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What drives and reduces disparities in health care
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Overview
Tune in to hear Alan Weil, Editor-in-Chief at Health Affairs, discuss what drives and reduces disparities in health care.
- Defining social determinants of health
- 3 building blocks to addressing inequality: Improve communities, social responses, and ROI
- The role of governance: Decision-making, measuring ROI, allocating resources
Topics: health care, health, inequality, social determinants, ROI, governance, data, equity, inclusion
Episode transcript
Find episode transcript below.
00:00:04:11 Welcome to the Next in Health podcast. I'm Igor Belokrinitsky, a Principal with PwC Strategy&, where I get to help leading health organizations with their strategies and operating models. And today we have a very special episode, with a very special guest, and I'm really thrilled to introduce Alan Weil the Editor-in-Chief of Health Affairs. This is a really really big deal for us. So welcome, Alan.
ALAN WEIL:
00:00:30:02 Thank you, Igor. It's great to be with you today.
IGOR BELOKRINITSKY:
00:00:32:07 Fantastic. And the reason this is a very special episode, so as a firm PwC, our mission is to build trust in society and solve important problems. And one of the most important problems that we see out there is the frankly shocking disparities in health outcomes that we see around the country.
00:00:54:07 And these disparities are driven by gaps in affordability, by gaps in trust, by gaps in data and incentives, and a number of structural problems that we'll all discuss today.
00:01:03:17 And so we as a firm, we care deeply about addressing this issue and all the way across from our U.S. Chairman and Senior Partner, Tim Ryan, who co-founded the CEO Action for Diversity and Inclusion, which brings together a coalition of more than 2400 other CEOs every time they meet and just talk to CEOs of various organizations.
00:01:25:17 This is a topic on their agenda all the way to all of our employees who volunteer and contribute hours every year pro bono work to help address this issue.
00:01:35:13 And across our firm as we continue to build tools, capabilities and skills to be part of the solution to this massive, massive problem. This is a big deal for us, and it is also a big, big deal to Alan and to Health Affairs.
00:01:51:13 Alan has dedicated his career to this and Health Affairs covers this issue all the way from the top, from the policy level to the population level and all the way down to the individual level, telling the stories of people who will encounter these disparities in these obstacles to great health.
00:02:06:21 So very excited to have this conversation, really been looking forward to it. And maybe just to get started. Alan, I wonder if I could ask you to tell your story, your career and how you ended up where you are today. That'll be a great place to start.
ALAN WEIL:
00:02:19:20 Well, thank you for the introduction. And you're right, equity is at the center of what I do and have been working on. You go back a few decades and I ran the Medicaid agency in Colorado, led a large research study about social policy. When I was at the Urban Institute, I led the National Academy for State Health Policy that works with states on a broad range of health issues.
00:02:40:00 And now I've been the Editor-in-Chief Health Affairs for a little bit more than eight years. Health Affairs is the leading health policy journal in the United States.
00:02:49:22 We have readers around the world and we have been working on equity for longer than I'd say many, not all. And I'm really looking forward to the conversation with you about what it is we can do to try to close some of the quite horrific gaps that we have in outcomes and care availability for people in this country.
IGOR BELOKRINITSKY:
00:03:07:12 Excellent. And so maybe as we start getting into the discussion, one of the first things to do is to make sure that we have the right terms and we're not talking past each other.
00:03:17:12 And so as we are preparing for this, one of the things that you raised as kind of an important issue for you is the conflation between health equity and social determinants of health and there's a whole universe of other terms, including ESG.
00:03:31:12 So I'm wondering if you would clarify the terms for us and zero in on what we're talking about?
ALAN WEIL:
00:03:36:22 Well, some people in the health sector have been working with populations that face significant barriers to health for a long time, people who are lower income, where English isn't their first language, where their housing is unstable, where they have difficulty getting access to health care services.
00:03:53:22 And people in that part of the health system have always paid attention to what we now often refer to as the social determinants of health.
00:04:00:19 As income inequality in the United States has grown, though I'd say a larger share of the health system, including suburban hospitals and clinics and commercial insurers, are finding somewhat to their surprise, that a significant number of their enrollees have difficulty making sure they can have food on the table every day and making sure that they have stable housing, making sure they have safe neighborhoods to live in.
00:04:24:08 So in the United States, the term social determinants of health usually is referring to these very specific types of things like a house and food and the things that you need in order to be healthy from a global perspective. If you look at the World Health Organization, when they talk about social determinants of health, they certainly refer to these things.
00:04:44:02 But they also say that it includes the economic policies and the social norms and the social policies and the political systems in which people live. Those are also social determinants of health.
