Just how much private money is invested in the social determinants of health (SDOH) and will it help or hurt outcomes?
To paraphrase the holiday favorite It's a Wonderful Life: Every time a healthcare bell rings, a cottage industry gets its wings.
The bell that's ringing, loudly, is health equity. The companies that have emerged improve outcomes through data, platforms, and analytics form the cottage industry. Many of these companies are funded by venture capital, traditional and corporate. And because they are, it remains to be seen which of the equities will be prioritized—private or health—and if new disparities will be created as a byproduct.
Growth of SDOH companies: 1985 to present
"The combination of increased SDOH funding with inefficient mechanisms to meet patients' SDOH needs has led to the emergence of the for-profit SDOH industry." This from an October 2021 Population Health Management analysis of SDOH companies from 1985 to July 2021. During that time, 58 companies have received $2.4 billion in private equity (PE) funding and have been valued at more than $18.5 billion. Highlights include:
Most SDOH companies (nearly 66%) were founded after 2000 but before 2010.
Between 2015 and July 2021, 19 companies have been founded.
Between 2017 and July 2021, nearly half of SDOH companies (46.6%) were focused on the home care/general caregiving sector.
Additional subsectors are community care coordination (20.7%), food insecurity and nutrition (10.3%), nonemergency medical transportation (10.3%), and value-based provider (8.6%).
More than 73% of SDOH companies during this time period have secured more than or equal to $100 million in funding. Another 88% have been valued at $1 billion or more.
Learning from value-based care
Healthcare has been here before.
Inc. once called the Affordable Care Act "the gazillion-dollar startup machine" whose emphasis on value-based care (VBC) had already spawned $10 billion in funding for 500 new companies by 2016. As Bob Kocher—a physician, venture capitalist, and leading healthcare policy advisor during the Obama administration—said at the time: "Anytime you take a sector and apply a whole bunch of regulatory changes and economic incentives to it, it creates enormous opportunities for new entrants to come and take advantage."
It still does and SDOH is the new vehicle. But not all SDOH investments, or motives, are created equal. To its analysis, Population Health Management adds:
"It is possible these companies structure their focus to the SDOH interventions most supported by new Medicare and Medicaid regulations. The most saturated subsector, home care and general caregiving, is responsible for nearly half (27, or 46.6%) of companies in the industry. Despite research heavily supporting outcomes from investments and interventions in food insecurity and care coordination, these sectors represent smaller components of the industry."
The study's authors specifically question "the downstream effects they [SDOH startups] will have on community-based organizations also working to improve SDOH."
Investment on a downturn
The PE bull market has now turned bear.
Citing CB Insights, HealthLeaders recently reported that Q1 2022 PE investment decreased quarter over quarter in two SDOH-associated areas: a 60% decline in mental health tech funding and a 32% decline in telehealth funding.
In a May 2021 letter that can only be described as scary, early-stage accelerator and investment leader Y Combinator advised companies to "plan for the worst." The letter's post-script adds: "If for whatever reason you don't think this message applies to your company or you are going to need someone to tell you this in person to believe it… please reassess your beliefs on a monthly basis to make sure you don't drive your company off a cliff."
Balancing need, utilization, and investment
While investments were down, other PE barometers were up. Funding for the Q1 2022 telehealth market was still $3.2 billion-funded and startup valuations climbed 350%.
While the positive role of PE and its long-term SDOH investment may be in question, the downturn clearly comes at a bad time as the need for more telehealth and mental well-being services remains high.
In its 2022 Environmental Scan, the American Hospital Association (AHA) reports that telehealth utilization is still 38 times higher than pre-pandemic levels. The AHA further reports that 40% of consumers and 57% of physicians want to continue using virtual care. FAIR Health adds that mental health continues to generate the highest percentage of telehealth claims at 64.2%.
Stakeholders have decisions to make
Payers and other traditional healthcare stakeholders—including those with PE investment arms—must navigate these contradictions. Two examples are integrated provider-payer giant Kaiser Permanente and not-for-profit, mid-Atlantic leaders CareFirst BlueCross Blue Shield.
