A post-pandemic look at how one health system is addressing social determinants of health and disparities in care.
When Lloyd Dean went off to college in 1969 — the first in his family to do so, as one of nine children — his mom gave him $50, with only one request: “I just want you to do something good.”
Growing up in an underserved, predominantly Black community that lacked access to healthcare and other public services, Lloyd saw what he calls the “catastrophic contrast” between his community and a white community just six miles away. They had schools and healthcare access nearby; he recalls having to be bused to school and never leaving early for a doctor or dentist appointment like his white counterparts did all the time, because healthcare wasn’t an option.
Living this divide every day, Lloyd knew that education was a critically important stepping stone — and one of his two main passions in life — towards carrying out what he calls his mission: To leave the world and communities better than how he found them by “being a voice and advocate for access to healthcare.”
Today, as the Chief Executive Officer of CommonSpirit Health, one of the largest health systems in the country, Lloyd is on a mission to improve care access and promote health equity for all. To do so, he is prioritizing collaboration, community outreach, and addressing social determinants of health (SDoH), all while building on the lessons learned from the past year’s epidemic.
Covid-19 Exacerbating Health Disparities And Racial Inequities
CommonSpirit is a $29.5 billion (revenue), nonprofit Catholic health system, operating more than 700 locations across 21 states. Created from the 2019 merger of San Francisco-based Dignity Health and Englewood, Colo.-based Catholic Health Initiatives, CommonSpirit is also the largest Medicaid provider in the country, with 20% of its revenue coming from Medicaid (a number that likely understates the number of Medicaid patients it serves, as Medicaid pays at lower rates than other insurers).
The Covid-19 pandemic has only exacerbated the longstanding, institutional and structural challenges that underserved communities face, including those that CommonSpirit serves. “The sad part is, we’ve talked about health disparities for decades,” said Lloyd, with the pandemic simply lifting the veil. “We saw from the pandemic the disproportionate deaths of people of color. They didn’t want to get vaccines, they didn’t trust the system, and we saw the impact of not having Black and colored physicians.”
“We saw from the pandemic the disproportionate deaths of people of color. They didn’t want to get vaccines, they didn’t trust the system, and we saw the impact of not having black and colored physicians,” said Dean.
Each of these factors is troubling on its own. But when looked at together, put in the greater context of our nation’s history, and combined with the fact that Black Americans have suffered the highest Covid-19 death rate, it sends what the AP calls “a loud message” from public health leaders: The U.S. must address the long-standing, deep-rooted inequities, which have led to stark disparities in healthcare and outcomes.
As was experienced by Lloyd growing up, Black and Hispanic Americans often don’t have easy access to medical care and have higher rates of chronic conditions, such as diabetes and high blood pressure. They are also more likely to experience negative SDoH, which include poverty, poor access to education, un- or under employment, insufficient housing, a lack of transportation access, food insecurity, and many other socioeconomic factors, including race.
Health Inequity’s Deep Roots Drive The Importance Of Addressing SDoH
Health inequity has a significant impact on both health status and costs, with racial health disparities costing health insurers $337 billion between 2009 and 2018 and driving $93 billion in excess medical care costs, according to a 2018 analysis from the W.K. Kellogg Foundation and the nonprofit Altarum.
As such, the past decade has seen insurers, providers, startups and VCs paying increased attention to addressing SDoH, even though the jury is still out on which program and initiatives are the most effective, and to what degree. Many programs are either still in their relative infancy, don’t measure the connection to health outcomes and costs, or ignore the underlying racial bias that has been proven to exist in the healthcare system.
In a recent study, which randomly assigned 1,300 African-Americans to Black or non-Black primary care physicians, researchers found that care for Black patients is better when they see Black doctors; those who saw Black doctors received 34% more preventive services, with the study showing increased trust and better communication as having made an impact.
Having diverse representation among providers, then, is not only critically important to ensuring Black patients receive equitable, quality care, but not doing so has far-reaching implications for everyone: Our economy and society can only be as strong as our limits, and inequitable healthcare delivery invariably cuts us all off at the knees.
“Not addressing inequities and not assuring opportunities for the most vulnerable in our society actually harm us all,” said Dr. Lisa Cooper, founder and director of the Johns Hopkins Center for Health Equity in Baltimore. “We’re all paying for the cost that this has had on our economy and health care system.”
These are the same kind of sentiments echoed by Lloyd. “During the pandemic, we also learned that we are only as healthy as the least healthy in our community. What I mean by that is, what happens to our neighbor, and their health status, is critically important to having a healthy community, which we saw play out again and again and again [at CommonSpirit].”
