Almost every major health insurer in the country is now focused on addressing the social factors impacting health, such as housing and food insecurity, as part of broader population health efforts to improve health outcomes and lower healthcare costs. A recent survey by Change Healthcare and the HealthCare Executive Group (HCEG) found that more than 80 percent of payers are integrating social determinants of health into their member programs. According to that survey, 42 percent of payers are integrating community programs and resources into their population health programs, and 34 percent said they are integrating census and socioeconomic data with clinical data to develop new insights.
In fact, among healthcare providers and insurance companies, the increasing focus on addressing the social determinants of health, or the upstream factors influencing health, supports the healthcare industry’s broader transition to value-based care and payment models, which focuses on the quality of the health care provided rather than just the volume of services.
Louisville, Ky.-based insurer Humana is approaching this issue through its “Bold Goal” initiative with the aim of improving the health of communities it serves 20 percent by 2020. Through this initiative, which was launched in 2015, Humana is working with local physicians and community organizations to address physical and mental health conditions as well as social determinants of health (food insecurity, social isolation and loneliness) in seven communities.
Humana measures "Bold Goal" community progress using the U.S. Centers for Disease Control and Prevention (CDC) population health management tool known as Healthy Days, which takes into account the whole person by measuring both mentally and physically Unhealthy Days over a 30-day period. In a report on the "Bold Goal" initiative issued in March, Humana reported that "Bold Goal" markets, on average, managed to reduce their number of Unhealthy Days. Knoxville, Tennessee; Baton Rouge and New Orleans, Louisiana; and San Antonio, Texas all had improved Healthy Days as well as improved clinical outcomes.
During a recent visit to New York City, Roy Beveridge, M.D., Humana’s chief medical officer, sat down with Healthcare Informatics Associate Editor Heather Landi to discuss the drive to value-based care, addressing social determinants of health, and the need for more transparency in healthcare. Beveridge joined Humana in 2013 and is board-certified in medical oncology and internal medicine. Below are excerpts from that interview.
There is growing recognition of how social factors influence an individual’s health. How is the issue of social determinants of health impacting the healthcare industry?
“Social determinants of health” is a buzz word that everyone is using, and many organizations are viewing it as a social “nice-to-have.” We look at it as an essential business component of the care of our patients. We believe that food insecurity affects someone’s health, and if someone’s health is affected, their costs are going to increase. Therefore, we need to improve their health, we have a number of years to do it and we’re willing to look at things in the long term. Now, others are focused on having foundations that donate money toward food banks or other issues. Donations without alignment with business imperatives mean that with the next downturn in the economy, or the next time the foundation sees something else they think is interesting, they are going to go somewhere else. From our standpoint, food insecurity is not going to disappear with the next economic downturn, it’s only going to get worse. We need to make this part of our business think, and that’s what we’re doing.
Roy Beveridge, M.D.
What are some initiatives that Humana is doing to address social determinants of health?
We’re focused on three areas—transportation, food insecurity and social isolation. In the area of transportation, we have been able to build into almost all of our Medicare Advantage (MA) contracts provisions to get people to their appointments for their primary care doctor, to the hospital, and to specialists. I’m not going to say that it’s not a problem now, but if you go down to Florida, everyone in Florida under our contracts can get to and from the doctor.
We have a number of pilots looking at the issue of food insecurity, with our biggest study in Florida. We screened 1,500 patients and 800 were identified as food insecure and, of that 800, with half of them we took steps to link them with Feeding America, a non-profit national network of food banks. We also used our social workers to engage them and help them to make sure they are getting food stamps. The goal with that study, over the next few years, is to see whether in fact the PMPM (per member per month) decreases in the group that we connected with food resources. We’re also doing another randomized trial looking at connecting with members through social work engagement so that we’re educating them and finding food sources for them in their communities and signing them up for public food services. We’re studying different approaches at different price points to see what is effective for a particular population. It’s a question of how much money you need to invest to get a benefit for what period of time.
What are some of the biggest challenges in this work?
I think the big issue is to figure out whether it is a ‘nice-to-have’ or a ‘must-have.’ I think a lot of people are paying lip service to social determinants by saying it’s ‘nice to have’ and we’re going to have our foundation give this amount of money to a food bank. But unless you drive it down and use analytics and figure out how it really works for your population, I’m not sure you can get the benefit that you need. I think many well-intentioned folks are giving large chunks of money for housing. I think that’s very noble, but I don’t know how you can use that approach to take care of a broad number of people. If a significant percentage of the population have these housing problems, how are we helping the population as a whole?
