Revolutionizing Health Care Delivery, Addressing Social Determinants

^{By Edan Stanley}

Caraline Coats, vice president of population health strategy, and Andrew Renda, MD, associate vice president of population health, both from Humana, discuss 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.

Please introduce yourself and explain a bit about your background.

Caraline Coats: 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.

I really love the role and work that I'm in right now given my provider background. There's such a great opportunity in the evolution of our healthcare system to marry our value-based provider delivery system to overall population health.

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 three 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: You're correct. 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.

I mention San Antonio in that we've had the most success in that market. I don't think it's a coincidence that it was our first market. 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.

Starting in San Antonio and growing to six other markets, we were really focused on 7 for a while, and now, we're up to 13 markets.

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. Andrew?

Dr Renda:  Yeah, 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.

I feel like we've got sort of the jump on a lot of folks, because we've been thinking about it for a long time. Now we're actually putting our money and our efforts where our mouth is.

Ms Coats:  Andrew, I have just one specific achievement that you reminded me of, buried in with all of what you just said, is you and 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 the 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 healthcare needs.

What you're both getting into leads perfectly into my next question, which is focused on social determinants of health, because they're quickly becoming the focus of conversation when discussing innovations in health care. 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 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 co-pay 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. Andrew?

Dr Renda: I think you gave great examples. 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. Caraline outlined two or three examples of that. That's one way we do things.

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 co-pays 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[The 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: I think, Andrew, 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.

What is the significance of community partnerships? How do they improve care, improve outcomes or lower costs?

Ms Coats: This is an easy one for me. Community partnerships are fundamental to everything we just talked about. We have this, if you will, a Maslow's hierarchy, this pyramid with what's fundamental on the bottom.

Before you can get to integrating and influencing policy, research, changing quality of life and reducing costs and all that, you have got to start with those community partnerships, especially around social determinants of health.

There are providers, I call them out there, they're not doctors, nurses and hospitals, but they are the community partnerships. They are the community-based organizations who are in our respective communities with resources to help our non-clinical healthcare.

Regardless of what statistic you want to reference, our social health is, what, anywhere from 60% to 80% of our health. It's a lot. It's not being treated consistently by the clinical provider community, nor should it.

Community partnerships are significant in a sense, that I believe, they're fundamental to driving population health. They improve patient care, outcomes, and costs, and all of that by being the provider resource group for our social health needs.

Dr Renda: I think Caraline just mic-dropped it on that one. The only thing that I would add is that health is local. That's not just a cliché, but it's absolutely true. I view community organizations and partnerships with them as critical, really on the front-end and the back-end, as I like to describe it.

On the front-end, if we want to impact the health of a community, of our members and people who live in the community, we first need to go into that community and talk to all the key stakeholders -- for-profits, non-profits, faith-based, business leaders. All that kind of stuff, and find out what are the key health issues in that community that need to be addressed for chronic conditions, social needs, etc?

We've got lots and lots of data at Humana. It's fantastic, but there's no substitute for getting that local insight on what's driving health or preventing health in the community. We've got to do that on the front-end.

On the back-end, once we figure out what those issues are, we absolutely have to partner with those local organizations on solutions and to impact the health.

Community organizations can be everything from the local government, to food banks, to other transportation organizations, things like that. They're absolutely critical if we're going to have an impact on the things that we want to impact.

Thank you, so what are some of the biggest challenges that you've faced in the last five years in Population Health Management?

Ms Coats: I hear you say the last five years of Population Health Management, and one of my first reactions is that I don't think five years ago people were even using the words "Population Health Management," or at least not in the work that we were doing.

I think social determinants of health and population health is not new, it's just that the healthcare industry is now paying attention to it. We need to think and work differently because our healthcare costs are rising, and our population is getting older, and more chronic conditions and all of that.

A challenge that stands out is almost education around what it is, and also as an industry, defining what population health is—What does it mean—so it resonates and is relevant to the work of providers, payers, and community. It's not just about community activation, and it's not just a business strategy. It's all of that. We as an industry, particularly in the United States, have been trained and geared via payment methodologies, and CMS, and everything, to be so laser-focused on the clinical part of our health.

A challenge is increasing awareness that population health is all-encompassing of our clinical and our social health, and how important that is on long-term clinical quality, outcomes, and benefits. Really recognizing the importance of that, so there is a consistent investment toward addressing it across health constituents. Not just healthcare—grocery stores, and banks, and the education system. Understanding again what it really means so we can align our efforts to make a difference. A big answer to a big question, but it stands out to me that when I hear five years in population health, again, we were just launching the Bold Goal then.

We weren't even saying social determinants of health. It's nascent in our industry and we shouldn't underestimate the education we collectively have to do around what it means to our healthcare system.

