S2E8 – The Effect of the Post-COVID Wave on Social Determinants of Health with Sara Ratner

Announcer: 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 to the leaders, innovators, movers, and shakers who are bringing new ideas, inspiring others, and leading the way.

Jenn: Welcome to the finale episode of RadioRev. I’m your host, Jenn Dellwo. Thank you for joining us. You’ve made it to the end. This is the final episode of our Social Determinants of Health season. As I’ve mentioned each week, this series dives deep into social determinants of health, offering various viewpoints on the topic with a different industry expert each week with the hope that you take away new insights and perspectives, and are inspired to look at SDOH in a new light from all angles.

As a collective, what we’ve said this entire season is the goal of these conversations is to inspire innovation and motivate the healthcare industry to work together to create meaningful solutions that help people live stronger, healthier lives. Today we’re joined by Sara Ratner, SVP of Government Programs & Strategic Initiatives at Icario. Sara, welcome back. Thanks for joining us.

Sara: Thank you for having me.

Jenn: So you’ve been on the show a few times. We know your favorite ‘80s song. We know your second-favorite ‘80s song. What’s your favorite ‘80s ballad?

Sara: I don’t really have a ballad. The Poison songs are always good ones to slow dance to. The song that I’ve been listening to the most when I run these days is “Under Pressure” by Queen and David Bowie.

{song plays}

Jenn: Oh, that’s a good one, and so fitting right now.

Sara: It really is.

Jenn: Perfect. Well, we’ve never fully dove into your background before when you’ve been a guest. So, I’d love it if you could take a few minutes and tell us about yourself, a bit about your career path, and your role at Icario.

Sara: Sure. My career path is a bit circuitous. I went to law school to help represent abused and neglected kids. That was largely centered on my commitment to just helping people. I realized that from a professional perspective I could do that, but I also wanted a more dynamic industry. At the time I went to the law school that had the number one healthcare program in the country. I loved this and thought this area would be great and a good fit for me with my desire to use my professional experience to help people. So after graduating from law school I went into private practice, where I focused on regulatory and M&A work for some of the largest U.S. and global healthcare companies. And then, when I was in private practice, I also was able to do a fair amount of pro bono work, which was nice and allowed me to kind of get back to my roots of helping people in need. From there, I went in house but ultimately ended up at MinuteClinic because my passion was around learning a business too, not just practicing law. Practicing law doesn’t necessarily afford you the ability to learn the actual business operations. I ended up as general counsel for MinuteClinic, which had recently been acquired by CVS. Shortly after I joined it was acquired by Caremark and created a formal healthcare division. During my tenure there I was responsible for the legal function, government relations, HR, and strategic relationships. Interestingly, at that time, there were really strong headwinds from the medical community and the medical association. They were trying desperately to enact legislation to block or restrict MinuteClinic’s ability to offer certain core services and in primary care really felt there was a threat to their business and the overall healthcare industry. At the time I had a theory that if we formed partnerships with health systems and demonstrated value, then that would create a much easier market entry and state of expansion. I knew through networking Dr. Mike Roizen, who was the Chief Wellness Officer at Cleveland Clinic, and I reached out to him to understand whether they would even entertain a conversation with us considering the consternation in the market. We met with their leadership and ultimately entered into a formal deal with them so that MinuteClinic could treat the traditional cold, cough, and flu, and Cleveland Clinic would take on much more complex patients. That exploded to hundreds of different relationships, and I think paved the road for an easier market entry to additional states and now the mainstream, which is nice to see. Ultimately, I went in a bit of a different direction and joined Prime Therapeutics, which is a PPM. There I reported to the audit committee of the board of directors, which was made up of 13 Blue Cross CEOs. This job launched me into a leadership role in Medicare and Medicaid, where I focused on pharmacy. It brought me back to the underserved space which had initially driven my focus in healthcare. In this role I had a lot of exposure to CMS and gained a true appreciation for CMS’ perspective around why it creates some rules and guidance and really their intent to protect beneficiaries. Also in this role, it opened my eyes to a lot of the non-health-related barriers which we refer to today as social determinants of health and especially as it relates to pharmacy compliance and med adherence. This also really brought to light the true importance of pharmacy and the pharmacist in helping to manage peoples’ healthcare conditions, with the relationship with the pharmacist being the most frequent health interaction and at times often treated as a primary care provider. From there I went and joined a company where I was president, NeoPath Health, and I ran onsite clinics for school districts and tribal reservations, really focusing on a core underserved population that was new to utilizing onsite clinics. That was very, very interesting to me because it also kept me in the space that I was very passionate about. I was ultimately recruited to RedBrick Health, where I ran operations and clinical services and launched the government programs business, which was focused on Medicare and Medicaid. Ultimately, RedBrick Health was sold to a private equity firm, so I transitioned out. While I was wrapping up different duties and responsibilities at RedBrick I started an insurance company called ProximalHealth. I also developed a separate company to help early-stage, venture-backed companies drive strategy around the underserved, focusing on government programs and mental health. That’s how I ended up at Icario. They became my client, helping the team there build out the government strategy. Ultimately I ended up working for them full time, which is what I do today.

