IBX: The Cover Story – Taking Action to Advance Health Equity

Peter Panageas (00:07):

If you’re looking for timely, relevant conversations about the most important topics in health coverage, you’ve come to the right pod. This is IBX: The Cover Story from Independence Blue Cross host by me, Peter Panageas. By day, I oversee all of our national commercial business here at IBX. I’m also a caregiver and a patient. We always say that healthcare is personal, and it is. So, my guests and I are exploring how the big picture and the big issues affect our everyday lives and the wellbeing of those we all care about. Together, we’ve got this covered, so let’s get started.

Peter Panageas (00:45):

Hi, everybody. This is Peter Panageas, and welcome to episode 11 of IBX: The Cover Story. For this month’s episode, I’ve invited two special guests to discuss how the Blue Cross Blue Shield Association Independence and Blue’s plans across the country are changing the trajectory of racial health disparities. This time last year, the Blue Cross Blue Shield association announced its National Health Equity strategy, to confront the nation’s crisis and racial health disparities. In August, Independence appointed our organization’s first ever executive director of health equity demonstrating our commit meant for a more equitable healthcare system. Joining me today is Dr. Adam Myers, Senior Vice President and Chief Clinical Transformation Officer for the Blue Cross Blue Shield Association, a longtime advocate for community health and health equity. Dr. Myers helps set the vision for the Blues Plans efforts to create a more equitable healthcare system. We also have Dr. Seun Ross, our Director of Health Equity at Independence Blue Cross. In her role, Dr. Ross is responsible for developing and implementing strategies to ensure equitable whole person health across Independence. Dr. Myers, Dr. Ross, thank you both so much for being with us today.

Dr. Adam Myers (02:01):

Thanks Peter.

Dr. Seun Ross (02:01):

Thanks for having me

Peter Panageas (02:02):

So Dr. Myers, I’m going to start with you. Can you give us some background and overview of what the Blue Cross Blue Shield Association’s National Health Equity strategy is?

Dr. Adam Myers (02:12):

Certainly. Health inequities are not new. We have in the area of healthcare and public health, known that our healthcare outcomes are inequitable for decades. It is not a new set of facts. However, as is most public health challenge or crisis, the pandemic revealed for us once again, the realities of these disparities. We saw throughout this time period, significant disparity in how COVID was affecting certain people groups and communities compared to others, whether it be severe disease, morbidity, mortality, uptake of the vaccine, even access to testing. And that reality has been stark, as I said, in results from hundreds of years of structural components of our society. And the association realized this before the pandemic, and was beginning to have thought about how do we address these inequities. But during the pandemic, the platform became so hot that it was clearly time to put together a national strategy to impact these things.

Dr. Adam Myers (03:34):

And since the pandemic brought them to light, once again, part of that strategy included vaccinations, fair and equitable access to vaccinations and testing was part of the strategy. Data leadership about data to guide the efforts of interventions was part of it. But also even just understanding that race, ethnicity, and language data are marginally available. And if we can’t measure it, it’s difficult to put programs in place to impact those realities. Then we have the National Health Equity program, which focuses initially on maternal outcomes, because we’re aware that maternal outcomes are quite disparate for black and Hispanic Americans compared to their white mother counterparts. And so, those stark realities are very real. And we focused a bit initially on the maternal outcomes. And then finally, we talked about network standards for how do we bring all of these solutions, share best practices from across the Blues, into a set of recommendations for the plans and for other stakeholders in the healthcare system.

Dr. Adam Myers (04:52):

And so, we put together a large compendium of best practices that distills down 10 best practices specifically in the maternal space initially. But over time, we’re going to move into other disease states, such as behavioral health is coming to the fore right now, as well as cardiovascular disease, diabetes management, et cetera. So, that’s a broad overview of the National Health Equity strategy. And part of where this came from was through robust conversations with a panel of external experts in the space. And those are called our national advisory panel, that came together. We partnered with them. And they are real subject matter experts. Some of the researchers, some of the policy makers, some of the business leaders that have had tremendous impact in health equity, and they’ve helped inform this approach.

