August 2019, Volume XXXIII, No 5

Minnesota health care roundtable

Social Disparities in Health Care

Correcting the curve

Minnesota Physician Publishing’s 51st Minnesota Health Care Roundtable focused on the topic of Social Disparities in Health Care: Correcting the Curve. Six panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on April 25th, 2019, to discuss this topic.

Our next Roundtable, on Clinical and Non-Clinical Care Teams: Improving Interoperability, will convene on November 14, 2019.

In this Roundtable we will discuss social risk factors in health care and what can be done to address them. It clearly costs more to serve populations with social risk factors in the emergency room than to provide them easy access to regular wellness check-ups and preventive care. Our expert panel will look at how we can change this dysfunctional social dynamic, and will examine the beginnings of a concerted movement to address this issue. We will begin by discussing terms that sound very similar but can mean very different things to different people, even those working to solve the same problems. Let us look at definitions for terms such as social disparity in health care, social determinants of health, social risk factors, health care disparity, health care equity, health care inequity, and others.

DR. SCHIFF: First, I’d like to propose we use the term “social risk factors,” because if you call it a social determinant, it means that it is a forever thing, while some risk factors are malleable. I think of these in terms of two different groups—risk factors that we can potentially impact, and risk factors that we quite honestly do not want to impact and wish to celebrate, such as diversity, disability status, LGBTQ status, and veteran status. The second group includes risk factors that can be impacted. We break those down into two sets. One is economic risk factors—homelessness, deep poverty, or food insecurity—then we have risk factors that have to do with family functioning, incarceration, Child Welfare involvement, and individuals with a serious and persistent mental illness or a substance use disorder. We try to create some sort of a holistic framework.

DR. JOSEPH-DI CAPRIO: I like the definition of social determinants or social factors to be the conditions in which we are born, we live, we work, we age, because that applies to everyone. There are some conditions, factors, or determinants that have the effect we want on health, and then there are others that are detrimental to health.

MR. MOUA: Public health and medical science confirm that most of what creates health occurs outside of health care. In many ways, you could see health care as a subset of health, and health as a subset of social determinants of health. That is not to minimize the importance of the downstream provision of medical treatment, but to see a distinction. When we say “health,” we are acknowledging all various social—and I would add, political—determinants of health as well. It is important to assess these as both risks and virtues so that we do not inadvertently stigmatize them. I use the word “political” very deliberately, and not in partisan terms. The World Health Organization recognizes that these social conditions did not arise out of nowhere. They were actually created by human decision-making, which is greatly influenced by power and privilege.

MS. HARDEMAN: We need to intentionally choose the words we are using in our work in this space. One of the ways to do that is making the distinction between disparities and inequity. A disparity is simply a difference. We see differences throughout our society, but when we talk about health inequities, what we really are talking about is a justice issue that must be intervened on, can be intervened on, and that has a direct connection to the power—and that is the political piece as well.

MS. WILLSHIRE: I sit on many committees with the new buzzwords “equity committee,” “diversity committee,” etc., and they never want to include people with disabilities. They do not even think about it. It is just amazing to me that with 2020 just around the corner, people with disabilities are fighting just to get at the table. It should not be that way. People with disabilities come from all socioeconomic areas. You can be a person of color and race and still be a person with a disability. That is sometimes forgotten.

A patient may present in a clinic and the doctor may not be able to understand that they have social risk factors. How can we address this?

DR. JOSEPH-DI CAPRIO: Doctors may have anywhere from eight to 15 minutes for a patient visit. You cannot really understand much about someone in that period of time, but what you can do is start to develop a relationship with them and build some trust to truly understand what is going on with them. There are other ways you can look at the social factors that people experience by building tools into your system so that you do not have to remember what to ask. The system will trigger you or your care team to ask as you are trying to understand the patient in front of you.

MS. HARDEMAN: We need to rethink how we train physicians and all of our future doctors that go out into practice to understand social risk factors, to understand the role that racism and other determinants play in the lives of their patients. Medical students are not getting enough of that curriculum, and then they go out into practice and into residency and continue not to be able to fill those holes. Since the majority of medical students come from high socioeconomic backgrounds and are predominantly white, they may not have that lived experience and may not understand what is happening in the lives of their patients. Awareness should be part of training from day one.

How can physicians better understand the problems faced by patients with social risk factors?

DR. JOSEPH-DI CAPRIO: It begins with training to build awareness. We cannot just assume people will understand the impact of these factors or the importance or the influence of these factors on the health of the folks they care for. There must be a way to assess for these factors and do something about them.

MS. WILLSHIRE: Everybody understands physical access to some degree, but one of our issues in the disability community is programmatic access. If you are offering a particular program, say on heart disease, diet, or nutrition, it is not just a matter of making your entrance accessible, but also making your website accessible—and then looking at how you administer the program. Moving forward, it is like peeling away at the onion. You have to look at all of those aspects when you talk about the wide range of people with disabilities. A lot of people want to pigeonhole people in one particular diagnosis—everybody with cerebral palsy category must be like this, for example—and that is when you get yourself in trouble. The programmatic piece is as important as physical access, and it is probably the one that is not looked at as much. It’s not just getting in the door, but what are you going to do when you get in the door? Can you access everything?

DR. JOSEPH-DI CAPRIO: At Hennepin Health, we asked patients before we left the room, “Is there anything else I can do for you today?” Sometimes they would answer, “Well, I don’t have a place to live.” You might have had five patients waiting for you, but you went to find the social worker, and hoped the social worker would find resources to help this family. As a doctor, you did not feel you had the resources to help.

MS. HARDEMAN: That is the perfect example of why we need to think about how to build a new system that better serves the needs of our communities, rather than trying to figure out ways to address these massive issues in eight minutes or have patients presenting to family medicine doctors with mental health concerns and mental health issues that cannot be addressed in that one single visit. Until we are able to start recreating a new system, we are going to continue to struggle with this.

MR. MOUA: It is important to recognize that the eight minutes itself is an inequity. It prioritizes efficiency and effectiveness over equity and treats equity as an amenity. If the question is around strengthening the capacity of physicians to act on social determinants of health or health equity, it is important to develop that skill and muscle through direct experience. When I began my work at Blue Cross, it was to pass local smoke-free ordinances. Our key messengers were physicians. They came out to testify. When we were working on active transportation policies, we had cardiologists come out to testify. We need to start with recognition, but also ensure that recognition pulls physicians outside their four walls.

How does recognizing social risk factors translate into better care?

MR. MOUA: Make sure that we frame and internalize cultural competence—not just for the individual, but for the entire organization. It is not good enough just to have your physician or other caregiver be culturally competent if they are under-resourced, if managers do not listen to them, or if they have no clout or influence within the organization. Cultural competence has to permeate the board of directors, the leadership team, all other levels of the organization.

MR. WATSON: This also applies to the front desk staff, community health workers, and throughout the organization. At Minnesota Community Health Centers, we hire from the communities we are located in. A Somali clinic with a lot of Somali patients is going to have Somali individuals working there, because the one currency that any provider has is trust. Those first impressions when you walk in the door and are greeted by front desk staff, if positive, can demonstrate that implicit bias is not present in that clinic. They can set the tone for your entire organization, regardless of how well your provider went through cultural competency training. This has to permeate through the entire organization. I know it is tough, but for the communities we serve—with 70% from communities of color—we hire from the communities at all levels.

DR. JOSEPH-DI CAPRIO: I love health care because it is so diverse in terms of who is working at the direct care level, but as you move more to the leadership in large health care organizations, there becomes virtually no diversity. The percentage of CEOs leading health care organizations who are female or other than European American is infinitesimally small, and the team around them oftentimes is without diversity as well. This does not result in picking teams with different views and different perspectives.

MS. HARDEMAN: If patients access a system that was not welcoming, we try to examine the front desk staff and all the different ways that patients are treated. The likelihood of follow-up care goes down if patients have a poor experience. When you layer that onto the social factors and all of the other things that are going on, it exacerbates the situation.

