Health Inequities and SDOH Affect Primary Care Across Insurance Types

The American Journal of Accountable Care. 2024;12(1):27-29. https://doi.org/10.37765/ajac.2024.89523

At an Institute for Value-Based Medicine (IVBM) event held by The American Journal of Managed Care^®, leaders from Banner Health, Aetna, and other organizations discussed the population health challenges in today’s primary care landscape.

Panel Focuses on Social Determinants of Health When Addressing Primary Care

The event, which was held on December 12, 2023, in Phoenix, Arizona, featured a panel of 5 experts from various organizations. The panelists focused on an article titled “Health Systems and Social Services—A Bridge Too Far?” published in JAMA Health Forum and written by Sherry Glied, PhD, and Thomas D’Aunno, PhD. The article argues that it is not the job of health systems to lead efforts in addressing social determinants of health (SDOH) and they should instead divert those jobs toward local community-based organizations. This would necessitate strengthening local social service providers through fundraising and lobbying.

The panel was moderated by cochairs Robert Groves, MD, executive vice president and chief medical officer of Banner|Aetna, and Ed Clarke, MD, vice president and chief medical officer of the insurance division and Banner Health Network at Banner Health. Panelists were Leslie Barakat, MD, medical director at Cigna Medical Group; Deborah Fernandez-Turner, DO, DFAACAP, CHIE, deputy chief psychiatric officer at Aetna; Mark Stephan, MD, MBA, chief medical officer at Equality Health; Sara Salek, MD, chief medical officer at Arizona Health Care Cost Containment System (AHCCCS); and Sandra Stein, MD, chief medical officer at Banner Health Plans.

Each panelist introduced themselves and their work before the moderators began the discussion. The first topic was whether health inequity across the board in the US occurs because of a lack of investment by health systems into SDOH or if there is another reason for the inequities embedded in society.

Stephan began by emphasizing that trust needs to be built between patients and health systems. Many individuals do not trust what the health systems will do with collected data, he said, which leads to much of the demographic information being left blank when participants take a survey. Time has to be spent to listen to the community, he said.

“If you put health care delivery in an ice cream truck and drive it through the neighborhood, people aren’t just going to come out of the building to take advantage of it,” Stephan said. “Trust has been mentioned several times tonight, [and] it’s a big issue.”

Barakat emphasized that although data have been collected for certain demographics that show the differences in SDOH, many health systems don’t want to look at or address the disparities, seeing them as too big of a problem to easily solve.

“Some of them are all about it. They want to…understand their employees better and how they can support them. And there are others where I can’t even have a conversation about it,” she said.

Barakat said that these organizations have to recognize that the best way to reduce spending is to reduce these inequities because happier and healthier patients would need fewer visits with their primary care provider.

“If your membership feels supported in their health and their social needs, then they’ll be healthier, and you will end up spending less money. It’s hard to draw that line [with our clients],” Barakat said.

Stein agreed with Stephan that trust is a key issue in solving health inequities but also emphasized technology and community as other aspects that need to be addressed. Health care needs to be a community issue, she said; a multipronged approach is essential. Fernandez-Turner talked about how confusing the health system is for individuals who change insurance due to loss of jobs, change of income level, or eligibility for Medicare or Medicaid. Fostering communication between all insurance types needs to be more heavily emphasized so that the data from one insurance company can be used for the patient going forward if they need to change insurance, she said.

The moderators also asked if the family unit needs to be considered when a positive test or laboratory result comes back for a member of the family. Barakat said that in pediatrics, her specialty, the family unit is a big focus in caring for the youth but that addressing health care and health outcomes in family all together needed improvement.

Groves asked the other panelists how these improvements should be paid for in real time in a way that would address disenrollment. Stephan said that many systems are not willing to take risks in this area because they don’t want to invest when the return is uncertain. However, revenue can’t be generated to invest in research that doctors are more interested in if those risks aren’t taken, he said. Stephan noted that collectively taking those risks would motivate everyone like never before while also generating revenue to invest in things that they actually want to do.

Fernandez-Turner said that the link between value-based care and behavioral health needs to be stronger. The data, including those around behavioral health, need to be correct and strong in order for providers to take that risk because, as of now, providers are passing on taking these risks due to the limited data. Fernandez-Turner also said those on exchange plans often are overlooked in these analyses, especially because most of the patients on the exchange are at high risk of disease but have only the base plan, which doesn’t include extended case management.

Stein agreed that behavioral health is becoming more important in insurer data, especially for disorders such as anxiety, depression, trauma, and substance use. Value-based care is the bread and butter of health care, she added, but family-based care plans should be talked about more as a way to engage families together.

Groves agreed that trust plays a part, saying that trust comes with time. In order to change how health systems take care of patients, the focus should shift toward communities. “Instead of chasing people, create opportunities that they want to engage with,” he said.

He also said that the value of community and culture has been underestimated when staging interventions because patients will often revert to the community and culture that they came from, regardless of interventions.

“Unless we engage community services, unless we engage members in experiential learning and create opportunities that they want to participate in, I think we’re going to have a really hard time having a major impact. And the other thing [engagement] does is it facilitates trust and creates community,” Groves said.

An audience member asked the panel whether Medicare Advantage was truly beneficial, to which Barakat responded that it’s a big topic but the existence of the program indicates that there’s an audience that wants to use the extra benefits available through Medicare Advantage. She also mentioned arguments that patients on Medicare Advantage had better overall health outcomes.

The panel concluded with Groves remarking that conversations such as this help with getting a start on these difficult topics. “This is how things happen. You get together and we get face-to-face. When we talk to each other as human beings, this is how change happens,” he said.

