Podcast Episode Transcript: The role of health plans in addressing social determinants of health

With L. Gordon Moore, MD

Gordon Moore: Hello, this is Gordon Moore, your host of the 3M Inside Angle podcast. With me today is Michelle Jester. She is the Executive Director of Social Determinants of Health at America’s Health Insurance Plans. Welcome, Michelle Jester.

Michelle Jester: Thank you for having me. I’m excited to be here.

Gordon: Thanks for coming. First, give me just a quick thumbnail of, what is AHIP?

Michelle: Sure. AHIP stands for America’s Health Insurance Plans, as you mentioned before, and we are the national association that represents health insurance providers. We represent those who provide coverage and health-related services that are really intended to improve and protect the health, and also financial security, of consumers, of families, of businesses, and communities.

Our members represent over 200 million people across the United States. We represent those that could be Medicaid managed care organizations. It could be Medicare Advantage plans. It could be those that participate in the exchanges. It could be small group, large group. We really provide the gambit across the health insurance providers.

Gordon: I want to talk to you about Project Link, but I want to set this up with, when I think about health insurance and I think about public health, I think about them as very different spheres. I look at your title, Executive Director of Social Determinants of Health, and I think well, how did that happen at AHIP? Why and what are you doing?

Michelle: Sure. Health insurance providers have been committed to social determinants for a very long time, as you are very well aware. There’s just growing understanding and acknowledgement that so much of health is determined outside of the healthcare system. There’s this eagerness and this intention to want to focus on those more upstream factors. Things such as where you live, where you grow up, where you work, where you play, where you age.

AHIP, knowing that a lot of health insurance providers are focusing on social determinants, AHIP also wanted to provide leadership in those social determinants of health space, they launched Project Link last year as a forum for health insurance providers to come together to share best practices, to discuss innovations in the social determinants of health space, to talk about challenges and use the collective brain power of the group to troubleshoot those challenges.

Are there partnerships that we should be engaging in? Both at the local level that then could also be modeled at the national level. And then are there some national partnerships that we might have in place that could help inform local partnerships on the ground? Also just to use this as a space to talk about potential policy solutions to social determinants of health challenges.

Something they worked on last year before I arrived was the Medical Loss Ratio and being able to include more social determinant interventions and programs as medical costs in the Medical Loss Ratio. That could really help facilitate health insurance providers to be able to do this work. This year, they created a social determinants of health position, so specifically an Executive Director of Social Determinants of Health, to focus exclusively on social determinants.

They previously had a Prevention and Population Health position, but from the Board’s commitment to social determinants of health, they have narrowed the focus of this position to social determinants, just given the importance of this issue right now.

Gordon: Not everybody who’s listening might know what MLR is. Give me a little unpacking of that, please.

Michelle: Sure. Health insurance providers are required to meet a certain percentage of their costs such that a majority of their costs can’t be used for administrative costs, for instance. The rate that they’re supposed to meet is around 15 percent administrative costs and then 85 percent medical costs. Administrative costs could be things such as marketing things they might use for claims processing, things that they might set up like hotlines that aren’t specifically health related.

But then medical costs are all of their costs that they incur to provide services or programs or things of that nature. Before, social determinants of health, it was unclear whether those could be qualified as quality improvement activities. Quality improvement activities could be included in these medical costs. To be consider a quality improvement activity, there’s a lot of tracking.

There’s a lot of evidence you need to provide to be considered a quality improvement activity. AHIP did a lot of work with the Project Link group last year to help track and determine the social determinants activities to include in the Medical Loss Ratio as medical costs.

Gordon: It’s always fascinating to me when I think about what gets in the way sometimes of what seems so obvious and doing the right things sometimes is just that policies need to catch up. Thinking telemedicine, which is a whole other conversation for another day. But the idea that we can do things to improve good food access, and therefore people are going to be more healthy. Be able to heal better from burns.

All sorts of things. It makes total sense to me. Then to be prevented by policy would be frustrating, so I’m glad to hear you’re working on that. But I want to go back to Project Link. Give me some idea of what that is and what your members are working on.

Michelle: Sure. Project Link, again, is essentially a learning collaborative where we can bring the health insurance providers together to again share best practices. Plans are very eager to learn from each other. They’re eager to think about, how did this plan do it in their setting and how can I take some key takeaways and be able to replicate it in my own setting given my own population in my own region of service.

There’s also a forum to be able to discuss challenges that we’re all facing and to be able to share potential solutions that if someone had tried a certain program or intervention before, here are their lessons learned from this and to be able to share that with the group. When it launched last year, we had been able to cover topics such as housing, food insecurity. The MLR policy solution was a big focus last year.

