4

The Health Care Response

Sanne Magnan from the HealthPartners Institute welcomed and introduced the panel on the health care response to the pandemic and the movement for racial justice. She asked panelists Philip Alberti from the Association of American Medical Colleges (AAMC), Dawn Alley from the Centers for Medicare & Medicaid Services (CMS), Kirsten Bibbins-Domingo from the University of California, San Francisco (UCSF), Von Nguyen from the Blue Cross and Blue Shield of North Carolina, and Stella Whitney-West from NorthPoint Health and Wellness to share their thoughts about changes that are needed organizationally, in the community, and in the field and system-wide. Key points from the panelists are provided in Box 4-1.

Alberti shared a story about partnerships. Recently, AAMC gave an award for outstanding community engagement to the Rush College of Medicine in Chicago. Medical students in the service learning program had been working in the city shelter system, which is part of a large partnership that includes health care, government public health, community organizations, and others. The students expressed concern about how heavily the congregate and the partnership sprang into action to administer tests, respond to outbreaks, and ensure continuity of care. Because of all of the planning and collaboration, the entire shelter system in Chicago sustained only two COVID-19 deaths, Alberti noted. According to program leaders, the partnership accomplished more in 5 months than it did in the 20 years prior—the new normal of COVID-19 is a committed partnering and investing in partnership, with COVID-19 acting as a catalyst that calls on an established partnership to be nimble and agile.

Nguyen shared how his organization started its own exploration of its role in advancing equity. His system recognized the large policy questions raised by the 2020 protests against racial injustice. The system recognized that it is not a primary actor on many of the aspects, but it still had an opportunity to participate as part of a larger partnership, as well as through structural changes. Nguyen remarked that the system recognized that network adequacy is one approach to help advance equity. Network adequacy, he explained, refers to the requirement that health care plans have providers in every zip code to ensure adequate coverage for its insurance policies. In a rural area, that provider could be 20 miles away, and although that may technically meet the definition, it is not really adequate and is inconsistent with the goal of advancing equity.

Alley remarked that the system is generally better at measuring issues related to cost and quality than those related to access, and the agency is grappling with how to measure access effectively. She acknowledged that health plans may not be enthusiastic about having network adequacy requirements increased, but she appreciates that some plans are engaging around those issues in a meaningful way.

Bibbins-Domingo said that organizations need to think internally about what they are uniquely poised to do. UCSF launched health equity councils at both of its hospitals and reviewed ways to integrate equity principles into all of its data collection on quality and safety and patient experience. Although the report Unequal Treatment: Confronting Racial and

Ethnic Disparities in Health Care (IOM, 2003) was released almost 20 years ago, a lot of these issues, even the measures, are not universally embraced. The pandemic has affected hospital finances, but the university has been involved in robust community partnerships, working effectively with public health to drive improvement.

Alberti asked if there is any movement to get community and patient input into what makes a network adequate. Nguyen shared that his organization is in the early stages of working on this issue. He noted that there is work to be done on the system definition of what is technically adequate on paper versus what network adequacy means from the members’ or patients’ standpoint.

Alley shared that on the Medicare program side there are a number of measures of patient experience that deal with trust, communication, availability, and timeliness of care. With regard to value-based payment in Medicare, the problem is likely to be people getting too much care or the wrong types of care (e.g., unnecessary testing, lack of coordinated care, multiple care coordinators). In the Medicaid context, Alley noted, the issue is people not getting care at all, and there also are difficulties in facilitating access to care in rural settings.

Stella Whitney-West, whose organization is a federally qualified health center (FQHC), shared aspects of her health center’s work that ground it in the community and underscore its relationship with community members. Whitney-West said that more than 70 percent of her health center’s staff is from the community, and 51 percent of the board is comprised of patients of the health center (a requirement for FQHCs). As part of the response to racial injustice, the health center focused on the emotional well-being of staff, who are drawn from the community and are primarily people of color. For example, the health center organized a protest march around the neighborhood, led by staff who are African drummers, and the community responded. This idea emerged from daily staff huddles that are not clinically focused, but are rather centered on having a “mindful moment” in addition to receiving COVID-19 updates and building team togetherness at the start of each day.

Alley shared her perspective about responding to the twin crises unfolding in the context of massive transformation occurring as the U.S. health system moves to value-based payments. Data and flexibility are needed for value-based care to be successful. What Alley noticed in the first months of the pandemic is that the providers who had been investing in transforming care “were better poised to be nimble and respond to this changing dynamic, ramp up telehealth, engage care teams, and track patients—all the things you really needed to be able to do to deliver effective care.” She shared how the U.S. Department of Health and Human Services is focusing on maternal morbidity and mortality both in general and in the context of

issues that have emerged during COVID-19. Telehealth has emerged as a potential benefit of the new environment—it makes care more accessible for some patients, but there are also barriers. There is an opportunity created by the pandemic to do things that are more patient centered and accessible, but there is also a risk of perpetuating or exacerbating disparities if people lack the technology or Internet access, Alley noted.