Peter Panageas (05:46):

So Dr. Ross, as you and I have spoken many times, we as Independence and certainly all the other Blues, nationally serve clients and members all over the country. Can you share with us how Independence has taken the Blue Cross Blue Shield Association’s National Health Equity Strategy, and how it’s applying it to the work you and members of your team are doing for our members. And also talk a little bit about how you are interacting with your peers from other Blues nationally.

Dr. Seun Ross (06:12):

Sure. So BCBSA has made us sort of the national leaders in this space. It has laid out some audacious goals to eliminate disparities in healthcare force members, that would inevitably translate to the state of healthcare in America. The first goal is to reduce health disparities in maternal health by 50% over the next five years. And our focus at IBC is severe maternal morbidity and mortality, and more specifically hypertensive disorders of pregnancy. Because based on the data analysis of our members and because hypertensive disorders of pregnancy have the potential of a negative [inaudible 00:06:53] that could lead to death of mom or baby, we’ve decided that this is the area of that we’re going to focus on for the next five years.

Dr. Seun Ross (07:00):

And what that looks like for us is partnering with community organizations so that our members, that those community organizations understand our members and know how to sort of affect their health more directly. And I think simultaneously we’re focused on reducing disparities and depression and comorbid anxiety, and taking a deep dive to diabetes and chronic kidney disease. My counterparts across various Blues, whether it’s in Massachusetts or whether it’s next door in New Jersey, have all taken all maternal health. And we have conversations, I would say at a regular cadence. So make sure that we are all in alignment, that what we’re doing makes sense, not only for us, but for pregnant women at large, I would say.

Peter Panageas (07:39):

Dr. Myers?

Dr. Adam Myers (07:40):

Love what you just said, Dr. Ross. We did declare a year ago, we’re coming up on a year, that we would reduce maternal disparities in maternal health by 50%, over five years. And that is an audacious goal. And people have said, is that just for the Blues or is that for America at large? And the answer is that’s really for America at large. And so, even though we’re 112 million lives in aggregate across the Blues, that’s still only a third of the American citizens. And so, the question has arisen, how can we impact that? Can we really do that? I think we can. And it’s through conversations like what we’re having right now. We can’t do it alone. None of us can do this alone. But we alone can do our part.

Dr. Adam Myers (08:28):

And I love particularly what Dr. Ross said, too. You all, at Independence have taken the large strategy and made it your own. Because in reality, healthcare is locally delivered. And within your area, your region, you have chosen maternal blood pressure as a primary focus for you. Other regions might decide that they want to emphasize doulas, or they might want to emphasize midwifery, or they may want to emphasize other components of the maternal health strategy. And that’s the purpose of offering up multiple different ways to impact this. And together, what we’ll see is a national strategy with local implementation.

Peter Panageas (09:14):

Dr. Myers earlier, you had talked about this has been building for hundreds of years that we have this level of inequity. And taking a first step around maternity and then ultimately moving into behavioral and cardiac and diabetes, is obviously the appropriate journey for us as we move forward. But this is an easy. I think you both would agree that this is not an easy task. This isn’t something that’s going to happen overnight. And I couldn’t agree with you more Dr. Myers, that healthcare is very locally driven. And I think that is one of the distinct advantages of Blue on a national basis in that when we talk to our local membership, and Dr. Ross, you, and I’ve talked about this, like a local client will really appreciate all the great stuff that we’re doing locally, and we educate and train them. And then some of our national clients will say, “This is wonderful, what you’re doing here in Philadelphia, but please tell me what you’re doing for my employee or your member out in Los Angeles or in Miami or in Chicago.”

Peter Panageas (10:07):

And so my question for the two of you is this. How have you seen other Blue plans take the association, National Health Equity Strategy, how they’ve applied it to work that they’re doing for our members, for the Blue Cross Blue Shield members on a national basis? Maybe Dr. Ross, I’ll start with you.