Stephan said, “If we all go home and nothing changes, we’ll wake up tomorrow and just go back to where we all were.” He added that starting somewhere is the key to getting the work done.

Addressing SDOH Through Community-Based Initiatives

Salek and Barakat then gave individual presentations on the efforts of Arizona Medicaid and Cigna to address SDOH in Arizona and across the nation. Both presentations included data on programs that have been implemented and those that will be in the near future.

Salek’s presentation focused on Arizona Medicaid’s efforts to address SDOH. Addressing SDOH such as housing, she said, can affect health outcomes across the board, including mortality due to weather.

“If you don’t have a roof over your head, think about the impacts on health care, including just basic survival. And we are seeing heat-related deaths. So that’s just the basic core of serving our population,” Salek said.

The largest provider of Medicaid in Arizona is AHCCCS, which has seen an increase in enrollment from 1986 to 2022, from less than 500,000 to 2.5 million. An increase in enrollment also occurred during the COVID-19 pandemic and even though enrollment decreased after 2022, AHCCCS still covered 2 million individuals in 2023.

AHCCCS developed the Whole Person Care Initiative to address overall health care delivery through a patient’s medical, behavioral, and health-related social needs (HRSNs) to improve health outcomes, lower costs, and promote health equity. HRSNs can include housing, employment insecurity, and isolation, among other aspects. Medical providers and community-based organizations are partnering for this initiative to advance the integration of medical and social needs. The initiative focuses on socioeconomic factors, physical environment, health behaviors, and routine health care.

Salek also emphasized the Closed-Loop Referral System that was developed in Arizona and launched in 2023. This system allows health care providers to put in referrals for community-based organizations to address other aspects of well-being. Salek said that 298 health care providers and 79 community-based organizations use the program statewide. The program is led by Contexture, which is a partner organization to AHCCCS. A financial incentive was given to encourage organizations to participate. HRSNs can be improved in this way by having health care providers screen and refer patients to other organizations, Salek said.

“How it works [is], ultimately, the provider screens for [HRSNs and] makes the referral into the community-based organization, then the community-based organization contacts the member, and the information is then sent back to the provider,” Salek said.

The Closed-Loop Referral System has had 9179 referrals thus far, and the top 5 HRSNs requiring referral were food assistance; housing and shelter; utility assistance; clothing, diapers, and housing supplies; and transportation. The top providers giving referrals included the Phoenix Children’s Hospital and HonorHealth hospitals; the top organizations receiving referrals included A New Leaf and HonorHealth Desert Mission Food Bank.

The last program that Salek highlighted was the AHCCCS Housing Delivery System developed by AHCCCS, which provides money to 3000 members who primarily have serious mental illness. The data from 2020 showed a 31% reduction in emergency department visits, a 44% decrease in inpatient admissions, a 92% reduction in behavioral health residential facility admissions, and $5563 in average cost savings per member per month.

“This is a demonstration of why we want to invest in regard to the basic tenets of humanity, which are housing, food security, and safety,” Salek said.

Barakat then delivered a presentation about addressing health inequities and SDOH. Payers, she said, are trying to encourage health equity by leveraging foundations and charitable grant programs and changing how coverage policies are created, updated, and reviewed. Barakat believes that the health care industry can set the course for health equity by establishing mission imperatives, weaving health equity into quality metrics, and using an anchor approach to equity. This anchor approach should ideally function as health care organizations hiring and supplying from local marginalized communities, supporting employees who have low socioeconomic status, and preparing them for financial success.

Cigna has been using data to identify the risk of SDOH, embed health equity into its culture through screening assessments for SDOH, leverage provider networks to drive equity, and innovate in addressing defined disparities, she said.

Barakat highlighted Cigna’s proprietary Social Determinants Index in particular because it characterizes SDOH at the neighborhood level and uses 6 domains and more than 20 measures to identify communities that are underresourced, improve predictions, and deploy additional support.

“During the COVID-19 pandemic, we identified some high-risk communities that were hard hit and had high Social Determinant Indexes and we deployed more resources in those areas. That includes [personal protective equipment] and education, vaccines, meals, [and] testing kits. So we were able to reach 5.8 million individuals during that period in those high-risk areas and have a really good impact there,” Barakat said.

She also highlighted other programs that have been developed and implemented across the country by Cigna, including a maternal health program, which aims to improve maternal health and reduce racial disparities by providing access to all services needed for a healthy pregnancy; a breast cancer screening intervention, which reduced disparities through the launching of a reminder campaign in Tennessee; a diabetes intervention, where 58% of patients improved their hemoglobin A1c level after culturally representative community health workers engaged with them; and a preventive care pilot project, which aims to increase preventive care utilization.

Barakat concluded that applying a health equity approach to payers’ well-being strategy, as well as using data to identify SDOH, can be beneficial.

“Again, just be thinking about this being embedded into your practice and your day-to-day or your organization’s everyday work. Understanding that it takes a partnership, that’s important. We cannot do this work alone. We all need each other to be successful here,” she said.

Key Takeaways and Next Steps

The main takeaways from the IVBM event included various ways that SDOH can be addressed in primary care. Collecting accurate data from multiple sources is the key to being able to implement new programs that address the areas that can improve health inequities. Gaining customers’ trust is the first step to collecting those data and getting beneficiaries to interact with any programs started in response to the data. Payers have a duty to address these SDOH through targeted programs, according to the panelists, and working toward these outcomes should be the goal.

Author Information: Ms Bonavitacola is an employee of MJH Life Sciences^®, parent company of the publisher of The American Journal of Accountable Care^®.