Stop oversimplifying the problem of social inequity. There’s a reason the issue has hung around for so long — it’s incredibly complex and multidimensional. Environmental, societal, health system, provider, and individual patient factors all contribute to disparities in a wide variety of ways. What that means is that we have to stop looking for a single “magic bullet.”
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. Joe Nicholson.
he is the Chief Medical Officer at CareAllies. There, Dr. Joe provides strategic direction, operational oversight, and thought leadership for CareAllies’ clinical programs and operations, including ACO and social determinants of health (SDoH) strategies and operations. Additionally, he supports business development and provides clinical oversight for all companies and programs under CareAllies, with a specific focus on optimizing quality care delivery.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
MOM! My mom was the only career medical person in our life. She taught nursing school for 30 years. I started out as a volunteer at my mom’s hospital when I was 13 years old. When I was 15 I was hired as an “ER Orderly” back in the day (yes — that phrase probably dates me). I later became a nurse, and practiced in that capacity for two years, before starting medical school where I spent my summers working as a Hospice Nurse.
After becoming a doctor, I have enjoyed a cross-section of experience: Chief of Emergency Medicine; Family Medicine doctor; Chief Medical Officer of a Blue Cross Plan; Lead negotiator as SVP National Medical Director of contracting and business development for a specialty hospital system; and now CMO for CareAllies (driving affordability in Value Based Care).
I sometimes say, “I’ve done every job in medicine” — which of course is an overstatement. But I have been blessed to view the art of medicine from a spectrum of vantage points.
What do you think makes your company stand out? Can you share a story?
CareAllies is one of the older and most successful Management Services companies in the USA — with a long rich history of success with our various physician group partners, whether they are organized as an independent physician association (IPA), accountable care organization (ACO) or clinically integrated network (CIN).
We have enjoyed remarkable success in moving physician practices along the value-based continuum to taking on risk-bearing arrangements and to help them achieve best-in-class quality metrics, Stars ratings and financial performance, including increases in value-based reimbursements.
In doing this we continue to advance AFFORDABILITY, SIMPLICITY and PREDICTABILITY for the patients our physician partners serve.
Can you share the most interesting story that happened to you since you began leading your company?
The most interesting story probably comes from my Social Determinants of Health (SDoH) team of nurses, pharmacists and social workers. A female patient who was referred to our program had 29 hospital admissions in 12 months and 8 admissions within the 2 months prior to referral to our program.
Case management had tried repeatedly to connect with the patient, but they were unable to reach her.
My SDoH team successfully connected with her by phone, and utilizing motivational interviewing techniques were able to arrange for a phone visit with our Social Worker, and later a home visit. Multiple medical and SDoH gaps were identified and closed resulting in a sudden and dramatic reduction in hospital visits for her medical issues.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
While funnier now… I was mortified at the time — it’s the classic “reply all” story when making a pesky comment about the author of an email. Oooops. I have learned to always pause for a half-second before hitting the SEND button to eyeball who might be on that recipient list!
What advice would you give to other healthcare leaders to help their team to thrive?
Seek to surround yourself with diverse leaders that do not “think like you” and have problem solving approaches that differ from your own.
Remember — a good idea should be able to stand a good shake. We are all flawed in our humanity — give each other a little grace. Be respectful. Be collaborative.
How would you define an “excellent healthcare provider”?
One whose singular focus is ALWAYS and ONLY about the patient, with a lens for population health and a heart for identifying and bridging SDoH.
Are you working on any exciting new projects now? How do you think that will help people?
The most exciting project which is rapidly expanding right now is our SDoH program, which includes the use of a sophisticated multidimensional multi-source algorithm to define SDoH risk within a population.
This information is then made actionable by my team of nurses, pharmacists and social workers who connect directly with those at-risk patients, and leverage a sophisticated CBO-aggregator data/analytics platform to close those SDoH gaps for patients and connect them to health insurance benefits, a compassionate listener or the community resources they might need.