Dr. Seun Ross (10:24):

Let me say this first. We at Independence, we partner with some organizations on project home, and that’s to make sure we recognize that infant mortality was high. And so, we wanted to make sure that they had appropriate housing to sort of minimize the deaths that we were seeing. Other Blue plans, Horizon has decided to focus on housing also. And they’re working actually with Accelerate, or is it Advancing Health equity in Chicago to help achieve those goals. In Massachusetts, they’re working on data and growing out how we can unbundle the way that payment is given so that we can identify when patients need interventions sooner from our perspective. And so, I think those are just two of the ways. But again, sort of what Dr. Meyers mentioned is that, all of the things that we are doing will advance maternal health equity for the nation at large. And so, it might not necessarily be what we are specifically doing, but we are piggybacking off of what other Blues are doing to advance our work.

Peter Panageas (11:25):

Dr. Myers, based off of what Dr. Ross was just articulating, talk to us about the role that the Association’s playing in coordinating with Dr. Ross and her peers, and how we’re collaborating on a national basis.

Dr. Adam Myers (11:36):

Yeah. We’ve collaborated a variety of ways. One, we asked it became a board priority and an operational imperative to impact these outcomes. That happened last year with the declaration that we’ve described. As a consequence of that, each one of the Blues Plan CEOs appointed from their own team, some health equity champions. We have been meeting on a regular basis with those health equity champions, garnering input, understanding best practices, discussing measurement, discussing different strategies and tactics about how to tackle these things.

Dr. Adam Myers (12:12):

And what’s really come to the forefront, is that the interventions cover a few large categories. One has to do with provision and coverage of care. One has to do with how we manage the social determinants of health. And one has to do with this concept of measurement. And so, I’ll take each one briefly. The provision of care has to do with things like, do people have the access that they need? Do they have the coverage that they need? And one of the initiatives that we’ve propagated now as a best practice is extending coverage in the postpartum time period for up to around a year, instead of the weeks postpartum. Because we know that a lot of the preventable adverse outcomes occur postpartum period and beyond those six weeks. So, if coverage has fallen away at that point, that there’s limited access to help mitigate those issues. So, that’s one example.

Dr. Adam Myers (13:11):

Another example is bias amongst the teams that provide care. And so we partnered with the March of Dimes on a national level to offer up their unconscious bias, implicit bias training for providers, for anyone who touches pregnant patients, because that’s part of how our own personal viewpoint comes to the table and can be impactful in either a positive or in a negative way toward people’s health outcomes. We’ve also focused on the pipeline of providers within the team. And so, there’s not enough obstetrician, gynecologists or family physicians to do deliveries in many locations. So, augmenting them with midway, supporting those care teams with doulas has found to be a best practice. So, some of it really again, as I described, focuses on direct provision of care, how that’s done, where that’s done, by which teams they’re doing it, and the spirit and cultural humility that they bring to the table.

Dr. Adam Myers (14:14):

On the social determinant of health side is another key component of it. Dr. Ross mentioned that with housing and food and other components, we know very well now that about 80% of people’s health outcomes are directly attributable to things other than what we would consider the traditional provision of care. So if one, we want to impact 100% of health outcomes, which I think is our shared goal, then we can’t ignore those social determinants of health. And many of the Blues partners as well have found some unique and novel ways to address that through supporting housing, through supporting parenting programs and providing other levels of support for food, nutrition, et cetera, throughout the pregnancy and the postpartum period, not just for the pregnant mother sometimes, but for the families as well. So, social determinants of health.

