On Tuesday, June 22, during the first day of the AHIP Annual Institute, the annual conference of AHIP, the nation’s largest health plan association, being held virtually this year, a panel of five healthcare leaders discussed the important topic of “Health Equity in America: An Urgent Call to Action.” Nwando Olayiwola, M.D., M.P.H., who in January became the vice president and chief health equity officer at the Louisville-based Humana Inc., moderated the panel. Dr. Olayiwola was joined by Mandy K. Cohen, M.D., M.P.H., North Carolina Health and Human Services Secretary; Cain A. Hayes, president and CEO of the Pittsburgh-based Gateway Health; Cheryl Pegus, M.D., M.P.H., the Portland, Ore.-based executive vice president, health and wellness, at the Bentonville, Ark.-based Walmart; and Cameron Webb, M.D., J.D., a leader on the White House COVID-19 Response Team, and director of health policy and equity at the University of Virginia School of Medicine (Charlottesville, Va.).
“For far too long, our nation has struggled with racism and oppression. Health insurance providers have a long history of working in various communities, including communities of color, to focus on better health,” Olayiwola said, and then introduced her panelists, asking each of them to share with the audience how they view the subject of equity, and what needs to be done in this vital area. All but one of the panelists are African-American healthcare leaders.
Gateway Health’s Hayes said that, “Given the events of last year, equity, specifically health equity is indeed at the forefront of the national conversation. In my view, it’s long overdue; the need to deliver equitable, accessible care, is more important than ever. I spent the first two-thirds of my career in financial services before going into healthcare, and I have a firm belief that one needs not only physical health, but mental, social, and economic health. At Gateway Health, we believe in caring for the whole person, and we envision a future where everyone has equal opportunity to pursue their best health. The COVID-19 pandemic has certainly magnified inequity. This tragically affects the health of vulnerable health, specifically of the health of people of color. Unfortunately, this is a complex issue,” he said, “which is why it hasn’t been solved yet. It’s going to take public sector and private sector partnerships to address the social determinants and influencers of health. Health plans, providers, employers, government agencies, and others, really have a unique opportunity to address the impact of race, gender, ethnicity, and other factors.”
What’s more, Hayes, said, “Achieving good health can become nearly impossible for people struggling to address their most basic needs. As healthcare professionals, I believe it’s our responsibility to remove these barriers by ensuring that vulnerable populations have resources, including access to safe housing, stable employment, healthy food, good education and transportation. There are numerous things we can do: providing transportation to doctors’ appointments, providing sustainable access to healthy meals and to safe housing. We need to use data analytics and all other tools. The bottom line is that health equity means every individual deserves their chance to achieve their best health.
“Secretary Cohen, how at the government level, can we begin to address these issues?” Olayiwola asked Cohen. “I want to thank AHIP for holding this conversation,” Cohen said. “First, you have to collect the data systematically on race and ethnicity, in order to address the issue. I have a friend who says we’re doing too much admiring the problem instead of addressing it. We have to obtain precise data to map the problem. When COVID started, we in NC didn’t have the data we needed to really make the informed decisions I wanted to make; we didn’t know who in our African-American community and Latinx community were getting tested, or being hospitalized. So we targeted data first. And we have the technology to make it a forcing function to select race and ethnicity at every step. So you couldn’t log a vaccination in North Carolina unless you logged race and ethnicity.”
Since then, Cohen noted, “We’ve logged 94 percent, whereas nationwide, 44 percent of the race and ethnicity data is missing. And I’ve heard people say it would take too much time, but it’s not true at all. Our hospitals said, actually, we could totally work this into our workflows. And the myth that patients wouldn’t respond: almost no one has refused to respond. So first, it’s data collection every single time. And if we want different results, we have to put our money, time and resources in the right places. In our Medicaid program, with the additional money coming from the federal government—we wanted to give our practices seeing a higher proportion of folks from the most vulnerable census tracts—we gave practices a score based on that, and we made equity bonus payments to physician practices seeing patients from the most vulnerable census tracts,” she noted. “We gave them support, and we’ve been thinking broadly about these things. And it’s affected how we pay our providers. It really is about taking that comprehensive look at your entire population.”