Like Dr. Cooper, Lloyd firmly believes that the economic strength of a community — and country — is directly correlated with the presence of racism. “We can’t be fiscally strong and have a strong economy if racism and inequalities exist… We have a brighter future as a country if we work together, but we have to start now.”
“We can’t be fiscally strong and have a strong economy if racism and inequalities exist… We have a brighter future as a country if we work together, but we have to start now.”
“I look at what’s happened in the last few years, and I think that corporate America, organizations, ministries, and companies like ours are going to be held – and are being held – to a higher standard,” said Lloyd. “I think we’re seeing a change in this country, but I believe that we and our communities can not be healthy unless everyone in that community is healthy.”
Prioritizing Education, Representation and SDoH
Driven by personal experience and a desire to enact change, Lloyd’s perspective has directly impacted his work at CommonSpirit, both in terms of the initiatives themselves and the architecture behind their design.
“I make sure my leadership team is diverse, the board is diverse, that we’re serving diverse populations, and taking care of the community,” said Lloyd. “People in my community [growing up] did not have access to transportation; it was all about access to food and the essentials.”
It’s perhaps no surprise, then, that CommonSpirit is also heavily focused on affordable housing, with nearly 45% of the system’s community program investments going towards the cause. This includes establishing affordable housing projects and improving low-income neighborhoods to address and prevent homelessness.
For Lloyd, improving education access for aspiring Black physicians is another priority, both as an organizational and societal imperative, and as a personal passion. To this end, CommonSpirit recently came together with Morehouse School of Medicine to expand medical education opportunities and help Black and underrepresented minority physicians complete their residency training. The educational collaboration is part of a 10-year, $100 million partnership to reduce health disparities and increase access to culturally competent care, while cultivating a strong pipeline of students that is representative of the diverse communities they serve.
Health Literacy And The Importance Of Going Local
One major, though often overlooked, contributor to the health of any community? Health literacy. Poor health literacy is a driver of poor health outcomes, with data from the Centers for Disease Control and Prevention (CDC) suggesting that only 12% of U.S. adults aged 16 to 65 have a high level of health literacy proficiency, and just 9% have the second highest proficiency level.
Per the Health Resources and Services Administration, low health literacy is more prevalent among older adults, minority populations, those who have low socioeconomic status, and medically underserved communities. Similarly, newer data from the Center for Health Care Strategies suggest that nearly 36% of adults in the U.S. have low health literacy, with disproportionate rates found among lower-income Americans eligible for Medicaid.
“When we look at literacy, it’s a very robust definition,” said Lloyd of CommonSpirit. “Health literacy is a critical component of us being able to effect change and affect people’s lives,” he said, adding that, “We’ve spent a lot of time strategizing about the most effective way to reach populations.” The health system created an outreach stratification tool that shows patient risk, and quickly saw that patients needed more education.
Data aside, “Knowing the local dynamic and leveraging local, community-based organizations is critically important to our goal of achieving health literacy,” said Lloyd, “and making it comfortable for people to say, ‘I don’t know, and I don’t understand.’”
This, again, is part of what makes accounting for SDoH — which can drive as much as 80% of health outcomes — so important, especially for those in at-risk communities. “The definition of a healthy community and being a health provider goes beyond just the clinical work that we do,” said Lloyd, adding that no matter how many resources the organization has, it can’t do it alone. Improving care access and reaching high-risk populations “requires the power of community, coordination, collaboration, and the utilization of technology,” with innovation and technology being vital to bringing care to in-need communities.
“We saw again that, because of [the industry’s] reticence of sharing information and engaging in the healthcare infrastructure, we could not target communities of high risk,” where Lloyd sees innovation around better information exchange and data sharing as a critical component to bridging care gaps and promoting health equity.
Part and parcel to improving care is having the right technology infrastructure, solutions and frameworks in place to be able to share data and get smarter about how to bring equitable care access to all. Towards this end, CommonSpirit has a number of initiatives in play, including its partnership with Docent Health, a healthcare technology company that provides patient engagement and care navigation services to help patients negotiate their care needs in and of CommonSpirit’s communities.
Using a text-based program from Docent that connects patients to virtual care navigators, CommonSpirit was able to look at SDoH and engagement rates by race/ethnicity. At the end of May 2021, results from an initial maternity pilot of five facilities in California and Arizona showed an engagement rate of 68%, with more than 50% of mothers being assessed and referred for social determinants of health. Of note, engagement rates for women of color were high (68% Black and 71% Hispanic), with 71% of women being on Medicaid.