Dr. Adam Myers (15:05):

And then the measurement piece. There has been stark disagreement across the nation about, can we have access to these data about people’s race, ethnicity, and language? Can we have access to these data when they’re members or patients? Can we have access to these data for people that are clinicians providing care? And the answer has been really mixed. We know that we only have this Riel data in about 40% of member experiences. And that’s not good enough. And then when we have access to the data, are we actually measuring the outcomes in a consistent way nationwide so that we can determine where we started, and track where we’re moving in a way where multiple stakeholders can be measuring toward the same true north. And we’ve worked with national quality forum and NCQA, to change the way that this is measured and reported so that we can have agreement across healthcare, not just within the Blues, but across healthcare, in such a way that we can together row in the same direction. So, that’s in broad terms, how we’ve seen this work, work at the national level, and then be implemented within the respective Blues Plans.

Peter Panageas (16:21):

Dr. Myers, you talk about access and coverage. You talk about bias. We talk about pipeline of providers. Many clients that we speak to really are trying to get their hands around that data. And I think this is not just a, it’s an industry challenge right across the board for all of us who are serving our members on a national basis and making sure that and taking those steps. Dr. Myers, as you talked about is how we’re going to be consistent in reporting the measurables that you spoke about. We also talked to our clients a lot about, and I’d love to get both of your perspectives on this, we talk to our clients about the responsibility that we as a payer, they as a planned sponsor, or also as a planned sponsor, depending on how they’re funded, have our responsibilities in serving our members.

Peter Panageas (17:06):

But we also talk about the reality is that our members need to be educated. And the analogy of we can have it all there for them, but if they don’t know how to use it or access it. Training, outreach, member engagement and taking ownership of one’s own health and wellbeing. We actually talked to a client locally who talked to us about one of its members who was literally two blocks from a major, major healthcare facility right here in the Philadelphia region, this is a globally known facility, and they were two blocks away, and didn’t know how to navigate the system to get there. And it was a challenge for them. And we did all the things that we thought we needed to do in order to engage that member. And yet two blocks away, they didn’t understand how to navigate through it. And I’d love to get your perspectives on that piece of it. We can do everything we need to do, but how do you get that member to engage a little bit more? I’d love to get your perspectives there.

Dr. Adam Myers (18:05):

I may jump in real quick. One of the things that you said a moment it ago is we did all the things we thought we knew. And that’s really, I think the crux of it. We do think that we know, and I’m not picking on you, Peter. I think it is endemic across leadership, period. We think we know what’s needed. And sometimes we do this thing that we forget the simple thing like asking. And so, that’s actually number one of our recommendations in the compendium of the top 10 list is, engage maternal voices and community stakeholders to craft, build, and sustain a holistic maternal health program from public and private partnerships to address the root causes of these issues. Rather than assume we know, pause a beat and say, help me understand. We want to be part of the solution. We don’t want to assume that we understand. Bring the two ears, one mouth approach. Seek to understand rather than assume that we do. And I think we get a lot further. Seun, what are your thoughts about that?

Dr. Seun Ross (19:10):

To bring it home to Independence to Philadelphia, we realized that in order to help people understand it really, we needed a structural catalyst. And so, we are going for NCQA accreditation in health equity. And part of the requirements is to create an advisory committee. And that advisory committee is to be made up of the community. Now, people have different definitions of what the community is. The community could be in terms of the plan, the client or the members that work for the client. And it is our goal to actually get the members that work for the client, so that we can understand how to more directly affect their care and not have it filtered through a third party.

Dr. Seun Ross (19:53):

So, I think it’s important just like Adam said. We need to talk directly to the people that we are trying to assist. And in doing that listen more than we talk.

Peter Panageas (20:02):

Well said. And thank you both for that perspective. And Dr. Myers, no, not at all. I think your approach is spot on. Look, we don’t know what we don’t know. And I think that’s one of the reasons I asked the question is because, I think the work that we are starting to do and asking the question in a different vein in a different way to a different audience, is something that we, not only as we as Blue, but we as an industry need to continue to do to overcome some of the challenges that we’ve just been talking about.

