Health Care’s Increasing Focus on the Drivers of Health

SHANOOR SEERVAI: When it comes to our health, where we live, what we eat, and how much we earn could actually matter more than the specific medical care we receive. Researchers use the phrases social determinants of health and drivers of health to describe this. That’s a lot of words, but how we talk about these issues and how much attention our health system pays to meeting unmet social needs has a very real and vital impact on people’s lives.

What’s exciting is that now, for the first time, federal policymakers are trying to measure and screen for these drivers, like food insecurity, housing instability, and transportation problems. I’m Shanoor Seervai, and today on The Dose we’re going to get into what this means for improving outcomes for patients. My guest, Dr. Alice Chen, is chief medical officer at Covered California, and a physician who has dedicated several years to caring for underserved patients.

Dr. Chen, welcome to the show.

ALICE CHEN: Thank you, Shanoor. It’s great to be here.

SHANOOR SEERVAI: Let’s start by talking about what is intended by the language typically used in this space. So social determinants of health, drivers of health. Is this language doing the job well?

ALICE CHEN: Well, it is not surprising that with the burgeoning interest in the health care sector to address issues like food insecurity, housing instability, and economic stressors, you have a whole new lexicon developing. It’s kind of an organic process, and as you mentioned, there are a lot of terms that are used interchangeably, social determinants of health, health-related social needs, social drivers of health, social risk factors, nonmedical risk factors. You could go on and on.

And in some ways that’s great because it means a lot of people are paying attention and trying to create the verbiage and the framework for addressing them. And I have to laugh a little bit because almost 25 years ago when I was a medical resident, I worked with the Boston Public Health Commission to do a hospital survey of access barriers like these things, like proximity to public transportation, hours of operation, availability of interpreter services. And we actually called them nonfinancial barriers to care, which is, again, a little laughable because all of them are intimately tied to fundamental financial and socioeconomic status.

But at that time, everyone was thinking about insurance coverage and ability to pay for care. So it really depends on the context. All of which is to say that I’m not actually a stickler for which term is used, as long as there’s a clarity in what we mean. Which is why, of all the terms that you mentioned, the one that I would set aside as distinct from all the others, is social determinants of health, which many people refer to as SDOH.

SHANOOR SEERVAI: And is that your preferred term, or why do you set it apart as distinct?

ALICE CHEN: Well, what I would say is it’s not necessarily preferred, it’s just a different concept. So the WHO defines social determinants of health as, and I’ll quote them here, “The conditions in which people are born, grow, work, live, and age, which are shaped by the distribution of money, power, and resources.” And so what I would say is most health care organizations, whether it’s health systems, payers, purchasers, aren’t actually trying to address the social determinants of health, but rather individual health-related social needs or social drivers of health or social risk factors.

So for example, my hospital has a food as a medicine program, which is invaluable. I refer my patients all the time, but it doesn’t change the fact that they may live in a food desert, where the only source of fresh food is a corner store with really ratty produce. And the reason I feel so strongly that we think about social determinants of health as separate from these other terms is because the health care sector actually needs to address both. As large as the health care sector is, 18 percent of GDP, we have a responsibility to think about how we invest in communities, particularly anchor institutions like hospitals, and actually get upstream and address things like inadequate availability of affordable housing, or food deserts, or lack of transportation.

And many groups are also addressing individual health-related social needs, attending to individual patients with programs like Food as Medicine programs or partnerships with Uber or support for rental assistance. So I think there’s a critical distinction between those two, and I think by conflating them, it lets us off the hook in terms of addressing the more fundamental social determinants of health. And they’re different, obviously, different solutions and interventions for each of those categories.

SHANOOR SEERVAI: So let’s talk a little bit about that. What language would be most useful, most constructive to see an impact on the ground?

ALICE CHEN: Well, again, I think it’s a both-and, but for most of the activity you’re seeing in the field, it really is health-related social needs or drivers of health. Because most programs that you’re seeing, whether they are being sponsored by Medicaid agencies, health plans, hospitals, really are focused on individual patients and addressing their health-related social needs in order to improve outcomes or utilization patterns.