Per Population Health Management, Kaiser has "a large databases of SDOH tools tailored to specific domains, as well as an evaluation of each." This is rare in an industry still searching for SDOH standards.
CareFirst has announced that it is expanding its investment in SDOH data across all business functions for an "enterprise-wide social risk intelligence strategy" with its existing partners, Socially Determined. What began as a pilot focused on the root causes of diabetes has expanded to employer, philanthropic, and care management decisions and investments.
Both Kaiser and CareFirst have distinct venture arms—Kaiser Permanente Ventures and Healthworx—although the above-referenced developments are not specifically tied to those companies.
The broader SDOH business case
An August 2021 HealthLeaders feature posed the question: When private equity firms invest in healthcare, who benefits? The article noted the importance of "build[ing] economic models that do not simply lead to near-term profits and cause damage to the healthcare ecosystem."
While the quote referred to PE physician practice investment, it applies equally to past decisions on VBC and evolving ones for SDOH. Improving health equity will require multiple business and ROI cases and companies that are in it for the long haul. That ROI ranges from lowering total cost of care and adverse utilization/readmissions, to improving care plan adherence for a specific condition/population, to increasing the number of healthy days that individual consumers experience.
Massive valuations do not equate to long-term success. And when the objective left in the lurch is health equity, it can be a lose-lose proposition.
Clinical trial innovation must be patient-centered, inclusive, and tech-enabled.
The Reuters Pharma Clinical 2022 virtual conference, held May 17-19, featured more than 20 presentations but one predominant theme: that "accelerated technology adoption in clinical trials … has neglected patient needs." The conference included 40-plus speakers, largely from the life sciences industry.
The event spanned traditional topics (trial design, engagement, and participation) while highlighting the need for greater inclusivity so that the following tech advancements do not come at the expense of patients:
Standardizing trial data and digital health developments
Expanding clinical trial virtual options post pandemic
Using AI and machine learning to enroll more diverse participants faster
These topics were presented against the backdrop of the conference’s stated mission: "We must establish new industry-wide benchmarks now, leverage recent digital innovations, and ensure permanent cultural change toward patient-centric trials. If we do not act immediately, we risk losing this opportunity to rebuild patient trust."
Additional conference presentations emphasized the importance of patient-reported outcomes, pipeline strategies that please both regulators and investors, and partnerships with advocacy groups to aid participant engagement.
Data standardization
The Reuters conference emphasized that data standardization in clinical trials is necessary to achieve a common healthcare industry objective: scale and efficiency. One panel (“Faster trials need unified data standards across healthcare”) highlighted the need for:
Specific performance indicators for data collection
Real-world data (RWD) to identify trial participants
Data standards that also speed automation and quality outcomes "across tools, sites, and … measures"
Data standardization has also become central to health equity, specifically the collection and use of race, ethnicity, and language (REAL) data. Beyond the world of clinical trials, multiple CMS regulations and initiatives will require this data—a focus stakeholders generally support while raising concerns about the lack of existing guardrails.
Breakthrough technologies, decentralization, and real-world data
The Reuters panelists also addressed trials involving digital therapeutics (DTx) and the growing role of decentralized clinical trials (DCT) during and post-COVID-19.
DCTs use telemedicine to conduct trials remotely and virtually. Meanwhile, DTx trials must increasingly use RWD and real-world evidence as patients, providers, and payers look beyond the pill for treatment. This is critical as drug costs rise—particularly for emerging one-time, curative, and gene/cell therapies.
While it's not a surprise that private payers incur higher pricing for hospital services, the percentage above average may be—224% of Medicare payment.
The figure comes from a new RAND Corporation report based on 2020 data that continues research from 2018 when those averages were slightly lower. The inflated pricing also applies to what commercial insurers and self-insured employers pay for physician fees and ambulatory surgery center (ASC) care.