Regarding technology access, Bibbins-Domingo commented on the communication challenges presented by language and cultural differences, and the ongoing efforts to find solutions. It is essential to recognize, she noted, that telehealth services are here to stay, but there are equity issues that need to be resolved. Nguyen shared that the Blue Cross Blue Shield of North Carolina saw a 7,000 percent increase in telehealth use. Telehealth services provide a great solution for an essential worker needing to take a day off, needing parking—barriers that are hard to overcome—but it can create inequities. For example, although telehealth has worked well for behavioral health care, there are some challenges, such as creating a therapeutic environment when people are home and surrounded by their children, or if circumstances cause them to be outside their home, such as shopping in a grocery store. It will be crucial, Nguyen noted, that systems ensure that telehealth can be a conduit for the same high-quality care that a patient would expect from an in-person visit.

Whitney-West spoke about her FQHC’s focus on providing care to patients regardless of ability to pay, but they also offer the services of the health center’s eligibility support staff to enable patients who may be unaware of their eligibility status to access care in other settings. To address patients’ challenges with Internet access, technology, and even data plan constraints, the health center replicated an idea it had learned about and created telehealth hubs around the community to help ensure access for patients. Hennepin County has a network of libraries and community locations where the health center established private offices where people could go to for telehealth visits, and community health workers are available to assist as needed.

Alberti commented on how this story clearly illustrated the difference between having an insurance card and actually having access to health care. He then shared a personal anecdote from someone who had been a skeptic about the federal government’s ability to afford universal access. The person had an epiphany that if the federal government can manage to fund a $1 trillion program (the COVID-19 stimulus), the lack of universal health coverage in the United States is not about cost but reflects societal choices. Clearly, COVID-19 has brought into high relief, in addition to injustice and inequity, “the fact that it is possible to make different choices when a crisis hits. The question for the nation to ask itself is how that momentum can be maintained to rethink what is possible.”

Bibbins-Domingo reflected on Alberti’s comment about the true meaning of access and shared that UCSF took its COVID-19 testing directly into the community rather than wait for people to come to it. Although the Latino community makes up about 15 percent of the population in San Francisco, it accounts for more than 50 percent of the COVID-19 cases, and the health system learned much by partnering with community organizations to set up neighborhood-based testing sites. UCSF learned how to deal with misinformation about payment, care, and what it would mean for job security, immigration status, and being considered a public charge. She added that it was the community-based organizations who did all of the follow up, linking people to resources and services they needed from food to even housing if someone needed to quarantine away from their household. Magnan noted that one audience question touched on misinformation. Bibbins-Domingo shared that in marginalized communities, COVID-19, injustice, and economic instability interact to contribute to misinformation, and marginalization feeds misinformation.

Nguyen said that his health plan, with leadership from the chief executive officer, found it critical to reinforce the messages coming from the North Carolina Department of Health about wearing masks and handwashing. Health systems, working through the providers, are often trusted actors in the community, which positions them to play an important role in being trusted communicators. The health plan worked with health systems and the business community in the state to disseminate trusted information coming from the Department of Health. That public–private partnership played an important role. Bibbins-Domingo shared how her health system worked with community-based organizations to communicate to the community in different languages, including Cantonese, Spanish, and Vietnamese, and respond to the real hunger for information it noticed in the community. Before COVID-19, Bibbins-Domingo added, the health system had made the commitment to embrace its role as an anchor institution and therefore realign its procurement and hiring to be an economic player in the local community. That is an important perspective that the organization brings to its COVID-19 response as well.

Magnan asked Alley if the Medicare policy team has considered paying for outcomes and disparity reduction, under the assumption that reimbursement of funding would drive change and better outcomes more quickly than many other methods. Alley said yes and noted that there is an upcoming meeting of a National Quality Forum (NQF) technical panel that will consider adjustments for social risk.¹ CMS is focused on balancing the need to establish incentives to close the equity gaps in providing

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¹ For a definition of social risk, see NASEM (2017): “Social risk factors capture how social relationships and contexts influence the health care outcomes of Medicare beneficiaries.”

high-quality care to everyone, particularly to those who need it most and ensuring high quality of care while avoiding potentially penalizing safety net providers. The agency is also considering different ways to collect social risk information, such as the Area Deprivation Index, which has been used in the Maryland cost of care model.

Health inequities related to COVID-19 have drawn attention to the dual-eligible population and population with end-stage renal disease as two very vulnerable groups. CMS is also focusing on quality measurement and data standardization in the context of the accountable health communities model, and it is collecting data on a large scale on health-related social needs such as housing instability and food insecurity. As a general insight, Alley shared that it is easier to measure processes than outcomes, and CMS aims to gather more information about what works and how to measure it.