Jenn: So it’s safe to say that you’ve been busy over the last couple of years!

Sara: Just a little bit.

Jenn: Well I’m going to do a quick plug for you. If you’d like to learn more about Sara’s background, she was recently a guest on the podcast “So You Want to Be a Healthcare Executive?” and you can take an even deeper dive into her background there. So all season long we’ve talked about different social determinants of health barriers and now even after nearly a dozen episodes we still haven’t covered them all, which I think speaks to the overwhelming need to address so many different things. What haven’t we talked about on this season so far that is important to mention?

Sara: Well, right now it’s really important to consider the time that we’re in. We’ve spoken a lot about the underserved, but the underserved has expanded substantially with COVID. When we look at who we historically consider the underserved, it’s really centered on axes covering culture, health, economic, and physical categories and characteristics. But in the context of insurance coverage, we thought of the vulnerable and underserved as those on Medicare, Medicaid, duals, and those that are underserved. However, these categories have expanded dramatically since with COVID it’s a much broader category now. These populations that I would consider underserved, and I’ll talk about them briefly, they’re situationally at odds with the shelter in place order and other safety mandates. Consider a couple of new areas that I would say fall into this category of underserved. First, I truly believe that ‘essential workers’ is a new category. There are 65, 70 million in hospital, grocery, mail and delivery, transit, and telecommunications roles. I could go on about these amazing workers who continue to have frequent physical interaction in close proximity to others, and they’ve not been able to shelter in place because they’ve been providing core functions to all of us. These are really unsung heroes during this period of time, not recognized fully for their sacrifice and being paid (some of them) much lower wages. They don’t have PPE in many cases. They have a higher rate of exposure, and as I mentioned, they can’t shelter in place. So another category I would also consider is those that fall within what’s call the digital divide. Many of these individuals still don’t have access to technology and broadband, and this group of people is referred to as the digitally divided. So pre-COVID there were a lot of people without residential access, but they were able to get on computers at work or at the library or school or other public venues that are available where people can access broadband. But now with the shelter in place orders, that’s not possible. Or at least it’s slowly coming back to possible but it hasn’t been for a long period of time, which we all have experienced. According to recent research, those with incomes $50,000 or less have the lowest rate of owning a cell phone. This is also a population that in the past 60 days has reported the highest job upheaval and job loss rate of all categories of individuals. Also, these people don’t have access to a traditional personal computer. Shockingly, this is a major issue and especially with rural people being hit particularly hard where if you look at the statistics, many still don’t have the government’s minimum download speed for broadband access. As we know also, this impacts health. Research recently done shows that many rural communities have the highest diabetes prevalence, and also have the lowest broadband access. The highest obesity rates that are 6-10 points above the national average are in areas with low broadband access. Now we are starting to recognize how critical this is to many different aspects of life, not just getting on a computer or having high-speed internet access, but it is becoming a super determinant of health since it truly exacerbates disparities in other social determinants of health. Since the start of the pandemic, there’s been a 10% increase in coverage, and minimum broadband, we know, is critical for technology. When we see the increase in the unemployment but not a corresponding increase to coverage, it certainly makes it very difficult to search for employment and also utilize the new telehealth benefits that many now have access to and are essential when we have up to this point not been able to go to the doctor for some of the nonessential services. You can see from statistics that this broadband adoption rate gets far worse as income declines, so it’s hitting particularly hard a population that is already underserved and needs access in a much higher degree to these types of resources. Another area that we haven’t focused on in the past is those that are incarcerated that are at a much higher risk during this period of time. Generally, the incarcerated have a much higher rate of mental health and substance abuse issues as well as infections disease. Frequently, these prisoners are released without their medications or follow-up physician visits, which is scary because now their chronic conditions aren’t being treated. They also can’t necessarily afford healthcare with half of all former prisoners only having earnings during the first year after release. One of the most shocking statistics I’ve heard is that those released from prison are 12 times more likely to die within two weeks of release, which is just tragic. All of this is before COVID. So then you layer the pandemic on top of this, and it creates something that is insurmountable and just adds barriers. So those that are incarcerated today, including those in ICE facilities, are at higher risk for contracting COVID. This is a group that may already have compromised health conditions, so these situations and settings where isolation is impossible just continue to create this rampant spread of COVID. Another area that we have not discussed is the rural population and how they fall into this category. Now, we spoke a bit about that earlier, about the lack of broadband access, but there are more barriers than lack of broadband that are creating a much greater exposure to social determinants of health. So general statistics, just looking at things overall, show that two times the amount of rural residents compared to urban live in poverty. Many don’t have transportation, and then you layer onto that the fact that there’s a rate of 39.8 physicians per 100,000 compared to urban, which is 53 per 100,000 with 88% of counties considered by HRSA as medically underserved. Without the transportation, with the increased rate of living in poverty and the lack of physician access, it cascades the impact of social determinants of health where it becomes similar to other populations—a perpetual cycle. It’s very hard to get out of it. When you add COVID on top of it we’re seeing non-metro counties are seeing a much higher increase in cases and deaths compared to metro these days. Consider that without access to physicians—or more limited access—and a lack of transportation, it creates a very difficult situation for rural residents to get treated. So the overall adversity, lack of internet coverage, and much more limited physician access intensifies these negative health effects from the coronavirus. The last area that I would draw your attention to is mental health. Before COVID I believe this was an underserved category, but now I truly believe that it’s recognized by many more as a category that is highly underserved. Twenty percent pre-COVID suffered from mental illness, and providers were becoming more scarce. They were paid much lower rates than other providers. Obviously rural had a much higher rate of shortage. This also is an area where it cascades medical disability, with depression being cited as the top cause of medical disability. We can’t avoid this as a contributor to overall health. What I like to do is to think about things in perspective with comparisons. Suicide, we know is the tenth leading cause of death, claiming about 50,000 lives per year. About 1.4 million people per year attempt suicide. Today there are 1.2 million COVID cases in the U.S. with 88,000 deaths. The rate of people who attempt suicide and die by suicide is not that far off from those numbers. These are pre-COVID, where we now expect a substantial number of attempted suicides and deaths by suicide to increase at a much higher rate, with The Washington Post recently noting in an article that suicides during this period could increase by an additional 18,000. It puts it closer to and on par with the number of deaths by COVID. One of the areas or subcomponents within the mental health crisis that we’re seeing actually amplified right now is with healthcare providers. They’re suffering mental health issues at the most alarming rate. While access is increasing, we still know that they are seeing things on a daily basis that are very, very difficult to deal with. They’re being forced to make decisions that they have not been trained or equipped to make—that are contrary to their Hippocratic Oath. These really intensify existing mental health issues as well as create additional ones. We have to recognize that and create a system to help support these workers. What we’re going to see is this continuing second pandemic as it relates to COVID, which is the mental health crisis.