The percentage of CEOs leading health care organizations who are female or other than European American is infinitesimally small.— Julia Joseph-Di Caprio, MD

Why do some populations feel alienated by our health care delivery system?

MS. WILLSHIRE: Physical access is huge for people with disabilities. They do not want to have to figure out how to jump on that exam table, and if someone offers to help, they wonder whether that person has been properly trained, because you could end up in some bad situations if the training was not been done correctly. That’s just from the physical standpoint. I have talked to many individuals who are deaf and feel extremely alienated in some instances, because they are not talked to directly, they are talking to the interpreter. People with cerebral palsy, MS, MD, or any physical illness should not all be put in a little capsule as if they were all the same. It is easy, during an eight-minute visit, to do just that, but we must try to refrain from it.

MR. WATSON: African Americans and American Indian populations have a very different experience, too. There is history that you just cannot ignore, and these communities do not forget. Another concern is culture as we are diversifying and more immigrants come to Minnesota. They have a much different understanding of their former health care system—which may have been bleak, depending on where they are coming from—and how primary care and health care work here in the United States. Workforce is another concern. If you are coming from a community of color, you are coming largely to a provider type that does not look like you, and it is human nature to not accept that willingly.

MS. WILLSHIRE: From the disability perspective, it really is coming from the angle of who we are and what we are capable of doing. There may be limitations, but we need to accept it. People with disabilities want to improve themselves, but also need to have the ability to accept where they are at. It is crucial, but sometimes it gets lost in the hurry or the path to find a cure or provide treatment.

MR. MOUA: Patients coming from an immigrant/refugee community may be dealing with posttraumatic stress, or have a world view and religion that views health as spirituality. If their experience with the western medical system is purely about treating the body, they may feel that, “You are just helping my body but you are not helping my health.” Take into account the belief system, whatever that is, of the patient and the community member, who truly believes that their health is rooted in spirituality, in their ancestor’s wellbeing, and not their physical aspects.

What are some of the unique concerns that patients in Greater Minnesota face in relation to the issue of social risk factors?

MS. HARDEMAN: My colleague, Dr. Katy Kozhimannil, who is at the School of Public Health and the director of the Rural Health Research Center, has been a leader in examining rural health care disparities, including inequities by race and ethnicity that, in the rural setting, are often not talked about. There is structural inequity and structural racism that play out in rural spaces, and as a result rural African Americans have a lower life expectancy. Maternity care closures in rural areas impact family access to places of safe birth.

MR. WATSON: In our five clinics in Greater Minnesota, the things on the top of our minds are the opioid/substance use disorder crisis, access to behavioral health services, and the lack of anonymity in a rural small town. Here in the Twin Cities, we can kind of disappear if we choose to when we access care. I spoke about being welcoming at the front desk. They can do that in these small towns because everybody knows everybody, but that sometimes is a barrier for people, because, unfortunately, there is a stigma with patients who report these conditions. Rural disparity plays out in a completely different way due to the lack of anonymity.

We need to rethink how we train physicians.—Rachel R. Hardeman, PhD, MPH

DR. SCHIFF: Our rural Native American brethren suffer in some areas with lack of access, or with access that has implicit bias. If we can create nearby programs where there is less stigma, we can improve health outcomes. There are a lot of stories about patients who do not want to go in because they are afraid they are going to be judged, and then they do not go in, and their health outcomes suffer.

MR. MOUA: The themes here are physical and social disconnection and social and physical proximity to resources, whether that is a grocery store, a provider’s office, or a transit line. It was stated earlier that rural is not synonymous with white, and that there is a tremendous intersection in Greater Minnesota with immigration status, language, and education. It is important to understand that “rural” is not just white Minnesotans. Oftentimes the communities experience magnified inequities from a relational and ethnic standpoint because they are far away from a culture community where they could have solidarity and emotional support as well as social services and health care services.

MS. WILLSHIRE: In the disability community, especially in the rural area, transportation is a huge issue. Volunteer medical drivers are critical in rural communities, but we have lost around 25% of them in the last couple of years due to a snafu with the funding. Again, access is another issue within some clinics. The good news is that many of the older clinics are being renovated and new ones are being built. That certainly helps, especially in rural communities.

What does implicit bias mean and how does it play into our health care delivery process?

MS. HARDEMAN: Implicit racial bias refers to unconscious or automatic biases, the automatic thoughts that pop into our heads about people. One of my mentors, Dr. Michelle van Ryn, was one of the first people to dig into how implicit racial bias in particular was playing out in the clinical encounter between predominantly white providers and patients of color. When providers are in a time crunch, they may draw on these automatic biases or these unconscious biases to make decisions and conclusions about who this person is. If we are not able to understand why we have implicit biases, we are not going to be able to break that cycle. We talk about training a lot. Many people attending implicit bias training shift their biases a little bit, but not much. I am a co-investigator on a longitudinal study of medical students who we have been tracking since 2010. We administer an implicit bias association test to those students every time we survey them. We have about four data points right now of their implicit biases through medical school, and they are not getting better. Among those who have had some health equity four-hour training along the line in their curriculum, their implicit bias scores tend to stay the same. They are definitely not getting lower. And among those who do not have any training, they are getting higher. We should not rely on training as a solution to the problems that we see with respect to discrimination and racism in the health care system.

DR. SCHIFF: At all levels in the health care system, institutional racism and institutional bias affect how people put together products or expectations for work at the policy level, and then that trickles down into the expectations at the local level. We have to address this bias, not just in the exam room with the provider—not to say that is easy—but that is where we put everything at the tip of the spear. The reality is further back in the organizations. If we can figure out a way to have those conversations, we can create the opportunity for more equitable interactions downstream.

MR. WATSON: At the Community University Health Care Center, you walk into the waiting room and they have welcome signs in about 15 languages. Expecting a provider to be culturally competent and remove implicit bias for 15 distinct populations is really unreasonable. Even at our Native American Community Clinic, there are differences between the different tribes of American Indians, who have different cultural norms and backgrounds. My takeaway is that training is provided continually for the health center providers and the rest of the staff. At the end of the day, we need to put ourselves in their shoes. Every sort of interaction should focus on removing implicit bias.

MR. MOUA: We are in an era where explicit bias is actually rewarded, touted. You can get political points for campaigning on banning refugee resettlement in Minnesota. It is something that is within our subconscious, no matter what profession you are in. It is also becoming a public bargaining chip to be explicitly biased in a very xenophobic way. Whether you are a physician or a steward over tobacco settlement dollars, a legislator, or a teacher, implicit bias can easily form into a micro-aggression and have a macrostructural impact. The last thing I will point out is that we cannot wait for this equity enlightenment to happen and people just say, “I get it, I see the light.” The Cultural and Ethnic Communities Leadership Council, which I serve on, works with DHS to continue to nurture that understanding of implicit bias, but we are not going to hinge on that. We want an equity policy that governs your budgeting, your hiring, your policy analysis, all of your core functions. So whether you “get” it or not, whether you believe in it or you recognize it, your behavior will be equitable. We do not want to counter implicit bias with just becoming self-aware and writing in a journal.

MS. HARDEMAN: Here in Minneapolis, Dr. Stephen Nelson has done work at Children’s Hospital to look at what children get for pain medicine and at what levels. We are seeing bias play out in the fact that Black children in the Children’s Hospital of Minneapolis waiting room are not getting the pain treatment that they need. On a national level, these outcomes have been highlighted in the way that the maternal mortality and morbidity stories are being told. There was a piece in Time Magazine by a professor at one of the Virginia universities who said her pain was ignored when she went into preterm labor. Implicit bias absolutely impacts outcomes.