Peter Panageas (20:26):

So Dr. Ross, I’m going to point this question your way, and Dr. Myers going to ask you from a Blues perspective to lay on top of it. So, as I had mentioned earlier, Dr. Ross, that you joined our organization, you joined Independence August of last year, and we’re so thrilled to have you as part of our team. And the role that you and your team are fairly new to our organization and certainly new to the Blues. Can you share with our audience, some of the plans that you and your team have to address health equities that our members locally nationally are facing? And then Dr. Myers, if you can also showcase some best practices that you’ve come across from other Blues that other Blues are doing nationally as well? So Dr. Ross, I’ll turn it over to you.

Dr. Seun Ross (21:05):

Sure. So yes, I’m only eight months in been here eight months. And my team is even younger than that. Look, the role of health equity officers and health plans is an emerging role. Prior to my arrival at Independence, Independence before of bold corporate strategy of equitable home person health. And my role is to operationalize that strategy. And that is leading the work that creates and defines measures of equity and improvement goals for all Independence lines of business. So to that end, I have a few priorities.

Dr. Seun Ross (21:37):

One, holding us accountable by data driven improvements. Benefits and care delivery redesign. Our success again, depends largely on our relationship with the community. So community engagement and investments. Population health and digital health. And then academic community collaborations. And I think I would be remiss if I did not mention. Here in Pennsylvania, there was a state policy or law actually, that prevented us from asking race, ethnicity, and language questions on an insurance application. So, you have this sort of conundrum. We’re being asked to improve health outcomes. We’re being asked to eliminate health disparities. But we cannot ask a member or a potential member sort of the gold standard, how they identify themselves.

Dr. Seun Ross (22:27):

So, my colleagues in informatics and government affairs worked really hard and sort of lobbied the state to change that law. And last week, it actually was changed. So we are now able to ask those very important questions on these applications. And that will get rid of the question of how do we even get data. Because since this track data is not enough, imputed data has so many holes in it. So, government affairs, IX, their work really helped us get to where we needed to go.

Peter Panageas (23:01):

Excellent. Dr. Myers?

Dr. Adam Myers (23:03):

Yeah, there are a few. I mean, there are quite a few best practices that we’ve seen across the Blue where we’ve seen elements of this strategy implemented with material success. I’ll mention one. Blue Cross Blue Shield of South Carolina and partnership with Anthem Blue Cross Blue Shield implemented a centering pregnancy group, prenatal care for the Medicaid mothers in South Carolina. The group prenatal care model includes health assessments, interactive learning, as well as community building. And has observed a 33% decrease in preterm births. 33% decrease in preterm births. Blue Cross Blue Shield of Minnesota is increasing the reimbursement rate in frequency for doulas, to encourage them to accept Medicaid membership as well. And they also are funding 48 scholarships for doulas of color in their communities, to try to really round out and bring diversity to that workforce that can be so impactful.

Dr. Adam Myers (24:02):

We’ve talked about the partnership with the March Of Dimes. Many Blues Plans are really encouraging that, or have other opportunities that they offer to their provider partners for unconscious bias and culture humility training. Blue Cross Blue Shield of Massachusetts has incorporated incentives linked to health equity measures into their alternative quality contracts, their valued based contracts. They’re including health equity measures into those contracts. And then as I described, Vermont is an area where is a fairly rural state, and they simply don’t have enough traditional OBGYN or family physician providers to support their population. So, they’ve worked with vigor to help equip and produce more certified midwives for their population.

Dr. Adam Myers (24:49):

So, that’s just a taste of the variety of local implementation strategies that have been brought to bear across the Blues in order to address these challenges. But then there’s also public support of things like the omnibus package, which is actually 12 separate bills that are working through the legislative process at a federal level, that are each in and of themselves materially impactful to health outcomes for women. And so, we are by the one supporting each one of those packages as they make their way through, each one of those legislative offerings as they make their, our way through. And on the hill with policymakers as well. And so, it’s day to day conversations with policy makers about how can we do this better, and what elements do we each own in solutions that can be brought to bear? Because we can’t point fingers. We can reach out hands, as way that we do this together. And only together can we accomplish these outcomes. And I think that measure is resounding loudly and clearly. And I will tell you, policy makers are eager to make impact in this regard as well.

