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Transcription:

Brigit: Hi and welcome to another episode in Avalere’s Social Determinants of Health podcast series, focused on understanding the importance and relevance of social determinants of health (SDOH). My name is Brigit Kyei-Baffour and I am a Consultant on our Market Access team at Avalere. Today, I am joined by my colleague, Nelly Ganesan, who is a Principal in our Center for Healthcare Transformation. In today’s episode we will continue our discussion from our overview episode, and dive into the strategies for both identifying and incorporating SDOH solutions, specifically in the manufacturer space. To level set for this conversation, when we mention SDOH, we are referencing the definition as provided from www.healthypeople.gov, which defines social determinants of health as the social, economic, and physical conditions in a person’s environment that can affect their health and day-to-day functioning. Now, with that we will dive right into our discussion for today. Nelly, what are the key determinants most relevant to manufacturers?

Nelly: Thanks, Brigit, for the opportunity to talk about some of the work that Avalere is doing in this space. We are pretty excited about where the field of social determinants of health is going. Based on some of the work that we’ve done, and the questions we continue to receive from our clients, mainly in the manufacturer space, we are learning they are most interested in how to improve access to medications, treatments, and access to emerging technologies, especially support care management. For example, we often receive a lot of questions. “Does my patient have access to the Internet?” “Are they using wearables?” “Do they have access to patient records to be able to manage their care?” Based on that, they then ask, “What are the services that are available to support them in health literacy and telehealth to help them get the care they need?”

Brigit: Okay, so given what you are hearing in the market, is there a reason manufacturers should focus on SDOH?

Nelly: I think Brigit, besides the obvious thing that “it’s the right thing to do,” we know that patients are not just defined by the disease they have, but rather how various social risks impact the severity of their disease. SDOH will play an  incredibly important role in the long run as the complexity of an individual’s health grows. But specifically, for manufacturers, we have heard from providers that one of the biggest struggles they have in identifying a patient’s social needs is around the lack of data that they have. While clinicians have access to demographic data in their electronic health record (EHR), including social lifestyle information like alcohol and tobacco use, they are not necessarily consistent data. So, I think this is where manufacturers have a huge opportunity from the amounts of data that they collect through clinical trials and registries on a variety of non-clinical determinants. So, things like geography, socioeconomic status, household income, and education are vast, but not consistently used in conjunction with clinical data to support population health research or intervention implementation.

Brigit: Interesting, so any thoughts as to how others may benefit from this data?

Nelly: I know there a large number of legal hurdles to face when it comes to open data sharing, and that question comes up frequently; however, we are starting to see more data-sharing partnerships and cross-sector collaborations in the marketplace, which are critical in matching patients with the support services they need to start addressing SDOH more widely.

Brigit: The most commonly cited example of manufacturer interest in social determinants is to increase medication adherence to therapies and use of devices. Can you speak to any examples of targeted activities a manufacturer has done to tackle adherence using social determinant data?

Nelly: Yes, medication adherence is widely discussed among manufacturers because it is a huge issue when you look at Medicare programs and issues clinicians are facing. I think this is one of those issues where it “raises all boats,” where there are a lot of folks who care about this issue where SDOH can help with medication adherence and something we get a lot from our manufacturers. We have seen data from shifting patients from non-adherence to adherent that shown a significant impact on cost utilization. One study showed that if you could take 25% of non-adherent patients, especially in the hypertension space, and ensure that they started taking their blood pressure medications on a daily basis, you could save Medicare almost $14 billion annually. This will likely prevent 100,000 emergency room visits. So, the cost savings there are enormous. In parallel, data has shown that addressing SDOH of food insecurity can help patients manage or prevent hypertension. So, to that end I think there are some manufacturers that have taken the concept of food insecurity and married it with their hypertension patients to ensure that their provider-customer segments include information where they can access healthy food in addition to their blood pressure medication. This is not just addressing the simple SDOH and not taking your medication and partnering those together for a more optimal outcome. To my earlier point, looking at a patient not just for their specific health condition, but how they need to be managed holistically is another great way to define ways in which manufacturers can think of SDOH.

