Recovering from COVID-19: Refocus on Health

With more news coming out daily on the disproportionate numbers of minorities contracting COVID-19, suffering severe diseases, and dying, the need to address social factors that place minority populations at greater risk of poor health and health outcomes is greater than ever.

As a pioneer in helping to define and clarify what it means to look at health through the broad lens of population health, David B Nash, MD, MBA, founding dean emeritus, and professor of health policy, Jefferson College of Population Health, Philadelphia, PA, sees the current pandemic and social unrest as starkly shining a very unflattering light on the United States health care system.

“If you are poor, you have poor health,” he said. If you are a minority, particularly Black and Latino, you are disproportionately suffering. “If I were a managed care leader right now, I’d be all over looking at minority health,” said Dr Nash.

If left unaddressed, the pandemic shows the potential ramifications. Hospital systems are stressed beyond their capacities to provide care. Social systems fray under economic and psychological distress, and economies struggle to maintain revenue to sustain basic needs for their populations.

Beyond the pandemic, improving conditions for disadvantaged populations to achieve health remains critical to address what managed care knows well—reducing the extraordinary and unsustainable high cost of care in the US mandates a change toward improving quality of care while reducing unnecessary services. Improving quality of care at lower cost, particularly of high-risk patients with chronic conditions, is already a strong focus of health care systems as they try to bring down the high costs of this population.

But more is needed. Estimating that the US health care system wastes about $1 trillion each year, Dr Nash questioned what would happen if that money were used to support health and prevent illness instead of waiting until disease develops.

“Imagine if we could reallocate those resources to tackle the social determinants and focus on health, go upstream and shut off the faucet instead of constantly mopping up the floor,” he said during a session on the role of population health and social determinants of health in the pandemic recovery held on June 24 during the Virtual Summit on Health System Recovery from COVID-19.

Going upstream means to look at those social factors—poverty, geography, food scarcity, housing scarcity or homelessness, education, and others determinants—that keep people from maintaining health and preventing high-cost chronic conditions developing in the first place. Mopping up the floor refers to the current health care system that largely focuses on health only after it is gone and cleaning up after a spill that perhaps could be avoided in the first place if the fundamentals of health were better addressed.

During the webinar, Dr Nash hosted a panel that discussed ways social determinants of health are taking on greater urgency during the COVID-19 outbreak and how efforts during to better integrate them in the health care system may show a way forward to transforming an unsustainable system to one that truly serves the health of all.

What Did COVID-19 Teach a Large Healthcare Provider to Medicaid and Uninsured Patients?

Dave A Chokshi, MD, clinical associate professor, NYU School of Medicine, who was the chief population health officer at New York City Health + Hospitals  (NYC H+H) when COVID-19 hit in early March, noted with some irony what he and his colleagues were seeing among Medicaid and uninsured patients coming to the NYC H+H system with COVID-19.

“As we were all putting on masks, so much was being unmasked in terms of inequities, particularly for low income people and communities of color,” Dr Chokshi said. “Much of this has to do with social determinants of health in terms of poverty and how that intersects with racial discrimination and issues of physical and behavioral health.”

In response, the hospital adopted a two-prong approach. It first directly responded to COVID-19 by tracking patients coming into NYC H+H to ensure the hospital system was adequately prepared and sufficiently flexible to treat and save as many lives as possible. Simultaneously, Dr Chokshi and his colleagues collected data to assess why some communities were being hit harder by COVID-19 and how the hospital system could calibrate an appropriate response that addressed not only medical care but the social and behavioral needs of these communities.

“That was really critical information to have in terms of implementing virtual services for some of our patients with chronic diseases, such as hypertension and diabetes, to make sure they did not go without care and show up weeks later with more severe cases of COVID-19,” he said. An important component of this was recognizing the economic dislocation caused by the pandemic and the social needs of many of these patients who were grappling with hunger, being evicted from their homes, or homeless.

On July 16, Dr Chokshi and his colleagues published an article in Health Affairs that details the ways they built on an already strong foundation of social support of their patients to meet the intensified social needs brought on by the pandemic.

Their article highlights four key social needs: food insecurity, housing, legal resources, and income support. NYC H+H incorporated these needs into its assessment and interventions for its COVID-19 patients, and shares lessons for other health care systems in addressing COVID-19 as well as how to integrated social needs into a health care delivery system.

