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Transcription

Matt: Welcome to the first episode of the Avalere Health Essential Voice series focused on the 2020 election. In this series, we will be covering the state of play of the 2020 election and the role of healthcare within it.

I’m Matt Kazan, a principal on Avalere’s policy team. Today, I’m joined by Dan Mendelson. Dan founded Avalere in 2000 and served as CEO for almost 2 decades. Previously, he was associate director of health at the White House Office of Management and Budget during the Clinton administration.

In today’s episode, we will be focusing on healthcare disparities and which healthcare issues to watch during this week’s Democratic National Convention. Dan, thanks for sitting down with me.

Dan: Great to be here.

Matt: Let’s start with the COVID-19 pandemic. The pandemic has reshuffled the deck in terms of what we thought this election was going to be about, but it has also elevated some issues that this country has been dealing with for a while. For example, many researchers have highlighted that COVID-19 disproportionately impacts communities of color.

How much of this disparity is due to the nature of the pandemic itself, such as access to testing or high-risk jobs, versus fundamental issues that face our healthcare system?

Dan: That’s a complex and important question. It’s both. I have seen these disparities my entire career and have spent years researching them. With COVID-19, the pace and focus on these issues has accelerated. They are right in front of us. We can see them in the infection and mortality rates in minority communities.

2020 is not only an election year, but it is also a year when 50 million people have spoken out against racial injustice amid the pandemic. These events have forced our focus on the disparities, and there is an opportunity for us to address them as we move forward.

Matt: We’re going to be facing this pandemic both in the near and distant future. What are some opportunities from both a policy and business perspective to deal with these system-wide challenges while also addressing COVID-19?

Dan: Going back to your initial question, the other reason we see disparities is because of the healthcare system itself. Insured people tend to make better use of the healthcare system, but fewer minorities are insured. Minority communities also have higher comorbidities and subsequently a higher likelihood of an adverse COVID-19 experience. We’re facing many different issues. Every stakeholder in the healthcare industry has an opportunity to find ways to reduce disparities in the healthcare system.

Matt: Do you anticipate policymakers taking this dual view of reacting to COVID-19 while also focusing on these broader issues?

Dan: Absolutely. This will be a major electoral issue in 2020, particularly with the selection of Kamala Harris. She is very focused on and passionate about this topic. There are many policy solutions that we could put in place. Medicaid, for example, is an important focus because about 40% of Medicaid beneficiaries are Caucasian, while the balance is made up of minorities. Any policies that focus on Medicaid will inevitably target minority communities. Medicare is another great policy lever. There are many ways to use quality scores to hold plans accountable with respect to disparities. There are many policy levers through the entitlement programs, and I think they will be a major focus during and after the election.

Matt: Let’s talk about the public programs and what we might hear about them at the DNC. Obviously COVID-19 has both a healthcare and an economic impact. Avalere has released estimates about job loss and the shifts in coverage as a result. Nearly 1 million people may enter the exchange market due to COVID-19. Black and Hispanic Americans are uninsured at a higher rate, even with the passage of the Affordable Care Act (ACA), which I believe we’ll hear quite a bit about during this week’s DNC. Are there things Democrats should focus on that would shrink the uninsured gap between communities of color and Caucasian Americans?

Dan: Having universal coverage will reduce disparities, and I think that goal is going to be articulated at the convention. Medicaid and Medicare expansion and the stability of the ACA and individual markets will also be discussed. If we are moving toward this goal of universal coverage, we will be addressing disparities in that respect.

I think it is important to acknowledge that, because of COVID-19, there has been tremendous job loss and instability in these markets. Anything we can do from a policy perspective to ensure that individuals can maintain the policies they held before is valuable for continuity of care and to reduce disparities.

Matt: Right. I think that’s a great point—shifting from coverage policy to payment and delivery of healthcare itself. Transforming the way in which payers pay for services and reflecting that a portion of that payment is based on quality and value. That has happened at the provider level, with ACOs, Medicare Advantage plans, and even with drugs. The direction we generally want to go is paying for value and quality, but I think the flip side is that there are these social determinants of health that also impact quality, such as access to healthy food or transportation, that are often outside the control of a plan or a provider but still affecting the patient’s quality of life and care. What are your thoughts on how we continue to go down this road of paying for value, but also accounting for these larger issues?

Dan: I think it makes sense to start with economic incentives for health plans because they are a great lever point. Plans have data on the beneficiaries, and they can drive care. Many are providing food and transportation services associated with medical care. To work with the plans in a collaborative way and have them be responsible for reducing disparities makes sense. The National Medical Association recently released a proposal that focused on increasing core funding for Medicaid. For years, Medicaid has paid for transportation and other services that can reduce disparities. Improving core Medicaid funding could improve matters. I believe that if you put an economic incentive in front of plans and have that be a core aspect of how they’re getting paid, it will have more of an effect than simply increasing the funding levels from a targeted perspective.

Matt: I agree, and I think history bears that to be true. The ACA based a portion of Medicare Advantage payments on quality and we saw plans respond to those quality measures very quickly. A more recent incentive put in place for Medicare Advantage plans has been greater flexibility on non-medical benefits, but we’re only in the first year of that being rolled out. Avalere has released some data on what plans are doing, but it will be interesting to see how plans use those tools and the impact they have on certain communities, and whether this flexibility is being used in the way in which Congress and CMS intended.

Dan: Absolutely. Plans will do what they’re asked to do, and it’s really a matter of being explicit and making sure that they are selecting quality measures that are feasible. We have these measures such as diabetes and cholesterol levels, we know who the beneficiaries are, and we have race information. Implementing incentives that use existing quality metrics intended to reduce disparities could be very effective.

Matt: We’ve talked a lot about this from a policy perspective. If you’re thinking about the issues from a specific business or stakeholder perspective, what things could stakeholders like a health plan provider group or drug manufacturer do to really engage in some positive changes around reducing disparities?

Dan: For all stakeholders—health plans, providers, pharmaceutical companies, and other life sciences companies—this is a great opportunity to be positively engaged to address health system issues. Plans can figure out the metrics that they want to be measured on because it always works better when plans are positively and actively engaged in defining those metrics. Providers need to make sure that minority communities feel comfortable coming in and getting care, since historically there are many reasons why they might not be. There are also federal responses that could be deployed around the health professions to make sure that minority communities are well represented in our medical schools and our nursing schools and in other allied health professions.

There are many ways that companies can support these different policies and make sure that they are congruent with their goals. In the pharmaceutical industry, they should be focusing on minority representation in clinical trials, but even just selecting a few of these items and making them visible going into the next cycle would be quite productive.

Matt: I agree, and I know the clinical trial issue is one that we’ve talked about, specifically in terms of the COVID-19 vaccine. Thank you, Dan, for providing your insights today. It has been incredibly enlightening.

Thank you all for tuning in to Avalon Health Essential Voice. Please stay tuned for more of these episodes as we get closer to the 2020 election. If you’d like to learn more, please visit our website at Avalere.com/2020-election.