We recently just talked about employment and programs around job training and job connections. We’ve discussed social isolation especially given the social distancing that we’re all experiencing during the pandemic. So we’ve discussed solutions to social isolation as well. Those are some of the key topic areas that we have discussed so far.

Gordon: When you talk about the plans getting together and working in this sort of collaborative environment, can you give me an example of something that either you or several plans have worked on.

Michelle: One example is the employment that we recently had some meetings around. We had one plan in particular that’s based on Ohio, they decided to focus on jobs and employment first out of all the social determinants that they would plan to focus on. Because they felt that jobs were a little bit further upstream. Yes, you could focus on food insecurity, but if someone still doesn’t have access to a good job, the food insecurity still might be a recurring issue.

So they wanted to move a little bit further upstream with that. They created a very innovative program where they have life building skills courses. They have job training opportunities. They’ve built partnerships with over 500 employers to be able to connect their members with jobs. They were able to still do this during the pandemic as many of these businesses were continuing to hire.

There were some other plans that were interested in this model, so this health plan in Ohio who initially started this worked with these other plans to help them implement it in their own setting and think about what are the other key considerations you should consider given your certain population and your certain setting.

It was very warming to see these health plans work together that I think sometimes people think of health plans being very competitive with each other. But I think in the social determinants space in particular, there’s a lot of sense of collaboration and wanting to help each other. I think there’s an acknowledgement that we’re all on this journey together and it’s the right thing to do for our members and the people that we serve. So we want to help each other.

Gordon: I hear they identify employment as an upstream issue. They work on job training and building life skills and they partner with employers. That, to me, sounds like a nice wrap in terms of setting it up and connecting with community resources like the classic things you need to do if you’re going to have interventions working on the social determinants of health.

It’s not good enough just to identify the problem. You need to connect with community resources that have been around probably for a long time, but may need partnership and help in standing up for larger groups of people that they want to address. Give me another example from Project Link that has been worked on. That has that kind of story.

Michelle: I think there’s a lot of examples. This is something, a key question for plans is, what is our role in the social determinants space? Is it that we help provide funding to bolster these community-based resources that, as you mention, have been around for a very long time? Is it that we should be providing services ourselves? Can we be providing the infrastructure to help analyze the data, provide some population health management?

I think that’s one of the key questions, but I do think most plans definitely see the value in partnering with these community-based organizations because they’re the experts. They have the connections with the community already, they have the trust of the community, and they have the knowledge of what to do when these health-related social needs or the associated economic barriers are identified and brought forth. I think some other great examples in this space are partnering with housing institutions.

So local housing providers, in terms of being able to provide either transitional housing or permanent, supportive housing. A partnership could potentially look like a health plan would partner with a housing institution to be able to provide these people who qualify for this transitional or this permanent, supportive housing and the health plan would cover a lot of the additional services that are provided in house, on site, at this housing building or institution.

It could be the case management, it could be some life skills, it could be some peer support. It would be access to healthcare services, access to behavioral health services, and those kinds of things. I think that’s another example of how a health plan would be partnering with a community-based organization as well.

Gordon: When you talk about that, it sounds like you’re actually bringing health services into the housing. Is that through collaboration with local providers? Is the health plan actually standing up BHO? How does that work?

Michelle: I should say this, that in every community and every location, partnerships are going to look different. Because it’s a matter of what works best in which setting. But I think in a lot of cases, they would be partnering with the local provider. So this could be a local federally-qualified health center. This could be a local community health center. It could be in partnership with a local hospital that they’re able to transport people to if they need other types of services. But in a lot of cases, the health plan is paying for these services as well.

Gordon: That makes me think it’s so costly to think about housing someone. If I’m paying for medical visits, that’s one thing, but paying month-on-month for housing, how do you justify that over time as a health plan?

Michelle: I think that’s something a few plans have considered in terms of, is it cheaper to pay for someone’s housing versus paying for someone’s recurring visits to the emergency department. Again, this is where it’s hard to come up with a business case in this sense. But in this sense, it could be argued that the money is more well spent by keeping someone housed rather than paying for someone to go to the emergency department.

I think there’s some justification you can put there, but it’s very hard. It’s hard to build that business case in a lot of areas because you don’t necessarily see the return on investment immediately, and we live in a very immediate world nowadays where people are expecting an impact immediately. You have to think about the long term, you have to think about what makes sense, what is based on the evidence, and then go from there.