Data and Technology: Integrating Systems and Sharing Information

Data and technological services, such as analytics and predictive risk-assessment tools, are critical to integrating including social needs into medical care. Heather Staples Lavoie, MBA, president and chief executive officer, Geneia, a health care analytics and services company, described tools to help health plans and provider groups improve the health and health outcomes of their patient populations.

“We have had an eye on social determinants for many years understanding that the data we get from medical care is insufficient to understanding how to care for a population broadly,” said Ms Lavoie.

During the recent outbreak, Geneia used its data analytics and predictive tools to predict which patients and populations of patients are at risk of disease onset, risk of COVID-19 complications, and the impact of COVID-19 based on chronic diseases a person may have. The data uses to generate this information is based on creating a unified patient record based on one’s social needs and medical information (from claims data, clinical data, biometric data, health risk assessment data).

“We provide that information through a population analytics tool in care coordination work flow out to health plans, provider organizations, and hospitals so they can take a comprehensive view of the person and take action,” she said. “They also can see the information from the population level and use that to take action of for a patient in terms of forecasting and intervention.”

In a June 30 blog, Ms Lavoie describes how Geneia enhanced identification and stratification framework integrates social determinants and analytics to help health plans identify members most likely to experience severe impacts from COVID-19. Ms Lavoie’s and Geneia’s goal is to identify patients at risk using the following parameters:

• Filter population by high, medium and low risk of COVID-19 severe impacts
• Focus on chronic and catastrophic risk tiers
• Add clinical markers, e.g. tobacco use or diabetes with complications, to further stratify population
• Add age band of 55+ years old
• Prioritize members with an overall risk score of greater than 5.0

Using this data, “Geneia’s enhanced ID and strat framework yields a sub-population that is ‘progressed forward’ to a care manager for outreach, care planning and coordination. The care manager can see them in their queue, with full detail on aging of the referral, the status, whether it has been started, in progress or complete,” according to the Geneia blog.

Aligning Incentives to Focus on Health: Value of Value-Based Reimbursement

Dr Nash minces no words. “I don’t think any intelligent person would agree that the system that brought us to the edge of the abyss [COVID-19] is the same system we need to get us into the future.”

A significant part of the old system that needs to change is the traditional fee-for-service reimbursement model, a model long been recognized as a barrier to integrating social factors into clinical care. Dr Nash emphasized the need to align economic incentives to address social determinants. Instead of paying providers for services rendered, paying them based on outcomes achieved creates the incentive to promote health.

Health plans and hospital systems that have adopted value-based reimbursement, he said, have fared better during COVID-19 because they don’t have to worry as much about what the downstream economic implications may be. “Also, any system that is designed to improve health was able to protect its patients better than systems designed to deliver care,” Dr Nash said. “In other words, a healthier population could withstand the virus better.”

For a recent discussion and point of view on the promise of value-based care in a pandemic, The Morning Consult published an interesting blog piece.  

Citing an example, Dr Nash pointed to a program Humana offers Medicare Advantage beneficiaries in which providers receive incentives for screening people for potential social needs, such as food insecurity.

When asked about the program, Andrew Renda, MD, associate vice president, Population Health, Humana, said it was built after extensive surveying of members on social determinants of health that included data from over 100,000 Medicare members. The survey showed that 41% of members were under financial strain, 26% had food insecurity, and 29% experienced loneliness or social isolation. “I think there is an erroneous assumption that these social needs don’t exist in great numbers in a Medicare Advantage population,” he said, “but these results indicate that they do and that they often occur in combination.” For more information on the program, see Humana's website.

To date, Humana has focused their attentions on two social needs, food insecurity and loneliness, using value-based purchasing as a tool to incentivize providers to screen, document, and refer patients to resources based on the identified need.

The value of this approach, Dr Renda suggested, was validated when COVID-19 emerged. “When COVID-19 first happened, we immediately responded around ensuring continuity of care for our members and to make sure medications were on hand, but we found that many of our members were asking for help with basic needs, like food and social connection.”

In response, Humana developed a basic needs program to provide members, particularly those with complex clinical needs, with essential needs like food. A challenge going forward, said Dr. Renda, will be to find sustainable ways to fund addressing social needs. He cited several possibilities, including leveraging newer Medicare Advantage supplemental benefit opportunities such as value-based insurance design and special supplemental benefit for the chronically ill, incentivizing clinicians, and through direct-to-consumer quality improvement projects that address root causes of poor health outcomes.