Most of what creates health occurs outside of health care.—Vayong Moua, MPA

MS. WILLSHIRE: As I started to use my scooter more and more, I think I lost around 50 IQ points along the way somehow. I do not know where they went, but it is quite amazing. When I went to social and everyday environments, into stores, and into work environments, I started noticing that reaction the more I used my scooter versus, say, walking with a cane or walker. So it does absolutely exist. I know from the deaf community that you do not dare say that they have an impairment. For many of them, they were born this way, it is who they are. That is the case with many other individuals with disabilities, too, especially those who have been born with their disabilities. Unfortunately, I think it just leaves the medical community and the community as a whole at risk of never being able to do the right thing no matter which way you turn.

What can be gained by screening for social risk factors, and how can it be done?

Mr. Watson: The PRAPARE tool, which was developed in conjunction with our national association of community health centers and a few other organizations, is one tool to get to know our patients better. The PRAPARE survey includes 21 questions, and health centers administer it differently. Some give it to the patients in the waiting room. Others use empathetic interviewing techniques when they are with the patient. A community health worker may do that. At times they do not ask all 21 questions at one time, to avoid scaring the patient off. The tool looks at such things as family and housing, money and resources, how many jobs you work each week, lack of transportation, and other factors, and it identifies whether you or your family members have been able to get food, clothing, or child care. Then there is a whole section about social and emotional health. It is an incredible challenge to understand a patient’s complexity in 21 questions, but this gives us a little bit of an insight into them. I know it was alluded to earlier, we are incorporating these into our electronic health records, and it spits out ICD-10 codes that can assist the provider in understanding what their patients are facing.

DR. SCHIFF: What is the right way to screen for which risk factors? If your patient has a history of ACEs [adverse childhood experiences] or has been a victim of childhood violence or sexual violence or neglect, you do not need to ask that another 10 times every time they come in. There are a lot of these tools and they are all important, but how do we prioritize what we can ask? I am hoping, over time, that we get to the point where as part of the visit or in pre-visit planning, people do some of this screening so that there is a mechanism to plan and address and then reassess and make sure the referral happens, and then chip away at the next thing that happens. Some of the programs require more work, but in some ways I think that is a much better model than saying, “I am going to screen and then I have to figure out how to address six things and I am going to give you a lot of pieces of paper about referrals.” I think that we have a challenge of how to bring this up in a way that prioritizes and makes sense, but I do not think it has to be done by the doctors themselves.

What do you see as the most important things that should be screened for?

DR. JOSEPH-DI CAPRIO: We talked about housing, food insecurity, and transportation, of course, but there are other pieces around social isolation that are important and that impact health—things that maybe are not thought of when we think about the different social factors that people are dealing with.

MS. HARDEMAN: As we think about screening tools that we are proposing to use, we talk a lot about telling people that they are at risk for certain things. The disability community, the African American community, and a lot of marginalized communities have been told that there is something wrong with them—that they are at risk for all sorts of things. Even in my work, the outcomes I focus on are the inequities in maternal morbidity and mortality, infant mortality, and preterm birth, and I always hesitate to go into a room full of Black women and Black families and say here are the stats, here is what is going on, because it is not necessarily useful. We have been told time and time again that there is something wrong. As we look at ways to understand this better, we need to also be talking about assets and screening. What are the assets? What are the supports that you have? It could mean reframing the question of how we fill in that gap, rather than asking what is wrong or what is missing or why cannot you do this.

MS. WILLSHIRE: People with disabilities have historically been left out of screening. In this past year—and I am not going to say anything that they have not already heard from myself and other disability state agencies—we took the Department of Health to task. When our friend and colleague, Jan Malcolm, took over as commissioner, I worked with her on many issues. They have many good programs there, but they never bother to include people with disabilities. We were able to show in all their brochures and programs that they never even talked about disabilities, let alone including them, and it was an oversight. That can happen sometimes. You get in your mode, you have been doing it the way you have been doing it for so long. It is not intentional. When we think about screening, how do we do the outreach to the populations that may need access to it more than ever? It might not be your traditional outreach method.

MR. MOUA: It is important to understand the importance of short-term tools to screen for social determinants, whether it is trying to pick up a yellow or red flag on their housing or their transportation situation. It’s also important to ensure that we are building for the long term. The best screen will not be a one-page assessment, but your staff, your people who have the skills to actually detect this from a mile away and who also have the relationships way before they even step into the clinic. Strong community partnerships can also serve as part of the screen to build the skills so you are not reliant on any kind of protocol.

Institutional racism and institutional bias affect how people put together products.—Jeff Schiff, MD, MBA

How can tools around value-based reimbursement of things such as chronic care management help leverage the screening data for better outcomes?

DR. SCHIFF: In this country, we put so much of our capital into health care dollars and health care and underfund other parts of our social safety net. Things by default seem to go through the health care sector, and that is not a terribly efficient model. The Integrated Health Partnership is the Department of Human Services’ and the state’s model that allows organizations that can improve the health outcomes and decrease the cost for populations they serve to share in those savings. I would argue that we are well ahead of other states in that model, but we have a long way to go. If we can create a model by which the health care sector values integration with the social service sector and there is enough capital there, then things will begin to move. But the challenge is, how do we move? We have said today that these are not health care problems that are solved in a doctor’s office. We can screen for them, we can learn them, but we are not going to take care of housing or food insecurity in a doctor’s office. So if we can figure out how to move some of those dollars through value-based purchasing models, we have a stronger case. As we do more of this work, I hope we will even more strongly understand the associated costs of some of these social risk factors on health outcomes and be willing to say we need an even bigger investment.

Could you explain what IHP 2.0 is?

DR. SCHIFF: IHP is our Integrated Health Partnership, an accountable care organization model under which all the FQHC [Federally Qualified Health Center] patients are attributed to those providers so we can actually go through our claims history. If a patient was seen at Minnesota Community Care or at Open Cities, we stack those up and figure out where they are. Then we ask those providers to provide care in a way that decreases cost—can you prevent hospitalizations for your patients with diabetes? Can you prevent expensive ER visits because you are more open and accessible? If that is the case, if you can do that and you have savings at the end of the day, we split the savings with those organizations, as long as they also have high enough quality. It is not just savings in the cost of health care, but savings with high quality. We have added, in IHP 2.0, a payment to all the IHP providers for what we call a population-based payment. We ask each provider organization to identify how they are going to address a social risk factor. We ask them to address those risk factors and we give them a per-member, per-month figure to address those. Ideally, we would figure out how to increase the per-member, per-month to address risk factors and maybe even decrease some of the other payments so that we will be revenue-neutral but shift more money to address social risk factors.

MR. WATSON: One of the greatest things about the IHP model is that it allows the FQHCs and any IHP a line of sight into where their patients are going throughout the health care system. Before health centers got into the IHP program, we knew that once that patient went outside the four walls of the health center, we had no clue what was happening with these patients. Through the IHP program, DHS gives us almost real-time information on where our patients are going outside the four walls. We had one patient who was visiting the emergency room 72 times in one year. We had absolutely no clue that was occurring. We got that down to 12, which is still absurd, but we are celebrating that reduction.

How can care teams help patients with social risk factors?

DR. SCHIFF: The goal of DHS’ Integrated Care for High-Risk Pregnancies program is to address the disparity in birth outcomes for the African American and Native American populations. We have worked on having culturally appropriate doulas from the community who are also now becoming community health workers. We have worked hard to ensure that the community owns the infrastructure of the program. The community should feel like it is not a program brought to them by those of us who are from European ancestry, but a program that helps the community figure out how to own and manage solutions.

MR. MOUA: In the Hmong community, shamans are healers and facilitators to the spiritual world. In the 1980s, the first wave of Hmong refugee settlers were faced with a serious clash and a disallowance of having shamans enter the hospital. I grew up in Eau Claire, Wisconsin, and my mom worked in public health for 25 years. My father was working in the city manager’s office. They infused me with both a civic engagement and public health mindset and skill set. I heard daily stories of these clashes. It was not just about not having care coordination within the health care system, but with community leaders and community health representatives as well.