In a press release for the report, lead author and RAND policy researcher Christopher Whaley encouraged stakeholders to use the data to "become better-informed purchasers of health benefits" and to look "for strategies to curb health care spending."
Among the study's highlights:
Employers and plans pay more for hospital care. The 2020 national hospital average of 224% declined from the 222% paid in 2018 and the 235% paid in 2019.
ASC and professional service rates are higher, too. Compared to Medicare, plans and employers pay on average 163% more for physician fees and 162% for ASC outpatient services.
Pricing varied significantly across states. Florida, West Virginia, and South Carolina log the highest prices (310% of Medicare) and exceed the study's average (310%). Hawaii, Arkansas, and Washington come in below the average, at 175%.
Spending is in the billions. In 2020, private purchasers paid more than $80 billion: $78.8 billion for hospital-based care and $2.0 billion for ASC care.
Facility-specific pricing is included. The RAND report is unique in that costs at individual hospitals and health systems is included with the overall, state-based, and facility-specific pricing averages. This is a boon for purchasers, who generally lack access to this information.
RAND's 2020 expanded research includes 4,000-plus U.S. hospitals, including short-stay facilities, and a near-equal number of ASCs—a first-time inclusion in RAND's ongoing research. RAND sourced data from self-insured employers, all-payer claims in 11 states, and participating health plans.
Co-pay and cost-share waivers improve access as PCP-specialist teamwork grows.
What stigma helped create, COVID-19 has made worse.
The crisis in question is mental health. Blue Cross Blue Shield of Massachusetts (BCBS-MA) is responding with employer benefits and integrated care delivery models designed to speed access, equity, and innovation.
"These are a few solutions we're developing along with our account partners," says Dr. Gregory Harris, BCBS-MA's senior medical director of behavior health and an architect of the plan's new offerings. "Employers want to think differently and so do we."
The question that spans all benefit design changes is does this help reduce the barrier to access? Harris adds: "There are so many angles to look at: some within health plans, some across the mental health delivery system." In an interview with HealthLeaders, Harris details BCBS-MA's new mental health benefits and the psychiatric collaborative care management that anchors them.
Benefit updates, employer response, and member impact
BCBS-MA's new employer designs are benefitting thousands of BCBS-MA members and include three offerings:
Co-pay cost-share waivers. Employers can offer the waiver for an employee's first one, three, or six visits for mental health/substance use disorder. Twenty-one employers have signed on, impacting more than 38,000 members.
Medication cost-share waivers. Employers can offer $0 co-pays for multiple prescription drugs; 10 customers are providing the mental health medication benefit for 27,000 members. Six employers have signed up for the substance-abuse medication benefit, affecting more than 18,000 members.
Wellness incentives. In a single month, 28 employers began offering a $300 reimbursement for employees who partake in programs, classes, and apps for stress reduction and relaxation. More than 93,000 members can benefit.
The decision-making process
Harris worked with account teams to execute a process that is giving employers more options:
Internal pilot beginnings. BCBS-MA offered enhanced benefits internally first. Approximately 3,800 employees have the waived co-pays for select depression/anxiety medications.
Clinical and account team collaboration. Before expanding to employers, Harris and BCBS-MA account leads collaborated to design benefits that expand access.
Employer engagement. While employee mental health is top of mind for most employers, some companies are more involved. "They are looking for the next inflection point," says Harris. "We discuss uptake, results, and decisions to create a product for them and to continue expanding."
Evaluation and next steps. Harris states that the plan is making decisions for 2023. "We're looking at what course of treatment looks like after the 1-3-6 visit approach gets patients in the door." BCBS-MA may also differentiate design between children and adults.
Learning from each other
Harris is equally invested in what he brings to BCBS-MA and what its teams have taught him. The practicing psychiatrist is charged with shaping and operationalizing the plan's mental health strategy with internal associates, customers, and clinical partners. Harris offers ongoing mental health chats, presentations, and interactive Q&A sessions across the organization.
