AHIP 2018 discussion dominated by social determinants of health
Discussion at the 2018 AHIP Institute and Expo in San Diego this week disregarded the 2019 individual market premium hikes and the most recent red state challenge to the Affordable Care Act. Instead, the conversation was dominated by how insurers can reduce health disparities and address the social determinants of health.
The focus on issues like food insecurity, housing instability and lack of transportation—factors that experts say have a profound impact on a patient's health—showed insurers are beginning to pay attention to what happens outside of the hospital, even if return-on-investment is still hard to measure.
There's been a "growing recognition in the past 12 to 18 months around social determinants and its impact on chronic disease," said Matt Eyles, the new CEO of industry trade group America's Health Insurance Plans, who took over from Marilyn Tavenner on June 1.
During a panel discussion Wednesday on reducing the burden of chronic illness, panelists agreed that addressing social determinants of health would play a major role in that fight, in addition to rewarding patients for taking responsibility for their own health. Dr. David Agus, a professor at the University of Southern California Keck School of Medicine, said health plans should give patients incentives to eat healthier, stop smoking and exercise.
But Dr. Leana Wen, Baltimore health commissioner and an emergency physician, said it's necessary to understand that patient choice is always "predicated on privilege."
"I'm an emergency physician. What do you do if I say to somebody who has heart disease: You should eat better. But they tell me they have to take two buses and walk 10 blocks to get food? That's something we can fix through the lens of social determinants," Wen said.
Baltimore has set up a program to bring healthy options to food deserts by allowing residents to order food at their local library or public housing and have it delivered at no cost.
The city also reduced its high rate of infant mortality by almost 40% in the past seven years by pulling together 150 public and private partners, including hospitals, faith groups and insurers, to coordinate care for pregnant women on Medicaid, Wen explained. The mothers were triaged to a central system and assigned a nurse, social worker or community worker who would visit their homes, look for hazards like mold, and provide necessary supplies like cribs. Not only did more babies survive, but the city avoided costs associated with premature births and NICU stays.
The program isn't easy to maintain, however, because reimbursement for certain care coordination services isn't available, Wen said.
Health insurers are making progress in their own communities as well. L.A. Care Health Plan CEO John Baackes said Thursday that the publicly-operated Medicaid insurer pledged $20 million to match homeless members to housing. So far, the program has benefited about 60 people since it began in December.
The insurer is also part of a three-year pilot project to deliver medically tailored food to 1,000 congestive heart failure patients in Los Angeles. L.A. Care and other participants hope to document that providing nutritious food to patients will reduce hospital readmissions. The goal is to change healthcare policy so food delivery is a reimbursable expense for insurers.
"What we're trying to prove is that food is medicine," Baackes said. "The investment in meals versus a day in the hospital. You know the math. It's a no-brainer."
Still, measuring an ROI is elusive. Dr. Sarita Mohanty, vice president of care coordination for Medicaid and vulnerable populations at Kaiser Permanente, said data is lacking to demonstrate whether these efforts can reduce length of stays and improve per-member-per-month costs, but Kaiser Permanente is still investing in addressing social determinants "because it's the right thing to do for members and our communities" and improves member and provider satisfaction.
On Thursday, Dr. Atul Gawande, newly crowned CEO of the Amazon, JPMorgan, Berkshire Hathaway healthcare joint venture, noted during a session on improving end-of-life care that payers and providers are in the very early stages of knowing how to address social determinants of health, adding that he has yet to see any scalable solutions from the health system.
Taking on pharmaceutical costs
Meanwhile, Dan Liljenquist, a vice president in the enterprise initiative office at Salt Lake City-based Intermountain Healthcare, told an audience Wednesday that Martin Shkreli—the former pharma executive who jacked up the price of a decades-old generic drug by 5,000% overnight—inspired the not-for-profit generic drug company the 23-hospital system is building alongside Ascension, SSM Health and Trinity Health.
Shkreli's move to hike the price of Daraprim, a life-saving drug used to treat a parasitic infection, prompted Liljenquist and his group to explore how pharmaceutical companies were able to corner the generic drug market and exploit desperate patients. Intermountain pharmacists are dealing with shortages of 190 essential generic medications like sodium bicarbonate, basic antibiotics, morphine and fentanyl, he said.
The problem stems primarily from a lack of competition in the generic drug market. Initially, Intermountain discussed creating a large group purchasing organization to gain leverage over drug companies, but decided it wouldn't make enough of a difference in a market characterized by monopolies.
So it decided to partner with other systems to manufacture the basic drugs hospitals need to care for patients and announced the initiative in January. Since then over 100 other health systems have reached out to partner. Intermountain completed its governance documents on Monday and will announce governing board members in the next couple of months, Liljenquist said.
"Our goal is to create what we think is the first of its kind societal asset," he said.
Liljenquist said he also hopes to partner with payers to collectively develop generic drugs.
"We think in this model we can raise $50 million in five years. We could put a $10 vial of insulin on the market," he said.
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