The one currency that any provider has is trust.—Jonathan Watson, MPIA

MR. WATSON: “NowPow” is one tool that is building those connections. It does not have the breadth in Greater Minnesota that it needs to, and that could be because there are not a lot of social service agencies in small towns. The other thing that I hear about from our members, in terms of connecting to social services, is that they come and go a lot. Funding for social services is even more tenuous than health care for safety net providers. Some agencies disappear for six months because they have to shut down and new ones come online.

What barriers exist in sharing new information about serving patients with social disparities across the health care delivery continuum?

MR. WATSON: We constantly run into a lack of data and intraoperability in the state of Minnesota. It has been described to me as “HIPAA on steroids.” I am envious of some of my colleagues in the health center movement in Denver and in Indianapolis. They have these robust, almost public utility -like exchanges of data. Those laws need to change, and there is a robust debate about that every year at that big white dome.

DR. SCHIFF: The IHPs sign a data agreement with me so that there is some security and accountability, and we feed data to them. They get all the claims monthly, and they get a moment-by-moment or daily feed of the Encounter Alert Service. So if somebody goes to the ER at Regions but is a patient at Open Cities, Open Cities will know, even as they are registering or when they are admitted, discharged, or transferred.

MR. WATSON: CMS’ Model One approach basically says, “We are going to give you money, in a sense gain-sharing, for attributed populations, their medical needs, their nutrition needs, their housing needs.” There is a spot for safety net providers that breaks down those silos and pays for services that connect patients to social services. I do not know of any model that does that now because the programs themselves are siloed, either in statute or in the implementation of the law—and, at times, by department.

DR. JOSEPH-DI CAPRIO: The payment alignment is really critical. The work out of CMMI, the Centers for Medicare and Medicaid Innovation, is a different primary care payment model. There is also some work out of the Center for Advancing Health Equity at the University of Chicago that addresses how providers, plans, and the state work together to enter into new value-based payment arrangements or new payment arrangements that demonstrate the improvement in health equity.

State and federal funding plays a large role in serving populations with social risk factors. What is working well and what needs to be improved?

DR. JOSEPH-DI CAPRIO: I used to say when I was at Hennepin, “I do not need another provider, I need two community health workers.” The movement on the part of the state and what we are seeing federally to have the payment align, we also see from providers and plans that are outside of those innovation models. They are saying that the only way we are really going to get at this is if we truly align the payment.

MR. WATSON: One of the things that has changed in the last five years is the whole concept around Telehealth, or as one of our health center folks said yesterday, “that iPad on a stick.” The reimbursement for that and the adoption of that and the funds that support Telehealth, particularly safety net providers, has been a welcome way to expand access and reduce disparities. It does need a little investment in broadband in Greater Minnesota, where many patients are still using dial-up.

MS. WILLSHIRE: It seems as if every legislative session focuses on how much we can cut from Medical Assistance without looking at the human being behind the MA face. There is a huge equity piece going on there in terms of how they divide money out, and it became particularly apparent this year. Just trying to raise the issue is difficult. We are still struggling just to be at the tables. When I go to conference committees, I sit in the room and have them look me in the face. I want to remind them what the stakes are. Sometimes that works and sometimes it does not.

Every legislative session focuses on how much we can cut from Medical Assistance.—Joan Willshire, MPA

MR. MOUA: The phrase we use in this movement is, “If you are not at the table, you are going to be on the menu.” Minnesota has a long ways to go, but Gov. Walz’s first executive order, on equity diversity inclusion, created the One Minnesota Council, which will push every state agency to weave in equity analysis into the way they design themselves and function. Gov. Dayton was the first governor in Minnesota’s history to ever create an explicit equity funding package back in 2016. They got about $67 million out the door, and a challenge to our health and health care community is the bulk of those dollars went to the Minnesota Department of Employment and Economic Development and to higher education. Not that it should not have gone there, but there was very little funding that was steered toward MDH or DHS. The current House proposal has about $75 million dedicated explicitly towards equity. So in terms of changing the narrative and becoming a political priority, equity is surfacing.

What are the most important things the health care delivery system can do to address social risk issues in health care?

MS. WILLSHIRE: Ask people what they need. Ask them. What I need is going to be different than what somebody else needs, so I would just start with having the conversation, and ask, “What do you need? What are you not getting?”

MR. WATSON: I would change that and I would ask the communities how they define health. That is really what we should be concerned about. This has been top-down for too long and needs to be bottom-up. We create these measures as health systems, as academics, as CEOs of trade associations, and we believe they are important, but the one thing I have learned at community health centers is some level of involvement in community-based participant research pays off.

DR. JOSEPH-DI CAPRIO: Health systems need to take risks. They do not need to dip their toe into value-based arrangements, they need to jump into the pool of value-based arrangements, and they will find that they will still be able to get their new MRI machines, fund their new advanced medical technologies, and improve the health of the population.

MR. MOUA: In my daily life, I am at advocacy and coalition tables fighting for the transportation funding package, for biking and walking transit. I am fighting alongside Second Harvest and Hunger Solutions to get good food access funding. These are major public policies that, on the surface, do not seem like health care policy—but transportation policy is health policy, and it is health equity policy. What needs to happen is that health equity has to be deeply internalized within our organizations and then also has to stretch out into our external facing work. The health system has to work further upstream, and that’s important in other areas as well. Our partners have to be farmers, engineers, lawyers, not just other types of doctors and physicians.

MS. HARDEMAN: On a big picture level, we need a new system and it needs to be one that is not driven by capitalism and the generation of financial incentives. In thinking about what we currently attend to and what we need, I would echo previous comments and also take it one step further. It is more than just asking communities what we should be thinking about and what they need, but lifting up the work of the Black Mamas Matter Alliance, which has been leading the efforts around the inequities in Black maternal mortality in our country. It is not just going to communities and asking them what they need, but getting out of the way and giving up some power. Whether we want to admit it or not, power is important. Until we can let go of that, we are not going to successfully solve these problems.

DR. SCHIFF: We need to have a different conversation. We lack a connection, and we also lack the willingness to make a connection. But those connections lead to dialogue, which lead to compassion. If we do that and those of us who have power spend some time listening to other people, we will hear things that will be the solutions and will build trust. I say that because it is not just a story that happens in the exam room, it is a story that has to happen on the eighth floor of DHS and the fifth floor of DHS and at UCare and everywhere. We need to change the way we approach this at all levels. If we do that, if we can just imagine what that looks like, we will all be enriched and we will have a different kind of product. That is what we all want. I guess I would say we think of it as equity, but it is also really a fundamental human thing. 

The Panelists

Julia Joseph-Di Caprio, MD,

is senior vice president and chief medical officer for UCare, leading the medical director team, as well as the clinical services, pharmacy, and quality management departments. These departments oversee multiple areas, including credentialing; response to complaints, appeals, and grievances; pharmacy; behavioral health; care and disease management; and many more.

Rachel R. Hardeman, PhD, MPH,

is an assistant professor in the Division of Health Policy & Management at the University of Minnesota’s School of Public Health. She is a health equity researcher who uses the frameworks of critical race theory and reproductive justice to inform her equity-centered work in health services research and population health. She seeks to improve outcomes for Black moms and babies.

Vayong Moua, MPA,

is director of health equity advocacy at Blue Cross and Blue Shield of Minnesota, where he is responsible for developing strategy and action for Blue Cross’ prevention and health equity advocacy initiatives to reduce tobacco use, obesity, and health inequities among all Minnesotans. He focuses on integrating health equity into policy advocacy approaches and structural solutions. He co-founded the Minnesota Complete Streets Coalition.

Jeff Schiff, MD, MBA,

served as the Minnesota Medical Director at the Minnesota Department of Human Services until recently. His interests include the role of social and family risk factors on health outcomes, integrated delivery systems, and mechanisms to improve quality measurement. He is committed to interweaving input from diverse communities to decrease health disparities and address health equity directly at all levels.