Dr Renda: Caraline is exactly right. To amplify that, we've made tremendous progress because 5 years ago people weren't talking about it. They didn't know the term. Now they know the term. The question is, what do we do about it? What kind of impacts on clinical health? What kind of impacts on financial models do social determinants actually have?

One of the biggest challenges we face now is that the further upstream you go in trying to impact somebody's health, sometimes the further out it is until you see that financial impact. When you think about ROI and things like this, you're going to address a root cause. You may not be able to stay in that traditional 12-month ROI model. You have to look two, three, four, five, and more years out to see that impact.

That's a big challenge from trying to almost legitimize addressing social determinants of health. We all believe it's really important, but figuring out that clinical model, the operational model, and the financial model is a big challenge that we have to do.

I worry that if we don't figure that out, that social determinants will continue to be relegated to philanthropy, grant funding, and things like that. We really need to elevate social determinants to be treated as clinical gaps in care.

We need to figure out those operational models and the financial models so that we can sustain the way that we address it. Sustain and scale, frankly, so that we can help more people.

Beyond social determinants of health, what are other current trends in population health management that healthcare professionals should pay close attention to?

Ms Coats: That's a good question. From a healthcare professional perspective, I'd probably go back to how I started this conversation.

We're in a place in population health where we're ready now more than ever, maybe not completely ready, but ready more than ever, to marry healthcare professionals, particularly in the world of value-based payment to population health more.

When I think of a trend perspective, something has got to change around reimbursement. Something has got to change around how we risk adjust and getting beyond a clinical focus.

I would expect, from a trend perspective, that our industry, with all this data that we're all collecting, that we will be moving toward a more holistic social and clinical risk adjustment around members, communities, and populations that in parallel would play a role in reimbursement.

There are a lot of Z-codes out there, for example, right now that are tagged with certain social determinants of health, but they're not reimbursed.

I would anticipate that as we evolve and develop some new payment methodologies to start incorporating the data we have on our individuals and our community's social health, that will result in some payment methodology changes for healthcare professionals. Not just about payment, but that should create a delivery system that allows for additional resources or additional time.

That social worker in the office or that other process to address social health. You read a lot right now that some physicians don't think it's their responsibility to address social determinants of health. I don't know that I disagree. Until we can provide the data to diagnose and the resources to treat, it's very challenging.

From a healthcare professional perspective, my optimism is that the trend around this will lean towards more data to diagnose and more resources to treat at a scalable level. Andrew, you are a healthcare professional so I'll turn it to you.

Dr Renda: I think all those specific trends that you mentioned are absolutely spot on. From a macro perspective, I've been thinking a lot lately about how the World Health Organization defines population health. They talk about three different aspects. They talk about health being the complete physical, mental, and social wellbeing of an individual, not just the absence of disease.

If we're really going to impact population health, we have to think about all three of those things. We have to solve for chronic conditions, either prevent people from developing them, or stabilize them once they get them, so they don't progress. The second arm, that mental health aspect, I feel like we underserve behavioral health conditions.

That's a trend that is starting to ramp up a little bit, but we have a lot to do there. Behavioral health conditions are far more prevalent than a lot of people like to talk about. Anxiety, depression, etc, as well as, the more serious personality disorders and psychotic disorders, and things like that.

Addressing behavioral health has got to be part and parcel of how we impact population health. That's something that is emerging but needs more dedicated resources and focus. The third is social, and that's really what we've talked about a lot over the last half-hour are those social determinants of health.

If you think of those three different aspects of population health, we need to invest in all three. It's all those trends that Caraline alluded to. We need to continue to become more sophisticated with our advanced analytics, being able to predict problems before they happen, or flag gaps as soon as they do happen so that we can address them. We need analytics and data to actually understand the impact of the things that we do. That's really important.

Payment mechanisms are absolutely critical. The dirty word nobody wants to talk about, money, but money makes the world go round. We have to understand, how do we pay physicians to address population health? How do we pay them differently?

As well as hospitals, and insurance companies, and pharma companies, and all the different healthcare stakeholders in this ecosystem, we have to understand payment mechanisms. We can't just pay fee-for-service anymore. We have got to pay for outcomes and figure out how to get there where it's equitable to everyone, but we're all aligned around the outcome.

We have to continue to innovate specifically around solutions that work. Figure out tests and learn quickly, figure out what works, and scale it. That often requires partnering within industry and outside of your own industry. That's my perspective on that.

Andrew and Caraline, thank you so much. 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 healthcare is delivered and that will certainly not end in 2020. That's it for me. I appreciate the opportunity. Andrew?

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 understand how they fit within the broader healthcare ecosystem.

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