Gordon: I look at the average spend on a person in a health plan, let’s say, the PMPM is $300, let’s say, in a somewhat sicker population. But I look at some subsegments of the population who have multiple medical conditions and behavioral health conditions, something like schizophrenia, and individuals like that can have a monthly PMPM that’s greater than $1,500, and then they have emergency room visits and hospitalizations and it just goes on and on.

Some of these individuals can be in and out of the emergency room almost weekly. If you can identify those subsegments of population with extraordinary issues around being homeless and schizophrenic and maybe drug abusing with medical conditions. Housing may be a much cheaper intervention than paying for basically the aftermath.

Michelle: Agreed. I think when it comes to social determinant space, if we really want to try to sustain this, to me we have to look further upstream and look at what are the causes of the causes? So how do we really break the cycle of poor health. We have to look further upstream. We have to invest in our social services. We have to invest in good policy that gives people the option to live healthy lives and be able to make healthy choices. In that respect, I think investing in social services is a more cost effective way to go.

There’s always the talk of trying to lower total cost of care, and while I applaud that as a goal in general, what some research is showing when it comes to social determinants or upstream efforts is that, you might still see an increase in cost, but the costs are in the primary care or in the prevention space rather than in the tertiary care or the visits to the hospitals. I think it’s important for us to reframe the idea about lowering total cost of care to thinking more about, where is the money going and where is it being invested.

Because if it’s investing in primary care or prevention, then maybe it’s not such a bad thing that costs might increase in those areas. Because it’s ultimately keeping people healthier and keeping people from getting sicker and leading to worse outcomes and higher medical bills for people.

Gordon: Part of that makes me think that a large part of the conversation, when you step back, is about how we define certain buckets of budgets. So in Harris County, Texas, for instance, I was talking to a colleague of mine, David Buck, who’s at the University of Houston who has this patient care intervention center that works with homeless people.

I learned a lot from conversations with him where he talks about the budget for police who are arresting people who are floridly schizophrenic, and then bringing them to the hospital and then sitting one-on-one with that person during the hospital stay because they’re kind of scary.

They’re floridly schizophrenic and acting out, which is why somebody called 911 and had them arrested. Then there’s jail time, there’s treatment time, and when he looks at how, across multiple budgets, if he can help that person be homed as opposed to homeless, and figure out what would it take for this person to be comfortable to be homed, he is able to demonstrate improvement, not just in reduced emergency room visits, but reduced arrests, reduced jail days.

And when you step back now as a society and say, we in Harris County are paying taxes for all this kind of stuff. Would we prefer to spend the money upstream and house this person, or spend maybe two or three times as much cleaning up the mess, essentially. Is that the kind of conversation that your members are getting into in the Project Link meetings?

Michelle: It is, and also, something that we’ve talked a lot about or we’re going to dive in more is research and evaluation of social determinants of health. You just mentioned in terms of reduced emergency department visits and arrests and jailtime and whatnot, but we need more research and evaluation into these areas to demonstrate the value.

Something else that you can’t measure, such as the improvement in that person’s quality of life. The joy that person might have by being housed that they may not have had housing for a long time. The feeling of being stable and the impact that would have. Those just aren’t as measurable, but they have a huge impact, these patient stories or these member stories.

That’s something else that we’re trying to think about how to better capture and better utilize to make the business case. But something else that you’re raising that is interesting to this conversation is the focus on the individual. I’m sure you’re familiar with the argument around medicalizing social determinants of health.

Just briefly, it’s essentially when we take something that’s essential a societal problem, but if it has to tangentially do with health, we think it requires healthcare solutions. That’s what’s happening right now in terms of the healthcare system getting so involved in social determinants of health. It’s great and it’s wonderful and it’s needed, but unfortunately when we have this kind of approach, it is more on an individual basis.

We have identified this individual’s socioeconomic needs. We need to help them address this. Rather than thinking about it from a societal lens as to, what is causing this person to have these socioeconomic needs. What is really going on and what can we do at a larger community or societal, political policy level?

With helping a homeless individual gain housing, it’ so wonderful that there are lots of healthcare organizations and social service organizations that are doing this work. Again, it’s needed because it’s not happening in a lot of cases. But what’s the root of the problem? The lack of affordable housing writ large. We can’t let these efforts detract us from looking at the bigger picture and what’s the causes of the causes?

Gordon: I totally did the usual doctor thing. I totally went to the person. You’re so right. And I was even making the case about this. In the public health arena, it’s how we think about society and we fund different parts, and I went right to the personal anecdote. That’s very wise. That’s exactly where I was thinking the conversation needs to go.