SHANOOR SEERVAI: And what’s at the core of these health-related social needs? Because sometimes I feel like the language or the policy jargon sort of masks what is very real and what we know that racism and poverty have a huge impact at the patient level.

ALICE CHEN: I think I’ll go back to what you said in the beginning, which is that these issues could matter more than health care. In fact, we know that they matter more. We’ve known for a long time that health care probably only accounts for 10, maybe 20 percent of health outcomes. I think the recent interest in people really getting to the core of issues of poverty and racism are, in my mind, started with passage of the ACA and a focus on population health and unaccountable care.

And as people started thinking about how you actually improve health and not just provide transactional health care services, you start to widen your lens and realize, oh, there are all these other factors that are actually driving population health. I think another piece of it for me is a book that came out, I believe it was in 2015, Betsy Bradley’s book, The American Health Care Paradox.

Essentially, it was an epiphany that answered the longstanding question of why in the United States do we spend more per capita than any other industrialized country, still leave some people out, and get really middling, if not poor outcomes, particularly on the population health level? And what she realized is even though we are a complete outlier in terms of health care spend, if you stack health care and social services spending, we are no longer an outlier. We’re middle of the pack.

But more importantly, when you actually look at the distribution of that spend, most other industrialized countries, for every dollar they spend in health care, they spend two dollars in social services. Whereas in the United States, it’s completely flipped. For every dollar we spend in health care, we spend 55 cents or 60 cents on social services.

And then the final piece, which I think really accelerated things, was COVID, which clearly many of us have been working in the disparity space for years. But you really could not avoid the fact that between the impact of COVID-19, the disparate impact on communities of color and impoverished communities as well as the Black Lives Matter movement. I think those two things coming together really enabled people to start talking more directly about what’s been in front of us this whole time, which is that poverty, structural racism that leads to higher rates of poverty in communities of color, is what is driving a lot of the poor health outcomes.

SHANOOR SEERVAI: What is most meaningful about the way the conversation is shifting now? What do you think has potential to actually have an impact on people’s lived realities?

ALICE CHEN: It really is a thousand flowers blooming. There was a 2019 JAMA study that showed that 92 percent of hospitals and 66 percent of physician practices were screening for at least one driver of health. I think one of the most exciting developments is CMS’s adoption of its first-ever drivers of health measure in August of this year. And it is a measure that requires screening for five domains, food insecurity, transportation issues, housing instability, need for utility assistance, and interpersonal violence, as well as importantly, the screen positive rates.

So it’s a two-part measure. Have you screened for these five domains, and what is the percent positive? This measure is required of hospitals for their inpatient stays and is being proposed for MIPS [Merit-based Incentive Payment System]. And the reason it’s important that it’s a two-part measure is because, one, we want the health care ecosystem to start thinking about these domains as critical to a person’s health and health outcomes. And so that screening will hopefully lead to intervention at the point of care for that person. But the screen positive rate then tells you at an institutional and even community level, what are the high priorities, in terms of investment by that organization, institution, or potentially community? So among those five things, if transportation really jumps out, then it gives you a sense of where to prioritize.

SHANOOR SEERVAI: So just to back up a little bit again, so CMS is proposing this. Is it only for people on Medicare or is it for all patients?

ALICE CHEN: This is in the Medicare hospital inpatient quality reporting set.

SHANOOR SEERVAI: What impact do you think that this screening measure will have for Medicare patients, but also the population at large?

ALICE CHEN: Well, I think particularly in the hospital setting, Medicare is such a large payer that once you have hospitals starting to screen their Medicare patients, it doesn’t make sense only to screen for Medicare. That’s not the way quality systems work. So I think there will be a wonderful halo effect, in terms of addressing all patients.

Clearly there is a need for alignment, and this is something that I know that CMS, CMMI, Medicare, Medicaid are all interested in. And I do think that adoption of this type of measure, in Medicaid in particular, is a no-brainer. And then we in the marketplace have also been pushing to have a similar alignment of measurement.

