Manatt Execs Place Equity at Center of Report on Imperatives for Change

In a new report, thought leaders at Manatt Health have updated their January 2021 white paper describing 10 imperatives for improving the U.S. healthcare system in the 2020s. During a May 24 webinar, they touched briefly on all 10 topics in their new report, “Ten Health Care Imperatives for the 2020s: Navigating Through the Surges.”

The report noted that “the past year brought significant challenges to realizing progress; we witnessed the erosion of trust in science and public health, an epidemic of behavioral health disorders exacerbated by social isolation, persistent and widening disparities in healthcare access and quality of care, and chronic healthcare workforce shortages and stresses.”

A large number of the 10 imperatives discussed in the new report touch on addressing social determinants of health, ensuring access to coverage, and advancing health equity.

The focus on equity
Linda Elam, Ph.D., M.P.H., is a public health and health policy executive leader in Manatt’s Washington, D.C., office. (Manatt Health is an interdisciplinary policy and business advisory division of Manatt.) She guides healthcare clients on issues relating to health equity, Medicaid strategy, long-term care and federal and local policy.

During the webinar, she stressed that we have made a lot of progress in the past few years across many sectors in acknowledging the importance of advancing equity, and taking action toward achieving it. The COVID pandemic provided a jarring and often tragic illustration of the health inequities in our nation, she added, “and it resonated with many people who don't think about these things every day. It has been heartening to see so many people begin to grasp some of these concepts around social factors and health, and then actually moving further upstream to look at the roots and the causal factors of these inequities, such as structural racism.”

However, Elam added, we are seeing backlash towards some of these concepts related to health equity, and sometimes deliberate misrepresentation of what it means to work toward health equity, including framing it as a zero-sum game, “so it's really important that this work continues, that health equity commitments are included in every organization’s strategic development, and that whether you're looking at government or industry, this understanding that there are health repercussions, consequences, health effects, from even industries that are not health-related, and staying aware of those and looking at where impact can be made. She noted that healthcare and insurance coverage are tremendously important, “but we won't be able to healthcare ourselves to health. It does take the interconnectedness of these different avenues or different components of people's lives in order to truly advance health equity.”

Social determinants of health
Liz Osius is a director with Manatt Health. She has experience across public health insurance programs, including Medicaid, the Children’s Health Insurance Program (CHIP) and the Health Insurance Marketplaces. Prior to joining Manatt, Osius was a program analyst within the Office of Evaluation and Inspections (OEI) of the U.S. Department of Health & Human Services’ (HHS) Office of Inspector General (OIG).

Osius said we have seen an increasing acceleration in terms of efforts to address social drivers of health and integrate the non-medical services into the healthcare delivery system. She said Manatt conducted a 50-state SDOH survey that showed almost every state with Medicaid managed care has at least one SDOH-related requirement in managed care contracts at this point, which is enormous growth over the last few years.

“We've seen some groundbreaking programs recently authorized by the federal government in states like California and North Carolina,” Osius said. “All of this effort, both at the federal and especially at the state level, allows us to see what it takes to actually build a sustainable SDOH initiative. It takes in particular two key components to make it successful, one of which is new infrastructure that is not usually on the ground already. You are often bringing together two very siloed industries, social services and healthcare. To do so, you need tangible things like legal contracts between entities that don't normally work together; you need systems that allow those entities like healthcare plans and healthcare providers and community-based organizations to exchange data that supports payment and evaluation of the services. You also need community investment. I think that's something we cannot overlook — that addressing social drivers of health is only successful if we leverage the strength and the value of the community-based organizations that are providing the non-medical services.”

Investing in the safety net
Eboné Carrington, managing director with Manatt Health, addressed the challenges faced by safety net hospitals. Before joining Manatt, Carrington was the CEO of NYC Health + Hospitals/Harlem, where she led initiatives to improve revenue performance, bolster patient experience metrics, reduce the patient readmission rate by 10 percent and eliminate a $40 million budget deficit.