"I came to BCBS-MA grounded in what patients and clinicians need and want, but not as familiar with what employers are looking for," says Harris. "Now, thanks to my work with our account teams, I'm also skilled at designing employer programs."
He adds: "I've spent a lot of my time working to align the needs and incentives for all parties, including patients, employer accounts, clinicians, and the health plan. I try to offer clinical options that will meet the needs of the employer and the member."
Layering collaborative care for added benefit
Part of what Harris adds is a focus on psychiatric collaborative care management. The model creates tighter bonds between primary care and mental health specialty care. The desired result? Faster screening, earlier consultation and referral, and the billing education and incentives PCPs need to integrate the model.
Harris emphasizes that CCM adds the right kind of layers to the delivery system, from patients to providers.
"In Massachusetts, you can self refer to a psychiatrist or therapist. You don't have to go through a PCP, but the unintended consequences are that you're on your own in a system of solo practitioners," says Harris.
"CCM knits things back," he adds, noting that in a fragmented system, it's important to get more done in primary care. "CCM helps connect the dots. Integrating mental health specialty care into primary care is a good 10 years behind other models."
"So many aspects are a supply and demand crisis. Many people are untreated and not thinking of options like their PCP. It's not a good layering of the system, which must meet mild, moderate, and severe need in a better way."
For Harris, it's a reminder of interests that date back to his professional beginnings.
"I started my career with the idea of putting mental health care into primary care," he says. "I always try to keep the patient at the center of everything I do."
One Michigan plan is bringing predictive power to patient drug treatment.
As the social determinants of health grab healthcare's spotlight, the genetic determinants of health provide precision medicine benefits that one health plan is banking on.
Blue Care Network, a subsidiary of Blue Cross Blue Shield of Michigan (BCBS-MI), has launched Blue Cross Personalized Medicine, the state's first pharmacogenomics (PGx) program. PGx is a subset of genomics that uses genetic testing to help predict an individual patient's response to specific drug therapies.
"Our first priority with the Blue Cross Personalized Medicine program is to ensure that a physician is able to provide the right medication, at the right dose, as early in the process as possible," stated a BCBS-MI press release featuring Dr. Scott Betzelos, Blue Care Network CMO and VP of HMO strategy and affordability.
Blue Care Network serves 670,000 members, a small portion of whom will have access to the program, detailed below:
What: Blue Care Network's PGx pilot will use genetic testing to help predict patient response to prescription drugs. The outcome is a "personalized clinical action plan prepared by a trained pharmacogenomic pharmacist" who then works with the patient's physician design to create a targeted care plan based on PGx results. Patients incur no costs for the program, which Betzelos describes as "an opportunity to bring not only pharmacogenomics to the forefront, but a wrap-around service for our members." Blue Cross Personalized Medicine will include PGx testing for behavioral health, cardiology, cardiovascular, and oncology drugs.
Who:MiBiz reports that the pilot includes approximately 500 Blue Care Network Medicare HMO members, with a possible rollout to PPO members. Physicians who believe their patients can benefit order the PGx test, with DNA sample collection managed between the member and Blue Care Network's testing vendor, OneOme.
How: Betzelos details the importance of keeping the PGx process secure: "Patients will manage their own DNA sample collection, using OneOme's easy-to-follow at-home kit, which is then mailed directly to the OneOme laboratory where results are processed and then shared only with the patient, their physician and supporting pharmacist provided by OneOme."
Betzelos adds: "Blue Cross, Blue Care Network and our members' employers are not involved in the test collection or analysis process and are not provided access to the test results at any time."
Why: PGx helps predict patient response, versus waiting to see whether a medication works and losing valuable treatment time in the process. In addition to the potential for better outcomes, PGx has the potential to disrupt the prior authorization, step therapy, and quantity limit processes that health plans deploy for utilization management.
When: The PGx pilot launched in March 2022, with full HMO expansion planned for January 2023 and PPO a potential for 2024.