Jenn: You bring up so many areas that we could dive into, especially with COVID, which has really changed the way we’re thinking and talking about social determinants of health. I think you just proved that we could dedicate an entire season to that topic alone. But I’d like to shift a little bit. We’ve talked before about how your ZIP Code can be the biggest indicator of health. Can you talk more about addressing social determinants at a block level?

Sara: Localization is a key feature in addressing social determinants of health. It’s probably one of the most important components in looking at it. The healthcare industry has looked at localization in terms of census track and how the differences may influence a population’s health. To understand the true need of a population, what we’ve experienced is a need to break the census area down to the block level. The block level is more narrow than a census track, so when you take a census track and break it down, there are multiple block levels. When you look at it that way there can be stark comparisons within a census track. Take for example, a census area with the following characteristics: There’s a 10% poverty rate, 15% SNAP coverage, 7% of the people live close to work, median income is $70,000, and the number of people on Medicaid is 17%. Now, let’s break it down into the block levels. In the first block level, the percent of poverty is 15%, the second is 4%. SNAP coverage for the first block level area is 23% compared to the second, which is 6%. Those that live close to work in the first block is 4%, with the second being 9%. In the first there’s median income of $53,000, and in the second it’s $83,000. Relative to Medicaid, in the first block 26% are on Medicaid, and in the second 7%. So you’ll see there’s a massive difference between block one and block two, although they’re not that far apart and they’re considered within the same census area. So if we look at things at the census level, it will completely skew the level of poverty represented in block one and potentially influence the resources that get deployed. If you’re looking at it overall, you may say this area’s not underserved. But when you break it down between blocks you can really get a sense for which area exactly needs the most resources.

Jenn: When we’re talking about localization, how can data help us understand who’s at risk? I think you’ve alluded to this a little bit, but where can this data be found?

Sara: This can be found in a couple of places. There’s clinical and non-clinical data that’s available. Clinical we know is claims and other encounter and experience data. And the non-clinical, what I’ve found is really interesting and a great way to garner information is through social determinant of health assessments that people complete, where you can understand at a personal level what people are experiencing and help assign resources that create a much more personalized approach in helping people address some of these barriers. Other data that exists: The CDC is a great resource, and they have chronic disease indicators. There’s the National Environmental Public Health Tracking Network. There’s a social vulnerability index. We’ve got a Vulnerable Populations Footprint tool. So there’s a ton out there, and this data can be fed into analytics tools like machine learning algorithms and other predictive models to help forecast future outcomes. We can do this at a block level. We use this to layer community resources, understand interventions, and then ultimately a very critical component that some failed to include as part of this process is measuring effectiveness of deploying these tools.