Alberti said that he is a co-chair of the NQF disparity standing committee, and that the committee has been overseeing a trial period of social risk adjustment for the past several years. That work is being concluded, and a subsequent expert panel will be reconvened soon. System leaders fear using social risk adjustment and having that mask inequity or allow for a lower standard of care, Alberti noted, but the data can be stratified. The greater challenge is that social risk data do not inform risk adjustment in a valid way. One approach is to try to adjust for Black race versus everybody else, but being Black is not a risk factor and “there’s no intervention for Black race—it’s not even a real thing,” he added. “Racism is the risk factor.” The other approach is to adjust for dual eligibility. Evidence indicates that dual-eligible patients receive poor quality of care, and that is related to the social determinants of health and individual social risks that the patient experiences in the clinical encounter, Alberti stated. What is needed in the future, he said, is a

Bibbins-Domingo said that the metrics available for risk adjustment, despite their limitations, are still useful if health systems like hers are given incentives not just for meeting targets (e.g., lowering hypertension), but for closing the gaps. Alberti noted that “tracking the gaps is not the same as measuring equity” unless a metric exists that can capture whether patients of any background feel they receive the same equitable opportunity for high-quality health care as “a White, cisgender, heterosexual, Judeo-Christian, rich man.”

Whitney-West commented that her FQHC is part of the Hennepin County government, which has declared racism a public health crisis. Health care often treats the symptoms but does not address the root cause; therefore, the county government built in metrics and goals, including furthering equity through county contracts and vendors. Looking at housing, benefits, employment, and other factors that help ensure equity in the population, these are all a part of what public- and private-sector organizations can do to address historic racism, such as when the county locked people out of opportunity through policies such as redlining and Whites-only housing covenants.

Magnan relayed an audience question about the fact that community health centers have a legal requirement to have a majority of their boards comprised of patients, and whether this could be made into a requirement for other clinical care organizations. Whitney-West said that patients on the governing board bring their perspectives and tools to the table—they are messengers and trusted sources with the community. Her message to other health care organizations is that they are missing an opportunity if they do not find ways to include their constituents, community, or patients in their organization in a meaningful way. Alberti said that there are organizations that have several boards—Massachusetts General Hospital is one that has four boards—for research, education, clinical care, and community. There are many examples of perfunctory, box-checking engagement, but there also is momentum to incorporate patient and community voice in ways that “share power and lead to real change.”

Bibbins-Domingo shared that her organization launched a patient community advisory board related to COVID-19 to both inform research related to COVID-19 as well as for community input on UCSF COVID-19 testing projects. She added that the advisory board exemplifies bidirectional communication and learning. A number of Center for Medicare & Medicaid Innovation models, stated Alley, include requirements for some type of community input or engagement, which may offer an opportunity to build in this important input. On a related note, Alley mentioned a call for feedback from Johns Hopkins University on ways to develop measures of the health of the community surrounding the hospital as an indicator of hospital quality.

Magnan noted that an audience member asked about the implications for health care of the call in the business community to diversify boards. Alberti clarified that IBM Watson Health’s hospital rankings initiative asked Johns Hopkins to develop a metric that attempts to capture a hospital’s contribution to community health and equity, but it also reflects on institutional culture, climate, gender equity, and so forth. The Lown Institute has a new metrics set that aims to assess health care organization performance on the organization’s civic leadership, the value of care it

provides, and patient outcomes.² There are, he added, some formal community benefit forms that attempt to capture some of the free care as well as aspects of community health improvement activity by hospitals. The challenge, Alberti noted, is identifying a national metric that captures the institution’s effort at community health improvement and whether it is responsive to the identified needs of the local community.

Magnan asked a final audience question about mental health services in the context of the pandemic. Nguyen said that his health system views this through three different lenses: (1) supporting employees by helping them manage behavioral health challenges; (2) providing access to mental and behavioral health care via telehealth for substance use disorder, depression secondary to COVID-19, and serious mental illness; and (3) in the community, engaging especially through their foundation in strategies to respond to social isolation and loneliness. Whitney-West noted that her health center provides school-based services, too, and a component of that is mental health. She also reflected on the fact that mental and behavioral health has been devalued in the United States, and the most striking examples occur in the context of police brutality, such as the cases where law enforcement arrives on the scene and community members experiencing a mental health crisis get injured or killed.

Alley quoted James Baldwin in that “not everything that is faced can be changed, but nothing can be changed until it is faced.” Alley said “we’re facing a lot of things right now, but we need to be able to continue to see them, and the language of health care is data and incentives and reimbursements, so we need to figure out how to take this conversation and really face” the need for change in the context of issues such as data and payment. Alberti asked how the data and the opportunities discussed can be leveraged to “position health care [entities] as a partner in developing a health agenda, and not just a health care agenda.” Nguyen added that beyond the data, what is needed is understanding the role of culture. Magnan emphasized the importance of feeling discomfort about the role of institutions and the need for leaders such as those on the panel to dig deeper. Whitney-West closed by remarking that the current crisis is one that the nation has been in for decades, and Americans have just become numb to it.

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² See https://lowninstitute.org/press-release-can-2020-push-hospitals-from-good-to-great (accessed December 18, 2022).