When you think about that, then, I’ve heard two sides of this argument. Oh, gee, the public health, underfunded part of our society says, now you guys get it. Terrific. Thanks. Well, come inside the tent. We can help. So I think jeepers, they really know this stuff well and we’re newbies. Here I am coming in as a clinician. But then they say, boy, do you guys have financial resources that we rarely get our hands on, so do come in. We are welcomed. Have you sensed either pushback in welcoming by the health community and the CBOs?

Michelle: I think it’s both. I think community-based organizations in the public health world are very interested and eager to partner with well-funded entities. I think there’s acknowledgement that it’s going to take a village. We are all a part of a large ecosystem, so we all need to be good partners in this larger ecosystem. Again, we all think and know this is the right thing to do.

I think it goes to, well, what are the right roles and responsibilities of each partner involved. Another challenge that has emerged is, as all of these groups are coming together and forming partnerships—that’s wonderful, it’s needed, it’s what needs to happen—but unfortunately, what’s happening is that a lot of these partnerships are happening in silos.

So you might have a community-based organization that is partnering with multiple entities, but each of these entities has their own data infrastructure or referral tracking infrastructure, and these poor CBOs have to learn and abide and do contracts for all of these different data infrastructure and sharing and referral tracking systems that it’s really becoming untenable and unsustainable.

I think somewhere that we all need to think about, in moving forward with working together on social determinants, is how can we align our efforts. How can we have common community health improvement goals that are stakeholder driven, that we can all rally behind, and then from there we can come up with a common infrastructure so that we don’t have to use so many different types of infrastructure. And that again, we’re all working together towards this common goal.

Gordon: Have you seen that? Is anybody at that level of their testing?

Michelle: The North Carolina Medicaid model, so it’s called North Carolina Healthy Opportunities, that’s the first at a state level, because what the North Carolina Medicaid Office did is that they all worked together with relevant stakeholders including the community-based organizations, the providers, the health systems, the payors, to one, develop a common statewide social determinants of health assessment tool.

Two, partner with one vendor to develop a statewide data infrastructure referral tracking system between the health and the social service side. They came up with a statewide contract in terms of costs for various fees and services and they have common goals that they’re all supposed to meet. That’s something I’ve seen at a state level.

I do believe it’s happening in various counties, as well, but then you also have a potential where you have entities that service multiple counties, so they still might be involved in multiple initiatives. But the North Carolina model is definitely one of the few statewide models on this.

Gordon: Nice. Have they been around long enough, or have any of the plans’ programs that you’re working with demonstrated early outcomes that are looking good?

Michelle: North Carolina, ideally they were supposed to launch this year, but the past couple years, they have been doing the stakeholder engagement, the building of the infrastructure, developing the fee for service pricing model and whatnot. That was all the leadup to launch.

Gordon: So it’s really early days. We won’t know yet if it’s working out in terms of improving outcomes. What kind of outcomes are your members thinking about tracking with this?

Michelle: It depends on what social determinant they are focusing on. Some examples could be, if you’re focusing on a transportation initiative that some of your measures of impact or your outcome could be a reduction in missed appointments, it could be an increase in prescription medication fulfillment. If you’re thinking about doing something along housing, it could be a reduction in emergency department visits or hospitalization. It could be a reduction in total cost of care. If it’s food, you could potentially track a change in behavior in terms of eating behavior or diet.

Something that’s interesting is, if we’re trying to think of more intermediate evaluation measures, there are some plans that are focusing on a metric of healthy days, if you’re familiar with those. That’s something that can be tracked more immediately in terms of how someone assesses their own health and how many healthy days they have over a period of time. Which could then be correlated with improvement and outcomes overall. But those are some of the evaluation measures that plans have been using.

Gordon: I’m presuming the healthy days is a validated instrument that somebody checks off and that gets aggregated over time?

Michelle: Yes.

Gordon: That’s cool. I like that. That sounds good. So if a plan calls you up and they’re exploring membership in AHIP, let’s say, and who knows, they’re probably all there, but I’m just imagining. And they say, we’re thinking about joining, but we really want to work on social determinants. I really want to know that you guys have insight and you have a plan and you can tell me, like, give me a skinny. What’s a little pitch and we’re going to be able to take action and see results. What would you recommend we do?

Michelle: We have lots of examples of what plans have done in various social determinant spaces. We have great issue kits and case studies and tool kits on what plans have done around housing in different areas and we catalog a lot of different plans’ efforts in that area. Same with food insecurity. Same with social isolation and support.