Brigit: That is a great point Nelly. I want to dive deeper into the holistic approach. Can you talk about other examples where you have seen manufacturers engage related to SDOH that go beyond medication adherence?

Nelly: Yes, and this is an area Avalere is really excited about. We had the opportunity to work with manufacturers to determine where they want to put their energy, how they want to tackle SDOH, and help define the return on investment (ROI) factors to their senior leadership team, and think about internal strategies. Our team in partnership with Inovalon has access to a SDOH data set that allows us to drill down on certain aspects like age, number of people in the household, median income, whether they live in an urban or rural environment, length of residency, and home ownership. And, this, allows some of these data points to be calculated into an isolation index or whether they have access to transportation to be able to go to doctor’s appointments and/or if they need to get infusions within a center, etc. These data points lend itself to the type of interventions that may be applicable within a disease state. So, interventions based on the data that we have are going to look different for someone who has diabetes versus someone who has Crohn’s disease. Again, back to my example of transportation, if the patient requires transportation weekly to get to an infusion center for an appointment, given their living situation are we able to drill down on that using zip code data? Specifically using this data set, Novartis has created a travel assistance program for their chimeric antigen receptor T-cells (CAR-T) therapy program Kymriah, which allows Novartis to directly assist with low-income patients for expenses for travel and lodging, and enable patients to better access to care, particularly those living in rural areas. This program was set in place because they were able to look at their patient population and see whether living in a rural area was impacting how patients got their care.

Brigit: So how are these services or programs that are offered by manufacturers like transportation and medication adherence, not in violation of any regulatory guard rails such as the Anti-Kickback Statute? How do manufacturers maintain compliant in the rollout of some of these services?

Nelly: That’s a great question Brigit, and I think this can get technical very quickly but this specific program was deemed permissible by the U.S. Department of Health & Human Services and the Office of the Inspector General earlier this year, January 2020, that signaled the need for inform support for manufacturers to provide high ancillary costs that would alleviate SDOH for patients burden. This specific example is where Novartis went to get extension on this decision, but we are seeing more of this activity.

Brigit: Okay, very interesting. I wonder if we will start to see other manufacturers seek similar exemptions to improve access to these types of therapies, especially for patients in rural communities where they have greater access barriers related to transportation. Another area that is clearly linked with data outcomes is health inequalities, as well as disparities and SDOH. Can you speak to any examples where you have seen manufacturers use interventions to address health inequalities in SDOH?

Nelly: Yes, and I should say that some of these are examples in the marketplace and ones Avalere has not always been involved in. But we have used a lot of those models to develop our own thinking on what could be feasible for a manufacturer. Other areas we have dived into given the disease area our team has been focused on; we saw some early activity in 2017 in the form of innovative partnerships. This was a partnership between Anthem, a health plan, and City of Hope, a large cancer and treatment center in the Los Angeles area, the National Urban League, an organization that has been focused on disparities for many years, and Pfizer, a manufacturer that collaborated together to create a pilot and web-based tool called “Take Action for Health.” The goal that was associated with this web-based application was to eliminate chronic health disparities in Black communities, which contributed to increase morbidity and mortality. The tool was specifically designed to educate, encourage screenings for breast cancer, track these screenings, and allow participants to share information with providers and others in 3 high-risk areas. I have mentioned breast health, but it was also for heart health and emotional well-being, which I think has been a clear issue for the Black community. There is a lot of stigma around it and so affiliating some of those elements within that Web-based platform allowed them to look at SDOH married with some of the disease-related conditions these patients had. The pilot results had validated the need for patients to have access to these types of services to improve outcomes. The pilot is ongoing and access to that tool continues to exist. Another example is Genentech, a large biotechnology company that is located in the San Francisco area with a large portfolio. Genentech initiated the Memphis Breast Cancer Consortium in Memphis, Tennessee, where disparities, including income disparities, are high. The consortium addressed racial disparities in breast cancer specifically. One of the main goals of the initiative was a large public campaign to encourage black women to encourage each other to get mammograms. There was this partnership and women working with other women to ensure they were getting the care they needed. Addressing access to services, social support, social norms and attitudes, discuss distrust and racial discrimination, and using culture as a mechanism to increase screenings, showed that through this initiative there was a total increase of 80% of targeted women taking steps to manage their breast health. In one year, the initiative saw 70% of women being appropriately screened due to having people in the community and women encouraging others to get their screening.

