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In this episode
of the MGMA Insights podcast
, Nwando "Dr. O" Olayiwola
, MD, MPH, FAAFP, chief health equity officer, senior vice president, Humana, discusses health equity, social determinants of health and the impact on at-risk patient populations. You can click here
to see her 2020 TEDx Talk on "Combating Racism and Place-ism in Medicine."
A year of pandemic forced everyone in the healthcare community — payers, providers and patients — to consider their role in care delivery. As COVID-19 case numbers dwindle and more patients fill up clinics and hospitals for more traditional care needs, healthcare leaders still need to develop an understanding of health equity and where there remain barriers to access for more vulnerable and historically underserved patient populations.
Q. Can you give us a sense of your background and how the issue of health equity has shaped your perspectives on healthcare?
I am a family physician, and I had the great fortune of joining Humana as its first chief health equity officer, which is a new role that Humana created trying to be much more intentional about the work that it does to focus on health equity, and building up a lot of really tremendous population health and SDoH-related work. … I stepped into this role having come from a role that has largely been on the delivery side of care, previously as the chair of the Department of Family and Community Medicine at Ohio State University and also working in community health center systems for many years.
I’ve got some stories from my childhood in my earlier years that have shaped some of my thinking around the way we care for patients and the opportunities that we have to give everybody — the opportunity for their best health. I’ve seen a lot of places where that didn’t happen, opportunities where we could have done better as healthcare providers.
Q. Can you help define what health equity means to you?
For people like me that have been in the world of dealing with health inequities and working on health disparities for so long, we assume a lot of people get what we’re saying. … Health equity is that every single person in our nation can have a full life with really good, high-quality health and healthcare and reach their full potential without the limitations of health. To do that, though, it requires a lot of intentionality around addressing the things that could stand in their way of having that opportunity for health. Those are things like oppressive structures, structural racism, discrimination, poverty and lower socioeconomic status — things that render people more vulnerable and less likely to have full health. So health equity is then removing those obstacles and barriers to full health so that people can achieve it.
Q. How do we achieve that? Do you see the U.S. healthcare industry making strides toward that, and what should we do to work toward achieving health equity?
It starts with us really understanding that we do have inequities and where those inequities have come from. With the COVID-19 pandemic, we saw pretty staggering and disappointing outcomes early on in the pandemic, [and] we’re still kind of seeing them today. We saw Black and Hispanic/Latinx communities disproportionately affected by the virus. … And while that was not necessarily a surprise to many folks who’ve been in the health disparities space for a long time, it still really did surprise a lot of people in the country because it was not realized that there were so many of these … underlying factors that made so many of these communities very vulnerable to a pandemic. When you put a pandemic on top of what have been some very historically disadvantaged populations and environment, you get what we saw and what we’re seeing.
We’ve got to get people to really understand, “why is this important to me?” … I think COVID-19 is a great illustration of why this matters to all of us. So if you think about certain risks that people have — poor health and lower life expectancy, maybe based on geography, ZIP code — where you live is a very good determinant of what your life expectancy might be. If you say, “Maybe I’m at risk of dying from poorly controlled asthma because of where I live,” and you say, “Well, I don’t live there, so I’m not likely to have a problem with dying from asthma” — that could be true. If you’re thinking about something like asthma, that’s not contagious. It doesn’t spread between people. ... But when you have something like a virus that moves around, it’s so easily spread, it’s mutating … you can’t really say, “Well, I don’t live in that neighborhood over there, so I won’t have it.”
We are increasingly globalized. People are moving in between cities. … There are so many ways that we are connected. … There’s no way to say that you have immunity from something based on your geography anymore, and that is why this has made us think about why this is important and why it’s everybody’s problem.
The second thing is being willing and open to address some of these structural factors that have made some of these inequities thrive and allow them to persist. And that’s the tougher one, because people aren’t necessarily comfortable talking about racism, gender discrimination, oppression of people with varying sexual identities or gender identities. We’re not necessarily comfortable talking about those things, but some of those things do really reinforce inequities and we’ve got to be able to do that as well.
Q. We’ve seen that COVID-19 has had a greater impact on certain communities. When you look at those communities, what are the determining factors? Is it economic status, comorbidities, environmental factors? What are you trying to address so we can have better health outcomes for those communities?