Similarly, through its partnership with Truveta, which uses AI and machine learning, the data platform’s goal is to deliver more personalized, equitable care while giving communities actionable information. This, CommonSpirit says, will enable unprecedented insights as providers are able to learn from each other with statistically significant scale and representation of diverse populations.
Additionally, through its newer partnership with Concert Health, CommonSpirit is looking to improve access and deliver more comprehensive behavioral healthcare, including the Medicaid population. One of the greatest deficits of at-risk communities is in the area of behavioral health, said Lloyd. Working with Concert Health will facilitate access to behavioral health specialists for patients with commercial health coverage, Medicaid and Medicare in a matter of hours instead of weeks.
Behavioral health is not just a top priority for CommonSpirit, says Lloyd, but it’s one of the things as a nation that we must come to grips with. “We have to invest more resources and infrastructure in behavioral health. One of the greatest deficits at-risk comms have is behavioral health.”
Working with Concert Health, CommonSpirit says it can initiate a patient handoff within 24-48 hours, which Lloyd said was “set up as an alternative to what we call the staccato of work.” Currently in pilot in Central California, CommonSpirit is hoping to expand throughout the system and nationwide. Though still in pilot, Lloyd noted that the current indicators show that patient satisfaction is “off the charts.”
But innovation, in Lloyd’s definition, “doesn’t just mean technology. It includes new approaches to innovation that improve how we can work together to achieve better outcomes.”
Covid-19 Reinforcing The Importance Of Community Partnerships
During Covid, for example, CommonSpirit created roaming clinics and shelters, and brought care to hotel rooms to vaccinate the homeless. “We set up in rural areas, developed partnerships and held clinics in large sports parks,” said Lloyd, having worked with the Los Angeles city government, Charles R. Drew University of Medicine and Science (a historically Black college/university), LA Care Health Plan, and the NAACP to host a vaccination site at a Los Angeles sports park. This event alone resulted in more than 20,000 Covid-19 vaccinations being delivered to people in high-risk populations, where a two-day clinic in Santa Cruz included efforts to reach farmers and farm workers.
“The pandemic helped CommonSpirit learn about how people want to be served, which are lessons that will help us as we look at how to best provide healthcare in the future,” said Lloyd.
In addition to Covid vaccination efforts, CommonSpirit is investing in and forming a bevy of new partnerships to better account for SDoH — both because it’s the right thing to do, and because Lloyd feels it’s a responsibility of CommonSpirit as an anchor and support system in the thousands of communities it serves. And there are no shortage of examples: its partnership with the United Way to develop new models of community-based care; its partnership with Salvation Army in to bring mobile care to the homeless; and providing the “last mile” of care through its partnership with Lyft in several states, including California and Arizona, where CommonSpirit’s social workers, case managers, and other medical staff request and monitor ride progress to help get patients safely to their destination.
The Delicate Dance Between Mission And Margin
Of course, CommonSpirit has another responsibility, as do all health systems in the country: to run a fiscally sound, profitable, and growing organization responsible for employing thousands of clinicians and beholden to investors who have financed $15 billion in CommonSpirit debt (to confirm: even a not-for-profit organization may have debt holders who view themselves as investors). Managing business and financial realities can complicate the mission of improving healthcare access and equity among underserved populations: the traditional business of health systems relies on driving traffic to high revenue inpatient services, which doesn’t fit well with trying to offer low-cost, accessible and convenient care to people where they are.
With healthcare spending increasing 4.6% before Covid-19, per the American Medical Association — and much of that being for hospital-based care and prescription drugs — delivering higher quality, value-based care is a top agenda item for health systems today, which is consistent with the desire to improve access and lower costs.
Cost-focused innovation is happening all around the country. From primary care focused Oak Street Health and Carbon Health to direct-to-consumer Ro to upstart insurer Oscar Health, innovative startups are pulling all the levers they can to try and deliver care at significantly lower costs. Those newer organizations that are achieving success in large part because they don’t have to deal with the burden of legacy systems and outdated infrastructure, something with which many large systems still struggle.
One of the ways CommonSpirit is trying to reign in costs and deliver higher quality care is through its participation in the Medicare Shared Savings Program, in which it established 16 Accountable Care Organizations. Accountable Care Organizations (ACOs) encourage healthcare providers to focus on the health of a member population and work to deliver care in the most innovative and low-cost ways.
CommonSpirit reported in September 2020 that its ACOs led a reduction in Medicare spend by $70 million during the 2019 performance year. Seventy million in savings sounds impressive, but during the same year CommonSpirit received more than $11 billion in total payments from Medicare. This suggests only ~0.05% of total Medicare cost savings, although not all of CommonSpirit’s regions participated in ACOs.