We also have launched a new population health algorithm designed to identify the rising risk in the population, and this informs the workflows of our population health nursing team embedded within physician practices — to close gaps in care, schedule annual wellness exams, and identify high-risk patients for immediate follow up with their primary care providers. The quality benefit to these patients is DRAMATIC — one IPA in Texas has enjoyed (compared to non-IPA TX members) 15% better rheumatoid arthritis management, 26% better blood pressure control, 20% fewer hospital admissions, and 26% improved ER avoidance.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
- Social inequities have become ingrained in our society, and thus in our health care system, and we know they lead to poor outcomes. COVID-19 has highlighted these inequities and the impact it leads to. Minorities have seen significantly higher infection and death rates from COVID-19 than non-minority populations. While it is spotlighted today, it’s not that we haven’t recognized the problem — it’s actually an old conversation. About 35 years ago government health experts conducted a study on racial and ethnic minority health to identify disparities. An Institute of Medicine report back in 2003 said, “Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable.” So, we’re aware of the problem, but it’s an extremely tough one to solve. There are lots of efforts to try to fix it. We just haven’t made enough progress yet.
- Second, providers have a fragmented and incomplete view of their patients. What data we do have about patients is usually limited to past clinical conditions — which is crucial, of course. But it doesn’t tell the whole story. It doesn’t tell me why someone might be vulnerable to certain health issues. Knowing Mrs. Jones has diabetes and prescribing insulin is one thing, but what if she can’t afford her insulin? Or doesn’t have transportation to get to a pharmacy? Or doesn’t have access to healthy food that is so important to effective diabetes management? Truly patient-focused care means understanding each person outside of their clinical diagnoses, and addressing the risk factors created by their social determinants of health (SDoH).
- Additionally, health care data, when used as the sole source of information, is extremely unreliable in its ability to identify those who might be at the highest risk for SDoH. In a recent gaff highlighted at the national level, an algorithm misjudged how sick Black patients were compared to their white counterparts. Ironically, this allowed healthier white patients to receive additional medical support more often than their black counterparts. They failed to account for the privilege of greater access to health care, writ large.
- It’s a multifactorial problem to unpack, but the fact that the U.S. has the highest obesity rate certainly contributes to the problem.
- Last, I would humbly submit, is the lack of social support funding in America. A significant percentage of GDP in other developed nations is aimed at building an infrastructure of social service systems, whereas in the USA — we rely largely on non-profit community based organizations to fill those gaps.
You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
- Stop oversimplifying the problem of social inequity. There’s a reason the issue has hung around for so long — it’s incredibly complex and multidimensional. Environmental, societal, health system, provider, and individual patient factors all contribute to disparities in a wide variety of ways. What that means is that we have to stop looking for a single “magic bullet.” There are lots of well-intended efforts that attempted to address these challenges — the Affordable Care Act, bringing more providers to underserved areas, more awareness and more knowledge. But we must continue to be open to collaborative and holistic efforts, such as joint ventures between community-based organizations (CBOs) and the health care infrastructures which surround them — including health insurance carriers, provider groups, and hospital systems. There are a growing number of CBO connectors that are readily available. Some are simply directories. Others have more sophistication with developed networks tied together with free web-based platforms allowing significant end-to-end closed-loop management of SDoH needs as they are identified.
- Institute new approaches to SDoH, including SDoH technology. There are a growing number of sophisticated data algorithms and solutions looking for those hidden indicators that reveal at-risk populations and trigger interventions to include SDoH screening tools such as PRAPARE or the American Academy of Family Physicians (AAFP) SDoH screening tool, which then become a springboard for gap-closure. A group in South Texas developed a tool to evaluate and score patients based on SDoH needs and risk. A team of trained social workers and licensed vocational nurses used technology to work directly with provider and community-based organizations to identify and resolve SDoH needs. They got substantial results, too, including an 86% patient satisfaction rate, 25% reduction in medical costs, 52% drop in readmissions, 38% decrease in admissions, and 23% decline in emergency visits. For the highest-risk individuals, in-home health programs can be used to help address SDoH challenges and questions that providers cannot easily observe — like whether someone has an A/C unit, transportation to the doctor’s office, or if they suffer from feelings of isolation.
- Rely on data. It’s astonishing sometimes what available data tells us. For instance, there’s something called the US Small-area Life Expectancy Estimates Project (USALEEP) through the NCHS, National Vital Statistics System. If you look at the data they compiled for Tulsa, Okla. as an illustration, it’s incredible to see the disparity in average life expectancy — anywhere from 56.9 years to 97.5 years — based solely on ZIP code and attributed to numerous factors. To really drive change in health care, we have to rely on more than just health care clinical data. Community- and faith-based organizations are much more likely to have access to truly impactful SDoH data, so health care organizations need to partner with them to collect, share and analyze data. The difficulty comes in bringing together all of that disparate data in a meaningful way. It requires a real investment.