SHANOOR SEERVAI: And so where are we in actually seeing this CMS measure impact the hospitals and the patients who are in hospital?

ALICE CHEN: So it just got adopted in August. So it is not widely used. I will say, for example, though again, this domino or ripple effect is very powerful. Here in California, our department of health care access and information has stood up a hospital equity committee to look at measures that all California hospitals would need to report on, regardless of who the payer is for a given patient.

And the fact that CMS has adopted this for Medicare sets a precedent for California to align to in moving forward. So again, I think one of the really important things, given where the field is right now, is trying to figure out if we can come together across multiple sectors, meaning hospital, ambulatory, health plans, as well as across payers to have a more unified systematic approach so that we can better aggregate the data and better understand what’s happening both at a community and then rolling up to a larger state and national level.

SHANOOR SEERVAI: So let’s talk a little bit about what’s happening in California. At Covered California, your mission is to ensure that people have insurance coverage, but of course, just having insurance does not guarantee excellent care. So what are the main obstacles the state is facing when it comes to delivering care at the patient level?

ALICE CHEN: I did want to start just by saying that Covered California is the state’s health insurance exchange or Obamacare exchange. And that from our inception 10 years ago, our mission statement is not just about coverage, but about quality, equity, and delivery system transformation. I will say there are obviously a lot of issues in California that are similar to what the entire nation faces in terms of a behavioral health crisis.

We have done a lot in terms of trying to increase investments in primary care, which again, is a national issue. What I’d like to share is some of the state programmatic and policy innovations, in terms of how we’re going to move forward. I think in the context of COVID-19, again, equity is really front and center for our state and Medi-Cal, our state’s Medicaid program, is the single largest insurer. It covers more than one in three people right now in California and has a very ambitious agenda to improve access, equity, outcomes.

And I’ll just give you a quick rundown of the four key pieces. The first is around expansion of Medi-Cal to all undocumented, which will start in 2025. And that really lays the groundwork for the beginning of a true safety net, regardless of your legal status, that everyone below a certain income level will have access to coverage. The second piece is around our waiver, Cal-Aim, addressing drivers of health for our most vulnerable. So folks who are incarcerated, folks who are homeless, people in the foster care system, and making sure that we can really provide the full scope of wraparound services in order to improve their health.

SHANOOR SEERVAI: So you’ve worked for so many years in the safety net. How has that really informed your approach both to your work now at Covered California and what you perceive as the most urgent issues?

ALICE CHEN: Yeah, I think when you work in the safety net and you really listen to your patients, these issues around health-related social needs, and then the higher-order issues around social determinants of health, structural drivers of poverty, structural racism, really are fairly self-evident. It’s been wonderful to see that the larger health care ecosystem and policymakers are tending to things that people have been trying to address for decades.

When you look at federally qualified health centers, the original model that Jack Geiger and Count Gibson stood up in Mississippi, it was meant to be a whole person care intervention, not just to provide medical care, but to address food insecurity. They created community gardens. To address public health, sanitation issues, they dug sanitation wells. Investing in early childhood development. These things are all clearly, to anyone who’s working with underserved populations, critical and likely more critical than the prescriptions you give for high blood pressure or diabetes. So I do think this societal openness and eagerness to address both individual and then moving upstream to structural determinants is long overdue and very welcome.

SHANOOR SEERVAI: But how do we scale this up, right?

ALICE CHEN: Yeah, I think it’s a both-and. I think ultimately health happens locally. And there’s certainly things that can be done at a national level to scale this quickly. And the prime example around food insecurity is enrollment in SNAP. There is plenty of evidence that being on SNAP improves health outcomes, particularly for moms and kids.

And my colleagues at the Health Initiative oftentimes say, “What we measure and pay for is the ultimate expression of what we value.” What if a measure, a quality measure for Medicaid managed care plans, was the number of enrollees or percent of enrollees who were enrolled in SNAP? That would be a fairly straightforward way to incentivize all MCOs across the country to create those linkages and the systems and processes to get people into a program that we know works and will improve their health.

