Vera Whole Health, now part of apree health, in partnership with the Puget Sound Business Journal, sponsored a recent roundtable conversation around health equity and affordability. PSBJ President and Publisher Don Baker moderated a panel with Malia D’Alio, manager, Workforce Inclusion Diversity Equity & Access (IDEA), Seattle Children’s; Truc Dever, director of human resources, City of Kirkland; Dr. Bruce Sherman, advisor to the National Alliance of Healthcare Purchaser Coalitions, adjunct professor at UNC-Greensboro’s Department of Public Health Education; and Dr. Kevin Wang, chief medical officer at apree health.
apree health brings together a best-in-class engagement platform with an advanced primary care model to provide better health and care experience, improve outcomes, and significantly lower the total cost of care for a population. Its proven solutions are built on a robust data and technology foundation that provides a rich understanding of each person, a navigation experience that engages individuals in their health and care and an integrated care team that manages the individual’s whole health. apree health was formed when leading advanced primary care provider Vera Whole Health merged with digital health innovator Castlight Health in 2022. apree health partners with top U.S. employers, leading provider groups and some of the country’s largest, most progressive health plans.
Donald Baker: How can purchasers of healthcare address the rising costs of healthcare, and would you share with us some innovations and ideas you’ve seen in your field or organization as well?
Malia D’Alio: As a society, we have to come to terms with the fact that trickle-down economics doesn’t work for the collective and that there is an established status quo that we’ve adopted in a lot of our models of healthcare that come at the expense of the marginalized communities that we serve. Failing to reduce the barriers to access healthcare ends up costing everyone more in the long run. When I’m speaking to the rising cost of healthcare, I’m really particularly interested in the impact that has on the patients and the populations that we are here to serve. America has the lowest life expectancy rates in the developed world, and we also have the most expensive healthcare systems. The math isn’t mathing. We at Seattle Children’s are comprised of 49% Medicaid and patient insurance distribution with managed care organizations. And there’s about 47% of commercially and privately insured patient families that we serve, and the Medicaid reimbursement rates have not substantially increased in the last 20 years. I think we’re really lucky to live in a region with such a progressive legislative body. They have done an incredible job in this last legislative session, helping to advance and address some of those issues. But I think that the gap is still very much real, and the uninsured, even for our families that are dually insured where the expenses of just a single inpatient visit, or a cancer care treatment are not fully covered by their insurance. And then that increases exponentially for our families that are covered by Medicaid or are uninsured entirely. And some of what I am really proud of at my organization is we have always had a strong commitment to helping to support the uncompensated care funds in our organization. So, none of our patient families are ever sent to collections for any of the costs of their care that are not covered by insurance. And we’re only able to do that because we have such a generous community that we get to be a part of here in the Pacific Northwest.
Truc Dever: I’d like to offer the perspective from the employer’s point of view. I think employers who provide healthcare to employees and who purchase healthcare really need to take an active role in managing those healthcare benefits they offer to employees. They really should be conducting market comparisons and looking at creative ways to combat those rising costs. So, for example, the City of Kirkland, Washington, about seven years ago worked with its health benefit brokers at Alliant and developed what they termed as the CDMH model or consumer driven medical home model of care, which is essentially a self-insured program using a high deductible plan, coupled with an HRA or health reimbursement arrangement VEBA card. That gives the city more flexibility in managing its costs while minimizing out of pocket expenses for the employee. And they did all of this while contracting with the near-site medical clinic run by Vera Whole Health to provide primary care at no extra charge to the employee. Now what this did was create more accessibility to primary care with no out-of-pocket expenses for the employee, while at the same time reducing costs to the city by incentivizing wellness and wellness appointments and checks. So, this really is a unique way of providing employee healthcare and really could be used as a model across the country.
Dr. Bruce Sherman: I’d like to go back to something that Malia said, which references the healthcare purchasing system which we employers currently utilize. The fact that the existing system is focused on revenue generation for the entities that are providing care, it’s quite challenging to find ways to be creative to reduce costs. To Truc’s comment on looking outside the system for novel ways of implementing care, there are substantially more opportunities to operationalize models that more closely align the value of the services provided with the cost of those services so it’s not a fee-for-service model, it’s a fee-for-outcomes. There’s a greater willingness in those settings to create value-based improvements in chronic condition management and more recently, reducing health inequities. So, while employers can nibble around the edges using centers of excellence or other outcomes-based contracting approaches within the current healthcare system, it can be more beneficial for them to look outside the current system structure to contract with those entities that are more financially aligned in terms of health improvement and health outcomes objectives.