"It's not that PGx is new," says Betzelos. "[It] has been around for 10 years or so, but the adoption of it is still not where it needs to be, or the awareness for providers." He notes that PGx expanded when the FDA recognized its potential beyond a handful of drugs.
"So, we thought at Blue Cross, let's develop this novel, innovative program, bring precision medicine to the front door of our physicians and our members," says Betzelos, adding: "This is not voodoo medicine. This is real. There is literature that supports it, and we looked at that literature and examined it and wanted to move forward with a program that would provide value to the membership."
The Clover Health president links the company’s open-network model to greater equity for patients and providers.
Health equity and open-network strategy are two of Andrew Toy’s favorite subjects. The Clover Health president links the two with an attention-grabbing description of what he believes narrow networks represent: “It’s provider gerrymandering.”
Gerrymandering: the process by which incumbents draw tortured maps to cluster constituents in the most favorable way possible. Toy believes narrow network design does the same thing—jutting here, constricting there, while leaving disadvantaged patients and providers stranded within the delivery system.
The narrow-network approach runs counter to Clover’s desire to “double down on the importance of health equity.” Toy notes that the company’s open-network, PPO-first approach allows it “to work with any provider, anywhere.” This is the puck Toy believes all health plans will eventually skate toward. “If we say we want health equity, and it’s a priority, the industry will be moving toward open networks to achieve better equity, quality, and care.”
Clover’s mission is to “improve every life”—traditional Medicare beneficiaries and Medicare Advantage (MA) enrollees alike. Clover supports both populations as an MA plan and a CMS Direct Contracting Entity (DCE) supporting traditional fee-for-service (FFS) members. “We are going after the entire one trillion dollar-plus Medicare market,” notes Toy.
“Serving all people is the right thing to do morally,” he adds. Clover reports that more of its MA members identify as people of color, report multiple chronic conditions, and live in disadvantaged area compared to other plans—another advantage of an open network of physicians who look like their patients.
“People often want a physician of the same ethnicity,” says Toy, adding that anything that helps increase trust is good.
Clover Health’s current enrollment stands at 85,026 insurance members (MA) and 172,416 non-insurance members (Medicare FFS lives through DCE). Clover expects to participate in ACO REACH, CMMI’s iteration of the DCE and Global and Professional Direct Contracting (GPDC) Model, beginning January 1, 2023.
Toy says of the new model: “We applaud and welcome CMMI’s evolution of ACO REACH to focus on advancing health equity for America’s most vulnerable by making value-based care accessible to more physicians.”
In other words, providers need equity, too? “This is only the second time I’ve heard anyone talk about health equity from a provider standpoint,” answers Toy, adding: “Doctors who serve more disadvantaged patients tend to be dropped by other plans. We want to include them and help them get through their day with better tools."
One of those tools is Clover Assistant, which Toy terms a “digital on-ramp for value-based care.” As highlighted in a 2021 HealthLeaders interview with Toy, Clover Assistant gives PCPs the tools for better, more personalized, data-driven care. Clover Assistant creates actionable data aggregated from EHRs, pharmacies, and labs, as well as socioeconomic data and evidence-based protocols.
Clover 2021 data shows lower MA medical cost ratios (MCR) for returning customers whose primary care providers use the Clover Assistant. And MCRs were lower depending on when the customer’s PCP went live with the technology and how long they have been using it. For example, members with doctors who started using it in 2018 had a 4.2% lower MCR than members whose PCPs who went live on Clover Assistant in 2019. Similarly, members with PCPs who went live in 2019 had a 5.5% lower MCR than members with PCPs who started using the technology in 2020.
Toy adds that Clover Assistant’s scalability is one component of its expansion into traditional Medicare, aided by the company’s unique business model.
Clover’s new CTO, Conrad Wai, has noted that “building … [a] proprietary tech stack within an insurer allows us to prioritize developing functionality that makes the product more useful to physicians. At the end of the day, helping doctors practice more effectively and efficiently, by definition, means healthier patients."