When I was at Ohio State, I was part of leading a massive campaign to get masks and sanitizer, and some of these essential items distributed to communities across Central Ohio. When we were thinking about … where to focus attention, we started looking at different indices that can kind of tell you where you might have problems. The CDC has a social vulnerability index — this lets you know which communities have high levels of vulnerability based on the number of different social and economic factors. There are health opportunity indices that look at communities and can tell you at a macro level, using geospatial imaging software and technology, what are the ZIP codes, the communities and locations where you would have very low economic opportunity, and very poor health outcomes for a number of different chronic diseases.
What we found was that the places where we had high social vulnerability, very low economic opportunity, very low health opportunity, very poor clinical outcomes from chronic diseases — like asthma, COPD, heart disease, diabetes, high blood pressure — were the very same communities that had high risk and high penetration of COVID-19.
Many of those communities were communities that have been historically redlined … in the earlier part of the 1900s, when there was this historic redlining that decided which communities would be invested in, where people could get mortgages to grow, and build families and achieve economic mobility.
There’s no one answer, honestly. These are places where there’s also limited primary care access, and maybe not as high quality of a hospital in the areas where a lot of these same communities live.
At Humana’s hometown in Louisville, Ky., there are significant and well-documented disparities in health outcomes between people who live on the West End, which is lower-income, predominantly communities of color, historically redlined area in Louisville that has very high social vulnerability. Then you see, just a few miles away, very drastic differences in life expectancy with people able to live longer, live healthier, have better access to schools, to healthcare, to primary care. The communities on the West End were not having luck getting the vaccines, [they were] having issues getting into appointments. What we did is take the vaccines to that community.
Q. Given your time at Humana, what do you see as the role for health plans to help the communities they serve to help raise the level of care and improve outcomes?
One of the things that really attracted me to the role was when I heard Bruce Broussard, our CEO, tell me that [Humana] was making a fundamental shift from being an insurance company to a health and wellness company that has elements of insurance. Thinking of it that way has really allowed Humana to be focused on our responsibility beyond just being a plan.
If people are having difficulty getting the vaccinations … let’s take vaccines to those communities and do outreach — not just in the West End, but in other parts of the country where we have those challenges. [We’re] being very upfront and intentional about bringing whatever is missing to the community that needs them.
Not every single problem can be resolved by Humana, but [rather] through partnership and through thinking of who are the community leaders and organizations that are embedded in the community — they have trust, they have access, they’ve got really good ideas, they might need some support, or they might need some of our resources or expertise.
The Humana Foundation, our philanthropic arm, started a program in partnership with an existing nonprofit called OATS (Older Adult Technology Services). … We realized that there were millions of seniors in our communities across the country that did not have access to reliable internet connections nor the skills and expertise to use it effectively for what was now being required, which is things like telehealth. … We’re making sure that we provide technology support services, helping people get connected, working to expand broadband access, and teaching people how to utilize digital tools to access healthcare, but also remain connected in a period where people became very isolated. … That’s another example of how we’re partnering to do those kinds of things.
Q. Obviously data and analytics play a big part in being strategic in these efforts. Are there any particular metrics that help you make decisions on these issues?
One thing that would be important is looking at community-level data. These are publicly available; you can look at the Social Vulnerability Index by the CDC, and the Opportunity Index by the Kirwan Institute. You can go to those websites and input your community ZIP codes … to see what the level of vulnerability is. That’s a really good first step to start to think about who we should be talking to, to provide new sources of support to the community that we take care of.
People should be looking at their data on their patient populations and their practices, what they call REAL (race, ethnicity and language) and SOGI (sexual orientation, gender identity) data, and try to look at who has good hypertension control and who does not. … Breaking that down and segmenting that data into racial and ethnic groups, into maybe language groups or gender identity groups, so that you can be intentional about what you do.
Q. Any final thoughts about health equity and how to make a difference in a medical practice?
I think that everyone plays a role here. This is not the work of one health system, one practice or one payer. This is the work of everybody. People can start by just asking, what is our role here? … What is my responsibility? What is my practice’s [role]? Is there a space for us? And I would argue that their answer would be “yes.”
If we can fundamentally believe that we all have a role to play, I believe that we’ll be much more successful in figuring out how we can play it. … I don’t have the resources necessarily to feed all the families that we find are struggling with food security, but I know organizations in the area where my patients come from, or partners that we can work with to help do that. If it’s just making those connections, that’s still a lot. Figure out what is your angle — what is your lens? What is your expertise and your capability? And then try to act on it.
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