SHANOOR SEERVAI: Just coming back briefly to the CMS measure, are we anticipating more federal initiatives like this that will drive the needle forward?

ALICE CHEN: I think there is a real interest in discussion around adopting the measure that’s currently in Medicare — thank you for pointing that out — and making sure that it gets embedded in Medicaid and marketplaces. I think the other place where you see the ripple effect is NCQA just adopted its first social need screening and intervention measure. It’s slightly different. I think, not quite as robust in terms of having a clarity of percent screened and then percent positive, but it is a really important step forward in signaling to health plans that this is a priority.

SHANOOR SEERVAI: And let’s zoom in a little bit to the provider level. I recall when we first talked, you mentioned a patient with diabetes but also who was struggling with housing at the time.

ALICE CHEN: Yeah, that was a humbling experience for me as somebody who’s been working in the safety net for over two decades and who teaches about this and coaches residents about it. But I recently had a woman who at age 70 became homeless for the first time, and she is living in her car. And her diabetes, not surprisingly, is not in control. And I prescribed her a diabetes medication that needs to be refrigerated. Did not think about it. And she then had to come back and engage with our nurse and have a medication adjustment.

And I guess what I would say is, even for those of us who are immersed in this and who think about this, that the exigencies of clinical care are such that it can get overlooked. Which is again, why I think we need these systems in place. And if, for example, there’s universal screening and there’s a popup on your screen, and what if there were even once in your EHR you are identified as having marginal housing or homelessness, that it would actually have an alert when you’re trying to prescribe a medication that needs to be refrigerated, right? We have alerts for contraindicated medications because of your renal function or for drug–drug interactions, but this is where we could go to the next level and bake into the system to have it really embedded in our systems.

SHANOOR SEERVAI: And so the last question I want to ask you is about systems. We’ve talked on this podcast before about how underfunded and beleaguered our public health system is, but then issues of race, poverty, and social disadvantage tend to be pushed into that space. And so what we have is that the most vulnerable people are relegated to the most vulnerable systems. And I’m curious how California is approaching this inequity and addressing it.

ALICE CHEN: Yeah, I think that is a really fundamental issue with our society. I remember many years ago going to a talk by Uwe Reinhardt when concierge medicine was first coming to the fore, and he said, “Why is everybody so upset? In America we have concierge education, we have concierge housing, we have concierge . . . why wouldn’t we have concierge medicine?”

And his point was, “Let’s not focus on the ceiling. Let’s focus on the floor and let’s focus on the fact that we need to have a floor and then raise the floor.” And so again, California is not perfect, but what I would say is that the things that California is doing in terms of particularly Medicaid expansion and also on the Covered California side, enhanced subsidies even before ARP, really trying to create a seamless safety net and then raising that floor, I think is a model for the nation. It’s not that it’s perfect, but I think that our strong network of FQHCs and public hospitals does provide access in most parts of the state that mitigate some of the other structural issues.

SHANOOR SEERVAI: So when you’re talking about the work that California is doing, do you think that there’s an implementation calendar in mind when we could get there, and then potentially when some of this could get to the rest of the nation? We’re talking years, decades? Do you hope to see this in your lifetime?

ALICE CHEN: I do hope to see it in my lifetime. And I think the one other thing I’d say is, as someone who’s been in the safety net for so long, what’s interesting is we’ve always said vulnerable patients are kind of canaries in the coal mine, but a lot of the issues that they are facing and a lot of the solutions are actually applicable to the larger health care system. And I do think that many of the innovations that you see coming are emanating from the Medicaid space are actually going to have implications and impact, certainly. You see that in Medicare Advantage already, and particularly for the duals, but across the entire spectrum of health care.

SHANOOR SEERVAI: Dr. Alice Chen, thank you so much for joining me today.

ALICE CHEN: Oh, my pleasure. Thank you.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.

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Hi everyone, it’s Shanoor again. This episode was recorded in October, and for the next few months, The Dose will be going on hiatus. We’ll be back in touch in the new year with more conversations about how to make health care better for all Americans. Thanks for listening.