Revolutionizing Health Care Delivery, Addressing Social Determinants

Caraline Coats, vice president of population health strategy, and Andrew Renda, MD, associate vice president of population health, both from Humana, recently spoke with First Report Managed Care about their company’s Bold Goal initiative, the importance of addressing social determinants of health, and offer their insight regarding the future of population health management. The following is an edited excerpt from that podcast. 

Please introduce yourself and explain a bit about your background.

Caraline Coats: My name is Caraline Coats. I’m the vice president of Humana’s Bold Goal and population health strategy. I’m with Humana about 12 years, been leading our Population Health Strategy for about a year and a half. Prior to that, I led our value-based strategy work. Prior to that I was in years of various roles in provider contracting and networks.

I often say, “As the industry has transitioned from volume to value, so has my career.” I have a master’s in health services administration from University of Michigan on both the plan and payer side.

Andrew Renda: This is Andrew Renda. I’m the associate vice president of population health at Humana. I work for Caraline.

I’ve been at Humana for 11 years in clinical strategy and our insurance product area. For the last 3 years, I’ve been in our Bold Goal population health social determinant team.

I’m a physician by background, and I also have a master’s in public health. I feel like I’ve got that individual patient perspective. I also have a “how do we effect population health” perspective.

Humana introduced the Bold Goal several years ago. Can you highlight some of the initiative’s top achievements so far?

Ms Coats: It was launched several years ago, really around 2014 with our first market in San Antonio, and officially in 2015 as this Bold Goal to improve the health of our communities, 20% by 2020 and now beyond.

An unspoken achievement in that is that we’ve highlighted the need for time. Population health is a long-term journey, and when you allot the time to build the relationships in the community and get deep, you can make a difference.

We’ve continued to take those learnings and really scale and focus on integration. That doesn’t happen with just the Bold Goal team. That happens with every consumer-facing person in Humana.

We’ve scaled quickly in the last few years. I’m looking at something like screening for social determinants of health. We, just a couple years ago, screened about a thousand of our members. Last year, we quickly jumped that over to half a million. We’ve set what we thought was a Bold Goal of screening a million members this year. We’ve already exceeded that, and that is credit to the enterprise.

That is a reflection of really integrating this within the operating model. Focusing on population health is about thinking and working differently. I really credit the work we’ve done in our communities in getting deep with it and creating that community activation as an achievement.

Then credit to the enterprise for really embracing our Bold Goal, which really started as our mission and has now evolved into this Population Health Strategy. Embracing the work around this is part of how we all think and work differently.

I highlight that as a top achievement because that enterprise wide approach, it will now allow us to get further into some specific...or influencing policy and further integration into how we change the delivery system beyond clinical.

Dr Renda: I echo everything Caraline said. When I think about our top achievements, I really almost go back to the beginning. One of the biggest things that we’ve accomplished is defining terms and codifying Population Health Strategy.

What I mean by that is we announced back in 2015 that we had this Bold Goal to improve health in communities by 20%. The first thing that we had to achieve is to figure out what is 20% improvement in health, what does that mean? What does that look like?

We evaluated a bunch of different metrics, and we ended up settling on CDC’s [the Centers for Disease Control and Prevention] Healthy Days tool. That asked simple questions, “How many days, in the last 30, have you been physically unhealthy or mentally unhealthy?” It’s a self-report measure by design. We really liked it.

By selecting that as a way of defining and measuring the improvements in health or population health, I think that was the first achievement that we did. Further to that, we did a lot of research, consumer research, and formal research into figuring out, “How do we impact health and population health and quality of life?

When we did deep dives that involved partnerships with organizations like Robert Wood Johnson Foundation, looking at external datasets, CDC, and so forth, we figured out that the way to actually improve health in a population—yes, it involves helping people with chronic conditions—but it also really, really importantly involves going upstream and addressing social determinants of health.

We had to plant a flag and establish the fact that if we’re going to improve health in populations, we need to not just look at when people develop chronic conditions but go upstream and understand the root causes of why they’re developing these chronic conditions. That was an achievement, our second achievement.

The third one was to say, “OK, if we all can stipulate that social determinants are important—the question is, there’s lots of them, where do we start?” We worked on narrowing our focus to things that we thought would have the biggest short- to mid-term impact on quality of life.

We settled on things like food insecurity and loneliness. Now we’re looking at things like transportation and housing but narrowing down to some things we’re going to do. That was achievement number three.

After that, it was developing research, analytic, and intervention pipelines to test and learn and figure out, how do we impact those things? Those are what I look at as our top achievements. There’s still a lot that we don’t know. We’ve made such progress in 3 or 4 years that now everyone’s talking about social determinants and population health.

Ms Coats:  I have just one specific achievement that Andrew reminded me of, Andrew and the team have developed predictive models around a couple of particular social determinants of health—food insecurity and loneliness.

That doesn’t happen overnight. That comes with a commitment to data analytics, and it comes with increasing the screening so we can get that data. It’s an achievement that reflects our commitment to going upstream to predict the needs of our members and using as much data as we have to more proactively meet their overall health care needs.