“Dr. Webb, we’re very interested in hearing about the work of the Administration; could you share about some of the efforts you’ve engaged in?” Olayiwola asked. “It’s such an important topic, and I love following Secretary Cohen and Mr. Hayes, because it tees up the issue,” Webb said. “With the Biden administration, it means going to where you were needed. We knew we were walking into a system built on structural inequality and systemic racism. And that’s why we were so excited by what Secretary Cohen has been doing in North Carolina. We really wanted to do three things: increase the number of vaccines, of vaccinators, and of venues for vaccination. Those first things we were able to do in terms of some policy changes; but in terms of venues, there, you’re really talking about what kinds of access you have. So on the access front, we wanted to make sure there were opportunities to access vaccine that were approachable, available, and accessible, and accommodating. So we had to create new partnerships with the states. We created mass vaccination centers, supported by FEMA, and located in areas of greatest vulnerability, while partnering with community-based and faith-based organizations. There’s one in Greensboro, NC that I went to visit. And they’ve been doing 3,000 vaccinations a day.”
What’s important, Webb said, is that, “Often, if something’s on fire, you don’t ask the fire to make its way to the water, you have to bring the water to the fire. And so now we have more than 41,000 retail pharmacies that are vaccination sites. And our FQHCs [federally qualified health centers] are so critical. When I first started my practice of medicine, I first practice in an FQHC. And making sure our 1,400 FQHCs were a part of this, was also a key. And finally, mobile vaccination units were very important. And if we’re talking about advancing or achieving health equity, there’s never been a fire drill like COVID. We’re emphasizing connections with community-based and faith-based organizations as places where we can tap trusted messengers, to make a difference; and we’re addressing health in schools. All that has to be a part of COVID response and recovery. And we’re talking about employment. And paid time off: we need to give folks paid time off, and childcare, to help folks get vaccinated. Ultimately, we have to go from this sprint around COVID to the marathon of health equity over the long term. We as a nation are only as strong as our most vulnerable people. So that’s what we’re focused on.”
“I really appreciate that idea of alliances, and building those trusted partnerships in communities where people have been disadvantaged,” Olayiwola said. “Dr. Pegus, how can we better integrated healthcare, social services, into environments where people are interacting and are spending a good deal of their time and can learn healthy behaviors? How have you thought through the integration across various sectors?”
“Thank you to AHIP for hosting this session,” Pegus said. “We’ve got about 1.5 million associates at Walmart, and 150 million people come through our stores every week. And 4,000 stores are in HRSA-designated areas of need, and that’s where most of our associates live, near the stores they work in. So the first step was addressing the needs of our associates. So we began with our COVID policies around our staff, including no repercussions for taking leave; making sure we had free, accessible COVID-19 testing.”
What’s more, Pegus went on to say, “This past year was a really stressful year, and stresses are continuing. How do you care for yourself? So we had a number of programs focused on mental health and counseling. We have a Thrive Program [the company’s Thrive ZP program, which aims to “help Walmart employees and customers make better choices and achieve healthier behavior changes”]. We as leaders were doing meetings on the road, sharing with colleagues, listening to what they needed, and making sure we were in constant communication, and making sure we had a diverse set of leaders meeting the needs; and giving people permission to learn and manage during a difficult time. Not only do you have people deeply impacted by COVID, but people are learning. And you may not be a scientist, but you want to understand what the vaccination trials, the studies, were about. And the learnings from that really informed how we reached out to our communities.”
Further, Pegus said, “I agree about data: you’ve got to know your communities. We looked at our communities by zip code to understand their needs. And the second element that’s been talked about today has been collaboration. Pharmacies have become a public health backbone. And even then, you have to focus on transportation. We’ve been partnering with community organizations, with providers, and with payers. So for us, there’s a piece of healthcare where success in communities means listening to and understanding communities. Partnering for success and speed to allow us to be able to have an impact; and finally, utilizing the data and reporting on it. And I like what Cameron said: these best practices are foundational for improving health equity. Lastly, these are not just immunizations. There’s the opportunity for pharmacists to ask, can you afford your medicine? Do you have fresh food? The ability for everyone in the system to participate—that matters. And as we work further towards health equity, we hope to partner with everyone, and further develop our best practices.”
