Special – SDoH Side Effects from COVID-19 – Social Isolation & Loneliness with Sara Ratner

Announcer [00:00:01] Welcome to RadioRev, podcasting from the heart of healthcare in Minneapolis, Minnesota. This is the podcast for change makers looking to do more than just health engagement. It’s about getting people to take action and do things that actually improve their health. It’s a radical idea, right? So we’re talking with the leaders, innovators, movers, and shakers who are bringing new ideas, inspiring others, and leading the way.

Jenn [00:00:26] What if we were told that the best way to slow the spread of the coronavirus pandemic was to smoke 15 cigarettes a day? What would you do? Loneliness, we know from the research, can be as bad for your health as smoking. It’s more predictive of mortality than obesity. And loneliness itself was a pandemic long before COVID-19 got its name. So canceling church, school, work, and sports means we are doing something that can be hazardous for our health in order to save lives. The entirety of the previous statement I just made is from an article written by Amanda Ripley in The Washington Post called “Four ways to help prevent loneliness while you’re social distancing.” And it’s sobering. Think about that for a minute. You’ll come to realize, as we did, that these facts cannot be ignored. We felt it was our responsibility to address this issue and discuss what can be done to build a community atmosphere while remaining physically distant as we all navigate this new reality together. With that, welcome to a special-edition episode of RadioRev. I’m your host, Jenn Dellwo. Today, we’re joined by Sara Ratner, Senior Vice President of Government Programs and Strategic Initiatives at Icario. Sara is a frequent guest of RadioRev and is here today to talk about some of the side effects of the actions being taken to protect citizens from COVID-19. We, of course, have been thinking about how to protect ourselves from the virus itself. But equally important is considering how to prevent the social isolation and loneliness ramifications of self-quarantine and social distancing orders due to the pandemic. Sara, welcome to the show.

Sara [00:01:55] Thank you for having me.

Jenn [00:01:56] So I wanted to start by talking about the drastic measures that are being taken in the United States to reduce the risk of COVID-19 spreading. So we have millions of Americans who are now working from home, at least those that are fortunate enough to have jobs that allow them to do so. And if people aren’t working, many are still confined to their homes, practicing social distancing. People are cut off from daily interactions and slices of life that make daily life pleasurable. There’s added stress because kids are at home and not at school. There are serious demands from employers to keep producing quality work in distracting spaces. And on top of that, many people have inadequate internet, or they lack technology at home altogether. And many people live in food deserts, so access to quality food has always been an issue. But with many people stocking up, options are becoming even more limited. And I could go on, but I’m going to stop there and ask you: Generally speaking, given everything I’ve just said, what’s going to be the effect of all this?

Sara [00:02:55] So the largest issue is going to be depression. That is going to be the new public health crisis. The social isolation is one of the biggest factors that’s going to contribute to this. We have that due to people being quarantined, who are exposed. We have that now because of the dramatically increased unemployment and school closures. So this social isolation is going to drive another public health crisis around depression, anxiety, stress that will manifest itself in another crisis that we will have to deal with shortly. Also, not everyone can afford this social distancing. It’s a very odd time. We have hourly workers who can’t afford to go on voluntary leave. They may have to go on involuntary leave or are furloughed or laid off. And that can become even more isolating. Also, gig workers can’t afford to take time away from work either if they can’t work remotely. So we have this time where we’ve got hourly workers and the gig economy and not everybody has the luxury of being able to work from home and continue their job as they would if they were at a physical office. Also, we know that there is unequal risk and equity distribution around isolation and social distancing. But we’ll talk about that more in a little bit.

Sara [00:04:52] Another item that I think is interesting and that we don’t think about around social support is those people who struggle with addiction and need support groups. So now we have to address an issue of people relapsing because they don’t have their support groups that help them deal with the stress and how to cope with addiction. And we know from studies that this will increase the relapse rate. We’re going to see a massive increase in Medicaid with unemployment. That’s going to skyrocket. And if you look at what people are predicting as 20% unemployment, we have to think that a lot of those people are going to end up on Medicaid or will qualify for those benefits. One of the other interesting changes at this time or in effect is the government is really looking at how benefits can be expanded in a way that enables quick action. So, for example, on the Medicare front, the government has enabled health plans to offer telemedicine across their entire population, not just within a subsegment that it did before. This telemedicine can be delivered across state lines by physicians not necessarily licensed in that state. And it even extends to things like mental health, teletherapy. So that can help combat some of this social isolation. But still, that isolation is a huge barrier.

Sara [00:06:43] Other benefits that the government is considering are enabling people to get their prescriptions sooner than they normally would be. Cost sharing waivers are now in place so that people can afford to access certain services. Eligibility is being loosened and fast tracked for Medicaid in various states. So some of the changes we’re seeing have a positive effect. But obviously, they’re in response to a very catastrophic and dramatic time that we’re dealing with.

