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“As a doctor, it is pretty humbling to reflect on the fairly minimal impact our health care system has on individuals’ overall health. One study I find particularly intriguing shows that socioeconomic factors (e.g., education and income), and physical environment (e.g., security and safety at home and reliable access to transportation), affect a person’s health outcomes just as much as their behaviors (e.g., mental health, diet, and physical activity) and the clinical care they receive. The data indicates an even, 50/50 split.
I suspect that many people view such data as interesting—but not exactly surprising. We have always known that sometimes there is little we can do medically to help a person until we have attended to their so-called social determinants of health (SDOH). Concerns about money, transportation, food security, housing uncertainty, and other socioeconomic factors nearly always prevent people from concentrating on their health.”
Joe Nicholson is a health care executive.
He shares his story and discusses his KevinMD article, “It is time to make a dent in social determinants of health.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Joe Nicholson. He is a family physician and health care executive. He wrote the KevinMD article “It is time to make a dent in social determinants of health.” Joe, welcome to the show.
Joe Nicholson: Yes, sir. Yeah, thanks for having me, Kevin. It’s really a pleasure to be here.
Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?
Joe Nicholson: Yeah, sure. I’ve got a bit of an eclectic path. I’m an old Army doc, chief of emergency medicine a lifetime ago. After that, I went into private practice for about seven years, and then wound up becoming a Blues executive, chief medical officer of a Blue plan, for eight years. And then I was recruited in a kind of interesting moment by a national specialty hospital system that was really trying to make the transformation from out-of-network to in-network, PPO-participating institution. Through that, I really wound up becoming their value-based care guy, bolting value-based care elements into all of their contracts. I was there for just short of a decade.
And now, for the last, coming up on three years, I’ve been with CareAllies. I don’t know if you know them. In the parlance, they call them an MSO, which means nothing to almost anyone, but we’re both an energizer and a facilitator of value-based care for physician practices across the nation, operating in about 10 states, with about a half a million patients under the hood. And we help our physician partners just hit the cover off the ball in all of their value-based contract arrangements with any payers that they have them with.
Kevin Pho: So you spent a lot of your career on the insurance side of medicine, and for a lot of physicians, that’s a little bit of a black box. So now that you’ve had experience on both sides, the clinical and the insurance side, what are some misconceptions about the insurance side that you want physicians to know about or to clear up?
Joe Nicholson: Yeah, well, it’s a great question, and thank you for that. What I would say first and foremost, on the insurance side in particular, is that they are genuinely trying to help. And then I would also say you would find almost every major health insurance company I know of willing to partner. So if you’ve got an axe to grind, or something that’s not working out for you, reach out to the local senior executives at that health plan and engage in a dialogue, because I think you would be pleasantly surprised that they are hungry for that kind of collaboration and input.
Kevin Pho: And if physicians ever want to transition outside of clinical medicine and, say, work on the insurance side, or do something similar to what you’re doing on the nonclinical side, what’s a piece of advice that you can share with these clinicians who are interested in making such a transition?
Joe Nicholson: Another great question, Kevin, because I actually get that one probably more often than just about any other single question from my clinician colleagues. In short, if you’re interested in that executive position path, and again, I’ve done it on both the hospital system side as well as on the insurance side, if you’re interested in the insurer industry, I think your best point of entry there is to get yourself engaged with committee work at your local insurance carrier of choice. Once you get involved in that committee work, then you’ll begin to see the inner machinations, you’ll develop relationships, and like so much of business, it’s relationships, relationships, relationships, and how well you can help them carry the ball and meet their own objectives.
Kevin Pho: So how difficult is it to make that transition away from clinical medicine into the executive side? Because as you know, we don’t get a lot of that training in residency and medical school. Just from your experience with other physicians, how difficult is it for them to make that transition?
Joe Nicholson: Yeah, I would say that’s a very individual journey, and for me, it was a difficult transition. It was hard for me to let go of. In an interesting moment, when I came on to Blue Cross as a medical director of medical services, one of the things I negotiated prior to joining was that I wanted to continue working emergency medicine or as a hospitalist every other weekend, which I did for a number of years, until I became CMO. So I sort of bridged my time by continuing.
And I know a few of my colleagues who are still on the insurance side of the equation, and they’ll continue to do this in different ways. They’ll either donate their time to a local nonprofit, or they will help at a university center, help the less fortunate, and really just donate their time. But I think keeping your hand in it is one clear way to help yourself make that transition.
Kevin Pho: All right, let’s transition into the KevinMD article that you wrote, titled “It is time to make a dent in social determinants of health.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?
Joe Nicholson: Yeah. The why of it is probably really centered around just my passion around SDOH and closing that gap. It’s something that is often talked about. I think it’s getting more airtime in the last maybe three to five years, Kevin, than in my lifetime, but there are not a lot of people doing stuff. And so part of what I try to do is take the opportunity, every time I’m blessed to have the mic or a pen and a platform, to encourage people to start where they’re at and just get involved. I think everyone needs an oar in the water in this. The solution is a macro, highly complicated solution. It’s not a simple solution. We would have solved it already.