Brigit: A lot of the work you mention sounds groundbreaking and interesting in this space. I think a lot of this information might provide some manufacturers with even more ideas of how to engage and strategize in SDOH. Are there are clear individuals or business units in a manufacturer that are more engage in this type of issues?

Nelly: This is a great question. Unfortunately, and typical of my answer in consulting that many people are probably not a fan of, is that it varies by organization. One thing we have learned is that you have to have buy in from the top to want and prioritize addressing SDOH, especially in the internal strategy of the organization. In many regards, it is not intended to be another thing you work on and add on, but rather a focus that should be integrated to a variety of activities that are happening across the organization. So, thinking about SDOH when we think of trial design, patient support program, and launch planning are the best way to think of it, instead of just one person thinking about it. We have seen that there has been some struggle in conveying this in other departments but where we have seen success is with folks in Health economics and outcomes research, patient services, and often times there is a group focused on population health specifically looking at the impacts of a disease. In market access there is a lot of SDOH focus and priority in the policy and innovation area, and lastly, where I think it will continue to play a role is in advocacy, since those terms come up on the partnerships and engagements they have outside of their organization.

Brigit: Okay, so we have talked a lot about what manufacturers are doing. There are several challenges to tackling SDOH. Can you talk a bit more about what some of those challenges are?

Nelly: Yes, I mentioned this before and I think it’s important to mention it again, truly the lack of data in demonstrating the value to focus on SDOH is the biggest challenge for this area. The question “what’s in it for me?” has a long way to go before we can respond to ROI. In fact to my earlier point, of this being the right thing to do, when you look at an individual’s health needs, they are not truly focused on a patient being diabetic, for example, but that instead there are a number of social risk factors that are leading to the complexity of their disease. This leads to the second challenge of funding to support these types of initiatives. We are starting to see more budget become available to building innovative partnerships with different members of a community that are looking to address SDOH. So, things like food insecurity and transportation. I think we will see manufacturers increase grants to organizations that are hyper-focused in SDOH and link it back to disparities.

Brigit: Well Nelly, this has been a really helpful conversation in understanding how a manufacturer can become more engaged in addressing SDOH. Is there anything you would like to add before we wrap up?

Nelly: Yes, and thank you Brigit. I have enjoyed this conversation, and I hope others have too. I will close and say that we have had an opportunity to work with a whole host of clients, life sciences, device companies, and patient advocacy groups to help them build SDOH into their internal strategy and launch planning activities. I think if you have only seen one company focused on SDOH, there is only one company focused on SDOH. So, every company has their own way of tackling this and this includes creating pilots to address SDOH in the community setting. We have helped in establishing innovative partnerships between a manufacturer, health plan and a clinic to tackle transportation and nutrition barriers. We also provide general strategic support on what it means to include SDOH within that patient support offering. There is a whole host of offerings and this is an exciting area and we look forward to exploring your desire to engage in the SDOH space in the future.

Brigit: Thank you Nelly for joining us today and the helpful information. Thank you all for joining us today in the Avalere Health Essential Voice. Please stay tuned for more episodes in our social determinants of health series. If you would like to learn more, please visit us at our website at www.Avalere.com. Thank you!