00:04:55:02 We don't tend to talk as much about those in the United States, and I suspect we'll do that some in our conversation here. Equity is closing the unjust, definable gaps or the unwarranted gaps in what people experience.
00:05:10:23 So you don't expect everyone to have the same health and you don't expect everyone to have the same outcomes. But when those outcomes differ by characteristics like people's race or their income or where they live, you have to ask why. And if there's no rational reason for it, then you say that's inequitable, then we need to do something.
00:05:32:20 So just one last thought. As we get started, which is that much of the attention on social determinants, I'd say more people started talking about that five plus or minus years ago.
00:05:44:20 Again, some have been talking about it for decades. It's in the wake of the murder of George Floyd and the attention to racism that I think people started thinking about equity and the role of racism in inequities in the United States.
00:05:56:14 And these two streams are now coming together. And I think people are trying to sort out how do we address inequities, how do we address racism, and how do we address social determinants that are getting in the way of people having good health and trying to help people have a road map of how to do that is, I think, important for those who see these as real problems.
IGOR BELOKRINITSKY:
00:06:16:23 That's a helpful delineation for us. And of course, through your publication, you speak to multiple audiences, you speak to policymakers and research institutions and academics, but also to the private sector, where there's a number of organizations, health organizations, some of which, as you mentioned, have been working on things that we now call social determinants of health for a long, long time.
00:06:41:10 There's mission-driven organizations, various nonprofits that make this central to kind of who they are and what they do and trying to go after, obviously, things that are in front of them that they feel they have relatively more control over. They may not control policy, although they do try to influence it, but they go after kind of what's in their neighborhoods and what's in their communities.
00:07:02:08 And so more and more organizations are declaring that this is important to them and putting out press releases and launching efforts and campaigns. As you look at these various efforts popping up around the country, what do you like about them and what do you see is missing?
ALAN WEIL:
00:07:17:07 Well, I love the way you asked that question because what I like about them is that they're happening, that they are paying attention, that people in the health system are aware that in order to assure that people have the best health possible, they have to address more than the health care services they get. And that's very, very good.
00:07:33:09 I have a lot of worries and I think there are a lot of limitations about this approach. The first is that you just mentioned sort of what's in front of you. Well, if you're an insurer, what's in front of you is your enrollees. If you're an employer, what's in front of you is your employees. The roots of most of these problems are not one person at a time.
00:07:53:07 They're in a community or in a city or sometimes in the whole country. And if you try to solve one person's unstable housing, you can help them have better housing and hopefully better health. But you're not going to improve necessarily the housing problem or crisis that we have in this country. And we're going to have partial solutions in the moment.
00:08:15:11 Either that initiative ends or the person moves to a different insurance company or something like that. Whatever effort was made, it dissipates, so social problems require social responses, not just individual person-by-person responses.
00:08:31:16 And that's tied very much to the return-on-investment mismatch that I also worry about here, which is there's so much talk about moving to pay for performance and paying for outcomes.
00:08:40:16 And the idea, of course, is that if a health system can improve someone's health by making sure they eat well, they may financially benefit as a health system because it's cheaper to provide the person with the food than it is to pay for all the medical services they might need if they're not eating well or they don't have access to healthy foods.
00:09:02:13 But that creates a very health-centric return on investment calculation, where the health system is deciding if we put money here, we'll make it there because of savings in health. But good food and safe communities and stable housing have benefits far beyond health.
00:09:20:13 And so as a society, if we make these investments only when there's a health return on investment as defined by a health enterprise, we're going to radically underinvest
00:09:29:18 --in what we need to address these social determinants. So, let's not think that we're going to solve them. And then I'll just throw out one more concern that I have.
00:09:39:18 And we've published some interesting papers on this, the social issues that we discuss. There are communities out there trying to address this. There are people working on housing and education and employment and poverty.
00:09:51:01 The health system tends to speak a really different language and tends to have a whole lot more money and has the ability to control resources in a way that many in the social sector don't have and frankly, are often a little dismissive of the approaches taken by less resourced enterprises that don't have electronic health records and billing codes and reimbursement systems.
00:10:15:08 They're just out there in the community doing the hard work. And I think if we're going to address these problems, the health sector is going to have to have some humility and step back from the resources that it has and embrace the strengths that exist in communities to address some of these social needs as opposed to thinking that the health sector or the health system has all the answers.
IGOR BELOKRINITSKY:
00:10:37:08 Very helpful. And I love the three challenges you articulated. Or perhaps there, you know, if I take a more positive view of it, the three building blocks of effective solutions, one, that it has to be social, one that it has to have a, an expansive view of the ROI, both in terms of what the impact we want and the resources that we expand and one that it needs to be street level.
