Patient Engagement

Moving from a Sickness Model of Health Care to One of Well-Being — Part 2

Interview · June 22, 2018

Karen DeSalvo and Kevin Volpp public health population health social determinants of health social services infrastructure

Kevin Volpp, MD, PhD, interviews Karen DeSalvo, MD, MPH, Professor in the Departments of Internal Medicine and Population Health at Dell Medical School, and former Acting Assistant Secretary for Health in the U.S. Department of Health and Human Services. Part 2 of a 2-part interview. Missed part 1? Catch up here.


Kevin Volpp:  One other area I want to ask you about is related to tools, specifically technology and digital health. You’ve done a lot of work in that space, and I’m curious what you see as particularly promising ways to leverage technology and digital health, and traditional public health programs and strategies.

Karen DeSalvo:  The challenge that we’re going to face, and some of the work, particularly as you’re interfacing with public health and social services agencies, is [that] they are not digitized. As much work as we did as a country in the last decade to create a clinical record that’s electronic, and that’s giving us much better insights into the clinical care experience gap and care opportunities for patients, we’re going to have a lot of work to do as a country to get the partners all digitized.

What’s been emerging in this space is probably three things that I see happening. One is that electronic health records systems are starting to build out tools that their clients in the health care world can use to connect with or help digitize the social services partners. Some of this was spurred by the Accountable Health Communities model, some of it by the various Medicaid models, and some even [by] the private sector across the country. It’s a health care focus pushing out with a new digital tool that creates essentially a portal for your social services partners, and you can have some bidirectional communication and start to build data there.

The second area is a suite of tools that either are marketed to health care and health plans, or to the social services sector. These are tools that some people may be familiar with, like Healthify, or TAVConnect, or NowPow. In some cases, the contract is with the Department of Social Services, or the city health department. In some cases, it’s with a local consortium of health providers. We’re seeing some variability in who’s going to own the license, but what’s interesting about those tools and others like them is that they’re interoperability platforms, basically, and they provide also some digital underpinning for the social services infrastructure.

The third thing for people to watch is when an existing digitally driven company becomes a social services provider — think about the ride share companies like Lyft and Uber getting into transportation — and doing that focused on health transportation. They already come with a pretty good digital platform, and they’re able then to share that information with the health system, so that everybody understands that the patient got picked up and was dropped off, and have a little bit more detail in there. Health systems are using different strategies, depending on where they are and how strong their partnerships are, and how many other resources they have available.

I have a bias: I’d like to see us modernize, including with technology, the social services infrastructure, and help it move from being more of a cottage industry into one that’s a lot more transformative and professionalized in the way that we’ve helped primary care and direct health care systems across the country. Just because there are a lot of jobs and content there, we don’t want to lose the humanity and the skills, but on the other hand, it’s going to be difficult for them to keep up with the demands of not only the high-cost, high-need patients, but the entire population, if we get to a place where risk models, payment models are going to want health systems and others to address not only medical needs, but social needs.

Volpp:  That’s interesting, when you contrast the time now with value-based payment mechanisms and providers in the 1990s, and you try to imagine managing a population of people using paper records, and having these file rooms where you couldn’t search for anything. It was probably hard to get a sense of what indices you were in and try to measure that. But now it should be much easier. You can imagine the same thing should, hopefully, eventually be true for social service agencies.

DeSalvo:  I worry a little bit that we’re ahead of them. I’m going to rephrase that — it’s not that I’m worried, but I think that we are ahead of them as partners. There’s going to be all this pressure, not only, again, from the state Medicaid programs that are already involved in this work — over half of the states are already asking their NPOs to look at social determinants, and as I mentioned, some like Massachusetts or Minnesota, Oregon, or Rhode Island are already moving into a world of downside risk as a part of where they are in that continuum — but also Medicare, and Medicare not just through [the] Accountable Health Communities demonstration, but the recent call letter about Medicare Advantage really expanded the opportunities for Medicare Advantage programs to address social determinants of health.

There’s a lot of activity on the health care and the payer side, but when they reach over to find a partner in the community, they’re going to be under-resourced in all the ways that that word means. It may look like, in some of the early evaluations, that it doesn’t matter to address the social determinants, because there’s not an infrastructure to meet the needs.

We don’t have enough healthy food or housing or transportation available, and so, until we get smarter about solving the wrong-pocket problem, where if a health care system or a health plan saves money, that money can be reinvested in the social services infrastructure — that’s a Pay for Success or impact bond sort of model — it might be like [what] we tried to do with value in the ’90s. It may not look as effective, or may have such small data or evidence to support it. It won’t be able to spread and scale in the way that it is now in health systems.

I hope we get smarter this time around, and we have a way to really digitize our partners. But it’s not just about digitizing and helping them be good partners, because there are legal issues and data privacy issues, and they’re non-covered entities. There are data-sharing issues that are already starting to come up in these communities where they want clarity on who can share data and what can be shared, what is the consent mechanism, and who’s going to host it?

The list is getting interesting and long, and there are people working on sorting through it — but the field is moving quickly, is what I’m saying. We need to make sure that not just the evidence is there, but that the policy is there and ready to help guide this exciting, but also important work around social determinants.

Volpp:  Ultimately, it seems like it would be nice to have evidence on a particular population of people, or better yet, for a given individual, if you had X dollars to spend, where would the return be greatest, in terms of improving that individual’s health. And it feels like we’re not quite there. It seems like, as you pointed out at the outset, the common approach has been to assume that if we ensure access to health services, that health will improve.