And then in the article, I just kind of walked through some of those challenges. I’ve got a call to action in there as well, and then I’ve got this crazy idea that I’ve been trying to press the action for that I think could act as an accelerant to the solution on the national stage. We’ll get to that in a little bit, if you like.
Kevin Pho: Yeah, sure. So why don’t we zoom in? Talk to me, first off, about your interpretation of what social determinants of health are, and some concrete examples of what you’re talking about.
Joe Nicholson: Yeah, no, that’s great, because it can feel a little amorphous, I think, to the audience sometimes. Let me start with a ZIP code dialogue, because this is really, Kevin, where my interest in the beginning became piqued. Probably almost 20 years ago, there was an article published by a doc at Oklahoma University, right in my home state here, and it highlighted the differences in life expectancy based on ZIP code, and I was floored by that.
So here I am, and at the time, I can’t remember if I was still in private practice or if I was at the Blues by that time, but I’m living, and I’m blessed to have a great lifestyle. I live in a very comfortable bubble in South Tulsa, in an affluent community, but guess what? That’s not true for everybody in Tulsa metro. And I was just really taken aback. There’s literally a difference in life expectancy, and it was a big difference. It was like 15 years or something, just staggering. That was my first sort of peek into what’s going on here. And at first, we always personalize things, but I thought, “Man, this is a real Tulsa problem.” And then as I really got into it, it’s like, “Oh, this is kind of an American problem,” like almost every major metro area that you’d want to name.
And so back to what SDOH is: These are the disparities that separate, in this case, I’ll think about my patients, but they’re the disparities that separate my patient from the health care they could or should or otherwise would receive. Maybe it’s a financial issue. Maybe they’re having to choose between paying their electric bill and getting the medications that they need. Maybe they’ve got some mental health issue that’s incompletely or entirely unaddressed. But it’s all of these different elements that represent a chasm between the patient and the treatment that they need.
And in an interesting moment, and now there are quite a few studies published on this, and a humbling moment, Kevin, for guys like you and me in the business, the work that we do inside of just pure clinical medicine honestly has less of an impact on health and life expectancy than these social determinant pieces. Probably by orders of magnitude, but more than one X for sure. And it’s a humbling moment, but that’s what social determinants of health are. Part of it, I think, is just a simple awareness piece. And then some of it is, as you delve into the different elements, they’re typically named, like, I don’t know, seven or eight different elements of SDOH, and transportation would be another one, but all of these different elements can have an impact, and then we’re looking for ways to bridge the impact.
And the other thing, just on my short rap specific to social determinants of health, that sometimes just sort of gets lost in the sea of dialogue on SDOH, is the importance of community-based organizations in bridging that gap. Just think about your local nonprofits. They could be faith-based or not, but it’s these nonprofits in your community that are trying to help a segment of society inside the community in which you live. It could be a food bank. It could be a geriatric center. It could be an Alzheimer’s group. You name it. But most of the heavy lifting is done by these CBOs, or community-based organizations, in your community.
And so the solution in my mind, and I think that’s why it’s been so difficult to tackle, is those single entity can solve it. I mean, the government can’t solve it by themselves. Docs like you and me can’t solve it by ourselves. The CBOs are trying, but they can’t do it by themselves. It really takes a true community lens, a community effort. We need to think differently about our solution for SDOH. So sorry to go long, but that’s my point of view there.
Kevin Pho: Yeah, so why don’t we go into more detail? If you were to bridge those gaps and try to solve some of these problems that you bring up, you mentioned that things like CBOs are a little bit patchwork. There’s no centralized organization that can improve things. So what would be your approach to help close some of these social determinants of health?
Joe Nicholson: Well, I’ll go with this in two different ways. First, in the micro, I would say start where you are. Make a difference in your own community, and then go to the next bubble, the organization in which you are. So inside of CareAllies, we started with a pilot. We now have a full-on SDOH program with social workers, pharmacists, and nurses who help connect the patients of the physician groups that we serve to CBOs to close their gaps, or maybe we’re connecting them to their insurance carrier, if they can help close that gap. But start where you are, either in your organization or personally, and make a difference.
My crazy idea would maybe be just that. Maybe, Kevin, it’s a banana sandwich of an idea, but the fundamental difficulty I see with so many CBOs is, to use your phrase, it’s like a patchwork quilt of organizations. They’re not connected with each other, unless they are somehow connected with one of these emerging, I call them CBO aggregators, these vendors that manage CBOs and pull them into some version of a platform, which I think is a baby step toward where I’d like to go. The gap is that so many of these are run by volunteers, and so much of their work winds up being managed on Excel spreadsheets or, worst-case scenario, with a stubby number two pencil and paper.