Jonathan Watson, MPIA,

is chief executive officer at the Minnesota Association of Community Health Centers. His background includes public policy analysis, managed care, and fiscal analysis. He previously served as a budget and policy analyst for the Wisconsin Department of Health & Family Services, where he conducted fiscal and policy analysis on Wisconsin’s Medicaid managed care expansion and the welfare reform project.

Joan Willshire, MPA,

is executive director at the Minnesota Council on Disability, which advises the Governor’s office, state Legislature, state agencies, and the public on disability-related issues. She previously served as both member and chair of the Council, as well as at Courage Kenny. She is active within the disability community and has served on several boards, including the Minneapolis Advisory Committee on People with Disabilities.

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Minnesota health care roundtable

Social Disparities in Health Care

Correcting the curve

Minnesota Physician Publishing’s 51st Minnesota Health Care Roundtable focused on the topic of Social Disparities in Health Care: Correcting the Curve. Six panelists and our moderator, Minnesota Physician Publisher Mike Starnes, met on April 25th, 2019, to discuss this topic.

Our next Roundtable, on Clinical and Non-Clinical Care Teams: Improving Interoperability, will convene on November 14, 2019.

The Panelists

In this Roundtable we will discuss social risk factors in health care and what can be done to address them. It clearly costs more to serve populations with social risk factors in the emergency room than to provide them easy access to regular wellness check-ups and preventive care. Our expert panel will look at how we can change this dysfunctional social dynamic, and will examine the beginnings of a concerted movement to address this issue. We will begin by discussing terms that sound very similar but can mean very different things to different people, even those working to solve the same problems. Let us look at definitions for terms such as social disparity in health care, social determinants of health, social risk factors, health care disparity, health care equity, health care inequity, and others.

DR. SCHIFF: First, I’d like to propose we use the term “social risk factors,” because if you call it a social determinant, it means that it is a forever thing, while some risk factors are malleable. I think of these in terms of two different groups—risk factors that we can potentially impact, and risk factors that we quite honestly do not want to impact and wish to celebrate, such as diversity, disability status, LGBTQ status, and veteran status. The second group includes risk factors that can be impacted. We break those down into two sets. One is economic risk factors—homelessness, deep poverty, or food insecurity—then we have risk factors that have to do with family functioning, incarceration, Child Welfare involvement, and individuals with a serious and persistent mental illness or a substance use disorder. We try to create some sort of a holistic framework.

DR. JOSEPH-DI CAPRIO: I like the definition of social determinants or social factors to be the conditions in which we are born, we live, we work, we age, because that applies to everyone. There are some conditions, factors, or determinants that have the effect we want on health, and then there are others that are detrimental to health.

MR. MOUA: Public health and medical science confirm that most of what creates health occurs outside of health care. In many ways, you could see health care as a subset of health, and health as a subset of social determinants of health. That is not to minimize the importance of the downstream provision of medical treatment, but to see a distinction. When we say “health,” we are acknowledging all various social—and I would add, political—determinants of health as well. It is important to assess these as both risks and virtues so that we do not inadvertently stigmatize them. I use the word “political” very deliberately, and not in partisan terms. The World Health Organization recognizes that these social conditions did not arise out of nowhere. They were actually created by human decision-making, which is greatly influenced by power and privilege.

MS. HARDEMAN: We need to intentionally choose the words we are using in our work in this space. One of the ways to do that is making the distinction between disparities and inequity. A disparity is simply a difference. We see differences throughout our society, but when we talk about health inequities, what we really are talking about is a justice issue that must be intervened on, can be intervened on, and that has a direct connection to the power—and that is the political piece as well.

MS. WILLSHIRE: I sit on many committees with the new buzzwords “equity committee,” “diversity committee,” etc., and they never want to include people with disabilities. They do not even think about it. It is just amazing to me that with 2020 just around the corner, people with disabilities are fighting just to get at the table. It should not be that way. People with disabilities come from all socioeconomic areas. You can be a person of color and race and still be a person with a disability. That is sometimes forgotten.

A patient may present in a clinic and the doctor may not be able to understand that they have social risk factors. How can we address this?

DR. JOSEPH-DI CAPRIO: Doctors may have anywhere from eight to 15 minutes for a patient visit. You cannot really understand much about someone in that period of time, but what you can do is start to develop a relationship with them and build some trust to truly understand what is going on with them. There are other ways you can look at the social factors that people experience by building tools into your system so that you do not have to remember what to ask. The system will trigger you or your care team to ask as you are trying to understand the patient in front of you.

MS. HARDEMAN: We need to rethink how we train physicians and all of our future doctors that go out into practice to understand social risk factors, to understand the role that racism and other determinants play in the lives of their patients. Medical students are not getting enough of that curriculum, and then they go out into practice and into residency and continue not to be able to fill those holes. Since the majority of medical students come from high socioeconomic backgrounds and are predominantly white, they may not have that lived experience and may not understand what is happening in the lives of their patients. Awareness should be part of training from day one.

How can physicians better understand the problems faced by patients with social risk factors?

DR. JOSEPH-DI CAPRIO: It begins with training to build awareness. We cannot just assume people will understand the impact of these factors or the importance or the influence of these factors on the health of the folks they care for. There must be a way to assess for these factors and do something about them.

MS. WILLSHIRE: Everybody understands physical access to some degree, but one of our issues in the disability community is programmatic access. If you are offering a particular program, say on heart disease, diet, or nutrition, it is not just a matter of making your entrance accessible, but also making your website accessible—and then looking at how you administer the program. Moving forward, it is like peeling away at the onion. You have to look at all of those aspects when you talk about the wide range of people with disabilities. A lot of people want to pigeonhole people in one particular diagnosis—everybody with cerebral palsy category must be like this, for example—and that is when you get yourself in trouble. The programmatic piece is as important as physical access, and it is probably the one that is not looked at as much. It’s not just getting in the door, but what are you going to do when you get in the door? Can you access everything?

DR. JOSEPH-DI CAPRIO: At Hennepin Health, we asked patients before we left the room, “Is there anything else I can do for you today?” Sometimes they would answer, “Well, I don’t have a place to live.” You might have had five patients waiting for you, but you went to find the social worker, and hoped the social worker would find resources to help this family. As a doctor, you did not feel you had the resources to help.

MS. HARDEMAN: That is the perfect example of why we need to think about how to build a new system that better serves the needs of our communities, rather than trying to figure out ways to address these massive issues in eight minutes or have patients presenting to family medicine doctors with mental health concerns and mental health issues that cannot be addressed in that one single visit. Until we are able to start recreating a new system, we are going to continue to struggle with this.

MR. MOUA: It is important to recognize that the eight minutes itself is an inequity. It prioritizes efficiency and effectiveness over equity and treats equity as an amenity. If the question is around strengthening the capacity of physicians to act on social determinants of health or health equity, it is important to develop that skill and muscle through direct experience. When I began my work at Blue Cross, it was to pass local smoke-free ordinances. Our key messengers were physicians. They came out to testify. When we were working on active transportation policies, we had cardiologists come out to testify. We need to start with recognition, but also ensure that recognition pulls physicians outside their four walls.

How does recognizing social risk factors translate into better care?

MR. MOUA: Make sure that we frame and internalize cultural competence—not just for the individual, but for the entire organization. It is not good enough just to have your physician or other caregiver be culturally competent if they are under-resourced, if managers do not listen to them, or if they have no clout or influence within the organization. Cultural competence has to permeate the board of directors, the leadership team, all other levels of the organization.

MR. WATSON: This also applies to the front desk staff, community health workers, and throughout the organization. At Minnesota Community Health Centers, we hire from the communities we are located in. A Somali clinic with a lot of Somali patients is going to have Somali individuals working there, because the one currency that any provider has is trust. Those first impressions when you walk in the door and are greeted by front desk staff, if positive, can demonstrate that implicit bias is not present in that clinic. They can set the tone for your entire organization, regardless of how well your provider went through cultural competency training. This has to permeate through the entire organization. I know it is tough, but for the communities we serve—with 70% from communities of color—we hire from the communities at all levels.