- Create a holistic view of every patient by integrating structured, unstructured and external data. This is a little different than simply relying on data; it’s deepening our views through data. Solving the inequity problem is hard because it requires a combination of multilayered critical thinking, intellectual curiosity and empathy. But solutions have to be driven by data. Community and healthcare leaders have to commit to a focused technology-driven approach to collect data, analyze it, and use it to operationalize change. Within health systems, that may start by convening multidisciplinary teams to help define the kind of data needed to open opportunities to identify at-risk patients.
- Leverage digital technologies in new ways to promote health and treat illness. One program I’m aware of used text messages to deliver appointment reminders, nutrition tips, and other tailored information to pregnant patients identified as at-risk for preterm delivery. The program drove a 24% increase in prenatal visit attendance and 27% drop in early preterm deliveries. Similarly, although telehealth technology has been around for years, COVID-19 showed us just how valuable it can be. Moving forward, 76% of consumers say they’re interested in using telehealth compared with just 11% in 2019. But that makes technology literacy a newly important SDoH. For patients with limited technology literacy, we must find ways to make telehealth technology easy to use. Perhaps we could supply user-friendly pre-programmed technologies or reach out to patients with log-in instructions prior to their telehealth visits.
Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
At a high level, most of us realize that we need to address SDoH in order to better manage overall health. Communities, employers, providers and payers will need to double down on SDoH initiatives including community engagement programs, assessment calls and home health visits. Health systems and community organizations can work together to implement or build up SDoH programs to help at-risk populations.
As importantly, providers and payers will need to use multiple sources of data to inform who is at risk and who needs additional interventions or care. I’ve seen the benefits of combining clinical data with consumer and other data, for example. It reveals a wealth of information you can’t get from traditional health care data alone.
Health systems can encourage the consistent use of ICD-10-CM Z-codes, too. Unfortunately, Z-codes aren’t always used because they’re not always reimbursed. But they identify issues related to a patient’s socioeconomic situation and psychosocial circumstances that may influence their health status — like education and literacy, employment and housing.
As far as communities, I feel it’s important to invest in more sophisticated technologies capable of sharing and analyzing data across the entire health care and community ecosystem — from hospitals and doctors’ offices to local food pantries, homeless shelters and city service departments. By bringing all of this data together and using advanced analytics, we can better figure out how to support “whole person” care. Predictive Modeling and scoring patient populations can spotlight SDoH risk. And health systems can enhance their SDoH programs by evaluating which workflows, operating procedures, and technologies they can use to screen, identify, prioritize, and support patients with SDoH risk factors.
I’m thinking of what one health system did to address the issue of malnutrition. The situation started when the Health Care Cost and Utilization Project revealed in 2016 that malnourished patients cost nearly twice as much as their well-nourished peers because they experience prolonged hospitalizations and higher readmission rates. As a result of that insight, Chicago-based Advocate Health Care launched two initiatives within its ACO. It started a nutrition screening program for all patients at admission. Those at elevated malnutrition risk received an oral nutritional supplement within two days. In addition, high-risk patients receive nutrition education, post-discharge instructions, follow-up calls, and coupons for retail oral nutritional supplements.
Within six months of launching these programs, the group reduced health care costs by $3,800 per patient, saw $4.8 million in total savings, and reduced hospital readmission rates among patients at risk for malnutrition. This is a terrific illustration of the all-around benefits of focusing on a single aspect of SDoH.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“LIVE every moment, LAUGH every day, LOVE beyond words.” This was crystallized for me the day my 16-year-old son was diagnosed with cancer. I changed my approach to life in that moment, and have never stopped striving to make the most of every day. [PS: He is now 32 years old and living the dream in Los Angeles. Marked by cancer, but living his own life to the fullest!!]
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
If I could inspire a movement that would sweep the country and the world, it would be this: GIVE MORE than you take.Emotionally. Financially. Your listening ear.
I coach young executives to “watch the teeter-totter” in their relationships (in business and in life). You should ALWAYS be giving more in these relationships than you are receiving.
When you begin to work at it — something transformational begins to unfold: human nature leans towards a balanced teeter-totter. (And sometimes to the negative — think “eye for an eye.”)
When you give, and give without asking or demanding for something in return from that relationship, almost always in my experience… the other person begins to feel an unconscious need to give something back.
And so it goes. It makes for a better life. Healthier relationships.A healthier happier you.
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