot have arcane writing on it like “Englewood Hospital Golf Tournament 2012”, and has to be fashion forward.  The idea is that your child, who despite what might be a challenging home environment, still wants to fit in at school and not add an additional stigma to what is already felt inside, gets to look good and feel good, thus develop confidence and embrace that learning and social environment.

So the thought is that the parents may have realized a marginal reduction in their expenses, and maybe they’ll use some of that margin to take a bus and see their doctor.  By itself, The Sharing Shelf doesn’t effectuate that doctor visit, but it is part of a mosaic of similar organizations each looking to remove obstacles to getting preventative care… and they are complemented by outreach efforts of the PAYOR and PROVIDER who are motivated to reduce costs and improve their margins.  Thus, they spend a bit up front by hiring care coordinators to make calls and follow up with these individuals to save on the long term ER and condition-related costs.  Their goals are financial because after all, this health care “thing” is a business after all.

Medicare did speak to the “triple aim” a few years ago in concert with the rollout of the Affordable Care Act.  The idea is that through value-based programs that incorporate Community Based Organizations, that financially incent all of the financial stakeholders to force adoption and meaningful data metrics, and are designed to migrate away from a volume-based model, we collectively achieve three things:  improved quality, lower costs, and healthier people.

This idea of the triple aim from the federal level, and through the Road Map introduced in NY as a state level program, invariably creates the “partner” concept I spoke of earlier.  No longer is the adversarial relationship of the big bad payor denying care left and right… and the expensive doctor or hospital ordering unnecessary expensive tests… the norm. The new normal sees these first two stakeholders working together to address the third stakeholder’s needs in a holistic way, and it inspires innovative solutions borne from having boots on the ground through relationships with community based organizations.  

IN CONCLUSION

What’s missing in all of this is you and me, though my role is bifurcated because I wear a business hat in health care.  How do we effect change in the social domain? How do we take care of our community in a way that puts quality of life and dignity at the forefront but also contemplates the empirical reality of health care economics?

If we make up-front the investments into addressing and mitigating the social obstacles to health care access, they will assuredly offset the long-term costs of this population but more importantly, we create a culture of responsibility, of positivity, and of extrapolating returns to our community.  While we do not have universal health care and likely won’t for some time or ever, we do have a number of meaningful solutions but they are only effective when they are accessible and utilized… so our work here isn’t done.