We’ve recently catalogued what plans have been doing during the pandemic in terms of addressing socioeconomic needs to help encourage that idea generation and that innovative planning that when resources are constrained or things are different, we just have to think differently. I would say that we have a lot of resources to be able to help them on this journey and that being able to connect with their peers, to have that extra brain power and extra collaboration, would be able to help them along the way.

That we’re here, and we’re all on this journey together so we all want to learn both from what’s working and also what’s not working. I think we don’t talk enough about what doesn’t work, because that’s really valuable learning as well as we move forward.

Gordon: That sounds like a terrific next question. Tell me what are the top one or two, or just good examples of flamingly bad ideas.

Michelle: I have to think about that, because it’s not talked about that much. You don’t read peer review literature about failures. Those are the things that don’t get published. I think it’s more of conversations of what goes well and what doesn’t go well. I do know some challenges that members face in doing work on social determinants is knowing that if you are investing in this work, that ultimately would reduce utilization and improve outcomes, ultimately your premium may slide such that in the long run, plans would be negatively affected by this.

We’re trying to think creatively about what can be done about that to ensure that premiums—there’s some acknowledgement about the community investment that plans are making that are leading to a reduction in utilization and in costs. To consider that for premiums, or is there a way to still incentivize plans to do this even if there is some premium slide such that maybe establishing some health equity goals or reducing disparities goals that maybe the plans would get a bonus if they meet those goals such that they wouldn’t be negatively impacted by this.

The turn issue is always a problem such that if a plan is investing in this population and then someone rolls off of their plan and then rolls onto another plan, all the money they invested, they might not be able to reap the benefits if the person turns off of their plan. Again, that’s the importance of having these more community or statewide alignment and goals, such that if we’re all working towards the same goal and if our population is broadened, that it’s not just about my members or your members, it’s about our community. Those are some of the things that we’ve been talking about on ways that can help facilitate and incentivize plans to continue to make these big investments to improve community health.

Gordon: That makes total sense. I think about it and some of the face plant disasters would be the inverse of what you’re talking about. So it would be like working locally without learning from other plans. Jumping into stuff where you haven’t connected with local agencies. Doing things that have high costs where you’re uncertain of the outcomes. Not testing and measuring the impact of what you’re doing. All the usual stuff.

And sometimes measuring too much. I remember early in my quality improvement days, I was measuring employee satisfaction in an outpatient department. We did it weekly, but we weren’t actually making changes that quickly. After a few weeks of asking without doing anything different, the employees revolted and said, if you keep asking me, you’re going to make me very angry unless you start doing stuff. So I could think of this setting along the line of, if we’re measuring happy days and we’re not bringing anything to bear to make things happy, that would be a mistake, too.

Michelle: Sure. It’s the same with social determinants of health assessments as well. I think it’s really important that when you’re assessing someone’s socioeconomic needs and circumstances, you have to tell them how is this information going to be used. This could be very private and trauma inducing. This could be shame-inducing conversations or questions.

I think to make people feel really comfortable about disclosing information about their lives, you need to be upfront and honest about how this information is going to be used and how you’re really going to use it to improve care and to improve community health. You have to follow up on that. It can’t just be an empty promise.

Gordon: Yes. I guess the last things I would think would be that you’ve described that I hadn’t thought about before our conversation but it makes so much sense is the idea of using coming together at a community level, hopefully as large as possible, to talk about shared goals, shared infrastructure, and shared data.

That sounds really important, because I think about if I’m some little CBO and now I have to respond to different data requests from nine different entities in my county, it’s going to make me want to just curl up and die. That makes so much sense.

Michelle: When these organizations were established, that wasn’t their main goal. Their goal was to help the people. So they are probably operating on limited staff, and that’s the importance of investing in them. I think that’s an area where health plans are happy to participate and help support the community-based organizations.

It’s learning new things. The CBOs may have had their own data infrastructure built over time, and then if they’re being asked to forego their own data infrastructure system for these other ones that are part of these larger initiatives, it’s a lot of things to take into consideration. There just has to be mutual sacrifice towards a common goal that we’re all working for.

Gordon: Well, Michelle Jester, any last words before we wrap?

Michelle: I really appreciate being here. I would encourage if anyone is interested, we would love to work with you and we’re trying to find solutions that will help facilitate and incentivize both health plans and any organization to be able to do this work. We want to be able to sustain it as well, so we’re really trying to look upstream so that we can prevent poor health from occurring in the first place.

Gordon: I’m looking forward to seeing the results of the Project Link work. It sounds fascinating. Michelle Jester from America’s Health Insurance Plans. Thank you very much.

Michelle: Thank you for having me.

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