Jenn [00:07:21] Right. So there’s a lot going on, but there are some things that we’re working on to hopefully combat some of this. So I’d like to go back to what was said at the very beginning of this episode, because it bears repeating. Loneliness equates to smoking 15 cigarettes a day. What are some of the ways we can prevent isolation and loneliness while still practicing social distancing?

Sara [00:07:42] Let’s go back to the loneliness issue. It produces stress. And the chronic release of this stress hormone in our system suppresses our immune system and triggers inflammation. So that alone creates an effect of…it’s taxing on everybody’s body. Also, you would think that isolation would cause obesity because people aren’t interacting. They’re staying by themselves. They may be more inclined to eat to self soothe, but loneliness is actually a greater predictor of mortality. People have a shorter lifespan if they experience loneliness. And it’s one of the reasons we’re seeing a lot of innovation in this space, helping seniors address that, because we know it will improve their health and livelihood and longevity. The elderly are really most at risk. And there’s two reasons. One, they’re more likely to normally say that they feel isolated and lonely. And second, they’re the ones who are most at risk for dying of COVID-19. So right now, the problem with the elderly is they’re exposed on multiple fronts, not just directly from the virus. Going to the point previously, this social isolation is going to really make us truly sick. And furthering our sense of isolation from one another just continues this vicious cycle.

Sara [00:09:25] One thing I wanted to mention that we’ve seen a lot about is social distancing in the media, but I really don’t believe we mean social distancing. I think it’s truly physical distancing that we’re speaking about during this time. And this was recently discussed in a New York Times article about the need to physically, but not emotionally isolate, because this is the time we’re in greatest need of being able to interact with people. And we need to look at really creative ways to engage. I’ve seen a ton of new resources come online being offered around yoga, exercise, different types of virtual engagement. I’ve even seen Netflix offer ways to be able to watch shows together as a group, virtually. And so it’s really a new time to experiment with ways to engage and not be literally next to each other. And there’s going to be those individuals who aren’t comfortable with this. Obviously, the millennials and younger generations are used to engaging in this way. But for the other populations, it’s not normal or natural. And so we’re really going to have to learn and teach people how to use a new way of engaging so that we help combat the social isolation that we are all experiencing right now.

Jenn [00:11:01] As we were preparing to record this episode, something was said that really hit me. It was something along the lines of “You may have survived the virus, but you died of isolation.” And that’s a really powerful statement. I don’t think we can ignore that. What are the health effects of being distant?

Sara [00:11:19] So physical distancing is really going to affect us all. A lot of us rely on work as a way of engaging socially. A lot of social interaction happens there. Other people go to church or their social support is around their religious institution. Also, kids rely on schools, sports, extracurricular activities, or just getting together with their friends as a way to interact, relieve their stress, have fun, feel good about themselves. But one of those things that struck me is that those that are going to be the hardest hit are the underserved. So a lot of people have luxury items today, like Instacart. We have Prime Now delivery so that we can get things delivered within a day. We can stock up on items and spend a little bit of extra money at the store. People who are underserved can’t do this. They have a hard time accessing the basic essentials in life. And even when they have some other resources like food shelves, they’re going to have a hard time accessing them because they can’t use or are being discouraged from using public transportation where they’re going to be very close to somebody. So this is going to create an additional layer of Social Determinants of Health for those that are already seriously underserved.

Sara [00:13:02] In addition, we’re encouraging people to do things like get outside, engage in physical activity. But people who live in high-crime areas may be underserved as well. And so they can’t go outside, and something that’s supposed to help boost their immune system, help with their mental health, they cannot engage in those necessary activities because of the risk to their safety. And that creates a feasibility issue for this population. This population has limited digital access. We take for granted our smartphones, our tablets, our computers. Many people don’t have computers, and they have very limited wireless. We’ll talk about that in a second. Another population that I think we ignore are those in prisons and institutional settings. They’re already susceptible to loneliness and now are at a much greater risk because they can’t have visitors or people who they’re able to at least engage in some type of social interaction with besides the people that they live with on a daily basis. And the last are rural residents. And this is another population that we look past quite often, and they may have limited broadband connectivity. And so now when we’re forcing people to isolate and encouraging them to use different technology, that may not be possible. So these different types of underserved populations are going to be impacted much beyond what we normally experience. And it’s really more of an inconvenience for us than a real-life limiter, which is unfortunate.

Jenn [00:15:12] Right. I think that’s a good distinction. And you’ve already touched on this a little bit, but from what we know about Social Determinants of Health, the precautions to avoid coronavirus are likely to cause other difficult challenges, not just health challenges, but life challenges. Can you talk about what some of those might be?