DR. JOSEPH-DI CAPRIO: I love health care because it is so diverse in terms of who is working at the direct care level, but as you move more to the leadership in large health care organizations, there becomes virtually no diversity. The percentage of CEOs leading health care organizations who are female or other than European American is infinitesimally small, and the team around them oftentimes is without diversity as well. This does not result in picking teams with different views and different perspectives.

MS. HARDEMAN: If patients access a system that was not welcoming, we try to examine the front desk staff and all the different ways that patients are treated. The likelihood of follow-up care goes down if patients have a poor experience. When you layer that onto the social factors and all of the other things that are going on, it exacerbates the situation.

The percentage of CEOs leading health care organizations who are female or other than European American is infinitesimally small.— Julia Joseph-Di Caprio, MD

Why do some populations feel alienated by our health care delivery system?

MS. WILLSHIRE: Physical access is huge for people with disabilities. They do not want to have to figure out how to jump on that exam table, and if someone offers to help, they wonder whether that person has been properly trained, because you could end up in some bad situations if the training was not been done correctly. That’s just from the physical standpoint. I have talked to many individuals who are deaf and feel extremely alienated in some instances, because they are not talked to directly, they are talking to the interpreter. People with cerebral palsy, MS, MD, or any physical illness should not all be put in a little capsule as if they were all the same. It is easy, during an eight-minute visit, to do just that, but we must try to refrain from it.

MR. WATSON: African Americans and American Indian populations have a very different experience, too. There is history that you just cannot ignore, and these communities do not forget. Another concern is culture as we are diversifying and more immigrants come to Minnesota. They have a much different understanding of their former health care system—which may have been bleak, depending on where they are coming from—and how primary care and health care work here in the United States. Workforce is another concern. If you are coming from a community of color, you are coming largely to a provider type that does not look like you, and it is human nature to not accept that willingly.

MS. WILLSHIRE: From the disability perspective, it really is coming from the angle of who we are and what we are capable of doing. There may be limitations, but we need to accept it. People with disabilities want to improve themselves, but also need to have the ability to accept where they are at. It is crucial, but sometimes it gets lost in the hurry or the path to find a cure or provide treatment.

MR. MOUA: Patients coming from an immigrant/refugee community may be dealing with posttraumatic stress, or have a world view and religion that views health as spirituality. If their experience with the western medical system is purely about treating the body, they may feel that, “You are just helping my body but you are not helping my health.” Take into account the belief system, whatever that is, of the patient and the community member, who truly believes that their health is rooted in spirituality, in their ancestor’s wellbeing, and not their physical aspects.

What are some of the unique concerns that patients in Greater Minnesota face in relation to the issue of social risk factors?

MS. HARDEMAN: My colleague, Dr. Katy Kozhimannil, who is at the School of Public Health and the director of the Rural Health Research Center, has been a leader in examining rural health care disparities, including inequities by race and ethnicity that, in the rural setting, are often not talked about. There is structural inequity and structural racism that play out in rural spaces, and as a result rural African Americans have a lower life expectancy. Maternity care closures in rural areas impact family access to places of safe birth.

MR. WATSON: In our five clinics in Greater Minnesota, the things on the top of our minds are the opioid/substance use disorder crisis, access to behavioral health services, and the lack of anonymity in a rural small town. Here in the Twin Cities, we can kind of disappear if we choose to when we access care. I spoke about being welcoming at the front desk. They can do that in these small towns because everybody knows everybody, but that sometimes is a barrier for people, because, unfortunately, there is a stigma with patients who report these conditions. Rural disparity plays out in a completely different way due to the lack of anonymity.

We need to rethink how we train physicians.—Rachel R. Hardeman, PhD, MPH

DR. SCHIFF: Our rural Native American brethren suffer in some areas with lack of access, or with access that has implicit bias. If we can create nearby programs where there is less stigma, we can improve health outcomes. There are a lot of stories about patients who do not want to go in because they are afraid they are going to be judged, and then they do not go in, and their health outcomes suffer.

MR. MOUA: The themes here are physical and social disconnection and social and physical proximity to resources, whether that is a grocery store, a provider’s office, or a transit line. It was stated earlier that rural is not synonymous with white, and that there is a tremendous intersection in Greater Minnesota with immigration status, language, and education. It is important to understand that “rural” is not just white Minnesotans. Oftentimes the communities experience magnified inequities from a relational and ethnic standpoint because they are far away from a culture community where they could have solidarity and emotional support as well as social services and health care services.

MS. WILLSHIRE: In the disability community, especially in the rural area, transportation is a huge issue. Volunteer medical drivers are critical in rural communities, but we have lost around 25% of them in the last couple of years due to a snafu with the funding. Again, access is another issue within some clinics. The good news is that many of the older clinics are being renovated and new ones are being built. That certainly helps, especially in rural communities.

What does implicit bias mean and how does it play into our health care delivery process?

MS. HARDEMAN: Implicit racial bias refers to unconscious or automatic biases, the automatic thoughts that pop into our heads about people. One of my mentors, Dr. Michelle van Ryn, was one of the first people to dig into how implicit racial bias in particular was playing out in the clinical encounter between predominantly white providers and patients of color. When providers are in a time crunch, they may draw on these automatic biases or these unconscious biases to make decisions and conclusions about who this person is. If we are not able to understand why we have implicit biases, we are not going to be able to break that cycle. We talk about training a lot. Many people attending implicit bias training shift their biases a little bit, but not much. I am a co-investigator on a longitudinal study of medical students who we have been tracking since 2010. We administer an implicit bias association test to those students every time we survey them. We have about four data points right now of their implicit biases through medical school, and they are not getting better. Among those who have had some health equity four-hour training along the line in their curriculum, their implicit bias scores tend to stay the same. They are definitely not getting lower. And among those who do not have any training, they are getting higher. We should not rely on training as a solution to the problems that we see with respect to discrimination and racism in the health care system.

DR. SCHIFF: At all levels in the health care system, institutional racism and institutional bias affect how people put together products or expectations for work at the policy level, and then that trickles down into the expectations at the local level. We have to address this bias, not just in the exam room with the provider—not to say that is easy—but that is where we put everything at the tip of the spear. The reality is further back in the organizations. If we can figure out a way to have those conversations, we can create the opportunity for more equitable interactions downstream.

MR. WATSON: At the Community University Health Care Center, you walk into the waiting room and they have welcome signs in about 15 languages. Expecting a provider to be culturally competent and remove implicit bias for 15 distinct populations is really unreasonable. Even at our Native American Community Clinic, there are differences between the different tribes of American Indians, who have different cultural norms and backgrounds. My takeaway is that training is provided continually for the health center providers and the rest of the staff. At the end of the day, we need to put ourselves in their shoes. Every sort of interaction should focus on removing implicit bias.

MR. MOUA: We are in an era where explicit bias is actually rewarded, touted. You can get political points for campaigning on banning refugee resettlement in Minnesota. It is something that is within our subconscious, no matter what profession you are in. It is also becoming a public bargaining chip to be explicitly biased in a very xenophobic way. Whether you are a physician or a steward over tobacco settlement dollars, a legislator, or a teacher, implicit bias can easily form into a micro-aggression and have a macrostructural impact. The last thing I will point out is that we cannot wait for this equity enlightenment to happen and people just say, “I get it, I see the light.” The Cultural and Ethnic Communities Leadership Council, which I serve on, works with DHS to continue to nurture that understanding of implicit bias, but we are not going to hinge on that. We want an equity policy that governs your budgeting, your hiring, your policy analysis, all of your core functions. So whether you “get” it or not, whether you believe in it or you recognize it, your behavior will be equitable. We do not want to counter implicit bias with just becoming self-aware and writing in a journal.