Toy adds: “While other companies may be constrained by antiquated technologies, geographic limitations, or asset-heavy approaches, we believe our tech-centric strategy enables us to quickly and cost effectively deploy software to providers nationwide, including in historically underserved markets."
Toy believes trust must be present for any technology to do its job, and that all technologies are not created equal in this regard.
“Member portals, for example, disintermediate care,” says Toy. “The best interface for a patient is their doctor, not an app. Trust is one of the most important ways that MDs help manage care.”
That and Clover’s open-network approach.
“Since we’re not tied to specific providers or physical locations we can scale at the speed of software.” It’s an approach that pre-dates the pandemic but seems designed for it and the continued adaptation that will follow.
Toy states: “Coming out of COVID, we see the tailwind moving toward where Clover is.”
Serving Medicaid and uninsured patients, the hyper-local model will address clinical and medical needs in targeted communities.
Sentara Healthcare has announced an innovative model of care (MOC) that will combine prevention and primary care with wrap-around behavioral health and social services. The MOC will target Medicaid members and uninsured populations in Virginia and northeastern North Carolina.
“These centers will touch individuals in a way that has not been previously attempted,” said Dr. Keith Newby, co-director of Sentara health equity, along with Iris Lundy, RN, in a press release for the announcement.
Newby added: “Integrating both clinical medicine and, equally if not as important, lifestyle modification and mental health assistance gives a broader approach to what is needed to improve our patients’ health and well-being.”
Sentara Healthcare is a non-profit, integrated provider that includes 12 hospitals in Virginia and Northeastern North Carolina, a large physician network, and 900,000-member Sentara Health Plans division. Sentara’s MOC components include:
Program Goals – The MOC’s three objectives are to: Create patient relationships that promote trust to ensure needed care; zero in on local needs and the programs that can help meet them; offer more convenience care rooted in neighborhoods and homes; and focus on prevalent and preventable health conditions.
Operations – Sentara Health Plans (Optima Health and Virginia Premier) will operate the community centers, which will be supported by professionals from Sentara, other health systems, and community organizations.
Where and When – The first community care location is planned for Hampton Roads, Virginia, in summer 2022, with multiple additional centers planned throughout the year and into 2023.
Three components – The Sentara MOC will embed neighborhood clinics where its more vulnerable members live, while also providing transportation where needed via a Mobile Health Bus as well as a Homeless Residential Program for patients who are discharged from Sentara hospitals but have nowhere to go.
Collaboration – Sentara worked with local leaders and groups identify, design, and create the new MOC.
Data – Sentara complemented its community collaboration with a combination of geographic information system technology and de-identified data to identify and prioritize Sentara customers and markets for the MOC.
In the press release, Dennis Matheis, president of Sentara Health Plans and executive vice president of Sentara Healthcare, stated: “It is critical that we come together and invest needed resources to build stronger, healthier, more equitable communities … This model does just that and is a testament to the benefits of Sentara’s integrated delivery network.”
Dr. Alison Lum explains why fixing a complex ecosystem is possible but requires all stakeholders.
Devouring an elephant one bite at a time happens faster at scale.
One of healthcare's elephants is prescription drug cost, effectiveness, and patient experience. Scale is achieved when commercial market players target these challenges systemically.
Blue Shield of California's Health Reimagined is an example. The initiative is taking a bite out of healthcare dysfunction by executing strategies at specific points of the ecosystem. This includes the plan's prescription drug programs with Civica Rx, Evio Pharmacy Solutions, and Gemini Health.
HealthLeaders spoke with Dr. Alison Lum, Blue Shield's VP of pharmacy services, and asked her about the brave new world that sees health plans involved in prescription drug manufacturing.
"That resonates with me," she says, detailing Blue Shield's efforts and how her love of chemistry and community pharmacy called her to make a bigger difference.
"It all ties back to being dedicated to a mission worthy of our family and friends. We can't do this on our own. It has to be holistic across the ecosystem—not just pharmacy—while also getting back to simplicity."
