On October 26, the senior leaders of the Jacksonville, Florida- and Wilmington, Delaware-based Nemours Children’s Health announced that their organization had committed itself to a program focusing on health equity for marginalized populations, in their work caring for communities in the several states in which the integrated health system operates.
As a press release published on that date stated, “COVID-19 and the social injustice crises of 2020-2021 shined a new light on the systemic disparities in the U.S. health care system. Some disparities – such as with maternal and infant health – have been understood within the industry. But startling new research published last month found that Black children experience higher complication rates than White children after having their appendix removed, an indication that such inequities are more widespread than previously believed. A dearth of data hinders a more comprehensive understanding. Recognizing that fact, a Health Evolution Forum work group has been convening across the past year to agree on a consistent set of measures and approach to collecting, stratifying, and analyzing disparities data. Already, approximately 40 leading organizations have signed the corresponding Health Equity Pledge, committing to collect data about race, ethnicity, language, and sex (REaLS), and then share what they learn to develop best practices that are ultimately disseminated broadly across the industry. Nemours Children’s Health, which earlier this year announced a new five-year strategic plan to redefine children’s health, joined the pledge to amplify its efforts to advance health equity for children. Nemours Children’s addresses the whole health of children by addressing the social determinants of health in addition to traditional care received in the doctor’s office,” the press release stated.
“To create the healthiest generations of children we must focus beyond medical factors and look at how communities, schools, and policies affect health,” said R. Lawrence Moss, M.D., FACS, FAAP, president and CEO of Nemours Children's Health, in a statement contained in the press release. “Joining this pledge will ensure that we are holding ourselves accountable for providing equitable care to all children and influencing others to act as boldly. Together, with the Health Evolution Forum, we hope to improve the health, wellness, and lives of children everywhere.”
As the press release continued, “Going forward, the Health Evolution Forum will convene executive leadership and subject matter experts to develop real-world solutions around:
> Increasing collection of voluntarily self-reported (gold standard) race, ethnicity, language, and sex data
> Strengthening industry partnerships to dismantle collection and stratification barriers, including with large employers
> Driving more consistent adoption of data standards and definitions for improved stratification and review.”
“A concerted commitment to such collection and stratification for all key quality and performance metrics is critical to understanding and, most important, redressing disparities,” said Richard Schwartz, President, Health Evolution. “We are pleased to serve as a learning lab for this important endeavor and welcome other industry leaders to join in.”
Per that, an Oct. 26 statement on the website of the San Francisco-based Health Evolution noted that “Going forward, the Health Evolution Forum will convene executive leadership and subject matter experts to develop real-world solutions around: increasing collection of voluntarily self-reported (gold standard) race, ethnicity, language, and sex data; strengthening industry partnerships to dismantle collection and stratification barriers, including with large employers; driving more consistent adoption of data standards and definitions for improved stratification and review.”
Shortly after the Nemours Children’s Health organization signed the Health Evolution Forum work group pledge, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed Nemours president and CEO R. Lawrence Moss, M.D., regarding the pledge itself and the broader movement to support health equity efforts. Below are excerpts from that interview.
How do you frame this broad shift in emphasis around health equity among patient care organization leaders?
Let me start by saying something that I said spontaneously once, but now say it deliberately all the time, and that is that, there can be no health without health equity. I feel very strongly about that. Given Nemours’ commitment to child health, health equity is inherently part of that, and part of who we are as an organization. If we did nothing else yet could create health equity with the sweep of a magic wand, it would address more than 75 percent of the social determinants and other non-medical factors that impact our children’s health. So I’m excited to be a part of this, because health equity is such a strong tool. I’m also excited about it because it’s the right thing to do as human beings. And the Health Evolution Forum combines the payer, the entrepreneurial business, and the provide sides of healthcare, brings them together. And the fact that this emerged is a pretty good indication that we’re all focused on the right thing.
What would you say to those afraid to wade into the health equity discussion, out of fear of controversy?