Donald Baker: Dr. Wang, apree health, formerly Vera Whole health, recently released its annual Workforce Health Index, and one of the findings showed that adults living in low-income communities had 77% fewer wellness visits than those living in high income communities. What are the main factors contributing to health disparities among different populations, and what can be done to effectively address those inequities? If you also would speak to why employers have a unique opportunity to address socioeconomic barriers to improve access to care.
Dr. Kevin Wang: If you were to look at published data by neighborhood in the CDC/ATSDR Social Vulnerability Index, they mirror a lot of our own data. Some of the big buckets are education status, housing status and household characteristics like single parent households. The social vulnerability index adds minority status and language as additional indicators. As you mentioned, income and employment are a big corollary. Oftentimes the challenge we have is to look at causation versus correlation. For example, per Milliman, the average cost for a family of four in a PPO insurance plan is about $31K per year per Milliman. Several of our clients have more than 50% of their workforce making less than $60K a year. If you take $30K out of $60K, and only $30K is left, and then suddenly you’re at a multiple of the Federal Poverty Level. The Area Deprivation Index says 150% of the Federal Poverty Level is considered a risk factor for health and equity. So, what ends up happening is when you add those pieces of inequity, they compound the underinsured. Employers can do something about it. I like to give examples of things like preventive screenings, such as colonoscopies. Once a provider finds an abnormality, every future colonoscopy is no longer a free preventive screening. It’s a diagnostic colonoscopy that usually costs a member out of pocket money. This can be a free benefit if an employer chose to do so. Other incentives an employer can give — dedicated access to free primary care, the ability to engage a member in a virtual and digital experience wherever members are — are routed toward more value-based care.
Dr. Bruce Sherman: I absolutely agree, research has shown there’s an intersectionality between race, ethnicity, and income. For example, we’ve taken a deep dive with respect to analytics and if you are in a minority subpopulation and you are a low-income earner, those two things together contribute to a much more reactive approach to healthcare use than higher earning, predominantly white populations. That means much greater emergency department use, much greater hospitalization rates. The unfortunate irony here is that low-wage workers, disproportionately represented by minorities, have a higher prevalence of unhealthy lifestyle behaviors. Consequently, they have a greater prevalence of multiple chronic conditions. Obesity prevalence rates are higher in these subpopulations, and employers have historically treated their employee populations as a homogeneous group. So, from an affordability standpoint, whether you are earning $15,000 or $250,000, plan design premiums and deductibles are the same for 93% of employers. At the patient level, concerns of medical mistrust among minority populations, compound the issues of implicit bias among clinicians who are preponderantly white males. Further, the persistent focus on clinical concerns rather than what are the pressing issues for those particular individuals who may have unmet social needs, which are a barrier to care and aren’t being effectively addressed.
Donald Baker: Dr. Sherman, would you address a little more on what are some of those consequences of high healthcare costs on a population, but taking it further into also how can we mitigate those effects?
Dr. Bruce Sherman: One has to look at the various stakeholders that are involved with the issues and address each one of those head on. For clinicians it’s an issue of implicit bias that is embedded into the healthcare system in the way that we deliver care. We also ask patients what’s the matter with them, not what matters to them. That perpetuates issues of medical mistrust from the patient perspective because they’re not feeling heard. We are narrowly focused as clinicians on their clinical issues, not on their broader health and wellbeing concerns. From the delivery standpoint, health systems, and health plans are just at the beginning of looking at issues of health inequities and how we can more meaningfully monitor the impact of current care on individuals in terms of those health systems and health plan’s ability to narrow the variability in health outcomes and compliance with evidence-based care. From a patient standpoint, health literacy concerns and medical mistrust are two important barriers. We have to build trust as a foundation to providing more impactful care. And lastly, from the employer perspective, benefit design has to be equitable. Our research has shown that disparities in healthcare use exist at the wage band level, at least some of which are due to inequitable benefit design. Until we start to take a closer look at those contributing factors, I think we’re not going to be making much headway with the issue.