Health Reimagined
In 2020, Blue Shield launched Health Reimagined to focus on whole-person care for its 4.4 million members and on systemic change for California. Initiatives address holistic health, high-tech and high-touch support, and personal care. A sample of program results through June 2021 included:
Community health advocates: Advocates helped segment the highest-priority social service needs across multiple regions—from transportation (21% in Butte County) to mental and behavioral health (21% and 25%, respectively) in Sacramento and Los Angeles counties, with added food assistance needs identified in L.A.
Real-time claims: Initiative expanded from a two-hospital system to a 20-hospital, statewide initiative.
Primary Care Reimagined: More than 100 physician groups gained access to tech resources that support care delivery, value-based care (VBC), and predictable revenue.
Prescription drugs are part of these efforts, given their role as cost driver and the complexity of what Lum calls the "prescription drug ecosystem." Detailing the path—from wholesalers, distributers, and pharmacies to providers, plans, pharmacy benefit managers, and patients—Lum emphasizes: "And this is the simple version."
She adds that while plans never touch a drug, they touch the dollars: "We won't be able to address unless every single stakeholder makes a change. Where we are part of the problem, we need to fix it."
Ecosystem inflection 1: manufacturing
How do you lower the cost of insulin? Make it yourself.
In March 2022, Blue Shield joined Civica Rx's effort to manufacture and distribute generic insulin at a well-below-market price of $30. According to apress release, "Blue Shield is a founding investor of CivicaScript … Civica's operating unit dedicated to lowering the cost of select high-cost generic medicines at the pharmacy counter."
In that release, Blue Shield president and CEO Paul Markovich adds that the collaboration "is an investment in public health in our state"—supporting the plan's commitment to systemic transformation through initiatives like Health Reimagined.
Lum tells HealthLeaders that Civica Rx is an example of "a generic manufacturer looking to disrupt the marketplace—trying to figure out how to ensure that there is a price, that it is transparent, and that [plans and patients] know exactly what we're paying for it."
Ecosystem inflection 2: from evidence to experience
If you can't help make a drug, prioritize the ones that are the most effective.
Blue Shield's investment in Evio Pharmacy Solutions targets data-driven prescribing decisions that help lower cost while improving experience across stakeholders. A Blue Shield press release states that Evio's purpose is "to create value for its investor health plans and the members they serve by improving medication affordability, patient experience, and clinical outcomes" via:
Analytics on real-world drug performance and patient experience.
Scaling and integrating findings across health plans.
Aggregating data and insights to advance VBC, including alternative payment contracts for expansive drugs.
Blue Shield's partnership with Gemini Health provides prescription drug information at point of care. The plan reports that since its 2019 launch, the program has saved more than $20 million, has grown to nearly 80,000 health system and medical group providers, and has identified lower-cost alternatives for 40% of patient drugs.
"A big part of someone's experience is how much they have to pay," says Lum. "That impacts their livelihood." In a press release, Lum announced that Blue Shield was expanding the Gemini Health initiative "to include pharmacists and other health care providers in our network as we reimagine how health care is delivered for all Californians."
From chemistry to systemic change
"Most pharmacists get into healthcare because they love chemistry," says Lum,: "I have worked in community pharmacy, helping my neighbors take care of themselves. I didn't want to continue to do that one person at a time."
Lum notes that she is now "thrilled to be working with an organization that is a leader in the state and nation." Noting the role that all stakeholders play to improve healthcare, Lum adds: "I hope we get to a tipping point—that we can inundate with new approaches that span all drugs and ways of paying for value to create sustainability across the system."
The health equity commitment of Kaiser Permanente's late CEO and chair lives on through annual honor.
Kaiser Permanente and The Joint Commission have opened applications for The Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity. The award will recognize "a healthcare organization for an intervention that led to a measurable and sustained reduction [emphasis included] in at least one healthcare disparity."
"The Tyson Award offers an opportunity to show that one of healthcare's most persistent, yet important, problems can be remedied," saidAna Pujols McKee, MD, EVP, CMO, and chief diversity, equity and inclusion officer for The Joint Commission.