What unique efforts has Humana made to address the social determinants when improving health care?

Ms Coats: Andrew mentioned how the Robert Wood Johnson Foundation data guided us to really focus on social isolation, loneliness, and food insecurity given the level of how they impact healthy days.

Specific to those, we’ve done some unique work around food insecurity, including testing some meal delivery benefit models, but also in some instances include a friendly visitor. I love that, because it touches on the food and a component of loneliness, if you will.

I love that, also because it’s hard to address social determinants of health individually. They’re very multifactorial. It’s rare that you’re going to find someone with just one. Any time we can have a unique solution or intervention that addresses multiple of these, it’s really impactful.

Specific to loneliness, I love the work we’ve done with an UCLA outfit via a pilot called Papa. That’s where they contract college age individuals to essentially do social visits to members. We specifically chose members via the predictive model that we use to show who’s likely to be not only lonely but extremely lonely.

We really targeted this resource on what our data showed us to be the most vulnerable population. The qualitative feedback on that was and continues to be fascinating. We measured their healthy days before and after, and we measured via the UCLA Loneliness Survey before and after. It had some pretty impactful results around that.

It’s that kind of stuff, that if we continue to do and expand and show the results on, that can go a long way, eventually, to influencing coverage around benefits. We’ve had a lot of leniency open around all of that but it is kind of like, where do you focus the efforts?

I often use the example of my mom who has Alzheimer’s. I’d rather pay a $25 copay to have someone go play the piano with her, than for her to go see a neurologist. It’s using these unique efforts in targeting specific social determinants of health that one, it’s the right thing to do. Two, as we get those results, it can be very powerful proof points as we look to further influence policy and ultimately improve health outcomes and quality of life. 

Dr Renda: If I could take a second and take a bigger picture view on how we approach innovation with social determinants, I think of three different ways that we go about doing this. The first being organic pilots that we create from scratch and go direct to consumer or to patient. 

The second way we do things is by integrating social determinants into current clinical operating models. Where we already do telephonic or in-home disease management programs for conditions like diabetes, we believe that social determinants should be treated as clinical gaps in care.

When you’re asking somebody are they taking their medicine, are they seeing their doctor? You’re also asking things like, “Do you have food in your refrigerator? Do you have transportation to get to the doctor?” Those types of questions.

I feel like the second avenue that we approach innovation is through integration into clinical programs that we already have operating. We’ve done that with disease management programs that we have in house.

The third way that I would look at is that we as an insurance company have unique opportunities to influence patients’ health through insurance product design. Everyone has an insurance product that they purchase.

It’s about copays and things like that but there are also supplemental benefits, additional things. They could be things like an over-the-counter benefit, a dental benefit, things like that. CMS [Centers for Medicare & Medicaid Services], through their innovation center, is now allowing for experimentation or addressing social determinants within benefit design.

Without getting into too much of the technical details, we are now able to design some products that deliver meals to a patient, or address a transportation gap, or things like that. I look at three different avenues where we have opportunities to do innovation. One is the pilots. Two is integration into clinical programs. Three, is to do it through the insurance product design. We have lots of opportunities. We have to go and test, learn, and figure out what is successful and impactful, and make sure that we measure everything. Those things that are successful, we want to scale to as many people as possible.

Ms Coats: What you’re hitting on also in testing and learning is that, especially around social determinants of health, they’re not one size fits all. There’s not one solution.

An important part of our work going forward is to measure, just like Andrew said, and understand those results and draw some insights from them in what holistically will create the best solutions for addressing social determinants of health across various markets.

Is there anything that I haven’t asked you about or anything that you’d like to add?

Ms Coats: Our Bold Goal, being labeled as 20% by 2020 and now beyond, is definitely beyond. How we define it going forward will be really interesting to know that. I think I mentioned at one point, the Bold Goal of our mission has really evolved into our population health strategies. It’s not ending. Our CEO launched this goal as bold as it was, back in 2015.

I realize now more than ever that this Bold Goal was only the beginning. It’s really just the initial part of it. I’m really proud to work for Humana and see how it has integrated throughout the enterprise, and how people are grabbing onto it and really trying to figure out a way to make it work differently so we can ultimately change the way health care is delivered and that will certainly not end in 2020. That’s it for me. I appreciate the opportunity. 

Dr Renda:  I just want to say thank you also, for the opportunity. I feel these conversations are absolutely critical. It’s important for us, certainly, to highlight the things that we’re doing and the progress that we’ve made but also to be transparent that we don’t have all the answers. There are a lot of things left to figure out.

Having conversations like these elevate to a broader audience and allow us to solve these problems together. Thank you for that. Just a challenge to ourselves and to anyone who’s listening to this, that we need to think about the return on health, the return on investment for addressing social determinants. We need to understandhow they fit within the broader health care ecosystem.

Big challenges to tackle, but they’re absolutely critical to population health. Thank you.