Peter Panageas (26:00):

Thank you so much. So, Dr. Myers, Dr. Ross, we covered a lot today. And I think the things that we’re talking about are obvious, not easy tasks. This is going to take a long time. And we’re taking the appropriate steps towards making change. And certainly starting with maternity and branching into a lot of other, very, very serious elements that need to be tackled. We talked about the importance of data. We talked about the importance of measurement. We talked about the importance of changing policy. One out of every three Americans hold a Blue Cross Blue Shield card. We’ve got a lot of membership on a national basis. And so, we owe it to our members to continue to drive that. And I think a lot of the things that you’ve both shared with our audience today was very, very impactful and very, very helpful with the understanding that we’ve still a lot more work to do. And maybe for a future podcast, we maybe agree to come back in maybe a year and see what types of strides we’ve made in the course of a year. And maybe that’s something we can do a year from now.

Peter Panageas (26:54):

But let me ask you about this question as I do with all of our guests. If there’s any one or two or three things that you’d like to share as a closing comment with our audience, what would it be? Dr. Myers, I’ll start with you.

Dr. Adam Myers (27:08):

Sure. Thanks Peter. We didn’t get here overnight. The results that we see now, come from essentially a societal structure and set of processes and priorities that we’ve had in place for hundreds of years. The problems are societal and broader than what we oftentimes view of as healthcare in the traditional sense. So, the fact that they’ve been going on for hundreds of years and that it is bigger than what any one of us can influence, it is tempting to give up. It is tempting to say, can we really do this? It is tempting to try to oversimplify the problems into solutions, and find single solutions that can be brought to bear. I will say there are no single solutions for this.

Dr. Adam Myers (27:57):

My take home message would be, don’t give up hope. We have the commitment, we have the wherewithal. And it will take long sustained commitment at multiple aggregate incremental solutions that are brought to bear. There’s not going to be a silver bullet. It’s going to take lots of little things that add up that will finally get us to the end of the rainbow here, of greater health equity. This is not ethical rainbow. I think we can achieve it. But it’s going to take long sustained effort in order to accomplish it. This is not a quarter to quarter issue. This is a decade to decade issue, from a results standpoint.

Peter Panageas (28:39):

Dr. Ross?

Dr. Seun Ross (28:40):

Thanks, Pete. I think that’s important to know that this is going to take years. It did not happen overnight. And as a result, it’s going to take us as Dr. Myers said, years for us to make some inroads. What my take home would be is that health equity is the end result. Before we get to health equity, I think it’s going to require us to be a little bit more uncomfortable. I don’t think that we are uncomfortable enough yet in talking about what it’s really going to take to achieve health equity, to get rid of disparities, to eliminate inequities. Social determinants of health, as Dr. Myers said earlier, is the primary factor in achieving health equity. And I don’t think that we started to have enough conversations around SDOH, to make the necessary inroads that we could. So, it is to be uncomfortable. I encourage everyone to volunteer at their community organizations, be a part of their community, and making changes for their community and communities that they don’t necessarily live in. So, if your community is doing well, I encourage you to go to a community who isn’t and help out.

Peter Panageas (29:52):

So Dr. Ross, Dr. Myers, thank you so much for being with us today and for sharing information with us on how Independence the Blue Cross Blue Shield Association, and certainly what other Blues Plans are addressing the health inequities our country is facing every day. Thank you.

Dr. Seun Ross (30:07):

Thank you. Thank you for having us.

Dr. Adam Myers (30:08):

Thank you.

Peter Panageas (30:10):

And to our listeners, thanks so much for joining us today, and I hope you’d enjoyed our discussion. Check out the show notes for more information at insights.ibx.com. That’s insights.ibx.com. Thanks again for joining us, and we’ll see you next month. Thanks everybody.