And so the big idea would be: Could we create a paradigm on a national level, from a policy perspective, where every health care-oriented or SDOH-oriented nonprofit in the nation would get free, no-cost access to a platform that does that aggregation? Think about it almost like an HIE, health information exchange, connector. If we can connect them all in a real way, using some version of, it would have to be HIPAA-compliant, but open-source data, where anyone who’s trying to help that community could tie into that data, see what the gaps are, and understand from their own lens how they could help that community that’s underserved. So anyway, that’s the idea, but I think it would be at least an accelerant to SDOH solutioning if we had some national platform that could connect them, that they could adopt at no charge, basically.
Kevin Pho: Can you give examples of what individual physicians have done in the past? A story that you could tell, or a case study that can maybe move the needle a little bit from an individual level in terms of closing these gaps?
Joe Nicholson: Think about our own SDOH program at CareAllies. It really was the brainchild of one doc that we work with in deep South Texas, and I won’t name him, but I should, because he’s just such a swell guy. They literally are supporting patients in some of the poorest ZIP codes in the nation, along the Rio Grande Valley, and they have just a ton of SDOH gaps in the community they serve. They reached out to us and said, “Hey, can we do something about this?”
And so, working collaboratively with that physician group, we’ve created something from nothing. It started with getting a couple of social workers to begin to focus on some of those SDOH gaps. In the earliest days, we were doing something as simple as referrals coming out of that group, where the physicians themselves were identifying needs, and then they would pitch it to our team to help try to close that gap on behalf of the member. That’s an example of really starting from nothing and creating something that today has now blown up into a program that’s operating in three geographies. I think we have two more expansion geographies for this year, but it’s meaningful.
And let me give you a patient-specific example that might be an interesting moment for your audience. This was a case that I think was referred into our team. We had a patient who had shown up, and I’m making up these numbers, because I don’t remember them exactly, but she had been to the emergency room something like a crazy number of times. It was like over 200 times in the last year, and it’s like, “What is going on?” And a number of those had resulted in admissions.
Come to find out, the driver for that was really an anxiety-driven moment, where her husband, the father in this particular family, had died. And it wasn’t a pretty moment, kind of, in health care, just the way the whole death went down. The entire family was there and kind of saw this thing unfold. So not just the mom had anxiety, but the children had anxiety, and every time Mom had the smallest amount of indigestion or whatever, it was, “We’re not going to do the dad thing again. We’re calling 911. We’re going to get an ambulance.”
And once we got mental health services engaged, and the primary care docs engaged in supporting the anxiety, and some counseling for the family unit, all of that dropped to almost zero over the next six months. It’s an example of a case where what was probably an unaddressed mental health concern, anxiety, was really driving, in an interesting moment, driving cost: not just services utilization, time, and energy, but driving the total cost of care delivery up. And it was really solved just with some cogent hand-holding and some mental health support.
Kevin Pho: We’re talking to Joe Nicholson. He’s a physician and health care executive. He wrote the KevinMD article “It is time to make a dent in social determinants of health.” Joe, what do you see as the future in terms of your path, in terms of closing some of these gaps? What do you see in the next year or two?
Joe Nicholson: Well, if there was any good thing that came out of this pandemic, it was a real focus, I think, nationally, on social determinants of health and how that gap has widened. We know historically that any crisis widens that gulf. And then, as if things weren’t bad enough in the pandemic, now you’ve got this crazy hyperinflation. So now we have a whole new tranche of people who were doing fine maybe last month, paying their bills and getting their gas and not going back to work physically, and all of a sudden, now they’re having to choose between their medication and their heating bill and so on.
But the reason I highlight that is that that chasm, I think, has at least created a national spotlight. I would like to think that over the next two, three years, we’re going to see, at a national level, some continued acceleration around social determinants of health. Even CMS, I don’t know if you clocked that headline. We do participate in the DCE, that direct contracting entity. It’s that alternative payment model out of CMS. They’ve now rebranded that ACO REACH, but it’s ACO REACH for a reason, because it really has an emphasis on addressing social determinants of health. So I think we’re going to see more and more organized interest in, and hopefully rewards for, people who take an active interest in closing those gaps on a national level. Specific to CareAllies, again, we’ve got two expansion markets for SDOH this year. I’d love to have three or four more for 2023.
Kevin Pho: And my final question: What are your take-home messages to the KevinMD audience?
Joe Nicholson: Take-home message: SDOH, get involved. This is not something that can be solved without really most of us being involved. And so whether it’s engaging with a local nonprofit, or whether it’s helping organize something inside of your local company, I would just say get out there, get involved, create something. Let’s talk less about SDOH and do more.
Kevin Pho: Joe, thank you so much for sharing your time and insight, and thanks again for being on the show.
Joe Nicholson: Kevin, what a treat. Thank you so much for having me. It was a pleasure to be here.
Kevin Pho: Thank you so much.
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