Humana launched its "Bold Goal" initiative in 2015. How is that initiative progressing?
If you think about population health as a whole, "Bold Goal" is almost a subsegment of that. What "Bold Goal" says is that we at Humana can’t do this by ourselves, Blue Cross can’t do it by themselves, United can’t do it by themselves, a hospital system can’t do it by themselves and I don’t think the government can do it. If you think that any one entity can, then they are going to fail. The reason that Bold Goal has been successful in San Antonio, Louisville, Tampa, Miami or New Orleans, is that we made a commitment—we’re there and we’re not moving. We meet with all of the stakeholders six times a year and we’re doing projects that engage everyone. The very first meeting we had in San Antonio, we had six non-for-profit diabetes entities that had never talked to each other, and we had multiple food banks that had never coordinated with each other. And, in fact, one of the food banks said, ‘We’ve got all this food, we just don’t know where it should be distributed.’ We were able to build strong relationships between physicians, communities and patients, and four of these communities demonstrated improvements in health over the past year.
More broadly, how would you describe the evolution of value-based care and payment models?
Our net promoter scores for our physicians who are in risk or value-based contracts are significantly higher than those in fee-for-service. [Editor’s note: In a value-based care report issued last year, Humana reported that patients treated by physicians in Humana MA value-based agreements had more preventative care screenings and better health outcomes compared to patients in Humana MA fee-for-service agreements.] We know is that in order for a value-based provider to be successful they need our data, and we have a mutually aligned interest, which is the health of that patient. And, if you improve the health of the patient, then the cost follows. It might take another year or two, for the cost to get there, but improved health always leads to reduced costs.
I was worried a few years ago whether physicians were really beginning to understand how quickly things were changing to value-based care and payment and to risk-based arrangements. As I travel around the country, I think more and more people are getting it. I continue to see that there is not a complete understanding of what full risk means. With regard to the MSSP [Medicare Shared Savings Program] accountable care organization (ACO) program, people still think ‘If I just take a little bit of upside [risk], I’m doing value-based care.’ However, I think the more organized, larger provider groups and hospital systems, they get it and they are investing a lot of money in population health now.
As you mentioned, providers need actionable data to successfully make this transition to value-based care and payment models. How do you see data sharing and interoperability playing into this movement towards value-based care?
When you look at the current Administration’s push, (U.S. Department of Health and Human Services) Secretary Azar basically said interoperability is one of the very important things that he wants to get done, so Blue Button 2.0 is something that they are pushing hard on. [Editor’s note: The Centers for Medicare and Medicaid Services (CMS) is encouraging health insurers to use data release platforms for enrollees that either “meet or exceed the capabilities of CMS’s Blue Button 2.0,” according to an announcement from the agency on 2019 capitation rates and payment policies. And, the announcement goes on to state that “CMS is contemplating future rulemaking in this area to require the adoption of such [Blue Button 2.0 compatible] platforms by Medicare Advantage plans by CY 2020.”]
Then look at what’s happening at Google or Apple and these other companies—the amount of interoperable data coming down is just profound. Right now, the EHR entities have to push data into their portals and then the portals connect to that, through Apple. And so, you’re getting this massive amount of data, which is becoming available, and interoperability is fundamental for the transparency piece so that patients understand what is happening with them. And, we applaud that 105 percent, because, unless you have that transparency, it’s hard to engage someone. So, I can talk to you about your mother’s health, but if on her iPhone, she can get all of her data from every hospitalization and every lab and make appointments, and then allow you as a caregiver to get in, that’s where you begin to get engagement.
HHS Secretary Alex Azar and CMS Administrator Seema Verma have made it clear their intention to push hard to transition the industry to value-based care and to empower patients. Do you agree with the direction they are taking?
No matter how you look at it, regardless of what risk model you look at, the quality scores are higher and the costs are lower. As we continue to move into member transparency and consumer transparency, consumers want to see the quality scores. That’s the transparency that needs to get out there, and I think they are right for pushing this from a quality standpoint. In fee-for-service, it’s the Wild West; quality scores are meaningless in fee-for-service.