On Feb. 8, on day one of the Healthcare Innovation Mid-Atlantic Summit, being held this week at the Bellevue Hotel in central Philadelphia on Wednesday, population health management leaders engaged in a probing discussion of the challenges and opportunities facing provider leaders working to address the social determinants of health (SDOH) in population health management.
Managing Editor Janette Wider led her panel’s discussants in analyzing where the U.S. healthcare system is right now in terms of the journey around SDOH. She was joined by Mitchell Kaminski, M.D., program director for population health at the Jefferson College of Population Health, a division of the Philadelphia-based Jefferson Health; Jeannine McMillan, executive director at the Jefferson Center for Population Health (also a part of Jefferson Health); and Kara Odom Walker, M.D., chief population health officer at Nemours Children’s Health (Wilmington, Del., and Jacksonville, Fla.).
Early on in the discussion, Wider asked the panelists the following: “Could each of you describe your organization’s relationship with SDOH and your journey?”
“I really wear two hats, one in terms of my role at the Jefferson College of Population Health, and the other as a practicing primary care physician,” Dr. Kaminski noted. “And by the way,” he added, “I actually prefer to use the term ‘social drivers of health’; ‘social determinants’ sounds as though you can’t change them. Meanwhile,” he said, “During the pandemic, we experienced great insights into health disparities” among diverse populations. Related to that, he noted that at the Jefferson College of Population Health, “We have a five-day intense training, our Population Health Academy, and we’ve devoted an entire segment of that to SDOH. Everyone is looking for answers and what best practices are in other organizations.”
Meanwhile, as a primary care physician, Kaminski noted, “In the clinic, I’m constantly trying to manage the drugs, the diabetes, etc. Fortunately, we have social work services, a pharmacist, care management, all in place” to help facilitate care management.” And, referring to Hierarchical Condition Category Coding, he said, “As clinicians, we’re constantly being harangued to report those HCC codes. Fortunately, we have a software program that serves up those codes from prior years,” in order support physician documentation in the electronic health record. Fortunately, “Now, there are Z codes that capture SDOH factors and opportunities for patients. And our EHR has an SDOH wheel that’s starting to get filled out. As clinicians, that’s one more thing we have to do, but we do have a team.”
“We’ve really focused on a data-driven approach,” McMillan said. “Cambria County [in west-central Pennsylvania, east of Pittsburgh] currently ranks 62 out of 67 Pennsylvania counties for health outcomes, 67 being the worst. So we’re looking at our local data to determine what we should be doing. And that really helped determine what we needed to do. Prior to our launch in September 2020,” she said, “we had no community health workers in our region. Bringing community health workers into this has been an amazing addition. And we’ve received so much feedback. The community health workers were observing the lack of coordination between clinical care and community health services. They’re also helping to identify gaps. When they’re trying to connect patients with community health services, they’re seeing waits of six to nine months to get in to see a mental health provider, so we’re addressing those gaps.”
“I’m in a pediatric health system,” Dr. Walker noted. “If we invest early, we can create healthier adult populations, in our clinical space, in our value journey, in our commitment to health equity.” As a result, she said, “We have three key areas of focus. Per the first area, we’re asking questions about social needs for each family, and trying to identify needs. And for example, one big area is housing access needs. And with the PHE [Public Health Emergency] unwinding, we need to understand how to apply resources.”
She continued, “Second, in terms of the value journey, the fact is that 80 percent of our patients are on Medicaid. We understand that as we take on upside and downside risk in our Medicaid ACO [accountable care organization], transportation matters, nutrition matters, and the family contact is terrifically important. We can help mitigate the impact of poverty, which is associated with adverse childhood events and mental health. And third, around our equity work, when we think about health equity, we need to stratify and collect data around race, ethnicity, and language. For example, those with language issues are more likely to have to come back repeated times. And we know that one in six children don’t have enough food in their home. And we’re really trying to understand the impact of collaborating with schools. How do we collaborate with a local school district around absenteeism data. We’ve embedded that data form the schools into our EHR. And what we’re seeing is that the most likely connection with absenteeism is health issues in the home—behavioral, asthma, etc. And if we can understand the data and build out more robust systems, we’ll be more likely to be able to intervene.”
“What is your policy perspective around this?” Wider asked Walker. “I spend a lot of time on our state and federal advocacy agenda,” Walker replied. “And the health needs are definitely interacting with all the social needs. So our work to create more supportive environments is essential. We need to move beyond the pandemic. We should all watch what’s happening with telehealth, with the moratorium on housing eviction changing, with the farm bill and its impact on WIC [support for Women, Infants, and Children]. There are changes in resources and programs. Many who thought they had coverage will lose it and they won’t even know. And if you watched the State of the Union last night [President Joe Biden’s address to Congress on Feb. 7, in which he referenced the debate over whether Medicare and Social Security should be treated as discretionary spending and potential cut or modified], there’s this question around the social safety net—whether through Medicare, Social Security, etc. We’ll see a lot more conversations around price sensitivity and price transparency, and that’s an area of focus for us. And many states are leaning into the care paradigm about how we think about mental health, and how we think about the opioid crisis, which continues to change. And those with substantive abuse history are at higher risk for losing jobs and therefore losing health insurance coverage. But the policy and advocacy needs are huge.”
“ I was stunned to learn that child poverty was reduced by more than 50 percent during the pandemic, through a law,” Kaminski noted.” And he referenced a Daniel E. Dawes’s 2020 book The Political Determinants of Health as a volume that people should consider reading in order to become enlightened on some of the key healthcare policy issues. “And when I give a lecture on population health and ask how much of what we spend on healthcare affects the health of the population? And the answer is 10 to 20 percent. So for all the clinical work we do, we won’t be able to create fundamental change through healthcare alone,” he emphasized.
“I think that everybody agrees—and this has bipartisan support—that we spend too much on healthcare and that number is going up too fast,” Kaminski continued. “And our outcomes are not as good as those of other countries. That’s why there’s bipartisan support for new care models. But we’re still predominantly in a FFS payment system, which means we’re still getting paid for volume. New models are moving towards total cost of care. And they call for different skill sets; it’s about looking at the total cost of care you’re responsible for. And there are models that wrap services around our sickest, highest-cost patients. They provide transportation, food; and the most amazing thing about that is that they save money.”
“What are you learning from the community?” Wider asked Nemours Children’s Health’s McMillan. “We have folks who do have boots on the ground; but one challenge is funding,” McMillan replied. “We’re so lucky to have the support from a local philanthropic organization, and the expertise of the university; but there are so many needs across the commonwealth and the country, which organizations that don’t have that seed money. So we need more support around things like, for example, transportation.”
“You clinicians are so buys all the time,” Wider said, addressing the physicians on the panel. Is there a need for a population health team in patient care organizations?”
“I don’t think you can do it without a team,” Kaminski said.
“I agree,” Walker added. “And maybe we’re a little bit biased here on this panel, but more and more, we’re hearing from primary care doctors, including solo docs, that they need help. They can’t hire a community health worker to navigate, because of the overhead cost. So what we’re seeing is more and more transitions to teams. Whether Oak Street or CVS—we’re going to see more and more connections for patients. And for my patients are just trying to navigate the system. And I don’t want them, in my value-based contract, to land in the emergency room when they could be cared for through urgent care, etc. So we need a robust team to identify patients at risk in advance. Or the school nurse who calls the pediatrician about a child at risk. So as we move towards paying for health in this value-based world, we’re going to see the need to use the provider at the top of their license, but support their work with a team.”