Beyond social determinants: the “social influencers” of health
“Mr. Hayes, we’ve spoken a lot about the importance of engaging with communities and building trust, and creating successful partnerships,” Olayiwola said. “Would you share about health insurance providers can reach underserved communities and communities of color, in a way that’s culturally and linguistically appropriate, and that builds trust?”
“We need to first address the social influencers of health,” Hayes insisted. “For nearly 30 years, Gateway health has been committed to funding various programs that address the social influencers of health. But we have a saying at Gateway that it’s more than a check. It’s equally important to be active in the community and volunteering these resources. The pandemic has forced us to change the way that we interact with our local communities. We’re committed to meeting members where they are. We launched our Whole Care Mobile Tour. We made nearly 90 stops across Pennsylvania. We literally took a huge bus and retrofitted it, in order to allow us to get into the community and deliver PPE [personal protective equipment], education, resources, to vulnerable populations. And due to the success of the 2020 mobile tour, we’re about to launch the 2021 mobile tour. HC organizations need to think differently about how they serve communities; we must deliver HC in a way that’s most convenient for members. And in order to so, our organization will partner with many community organizations across the state. By working together with these community-based organizations, we have a better chance of helping to sustain healthy lives.”
“Secretary Cohen, per that theme of partnerships and collaborations, where else should we be trying to forge partnerships and relationships, per equity?” Olayiwola asked.
“That’s a great question,” Cohen said. “We all know partnerships are key, trusted relationships are key to getting at the heart of equity. But partnerships take resources. For a small organization like a faith-based organization, to partner with a health plan or payer, it takes time and resources. So we’ve created a program Healthier Together, where we’re able to give resources to CBOs. Right now, that’s been a vaccine-based effort. And using community health workers are an important kind of glue in that regard as well. Also, in North Carolina, we’ve invested as a state in a centralized referral program. NCCare360 is using the UniteUs platform to embed from HC to social services and back—a shared platform with shared data. We’re collecting that data—but it’s resourced through a combination of public and private data. Partnerships are key, but you have to resource them and support them. NCCare360 is a statewide platform that people can log into.”
“Dr. Webb, your thoughts?” Olayiwola asked. “It touches on this concept that most of us are familiar with but that far too often isn’t actualized.; it’s the idea of health in all,” Webb said. “President Biden talks about a whole-of-government response. It looks like partnerships with, for example, the Department of Education: we have to address, through a health lens, in pre-K education. We have to do the hard work of reconnecting communities to opportunity and health. And we’re working with the Department of Justice, because criminal justice also involves healthcare. We know that race is a social construct; we know that your zip code helps determine your health. So we have mechanisms across agencies and departments, where we can collaborate. Right now, the inequity really is the biggest challenge; we can spend as much money as we want on healthcare, but it has to begin with addressing inequities in health.”
“I think the question of partnership really speaks to all these different approaches,” Pegus said. “It’s important that I should be able to look up the health status of every community. And if you look up a community and you see that it has no access to primary care or has the lowest percentages, you have to act. That’s where partnerships come in. 40 percent is social determinants, 30 percent is personal behaviors, only 20 percent is actual medical intervention. That initial 70 percent is fresh-food access, it’s community health workers, it’s access to telehealth. Nd sometimes the statement is made that, well, those communities don’t have broadband access. It behooves us to remember that smartphone access can make a huge difference. And because of telehealth, a lot of physicians finally got to see how their patients actually live. You’ve got to stay in your community and you’ve got to use not always the highest-cost clinicians to provide care. At Walmart, we use our pharmacists, our care coordinators, our people delivering food, our care coordinators are partnering with community-based organizations.”
What’s more, Pegus said, “We have to look at the resources we bring and understand what your partner may need. And in some relationships, you’re bringing more than 50 percent of the resources. We live in our communities, so we’re hearing about this from our associates. So you need to look at this not just through a project lens, but in a sustainable matter, to improve the health of communities long-term. Our partnerships are not just external; they also involve partnering with our own associates, and we’re trying to take the learnings and make the next turn at the wheel better than the last one.”