MS. HARDEMAN: Here in Minneapolis, Dr. Stephen Nelson has done work at Children’s Hospital to look at what children get for pain medicine and at what levels. We are seeing bias play out in the fact that Black children in the Children’s Hospital of Minneapolis waiting room are not getting the pain treatment that they need. On a national level, these outcomes have been highlighted in the way that the maternal mortality and morbidity stories are being told. There was a piece in Time Magazine by a professor at one of the Virginia universities who said her pain was ignored when she went into preterm labor. Implicit bias absolutely impacts outcomes.

Most of what creates health occurs outside of health care.—Vayong Moua, MPA

MS. WILLSHIRE: As I started to use my scooter more and more, I think I lost around 50 IQ points along the way somehow. I do not know where they went, but it is quite amazing. When I went to social and everyday environments, into stores, and into work environments, I started noticing that reaction the more I used my scooter versus, say, walking with a cane or walker. So it does absolutely exist. I know from the deaf community that you do not dare say that they have an impairment. For many of them, they were born this way, it is who they are. That is the case with many other individuals with disabilities, too, especially those who have been born with their disabilities. Unfortunately, I think it just leaves the medical community and the community as a whole at risk of never being able to do the right thing no matter which way you turn.

What can be gained by screening for social risk factors, and how can it be done?

Mr. Watson: The PRAPARE tool, which was developed in conjunction with our national association of community health centers and a few other organizations, is one tool to get to know our patients better. The PRAPARE survey includes 21 questions, and health centers administer it differently. Some give it to the patients in the waiting room. Others use empathetic interviewing techniques when they are with the patient. A community health worker may do that. At times they do not ask all 21 questions at one time, to avoid scaring the patient off. The tool looks at such things as family and housing, money and resources, how many jobs you work each week, lack of transportation, and other factors, and it identifies whether you or your family members have been able to get food, clothing, or child care. Then there is a whole section about social and emotional health. It is an incredible challenge to understand a patient’s complexity in 21 questions, but this gives us a little bit of an insight into them. I know it was alluded to earlier, we are incorporating these into our electronic health records, and it spits out ICD-10 codes that can assist the provider in understanding what their patients are facing.

DR. SCHIFF: What is the right way to screen for which risk factors? If your patient has a history of ACEs [adverse childhood experiences] or has been a victim of childhood violence or sexual violence or neglect, you do not need to ask that another 10 times every time they come in. There are a lot of these tools and they are all important, but how do we prioritize what we can ask? I am hoping, over time, that we get to the point where as part of the visit or in pre-visit planning, people do some of this screening so that there is a mechanism to plan and address and then reassess and make sure the referral happens, and then chip away at the next thing that happens. Some of the programs require more work, but in some ways I think that is a much better model than saying, “I am going to screen and then I have to figure out how to address six things and I am going to give you a lot of pieces of paper about referrals.” I think that we have a challenge of how to bring this up in a way that prioritizes and makes sense, but I do not think it has to be done by the doctors themselves.

What do you see as the most important things that should be screened for?

DR. JOSEPH-DI CAPRIO: We talked about housing, food insecurity, and transportation, of course, but there are other pieces around social isolation that are important and that impact health—things that maybe are not thought of when we think about the different social factors that people are dealing with.

MS. HARDEMAN: As we think about screening tools that we are proposing to use, we talk a lot about telling people that they are at risk for certain things. The disability community, the African American community, and a lot of marginalized communities have been told that there is something wrong with them—that they are at risk for all sorts of things. Even in my work, the outcomes I focus on are the inequities in maternal morbidity and mortality, infant mortality, and preterm birth, and I always hesitate to go into a room full of Black women and Black families and say here are the stats, here is what is going on, because it is not necessarily useful. We have been told time and time again that there is something wrong. As we look at ways to understand this better, we need to also be talking about assets and screening. What are the assets? What are the supports that you have? It could mean reframing the question of how we fill in that gap, rather than asking what is wrong or what is missing or why cannot you do this.

MS. WILLSHIRE: People with disabilities have historically been left out of screening. In this past year—and I am not going to say anything that they have not already heard from myself and other disability state agencies—we took the Department of Health to task. When our friend and colleague, Jan Malcolm, took over as commissioner, I worked with her on many issues. They have many good programs there, but they never bother to include people with disabilities. We were able to show in all their brochures and programs that they never even talked about disabilities, let alone including them, and it was an oversight. That can happen sometimes. You get in your mode, you have been doing it the way you have been doing it for so long. It is not intentional. When we think about screening, how do we do the outreach to the populations that may need access to it more than ever? It might not be your traditional outreach method.

MR. MOUA: It is important to understand the importance of short-term tools to screen for social determinants, whether it is trying to pick up a yellow or red flag on their housing or their transportation situation. It’s also important to ensure that we are building for the long term. The best screen will not be a one-page assessment, but your staff, your people who have the skills to actually detect this from a mile away and who also have the relationships way before they even step into the clinic. Strong community partnerships can also serve as part of the screen to build the skills so you are not reliant on any kind of protocol.

Institutional racism and institutional bias affect how people put together products.—Jeff Schiff, MD, MBA

How can tools around value-based reimbursement of things such as chronic care management help leverage the screening data for better outcomes?

DR. SCHIFF: In this country, we put so much of our capital into health care dollars and health care and underfund other parts of our social safety net. Things by default seem to go through the health care sector, and that is not a terribly efficient model. The Integrated Health Partnership is the Department of Human Services’ and the state’s model that allows organizations that can improve the health outcomes and decrease the cost for populations they serve to share in those savings. I would argue that we are well ahead of other states in that model, but we have a long way to go. If we can create a model by which the health care sector values integration with the social service sector and there is enough capital there, then things will begin to move. But the challenge is, how do we move? We have said today that these are not health care problems that are solved in a doctor’s office. We can screen for them, we can learn them, but we are not going to take care of housing or food insecurity in a doctor’s office. So if we can figure out how to move some of those dollars through value-based purchasing models, we have a stronger case. As we do more of this work, I hope we will even more strongly understand the associated costs of some of these social risk factors on health outcomes and be willing to say we need an even bigger investment.

Could you explain what IHP 2.0 is?

DR. SCHIFF: IHP is our Integrated Health Partnership, an accountable care organization model under which all the FQHC [Federally Qualified Health Center] patients are attributed to those providers so we can actually go through our claims history. If a patient was seen at Minnesota Community Care or at Open Cities, we stack those up and figure out where they are. Then we ask those providers to provide care in a way that decreases cost—can you prevent hospitalizations for your patients with diabetes? Can you prevent expensive ER visits because you are more open and accessible? If that is the case, if you can do that and you have savings at the end of the day, we split the savings with those organizations, as long as they also have high enough quality. It is not just savings in the cost of health care, but savings with high quality. We have added, in IHP 2.0, a payment to all the IHP providers for what we call a population-based payment. We ask each provider organization to identify how they are going to address a social risk factor. We ask them to address those risk factors and we give them a per-member, per-month figure to address those. Ideally, we would figure out how to increase the per-member, per-month to address risk factors and maybe even decrease some of the other payments so that we will be revenue-neutral but shift more money to address social risk factors.

MR. WATSON: One of the greatest things about the IHP model is that it allows the FQHCs and any IHP a line of sight into where their patients are going throughout the health care system. Before health centers got into the IHP program, we knew that once that patient went outside the four walls of the health center, we had no clue what was happening with these patients. Through the IHP program, DHS gives us almost real-time information on where our patients are going outside the four walls. We had one patient who was visiting the emergency room 72 times in one year. We had absolutely no clue that was occurring. We got that down to 12, which is still absurd, but we are celebrating that reduction.

How can care teams help patients with social risk factors?

DR. SCHIFF: The goal of DHS’ Integrated Care for High-Risk Pregnancies program is to address the disparity in birth outcomes for the African American and Native American populations. We have worked on having culturally appropriate doulas from the community who are also now becoming community health workers. We have worked hard to ensure that the community owns the infrastructure of the program. The community should feel like it is not a program brought to them by those of us who are from European ancestry, but a program that helps the community figure out how to own and manage solutions.