CommonSpirit also received $826 million in CARES Act funding (recognized as revenue) during the same time, even as operating costs increased and executives took a temporary 10% to 20% pay cut. Clearly, innovation at a $29 billion healthcare delivery organization does not happen as quickly as at Silicon Valley startups, especially when trying to pivot to adequately address a public health pandemic.
So how does one of the country’s largest health systems achieve a balance and do the delicate dance between greater purpose and greater revenues? One way CommonSpirit approaches these decisions is through its three-year decision making cycle whereby they prioritize and rightsize community efforts. Local CommonSpirit hospitals conduct needs assessments and create new implementation strategies to identify and address significant health needs in the communities they serve, focusing on a wide swath of SDoH, including housing, environment, job creation, arts and education, food and nutrition, and access to capital.
“It requires a lot of discernment to come up with those plans, but we prioritize, and we recognize that we can’t be everything ourselves and singlehanded answer every problem,” said Lloyd.
CommonSpirit also adheres to what it calls its “Total Health Roadmap,” developed as part of a partnership with the Robert Wood Johnson Foundation and launched in 2017. According to the health system, the roadmap is driven by three core strategies: “transforming our roles as providers, expanding our roles as community organizations and strengthening our leadership accountabilities.”
As for Lloyd, he likes to approach resource allocation and decision-making by asking one question from the start: “‘Are we doing the right thing?’ That’s the fundamental principle. Instead of jumping to the outcome. We are driven by and have established a set of principles.”
“‘Are we doing the right thing?’ That’s the fundamental principle. Instead of jumping to the outcome. We are driven by and have established a set of principles.”
“When I think about that problem between mission and margin, by being efficient with our resources and investing in others, I think that we can, in fact, achieve a fiscal balance with our mission, and not have to walk away from communities that if we weren’t there, people would be in peril,” said Lloyd, emphasizing that this means there has to be accountability in terms of utilizing technology and a focus on partnerships. “We are very clear that others are out there that have expertise that we need to bring to our communities. In terms of investing in infrastructure, we don’t just want to be in a community, we want to be integrated with others in the community.”
Policy Considerations, Educational Advancements And Moving Forward
If asked, Lloyd will tell you that healthcare is absolutely a right, not a privilege. While Supreme Court justices did not weigh in on this topic specifically — whether healthcare access is a right or not — it did recently vote 7 to 2 to uphold the Affordable Care Act (ACA) for the third time last week, leaving in place the broad provisions of the law enacted by Congress in 2010.
“I find it a tragedy that we sit here, in June of 2021, and find that the most admired nation on the planet, with probably the most resources of any other country in the world, is one of the few countries that does not have a national system that ensures access and healthcare for all,” said Lloyd. “We have made many runs at it, the ACA being the latest. But I think that, and I say this as ‘shame on me,’ and ‘shame on us,’ if we do not move forward with some means and some system – regardless of politics – where everyone has access to the basic and fundamental needs related to their health, we’re in trouble.”
As for Lloyd, he is optimistic that the country will embrace and strive for a more equitable health system going forward, hopefully putting politics aside. “Because it’s fiscally good, morally compelling, and we/I believe strongly that healthcare is a right, and not a gift we bestow on certain parts of our populations.”
These kinds of convictions led to CommonSpirit supporting legislation introduced by Congressman Frank Long (D) from New Jersey: the Doctors of Community (DOC) Act, which continues to move through the House. If passed, the legislation will permanently authorize and expand funding for the Teaching Health Center Graduate Medical Education (THCGME) program, which trains primary care physicians and provides care in medically-underserved and rural communities.
It’s important, says Lloyd, because it provides a reliable stream of doctors to high-need communities, and out of that will come funds for new graduate and teaching programs for doctors of color across the nation. Says Lloyd, “One of the biggest challenges we have is having the right clinicians in the right communities, which has been an issue for our nation for many decades,” which is one of the driving forces behind the system’s partnership with Morehouse School of Medicine.
Representation, education and literacy, healthcare access and health equity are an integral part of the health of any community — something that the last 16 months have made incredibly clear across the industry at large and CommonSpirit as a system.
“I will feel that I have lived a good professional life if — and my goal is to — do everything I can to use this gift of leadership, ministry, and the organization that I work for to help address health disparities,” said Lloyd.
Lloyd Dean has hope for the future, and knows the legacy he wants to leave behind. “I think that together, we’re contributing to that dream. I think that it’s currently out of our grasp, but within our reach.”