Dr. Kevin Wang: To truly impact cost, there are only two major levers: first, there’s utilization. How much do you use it? And secondly, what’s the price or unit cost? Those are two things that are very hard for an employee, a member, a person, to impact. One way to mitigate this is to give better informed choice by arming the person with better selection to help them choose the right care utilization, at the right place, at the right time — instead of waiting for things to go wrong. So, you arm the person with enough informed choice — which is price transparency, quality transparency and our organization also adds in direct access to care because you can’t have a member wait eight weeks to get an appointment to the right utilization. An example of impacting cost would be if an employer broke the typical cycle of switching health plans every so many years to try to get rate concessions which puts risk to price ballooning like the pharmacy rebate game. Employers can ask for more value and even work with groups like ours to contain costs.
Donald Baker: Malia and Truc, you’re both innovators in your fields. What strategies can be implemented to address the disparities in health outcomes among different populations?
Malia D’Alio: In order to address our health outcomes downstream, we are seeing a shift in the way that we approach healthcare to focus further upstream. And that really includes how we are integrating our understanding and our responsiveness to social determinants of health. There is a lot right now at my organization that we have been trying to tackle. I work closely with our Center for Diversity and Health Equity and report to our chief diversity officer. Seattle Children’s has gone through its own very public process and trying to reconcile with our own issues with racism and implementing commitments to anti-racism that have included actionable steps that we have absolutely been focused on. They’ve taken a deep dive at every single level and it’s not just the way that we are approaching our care. It has to be culturally responsive. We really have to acknowledge the fact that our systems are all connected, our academic systems that our providers and all of us who comprise the support systems of healthcare that we’re coming from systems that are inherently based in very racist structures, and we are having to kind of collectively unlearn that right now. And healthcare is not happening in a silo. So when you look at the health disparities that we’re seeing with our patient families, it can come down to something as simple as how we are communicating, how we are connecting with our patient families and how we are truly understanding their needs, meeting them where they are. I think we have had kind of a very egocentric approach to healthcare historically — where it’s you come to us, and we tell you we know what’s right for you better than you do. And I’m really encouraged by the progress that I’ve seen happen in recent years. I’ve been in healthcare for 23 years and I’ve worn many different hats and have done patient care for 12 years. We are addressing that divide between the business of healthcare and the delivery of healthcare in a way that I’m really inspired by, and I feel is going to be the trajectory that we all are going to be on in the years to come. So, there is a lot just dealing with access. We serve patients across our region. It’s not just Washington state. Our patient populations come to us from Alaska, Idaho, Montana all over Hawaii, and California. I’ve had the ability to go and actually visit with community members in Alaska, who have come to us for care and the extreme obstacles that they have to go through with transportation coming from remote villages and remote areas in Alaska, just to get to our front door is tremendous.
Truc Dever: I go back to basics. It doesn’t need any fancy technology, but we really need to invest in outreach and education in all its various forms. I think it’s really important when it comes to addressing disparities in health outcomes in different populations. People receive information differently, especially people who speak different languages, from different cultures. You have to meet them where they are. You have to build trust. We have to arm them with that choice by educating them. So, you need to make it easy for people to access the information on services, bring mobile clinics to them. Take those services to where people work, live and recreate. Provide information, webinars and seminars and conduct them in those different languages. Use low literacy infographics, for example, to improve accessibility and also use marketing tools with de-identified data that can customize health information for those targeted groups. Obviously, affordability is a concern. So, provide outreach on all the available programs out there and there are a lot of them now. Looking at a city like Kirkland, Washington, we make sure they understand what programs are available to them. We’ve also developed a Whole Health Council made up of different groups of employees from our different departments, from our different labor unions, so that needs and concerns about the employer’s healthcare benefits could be discussed and shared. And there’s a feedback mechanism for what works and what’s not working.
Dr. Bruce Sherman: When it comes to the health and wellbeing of employees, if employers could appreciate this, it’s not simply a cost of doing business, but an investment in workforce human capital. That’s where I think the value proposition becomes much more compelling. We know health and well-being are associated with employee satisfaction and, more importantly, retention. Gallup researchers have looked at a whole array of business-related performance measures and have shown that employee engagement is associated with many favorable business outcomes. So, if we can look at investments in health and wellbeing as an investment in an organizational asset that has quantifiable dividends, I think that can attract the attention of more employers resulting in a willingness to make those investments rather than looking at them as year-over-year expenditures based on cost-related factors.