00:11:04:07 It needs to be inclusive, it needs to be representative rather than sort of ivory tower driven in order to be effective. And this resonates a lot because as you mentioned, you've published on this and we've also been thinking through and envisioning these connected ecosystems that would arise from the notion that no single organization can solve this problem and not even a single type of organization can solve this.
00:11:28:12 Even if all the hospitals in the country got together, all the health insurance companies in the country got together, all the pharma companies got together, this would still not be solved.
00:11:38:12 And so there would be kind of these experiments happening around the country with these ecosystems coming together. But you're pointing out that it's not necessarily just for kind of the institutional entities to come together. You have to find a way to have representation and voices in this, for this to resonate and have that level of trust in the community.
00:11:57:13 So very helpful. And maybe one area that we could drill into is you mentioned kind of the measurement of the ROI and having it be more than just medically focused.
00:12:07:13 And it feels like there's several steps still to take towards having this because at the moment it seems like a lot of these efforts, they measure the effort, the amount of effort that's being put in, but not necessarily the outcome.
00:12:18:18 Even the medical outcome, even the equity outcome. So, any thoughts from you on what works for if you are outcomes-driven, if you're a results driven, what kind of practices, what kind of approaches work if somebody is trying to maximize outcomes?
ALAN WEIL:
00:12:32:22 If I may, before I answer that, I do want to reflect briefly on something you said a moment ago, and I want to introduce the word governance to this conversation, because I really think that what you're raising, which is that where these decisions get made, how resources get allocated, is determined by who is in the governance positions with respect to them.
00:12:52:09 And the health system in the health sector is filled with not very publicly accountable organizations that if they are making the allocation decisions, will make them in certain ways, which is different than can occur when you have a more participatory governance model. I just put that out there because I think it is important and ties into the question you just asked.
00:13:13:08 I mean, measuring the effect of social interventions, that's a topic way beyond what we can get into here.
00:13:20:08 But we need to keep an eye on the time dimension, which is that's the other risk, of course, that if you're looking at carving out some of this year's premium to do an intervention this year because you need a return on investment this year.
00:13:31:08 Because next year your enrollee may be in a different health plan, you're going to make very different decisions than if you're looking at a community where the burden of disease is 50% higher than it is in another community.
00:13:44:19 And the only way you're really going to drive down the long-term cost for people in that community is to invest in education in safe streets and grocery stores. That's not a one-year ROI. So, there's a time dimension as well as an outcome dimension that we need to bring in. There are sort of social investment bond models out there.
00:14:04:16 They're not broadly distributed, but there are various techniques designed to measure outcomes in all domains and to put a price tag on those and to put a return on investment on them.
00:14:18:08 But I do think we have to be careful here that when it comes to social challenges, that no matter how much you tweak the return-on-investment calculation, you may find yourself asking the wrong question.
00:14:28:21 If you treat it only as an ROI, if you treat it as human dignity, if you treat it as community engagement, if you treat it as listening to people and finding out what they need to thrive. That I think is a more likely mechanism for getting the right answer than trying to figure out how many dollars to put here to get out that many dollars over there.
IGOR BELOKRINITSKY:
00:14:48:18 Make sense and I'm glad you introduced the notion of governance. And it's, I think, governance at multiple levels. There's governance around coordinating across a bunch of entities and creating the transparency, as you mentioned.
00:15:02:18 But there's even governance kind of in the wiring, because for this to work, at least, we believe that a lot of entities need to have a way of sharing data with each other in a way that is effective and actionable and predictive, but at the same time respects privacy and security of the people that you're trying to help.
00:15:17:20 And so that's another area where this governance is so important to secure this data and confirm that it's protected and is used responsibly and equitably and so forth, so another role for governance.
ALAN WEIL:
00:15:29:11 So I totally agree. And the data ecosystem is so different in health care than in many of these other domains. We had the federal government make a huge investment in electronic health records. They have made no similar investment in exchanging information around most social goods.
00:15:47:18 If you think about people who interact with government systems around support, cash assistance or child care assistance or housing assistance, those are often antiquated county-based, paper-based processes that have no way of communicating with the more sophisticated systems we have in health care that were built largely for the payment imperative that simply doesn't exist.
00:16:08:01 That payment model doesn't exist in other domains. So it's governance. And it's also when we talk about interoperability within health care, but it's essentially impossible to think about interoperability across these different systems where places outside of health care are not even digitized and there's no strong information infrastructure architecture to enable data sharing, even if we wanted to.