Sara [00:15:30] Sure. So I was speaking to a public health official the other day and we were talking about this. And one of the things that she brought up and dawned on me was people who are dealing with domestic violence. That is a huge challenge beyond COVID-19. And for many people, that refuge for them is going to work and getting away from their house or the abusive situation. And now that people can’t find that away time, they are going to have to continue to face this reality, but at a much higher magnitude and on a much more frequent basis, which is very, very sad.

Sara [00:16:15] Some of the other challenges that exist include education for kids. I know that we’re talking about education online, but a lot of kids don’t have a computer. So what do they do when they normally only access education on site at a school? And I want to go back to the whole technology issue. Technology is a luxury for us, and we don’t always realize that. We, like I said, take it for granted. And many of those people at risk before would access technology through the library, or internet cafes, or school, or at work. Now, they don’t have it, so they’re not left with that way we can engage with people through technology. We talk about having Hulu, and Netflix, and Xfinity, and all these different things to combat boredom. That is a luxury as well. And so a lot of these things that we are referencing that will help alleviate some of this social isolation, the underserved do not have. And they’re going to be left without much to do except just feel much more isolated than before. Last, and I touched on this briefly, the elderly are particularly vulnerable and at much higher risk for loneliness. And that’s a derivative of technology as well. I saw in an article today that the elderly still do not have a high use of and access to technology. And so before they may have relied on family members to help teach them. Well, now family members are being discouraged from going around the elderly because of their increased risks. So that becomes another barrier to actually engaging. The other thing that I think about relative to the elderly, is medications. I know people who fill their parents’ prescriptions for them. I know people who put pills in the daily pill pocket or packet in order to create a much easier way for their parents to take the medication and remember to take it. Now, we can’t go to our parents’ and grandparents’ homes to do that. That is going to create a barrier to taking their medication, something that is so absolutely critical. So we’re going to see serious health effects from that as well.

Sara [00:19:02] One other item I just I want to touch on is the ramifications that we’re seeing, or the collateral damage, I should say, that we’re seeing from some of this as it relates to the financial markets. The social isolation combined with the financial insecurity that is being created in this environment compounds all of these issues: the stress, the depression, the fear. It is magnifying the effects of social isolation. And so before, if things were fine, we may just be isolated, but financially we feel comfortable. Now we have that additional layer where we think it’s a serious financial crisis, and we may not know what is to come with respect to each of our financial situations. So that uncertainty, combined with the isolation and insecurity, just becomes toxic for people of all different types of populations.

Jenn [00:20:20] I do want to mention at this point that we are going to get to some solutions. But before we do that, I want to narrow the focus for a minute and talk about the impact of COVID-19 on the Medicaid population and those already dealing with social determinants. What do you see happening?

Sara [00:20:34] A lot of what I’ve said touches on this, but this situation is magnifying and highlighting the haves and the have-nots. So we are getting our information through our computers, through TV, through our smartphones. And a lot of people still pick up the phone, their landline. A lot of people read physical newspapers. People still get mail, and they read it. And so we’ve eliminated a lot of those channels to accessing information. So people who don’t have access to that, to what we typically have, are going to miss out on information that may be critical, even save their life in some cases. With respect to Medicaid, obviously, as I mentioned, there’s going to be people who are newly eligible, and many of them. There needs to be a way to seamlessly enroll in Medicaid, especially in states where they don’t have retroactive coverage and the bills associated with any medical issue can cause bankruptcy. And so creating a way to be able to help that group of individuals is something that we have to deal with and be able to deliver on. Also, relative to the Medicaid population, we have people who are employed but are underinsured. Now, people will become unemployed. And the question that we will have to also address is how do we quickly enable people to file for unemployment benefits, teach them to do that. We will need a resource to expedite this process. I have a friend who helped another friend file for unemployment because she’d never done it before. There’s going to be a lot of us that have to go through this, and we need a mechanism to be able to help enable that quickly so that people don’t lose stability in income.

Sara [00:22:57] But on a positive note, relative to Medicaid, we’ve seen a lot in what CMS is doing in the states to act quickly. And CMS has given states relatively broad authority to make changes that they deem necessary to help support their population. And this has come in the form of new benefits and new eligibility, as I mentioned before. And so I think that is a positive note and a way that I hope can benefit the Medicaid population, especially in addressing some of these barriers. I think we’re at a time where states have looked at investing in solutions around Social Determinants of Health. And a lot of them have been nonmedically related solutions. And I hope this is a time where we consider continuing and doubling down on investing in some of those solutions with the increased flexibility that the federal government has given to states so that people who are highly vulnerable, whose isolation is magnified, can get some sort of additional benefit to alleviate any of these barriers, even in the slightest way.