Donald Baker: With more than 70% of Americans receiving healthcare coverage through their employer, the employers do have a lot of influence. What measures can employers take to support employee health equity and affordability, including benefits packages and programs?
Dr. Bruce Sherman: An equitable benefit design that allows for individuals who are at the lower end of the wage spectrum in particular, to have affordable access to care is critical, ensuring that their voices are heard in the discussions about benefits planning. We tend to impose benefits plans on employees rather than ensure that we are eliciting their input and identifying and addressing their unmet needs. The more we know about unmet social needs, the more able we are to address some of those issues as part of a broader benefits offering.
Dr. Kevin Wang: I am always fascinated that America’s first insurers were employers. Early employers came together and said, ‘we need to have something in reserve for when things go wrong, or things go bad.’ That mentality is still there with the vast majority of Americans having healthcare insurance through their employer. Yet, reimbursement is still pushing the wrong incentive: the other day, I was reading about how there are providers trying to generate a reimbursable code for time spent replying to portal messages. Trying to get rate concessions on costs while providers are trying to squeeze out higher reimbursements ultimately blows up total healthcare costs. Employers can do more and the specific example I’ll give is behavioral health — where just getting access to psychological and psychiatric services is already extremely tough. Employers have the ability to change this by starting with employee assistance programs (EAP), and then adding digital applications, and in cases like our clients, additional programs like a behavioral health clinician embedded directly into primary care with preferential virtual or in-person access readily available to employees when they need it. All benefits an employer can do on their own.
Donald Baker: During COVID employers deployed a multitude of digital health point solutions to get employees connected to healthcare. Now employees have many options available to them. Are you seeing greater engagement and are all your employee populations utilizing these programs in the way that you intended?
Truc Dever: Telehealth has been one of the big winners from the COVID era. And we work very closely with our team at Vera Whole Health by meeting with them regularly to look at utilization information and it’s very clear that’s something that the employees find really improves accessibility. They can set up their appointment, they can go sit in their car at lunchtime, during work. They don’t have to take time off of work. They don’t have to drive to the clinic, and they can meet with the provider or health coach for their telehealth appointment. So, it just improves accessibility, and I think more employees can go in that direction.
Malia D’Alio: That was our biggest win from COVID. One of the biggest takeaways we had from a healthcare system perspective is the way we’re now embracing telehealth and it took a pandemic to get us there, but I’m so encouraged. A pivotal point for us with COVID is that it represents a cultural shift for our leaders and healthcare organizations and the way that we’ve been able to move away from this rigidity and shame-based culture around needing healthcare. U.S. healthcare workers, we are human too. I’ve been a part of organizations in different states that didn’t approach their employees that way. You truly did feel like a cog and disposable and part of a system that didn’t see you as a human being and didn’t value you. And I think that we’re realizing this now because of the burnout rate for healthcare workers, and COVID was such a tipping point for that. But we’re not out of the woods with that. We still have a lot of traction to make in helping to cultivate a robust workforce moving forward and I really feel like the more we can apply a lot of the innovative models that we are now embracing and valuing towards our patient populations, to our workforce populations, the better off we’re all going to be.
Donald Baker: Dr. Wang, in what ways can technology and innovation be leveraged to remove barriers to care and create greater engagement with employees and their healthcare to improve health outcomes?
Dr. Kevin Wang: Vera Whole Health and Castlight Health recently combined to form apree health. At apree, we have a simple flywheel concept which starts with getting really good at engagement, so you really know and understand the person. You try to get that person routed to enough value-based services, which then engages the person to manage their whole health better. It’s a very simple flywheel, but actually very hard to start. Digital point solutions à la carte are very different than if part of an integrated, connected ecosystem. A digital solution that measures a COPD patient’s chronic low oxygen saturation is good; better if that information is known to a care team to avoid an unnecessary visit to the ER because low oxygen is the person’s baseline. My biggest takeaway when we think about this flywheel is there’s a time and place for certain technology, but that has to be connected into a member’s ecosystem. You have to make it simple for the member to navigate and it has to then be connected to where the member’s care team has the same view. And when you get those pieces right, that’s when you can really see this flywheel of value take off.