When you look at the impacts on health of, let’s say the Medicaid expansion in Oregon, the effects on health weren’t that big. It’s clear that there are a lot of benefits to having health insurance and reducing anxiety and reducing the risk of financial catastrophe, and that, in itself, is important. But for a lot of people, it may be more about health behaviors and social determinants that are holding them back, and it may be that it’s more cost-effective to make some of those investments.

Ideally, it wouldn’t be an either/or situation, but we have to recognize that sometimes providing health insurance alone is not enough if health insurance is limited to providing access to medical services.

DeSalvo:  That’s exactly right. You remind me of a couple of things that I want to make sure people are aware of. You mentioned that I’m on the board of Humana. Humana has published in this area that if you can improve self-reports of Healthy Days — a composite outcome based on some of the CDC-based mental health and physical health days — if you can improve those for a member, you can lower health care costs by $15.60 per member per month. A lot of that list seems to be in the area of addressing things like food insecurity, so we’re involved in and doing a randomized trial to understand the best ways to address food insecurity.

It’s one of the first, if not the first, kind of social determinants–related, randomized trial that will start to not only build the evidence, but also think about an actuarial basis, or get us closer to a place where we can start to put a number on it, to your point, because we have to know what the savings are, because that also tells us if the expense matters, and where we should be spending those dollars, in order to save and improve the health of people.

A lot of the scientists who are involved in this area are engaged in a group called SIREN, which is the Social Interventions Research and Evaluation Network that is based at UCSF and run by some scientists out there — it’s a virtual research network — to get to this place of, can we build the evidence base, try to not only stay ahead of where the practical applications are in the field, but to inform fieldwork and inform policy work. They are a good example of the rapid dynamism causing people to come together and say, “This seems important, we need to understand it better.” The science base isn’t as strong as we’d like it to be, but we certainly want to know, we certainly are recognizing as a country that you can’t just provide insurance or great clinical care.

There’s more to this, and we want to be able to have a strong scientific foundation, and a strong financial foundation, frankly, for understanding the business case and the value proposition around addressing the social determinants.

Volpp:  That’s a very exciting area. I’m hoping that there’ll be a lot of valuable new evidence that gets generated in the next few years, because clearly we need that in terms of giving payers the confidence that they can invest in different approaches that might improve health as much, or more than, some conventional clinical services that are being covered. We’re almost out of time, and I want to ask you about a slightly different area, around patient engagement, since that’s one of the main themes of NEJM Catalyst.

One of the big challenges health providers and the public health community face is getting people engaged who either can’t or don’t prioritize future health and well-being, often because they have a lot of competing priorities in their lives. Many patients have poorly controlled chronic diseases, and I’m wondering if you see any particularly promising avenues in terms of making it easier for those patients to prioritize their future health.

DeSalvo:  Let me begin by reminding everybody about William Osler’s comment that “the good doctor treats the disease; the great doctor treats the patient with the disease.” [This] seems to be borne out in some evidence, that if you ask people about their lives, which means asking them if they have a place to live, and if they have social networks, etc. — the sorts of things that show you’re interested in the context — and you’re not just treating their disease, it actually is linked to improved adherence to medication and control of chronic disease.

I’ll tell you that intuitively as a doctor, that resonates with me, because when I build a relationship with my patients, it’s not just over their disease, but it’s about them, and how together we’re going to be either preventing or treating your disease. My anecdotal experience would be that things always went better when they were with me, but also when they were trying to self-manage at home. I also know that this is not going to be solved by the physicians alone, or the health care system.

If we really want to help people to stay healthy, to stay on a care plan, to get healthy — whatever the goals are for them and for us — we have to remember that they’re away from us most of the time, they’re free, living beings, and think about how our care plan can be translated mostly into virtual medical homes, that can be with them on their smartphones, or on their wrists, or on their smart speakers, and then also in the humans we would send to their house and would be part of their care teams.

We’re going to have to distribute the model more. We’ve been too focused, as doctors, on, “Oh, our patient’s not compliant because they’re not listening to us.” But that’s a normal thing for everybody, that when you leave the doctor’s office, you forget exactly what was said, and you need a lot of nudges and reminders and assists. This is why I think it’s so exciting to be at this point in the world where we now have enough data to start to use artificial intelligence, and do some machine learning that can mass-customize care and services and care plans to our patients — and also that we, the health system, can be with them, and they can be with us because of the connectivity that we can enjoy through technology, whether it’s on their wrist or in a smart speaker in their kitchen.

Those models are just starting to emerge, thinking about having virtual members of the team — and when I say “team,” I’m including the patient as part of that team. We’re going to learn a lot, though, about how being with somebody outside of the clinical environment is going to help them to stay well. I’ll go back to the thread of this whole conversation, and this point about treating the patient with the disease: We have to remember that it’s not enough just to get the right dose of the insulin.

We have to know somebody has electricity, or if they have a house, and if they can’t afford the medication; it’s just as important for their health outcomes. And it seems to be obviously important to them, because it points to them wanting to be more engaged, and feeling more that people are with them on the journey and not prescribing stuff that doesn’t make sense for their lives.

Volpp:  That makes absolute sense. Karen, it’s been great talking with you. I thank you for sharing your perspectives with the NEJM Catalyst audience. I think a lot of people will be interested in what you have to say and what you now go on to do at UT Austin. Thank you for joining us today.

DeSalvo:  Thank you, Kevin. It was great talking to you.


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