IGOR BELOKRINITSKY:
00:16:29:23 Absolutely. So maybe as we start bringing this to a close, very curious on your thoughts as you think about different communities around the country, there's probably not one solution that's going to fit everywhere. You need a variety of organizations to come together, variety of types of organizations to come together and share and coordinate. Who will be the catalyst?
00:16:51:03 Where's the hero that will come along and catalyze and get all the right stakeholders at the table, looking at the same data, setting the same priorities and collaborating? What kinds of entities or organizations do you think could play this role? And what do they have to look like?
ALAN WEIL:
00:17:05:23 Yeah, I'm less looking for a hero than what you just said. What do they have to look like? They need to be participatory. They need to be built from the community level. And community again, is a nice term to throw around, but it can mean a lot of different things.
00:17:20:23 It can literally mean a small physical space. It could be an entire city or it could be a shared interest that isn't even geographically bound. I think the main dimensions of it that are needed are participation inclusion.
00:17:33:15 And this is where I think, again, the health sector really runs a risk when you're a four-plus trillion dollar sector that is mostly used to talking to itself. If you're going to participate in these conversations, going to have to start talking to people, you've never engaged with before.
00:17:46:06 I don't have a hero. What I do have is some hope that there are growing efforts, and I can't help but go back to the governance concept of looking for ways to instead of putting the burden for addressing these issues on individual hospitals or health care systems or carriers to pool resources across enterprises and entities and provide some governance at the community level to identify where those resources should be allocated.
00:18:14:18 In my sense, we although there are a lot of resources in health care, we need to take them out of thinking of them as health care resources and think of them as social resources that have some governance that is accountable outside of the health care sector.
00:18:29:18 That may sound very vague, and I apologize if it does. We're still experimenting with some of those models, and I think we still don't even know which ones of them will work in the end. But that's the direction I would be looking if I wanted to be optimistic, which I always am about our ability to find better ways to address this problem.
IGOR BELOKRINITSKY:
00:18:47:11 Well, Alan, you said hope, and I think that's perhaps where we'll leave it is with hope. And I think it's informed hope, right? It's because, as you mentioned, experimentation continues, investment continues. There's attention and focus on this issue as we've never seen before. Our tools get better every day. Our algorithms get smarter every day.
00:19:09:11 And as these experiments continue we will hopefully see better models emerging that meet the criteria that you established, which it needs to be long term in its outlook and not just kind of quick fixes.
00:19:19:10 It needs to be inclusive and participatory. It needs to be rooted in trust and it needs to be governed in a way that is transparent and trusted and aligned. And so, we kind of know what good looks like and we'll keep pushing for it as we draw to a close. And it's a fantastic conversation, really grateful to you.
00:19:37:19 Any sort of final thoughts to organizations out there that are looking to play a role in addressing this critical issue that's in front of us?
ALAN WEIL:
00:19:47:04 Well, I love how you just said it, so I'll just say two things. One is, even if it's not the perfect approach, engaging with these issues, engaging with partners, trying to identify the challenges and work through them is the first step.
00:19:55:04 And if you don't take that step, nothing else really matters. So, I'm a big fan of learning and exploring even if we can't solve these problems one health system at a time.
00:20:07:16 And that ties to the second, which is maybe just repeating what I said earlier, but respecting the strengths and the wisdom in other communities, whether it's outside of health care or geographically in the communities where the people live, viewing that as an asset and wanting to engage with it, as opposed to thinking that you are bringing your asset to them and you know what's best for others.
00:20:36:10 I just think that that's essential. But there's a lot of reason for optimism now, and I think you captured it very nicely. So, we should build from the strengths that we have and always keep trying to do better.
IGOR BELOKRINITSKY:
00:20:47:01 Thank you, Alan. I really appreciate your joining us today and thank you for the insights and all the great work you're doing at Health Affairs.
ALAN WEIL:
00:20:53:05 Thank you, Igor, for having me on and what a wonderful conversation and I appreciate the leadership you are showing in this area.
IGOR BELOKRINITSKY:
00:21:01:08 For more on these topics and other health industry insights driven by policy, innovation and care delivery changes, please subscribe to our podcast and also be sure to listen to the prior episodes. Until next time, this has been Next in Health.
ANNOUNCER:
00:21:21:22 This podcast is brought to you by PwC.All rights reserved. PwC refers to the U.S. member firm or one of its subsidiaries or affiliates and may sometimes refer to the PwC Network. Each member firm is a separate legal entity.
00:21:36:05 Please see www.pwc.com/structure for further details. This podcast is for general information purposes only and should not be used as a substitute for consultation with professional advisors.
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