We’re a multiple-state, multiple-facility health system that operates in several states, from the bluest to the reddest. We’re in the position of being a microcosm of the U.S.; that gives us the privilege to be able to lead by example; if we can do it, others can do it. I hope that our peer organizations across the country can willingly join us. We’re not in this to get headlines, we’re in this to do the right thing. And frankly, I hope that this becomes no longer a newsworthy thing; because it’s a win if everyone is for it.
What will the biggest challenges be going forward around the principle of health equity?
In my mind, it’s always about economic incentives, which in our system are always backwards. We don’t pay for anything close to health. There are three-and-a-half-trillion reasons involved; it’s all those dollars incentivized to do what payment dictates. So Nemours is all about payment transformation. As an organization, we’ve invested upwards of $70 million now into our value-based services organization, the VBSO. It represents our investment in transitioning to the type of health system that we believe will optimally create health. In the current economic environment, that’s a cost to us, it comes right off the bottom line; in the future system, it will be a home run for us.
Will the landscape around Medicaid reimbursement and policy change anytime soon?
You are absolutely correct that more than half of the healthcare to kids in this country is funded by Medicaid. And in almost all cases, Medicaid pays less than the cost of care; and that creates some inherent challenges to taking care of children in this country, and that needs to be fixed. That being said, there’s a positive built into this, and that is that, if you’re caring for children, you’re dealing with one major payer, so transformation is possible. With respect to what’s going to happen with Medicaid, that’s a tough one to predict. And perhaps I do deviate from some of my respected peers in that I strongly believe we need a global reform of how we pay for children’s care in this country that covers costs and is sustainable. Right now, a huge proportion of support comes through this arcane supplemental system of payments. Sometimes we win big and sometimes we don’t; the fact that there are always some institutions winning big, tends to thwart overall reform. Recently, we’ve fared decently at Nemours under this supplemental system. But an overhaul of the system that recognizes the need for reform, is where we need to go.
You don’t mind being an open advocate for reimbursement reform?
I don’t mind, but that one isn’t always at the top of the list often because of the complexity involved and the low likelihood of success. Part of my motivation is to choose battles I think I can win for kids; and Medicaid reform is a steep hill.
How does your current work involving the social determinants of health (SDOH) fit into the broader landscape around addressing health equity?
We’ve piloted an SDOH screener in our primary care clinics. That was incredibly widely and enthusiastically adopted. We piloted and then spread it across all our primary care clinics in the Delaware Valley now. That has allowed our primary care docs to have unique insights into their patients’ lives that they wouldn’t otherwise have had. Out of that, we’ve been developing tighter and together relationships with our community partners. The Holy Grail is when food insecurity, housing, and other elements are involved in a closed loop with social service agencies, in a way that benefits kids. That’s our destination. And it’s a challenge, but it’s a destination we intend to reach.
Can you speak to the role of data, data analytics, and health IT in creating all the needed changes?
Medical management, population health management, our clinically integrated network, and data and analytics, are the four pillars of operations in our value-based network. And that involves using disparate data in a very sophisticated way, to learn things about patients. For example, to have the power to ask a question such as, from what neighborhoods am I seeing the most asthma exacerbation in a particular area? Or, what is our payer mix, and how does that relate to causes? Until recently, it was unheard of to be able to look across claims data, clinical data, social service agency data. And through the VBSO, we’ve been able to create the power to create, ask, and answer those questions, and that’s a game-changer in healthcare.
As the Medicaid programs in the states become explicitly managed care programs, does that help you in your work, in terms of the population health management and care management elements involved?
I’m certainly not an opponent of Medicaid managed care. That said, managed care doesn’t inherently put the risk on the providers, as it should. Frankly, we should make more money when patients are healthy and less or no money when they’re not. Now, whether the execution of that should go through managed care organizations, I’m really agnostic on that. There are different ways of doing that, that could include a variety of potential partners.
What does the next couple of years look to you, around all the subjects we’ve been discussing?
I’m extremely optimistic about the next few years. I have never seen a time in my entire career in healthcare where there’s been more opportunity on the table to transform the system. And a large part of that is because of COVID, which has put things on the table that were never on the table before. It’s opened up the discussion in a way that it hadn’t been opened before, and enhanced the potential for health system transformation.