MR. MOUA: In the Hmong community, shamans are healers and facilitators to the spiritual world. In the 1980s, the first wave of Hmong refugee settlers were faced with a serious clash and a disallowance of having shamans enter the hospital. I grew up in Eau Claire, Wisconsin, and my mom worked in public health for 25 years. My father was working in the city manager’s office. They infused me with both a civic engagement and public health mindset and skill set. I heard daily stories of these clashes. It was not just about not having care coordination within the health care system, but with community leaders and community health representatives as well.

The one currency that any provider has is trust.—Jonathan Watson, MPIA

MR. WATSON: “NowPow” is one tool that is building those connections. It does not have the breadth in Greater Minnesota that it needs to, and that could be because there are not a lot of social service agencies in small towns. The other thing that I hear about from our members, in terms of connecting to social services, is that they come and go a lot. Funding for social services is even more tenuous than health care for safety net providers. Some agencies disappear for six months because they have to shut down and new ones come online.

The Sponsors

What barriers exist in sharing new information about serving patients with social disparities across the health care delivery continuum?

MR. WATSON: We constantly run into a lack of data and intraoperability in the state of Minnesota. It has been described to me as “HIPAA on steroids.” I am envious of some of my colleagues in the health center movement in Denver and in Indianapolis. They have these robust, almost public utility -like exchanges of data. Those laws need to change, and there is a robust debate about that every year at that big white dome.

DR. SCHIFF: The IHPs sign a data agreement with me so that there is some security and accountability, and we feed data to them. They get all the claims monthly, and they get a moment-by-moment or daily feed of the Encounter Alert Service. So if somebody goes to the ER at Regions but is a patient at Open Cities, Open Cities will know, even as they are registering or when they are admitted, discharged, or transferred.

MR. WATSON: CMS’ Model One approach basically says, “We are going to give you money, in a sense gain-sharing, for attributed populations, their medical needs, their nutrition needs, their housing needs.” There is a spot for safety net providers that breaks down those silos and pays for services that connect patients to social services. I do not know of any model that does that now because the programs themselves are siloed, either in statute or in the implementation of the law—and, at times, by department.

DR. JOSEPH-DI CAPRIO: The payment alignment is really critical. The work out of CMMI, the Centers for Medicare and Medicaid Innovation, is a different primary care payment model. There is also some work out of the Center for Advancing Health Equity at the University of Chicago that addresses how providers, plans, and the state work together to enter into new value-based payment arrangements or new payment arrangements that demonstrate the improvement in health equity.

State and federal funding plays a large role in serving populations with social risk factors. What is working well and what needs to be improved?

DR. JOSEPH-DI CAPRIO: I used to say when I was at Hennepin, “I do not need another provider, I need two community health workers.” The movement on the part of the state and what we are seeing federally to have the payment align, we also see from providers and plans that are outside of those innovation models. They are saying that the only way we are really going to get at this is if we truly align the payment.

MR. WATSON: One of the things that has changed in the last five years is the whole concept around Telehealth, or as one of our health center folks said yesterday, “that iPad on a stick.” The reimbursement for that and the adoption of that and the funds that support Telehealth, particularly safety net providers, has been a welcome way to expand access and reduce disparities. It does need a little investment in broadband in Greater Minnesota, where many patients are still using dial-up.

MS. WILLSHIRE: It seems as if every legislative session focuses on how much we can cut from Medical Assistance without looking at the human being behind the MA face. There is a huge equity piece going on there in terms of how they divide money out, and it became particularly apparent this year. Just trying to raise the issue is difficult. We are still struggling just to be at the tables. When I go to conference committees, I sit in the room and have them look me in the face. I want to remind them what the stakes are. Sometimes that works and sometimes it does not.

Every legislative session focuses on how much we can cut from Medical Assistance.—Joan Willshire, MPA

MR. MOUA: The phrase we use in this movement is, “If you are not at the table, you are going to be on the menu.” Minnesota has a long ways to go, but Gov. Walz’s first executive order, on equity diversity inclusion, created the One Minnesota Council, which will push every state agency to weave in equity analysis into the way they design themselves and function. Gov. Dayton was the first governor in Minnesota’s history to ever create an explicit equity funding package back in 2016. They got about $67 million out the door, and a challenge to our health and health care community is the bulk of those dollars went to the Minnesota Department of Employment and Economic Development and to higher education. Not that it should not have gone there, but there was very little funding that was steered toward MDH or DHS. The current House proposal has about $75 million dedicated explicitly towards equity. So in terms of changing the narrative and becoming a political priority, equity is surfacing.

What are the most important things the health care delivery system can do to address social risk issues in health care?

MS. WILLSHIRE: Ask people what they need. Ask them. What I need is going to be different than what somebody else needs, so I would just start with having the conversation, and ask, “What do you need? What are you not getting?”

MR. WATSON: I would change that and I would ask the communities how they define health. That is really what we should be concerned about. This has been top-down for too long and needs to be bottom-up. We create these measures as health systems, as academics, as CEOs of trade associations, and we believe they are important, but the one thing I have learned at community health centers is some level of involvement in community-based participant research pays off.

DR. JOSEPH-DI CAPRIO: Health systems need to take risks. They do not need to dip their toe into value-based arrangements, they need to jump into the pool of value-based arrangements, and they will find that they will still be able to get their new MRI machines, fund their new advanced medical technologies, and improve the health of the population.

MR. MOUA: In my daily life, I am at advocacy and coalition tables fighting for the transportation funding package, for biking and walking transit. I am fighting alongside Second Harvest and Hunger Solutions to get good food access funding. These are major public policies that, on the surface, do not seem like health care policy—but transportation policy is health policy, and it is health equity policy. What needs to happen is that health equity has to be deeply internalized within our organizations and then also has to stretch out into our external facing work. The health system has to work further upstream, and that’s important in other areas as well. Our partners have to be farmers, engineers, lawyers, not just other types of doctors and physicians.

MS. HARDEMAN: On a big picture level, we need a new system and it needs to be one that is not driven by capitalism and the generation of financial incentives. In thinking about what we currently attend to and what we need, I would echo previous comments and also take it one step further. It is more than just asking communities what we should be thinking about and what they need, but lifting up the work of the Black Mamas Matter Alliance, which has been leading the efforts around the inequities in Black maternal mortality in our country. It is not just going to communities and asking them what they need, but getting out of the way and giving up some power. Whether we want to admit it or not, power is important. Until we can let go of that, we are not going to successfully solve these problems.

DR. SCHIFF: We need to have a different conversation. We lack a connection, and we also lack the willingness to make a connection. But those connections lead to dialogue, which lead to compassion. If we do that and those of us who have power spend some time listening to other people, we will hear things that will be the solutions and will build trust. I say that because it is not just a story that happens in the exam room, it is a story that has to happen on the eighth floor of DHS and the fifth floor of DHS and at UCare and everywhere. We need to change the way we approach this at all levels. If we do that, if we can just imagine what that looks like, we will all be enriched and we will have a different kind of product. That is what we all want. I guess I would say we think of it as equity, but it is also really a fundamental human thing. 

Minnesota health care roundtable

DR. SCHIFF: We need to have a different conversation. We lack a connection, and we also lack the willingness to make a connection. But those connections lead to dialogue, which lead to compassion. If we do that and those of us who have power spend some time listening to other people, we will hear things that will be the solutions and will build trust. I say that because it is not just a story that happens in the exam room, it is a story that has to happen on the eighth floor of DHS and the fifth floor of DHS and at UCare and everywhere. We need to change the way we approach this at all levels. If we do that, if we can just imagine what that looks like, we will all be enriched and we will have a different kind of product. That is what we all want. I guess I would say we think of it as equity, but it is also really a fundamental human thing.