In the announcement for the award, now in its second year, Kaiser EVP and CMO Andrew Bindman, MD, added: "In Bernard Tyson's honor, we are pleased to recognize organizations that make a meaningful and measurable impact on reducing the health inequities that have plagued historically underserved and underrepresented populations for far too long."
Explaining the joint award, Kaiser told HealthLeaders: "The Joint Commission looked to leaders in healthcare and healthcare equity and identified Bernard Tyson as the inspiring figure who would be the ideal namesake for a new award program aimed at providing incentives and best practices for the field to improve in healthcare equity. They engaged Kaiser Permanente and worked with us to design and launch the program."
Submitting a winning application
UMass Memorial Health was the first Tyson Award recipient in 2021. In an initiative that promoted well-child visits, UMass streamlined the appointment process, educated and provided reminders to and follow-ups with families, and used telehealth and transportation services to ensure check-ups took place. During the pandemic, visit numbers increased 12% and 16% respectively for children who were Latino and Black.
Last year's Tyson Award finalists included Atrium Health, Children's Minnesota, Northwestern Medicine, The New York and Presbyterian Hospital, and Yale New Haven Health System. Thirty-four unique organizations applied, including providers, health plans, and social needs organizations.
The data must be there
Data's importance is a common refrain for health equity efforts. Data collection on race, ethnicity, and language (REL), as well as sexual orientation and gender identity (SOGI), is difficult to collect from patients but is seen as the best source.
A programmatic emphasis on health equity prioritizes this data and its goals, even as collection, standardization, and ethics questions remain. CMS, individual health plans, and multi-stakeholder collaboratives have all committed, knowing that there is much work to be done.
REL and SOGI data challenges mirror those that linger from the HITECH Act and the Affordable Care Act and that continue to impact broader healthcare transformation. Improving quality, cost, and utilization remains a focus areas of value-based care as social determinants of health (SDOH) add a new but long-standing layer that differentiates the current system from one that is accessible, affordable, and equitable to all.
Application details
Organizations can submit applications through June 20, 2022. The award webpage includes eligibility criteria and submission guidance.
To shrink health equity data gaps, BCBS emphasizes the need for more self-reported patient data to promote greater volume, quality, and consistency. The Blues collaboration calls for more granular and regularly updated information on race, ethnicity, and language (REL) as well as social needs, sexual orientation, and gender identity (SOGI).
2. Following national standards.
BCBS recommends standardization in not only in how data is collected but how REL and SOGI questions are presented and across the technology systems that gather and analyze this data. BCBS companies are working with their partners to make interoperability a key component of health equity strategy, noting the individual efforts of Anthem, Regence, Florida Blue, and BCBS of Michigan.
BCBS and other stakeholders are also working with initiatives such as the Gravity Project, "a national public collaborative that develops consensus-based data standards to improve how we use and share information on social determinants of health (SDOH)."
3. Making collection ethical and transparent.
Noting that patients are often hesitant to report REL and SOGI information, BCBS stresses that healthcare stakeholders must clearly communicate how the data will be used while safeguarding it and ensuring patients have access.
The BCBS action plan seeks to address divergent aspects of health equity: individual and population health. "Every data point is a person with a story," said Sean Robbins, BCBSA external affairs EVP, via company press release. Robbins added that BCBSA and BCBS companies are "eager to work with policymakers and colleagues across the industry to develop and adopt common industry data standards in pursuit of our shared goal to build a more equitable health care system."
In the press release, BCBSA SVP of market solutions Kari Hedges stressed: "To make a meaningful difference, we need the full force of the industry."
The BCBS announcement—part of the Blues Association's National Health Equity Strategy—mirrors a growing trend of industry collaboratives such as Civica Rx and the digital health-focused Graphite Health. These collaboratives seek the kind of programmatic improvements in the commercial market that CMS has sought for the Medicare and Medicaid programs.