Jenn: You’ve spoken about several different barriers throughout the episode, but what do you see as the biggest barrier or barriers to successfully address SDOH?

Sara: The difficult thing is social determinant of health needs are shifting, especially these days with COVID. Pre-COVID we saw barriers like transportation and food access and access to care and environmental barriers—we saw all of these as issues. We solved them in ways like providing vouchers for Uber rides or helping to locate housing or giving access to food banks. But now there’s food scarcity. We can’t afford to stockpile or pay for more food. The food banks are much more limited with more and more people needing them. So we have to look at how things have shifted in addressing these determinants. Social determinants are highly correlated with mental health issues as I just addressed and discussed. These are very hard to help solve for. Historically, we have not managed mental health issues very well, but today we’re trying to leverage digital solutions. But as I also previously mentioned, people fall in the digital divide. They can’t access these things, so it’s very, very complicated when the barriers are constantly shifting. There’s a culmination of them, and that culmination changes every single day. It’s kind of a moving target in some respects, and I think the industry is doing a good job, or a better job than it has in the past, in trying to stay on top of this and create solutions. But we have to recognize the dynamics, and I think in some ways innovate more around this to be able to predict where things are going and barriers that people are going to experience in the future and create resources before people go through them. And I know that’s tricky and that’s a bit hard to do, but until we’re able to do that I think we’re going to always be playing catch-up in this space.

Jenn: That’s the perfect segue into what I wanted to ask next because there’s a lot of heaviness in what we’re talking about right now. I’d love to hear some health plan examples of where innovation is happening, but also what you’re seeing people doing to support social determinants outside of healthcare.

Sara: So there’s a lot of innovation that’s happening, and we see this every day in the journal articles and in the newspaper of the big healthcare players and the provider systems helping to solve for this issue. I think they’re doing a good job. There are solutions for food, transportation, housing, and employment. We’re starting to see a little bit with technology access. There’s innovation happening. Access to telehealth—I think we’re trying to solve for that problem. Some of the companies are focusing on treating social determinants of health, like pharmacogenetics, which is very interesting to me. At a granular level, like a DNA or core level, organizations are trying to understand effective interventions, so it’s really a one-on-one, personal approach. And this is in very stark contrast to a more population health-focused approach which we’ve utilized in the past. The other area of innovation is trying to preempt some of these barriers. There are leading indicators that we can express and know someone’s predisposition for getting into a situation where they may be experiencing, to a greater degree, social determinants of health. For example, if we know somebody is a lower-wage worker, chances are they are going to be underemployed. So, the plans and the social service organizations can look at this as kind of a preemptive approach to tackling future problems for this individual or these individuals by sending resources to the extent that they do become unemployed, they’re on top of it. They’re not struggling to figure out what their resources are for a period of time when they forego income or have to wait for their unemployment benefits and can really try and get ahead of this. It’s kind of like dealing with somebody who’s pre-diabetic. You want to intervene before they become truly diabetic and drive engagement in a way that brings them back versus having them continue on a trajectory where they fall farther and get worse and worse. We know diabetes, for example, can lead to other, more severe health conditions. So I think seeing some of the organizations treat social determinants of health in this way is encouraging to me.

Jenn: Yeah, that is good to hear. Because this is the final episode of our SDOH season, you get the final word to wrap it up. What’s the single most important takeaway you’d like healthcare organizations to remember about social determinants of health?

Sara: Think of this population you’re serving as your mother, father, sister, or brother and what would you want for them? I would also continue to challenge the status quo and what can be at times a perfunctory check-the-box approach to this. I would also say don’t take the care out of healthcare. You can’t manage what you can’t measure. Said another way, what gets measured gets managed. So we have to be able to measure what we’re doing in ways to assess the results and change it going forward. Along those same lines, continue to quickly collect this data and iterate around what is working and what isn’t working and pivot quickly so that we create test-and-learn models that make this successful.

Jenn: You’ve given us a lot to think about. Thank you for that. Personally, what’s the coolest thing you’ve done lately while under our shelter in place order?

Sara: I have never done this before, but I saw a story on this woman whose husband passed away, and it just struck me how fortunate we are and how our situations can change in a matter of moments. And so I went to her GoFundMe page and made a donation just because I feel like I’ve such an immense amount of gratitude during this time, and anything we can do to help those who are less fortunate or suffering, we need to do. There’s not a ton that at least I can do these days besides those small acts of kindness, but they go so far, and it really felt awesome.

Jenn: That’s awesome. Sara, your insights are always appreciated. Thanks so much.

Sara: Absolutely. Thanks, Jenn.

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