She noted that safety net hospitals form an integral component of our public health service, yet many are on the brink of insolvency. They require structural financing reform to reverses decades of policy and communal market failures, Carrington said. “The pandemic specifically exposed that we've had longtime structural inequities in the care received by individuals living significantly below the poverty level, many who are supported by government insurance. The rural healthcare systems are there they are on the frontline of addressing and trying to achieve health equity but they are not sufficiently funded to do so. My take-home message is that structural payment reform is required for our safety net system to move from straining to sustaining.”

She added that in neighborhoods all across the country, we saw that Black, Hispanic, American Indian and Asian populations experienced two to three times the rate of hospitalization and death. But prior to the public health emergency, they also experienced high rates of diabetes, hypertension, maternal morbidity. “The pandemic really exposed both strengths and weaknesses of the safety net hospitals,” Carrington added. “We saw was a very nimble approach to standing up testing and to being able to scale tracing and vaccine distribution avenues, but there are perpetual operating challenges that we have to address. Low levels of technology and data investment have led to the inability for some of these organizations to participate in research and grant activity. They weren't able to access federal funding to transition well into the telehealth environment. I would just say that the safety net system in general requires a bit more love, a bit more attention and a significant amount of investment."

Insurance coverage uncertainty
During the webinar, Julian Polaris, J.D., a Manatt Health associate, spoke about threats to recent improvements in health insurance coverage. He noted that the country has seen robust increases in coverage due to temporary pandemic-related policies, including the continuous coverage requirements in Medicaid, as well as enhanced subsidies for marketplace, enrollees. “Those policies are scheduled to expire in the near future, however. Unless we see action from Congress to extend those, we can expect significant coverage losses, following the end of the marketplace subsidies at the end of this calendar year, and the end of the continuous coverage requirement in the Medicaid program at the end of the public health emergency, which was most recently renewed through July of this year.”

We're expected to see the largest drop in the insured rate possibly ever in American history if all policies do expire, as they are currently scheduled to do, Polaris said. “This is obviously a major source of concern for health plans, who may see fewer people enrolling. It is, of course, a big concern for healthcare providers, particularly those who serve a large number of lower-income patients who are most likely to be just too high in terms of their income to qualify for Medicaid but not able to afford Marketplace plans once the subsidies expire. I think those two groups in particular, are already and should continue to plan for possible significant coverage losses.”

The potential role of digital health
Jared Augenstein, a director with Manatt Health, said that one of the silver linings of this awful pandemic has been that almost everyone has tried telehealth at this point. “One question going forward is how do we sustain the progress that's been made over the last few years,” he said. One of the keys to that is fundamentally redesigning care models. “By that I don't mean just taking a visit that used to happen in an office setting and moving it into to a virtual visit, but taking a look at clinical care models from the bottom up, and figuring out how they can be redesigned and optimized, leveraging the best of in-person care, the best of virtual care, at-home testing, home diagnostics, home-based care, to optimize the kind of care model leveraging the new technologies that are available.”

For that to happen, he said, there is a need to grow the evidence base for digitally enabled care. “There needs to be much more research on what the clinical and financial impact of different virtual care models is. The research needs to be clinical use case-specific, population-specific, and modality-specific,” Augenstein added. “We talk to policymakers all the time who are really struggling with making policy on the future of coverage and reimbursement for virtual care services, because they feel like they don't have the evidence base that they need in order to make data-informed policy decisions. That is a huge opportunity for academic health systems to play a big role in that evidence generation, and also for digital health companies to play a role in studying the efficacy of the interventions that they're delivering.”

Focusing on the digital health market, Augenstein noted that last year was probably going to be a peak year for a while in terms of venture investing in the digital health space. There was $29 billion invested in digital health companies, and also a record level of merger activity. “We're expecting this year to be a down year,” he said. “Publicly traded telehealth stocks are trading about 90 percent lower than they were a year ago, which is sort of incredible to think about. That's going to trickle down to the venture space, and we're going to end up seeing a lot of consolidation in that space as well.”