Jenn [00:24:25] I’d like to turn the corner here now and talk about some of the potential solutions. How can we use AI and advanced analytics plus key population and behavior data to reach people and motivate behavior?

Sara [00:24:37] Any potential solution needs to be highly person-specific, and that includes the channel, as I mentioned before, the way in which they are most likely to access the information. Some of this data we can’t just send out globally. We have to look even more granular than the census level to a block level to understand how to target and message certain people and to generate engagement around a particular message. So everybody needs something different, especially to address Social Determinants of Health and the COVID-19 pandemic. Oddly and ironically, we give millennials and our kids a lot of flak for using social media and being on their phones so much. But we can take a page from them and understand how to stay connected even when we’re not in the same physical space and create that engagement around technology. They engage through fast, quick messaging that is direct and has a call to action, which is a great way to get somebody to change their behavior. I’ll give an example. My daughter received an Instagram the other day. It was an ad to buy an in-home manicure package. And within 10 seconds of receiving it, she had tagged me and said I should get this since it might make me happy during a time of such isolation. And so that took 15 seconds for her to get that and try and influence me into buying something that will make me happy. So it’s a very interesting time where we can reflect and take some of the lessons learned and ways to interact from our kids and start to deploy them.

Jenn [00:26:50] That’s super interesting and a great example. Let’s talk about what Icario is doing to help. What programs have we developed for health plans to keep their populations from becoming lonely, depressed, and at risk for the side effects of self-quarantine and the “stay and shelter” orders?

Sara [00:27:07] Sure. One of the most interesting and profound ways that we can message individuals is around letting them know about new benefits that are in place. We are all getting bombarded with messages about washing our hands and singing the ABCs, or doing it for two minutes, or just different techniques to wash your hands. That’s great. And we need to remind people of that. But we also need to tell them how to access their benefits. Like I mentioned before, telemedicine is a new benefit that the Medicare Advantage population can now access. So that serves a huge public health need because now people who may be at risk don’t need to go to the doctor and can engage with the medical system remotely and prevent them from taking away physician time and resources that may need to go to those who are afflicted with COVID-19. There may be medication that they can fill more quickly and still have it covered. They may be able to get a waiver of a copay or a deductible even for accessing certain services, whereas before they may have been reticent about because of the out-of-pocket costs. So Icario has a really important role in being able to educate people on these new benefits that they now have access to, and drive behavior change in a way that serves a public health need. Icario also can encourage preventive action. We know that people need to continue to get their flu shot so that they don’t get the flu. That’s equally as important so they don’t have a suppressed immune system if they are exposed to COVID-19. We need to encourage them to wait to go to the doctor, or if they’re having a nonessential procedure, to delay it if they can. So these messages that we hear from the government, from the CDC, from all of our different public health officials that we get electronically, Icario can play a role in distributing them more globally across a much broader population and a population that may not otherwise receive these messages consistently. Icario can also help drive certain programs around just being healthy, exercise benefits that people may have at home or virtually, teaching people how to stay in touch with others in a more effective way, referencing programs to eat healthy, or direct them to new recipes that they can be making during this time.

Sara [00:30:23] So there is a way to help shift or direct people to resources that they may not otherwise think about and to get them to engage in something that does help address social isolation. To that end, health plans are developing creative solutions and resources, and these vary greatly between plans. But Icario is an expert in driving these resources and the messaging associated with it to people who need to receive it. And those messages get people to take action that can help prevent certain diseases, get the help that they need at a given point in time, and direct them to these resources that are new to them and they may not understand how to access. And everybody is going to get the message differently and engage in the message or the action around the message in a way that is specific to them. And Icario’s targeted approach, matching the individual to the mechanism and the channel that will get them to take that action is so critical, and more critical now than ever, because these are things that are going to help save lives in the near future.

Jenn [00:32:04] So if there are people listening to this right now, and they want to take action, and they want to get in touch with you or would like to learn more about the COVID-19 programs Icario has, how should they connect?

Sara [00:32:15] If you’d like to reach out to me, you can go to my LinkedIn. Feel free to email me directly at Sara.Ratner@dev-revel-health.pantheonsite.io. Or go to our website at dev-revel-health.pantheonsite.io to learn more.

Jenn [00:32:32] Great. Sara, thank you so much.

Sara [00:32:34] Thanks, Jenn.

Announcer [00:32:35] Thanks for joining us for the RadioRev podcast brought to you by Icario. If you found today’s conversation as informative and energizing as we did, please take a moment and subscribe to the podcast. As always, we invite you to learn more about us and check out all of our content at dev-revel-health.pantheonsite.io/RadioRev.