Health Equity Conversations
Through Health Equity Conversations, Joshua Liao hosts a series of discussions featuring people and groups around the country working to improve equity and health through systems change.
In this episode, Josh spoke with Kisha Davis, MD, MPH, a family physician and Vice President of Health Equity at Aledade.
This interview is a condensed version of the conversation between Dr. Liao and Dr. Davis, and has been edited for clarity and length. For full-length discussion, please access the audio recording (available episodes accessible via Apple Podcasts and Spotify).
Joshua Liao: Could you tell us about your journey and what led you to your current career path and position at Aledade?
Kisha Davis: Sure, well thanks again for having me. I’m really looking forward to this conversation around health equity. My career journey started as a Family Medicine physician. Just out of residency I worked at a community health center outside of Baltimore. At the same time, I was working on my MPH degree and was seeing this confluence of need - patients coming in with diabetes and more patients coming in with diabetes and more patients coming in with diabetes and at the same time learning about all of those other determinants and drivers of health that are impacting their diabetes, and the likelihood for them to develop diabetes. And was
Kisha Davis, MD, MPH
Vice President of Health Equity, Aledade
feeling very limited in my capacity as a physician to be able to help them. I could help that individual patient in front of me, but I couldn’t help the bigger problems that they were facing.
I like to say their problems were bigger than my prescription pad. I could adjust their Metformin or adjust their insulin and do some counseling. But I couldn’t address the fact that they were living in a food dessert and it wasn’t safe to walk, and they didn’t understand nutrition labels. I couldn’t address the fact that they had life stressors that were just getting in the way of them being able to be healthy. So, I wanted to learn more and better understand the drivers of health and the role that government and community building can have in really helping to affect healthier communities.
With that, I pursued and was blessed with being accepted into the White House Fellowship Program, really with the goal of trying to better understand government and what are those levers that can help us have healthier communities. I spent a year at the US Department of Agriculture really working and looking, and better understanding the coordination between the health safety net and the food safety net. When we think about the food safety net programs like WIC and Supplemental Nutrition Assistance Program, and school lunch and school breakfast programs, and how that intersect with the health care world. And often that is at community health centers, and how can those programs better coordinate and collaborate in that they’re caring for many of the same patients.
After that experience, I really knew that I wasn’t ready to leave medicine yet and wanted to go back into primary care but also wanted to find a way to do that a little bit differently. So, I was able to start up a new practice called at the time the Casey Health Institute, where our focus was really putting primary care at the core, focus on whole person health. We had a very integrative team-based model that brought together primary care, acupuncture, behavioral health, chiropractic, nutrition, massage, yoga, naturopathy, all working under one roof collaborating on similar patients. But doing so in a way that respected the perspective of each of those clinicians in their care for the patient.
We really wanted that to be for all patients, so we took Medicare and Medicaid, and commercial insurance, and had a sliding scale for uninsured patients – really wanting to give folks tools to improve their health in the community.
When I think about it, yes, some people say, “that’s great for folks that can afford it but what about the person who cannot afford it?” I think about that single mom, who if I can help her control her high blood pressure and get her prediabetes controlled, that not only helps her, but it helps her be more present for her kids, it helps her be more present for her community. When we think about health care and primary care, our community should be better because of that practice being there. In [the Casey Health Institute] practice, one of the things that we really were intentional on or banking on was value-based care. And if we were going to give this patient personalized care, it really needed to be more than just 15 minutes, and trying to change that paradigm.
That’s how I had my first interaction with the company called Aledade, which is who I work for now – that was really pushing the needle and thinking about value-based care and how do we start to care for patients differently that really prioritizes that primary care relationship. Unfortunately, [the Casey Heath Institute] closed and at that point I joined Aledade as a Regional Medical Director, really working with Accountable Care Organizations (ACOs) to help support their physician practices in their journey on value-based care.
I have been with Aledade now for about 2.5 years. After about a year of being with the company, I transitioned into the role of Vice President of Health Equity. In this role, I’m really looking to help lay that foundation of how we talk about disparity, how we look at and examine disparity, and a lot of that work has focused around hypertension.
JL: How do you think about this interface between payment, along with all the other things that you’ve been talking about, and its impact on equity?
KD: I mean I think the two are certainly linked, and until there are incentives around health equity and making sure that we are doing better on disparities, then it continues to feel like “an add” on or an “other”. Equity really needs to be at the core, at the center. It should be guiding everything that we are doing but if you’re not incentivizing it, if it’s not part of the distribution, shared savings, formula, if it’s not part of the performance metrics, then it’s not really being integrated into the work. Organizations need to be intentional about how they think about embedding equity throughout the organization.
Our approach to health equity, we’re really thinking about it in terms of three key pillars or objectives. The first of those being embed equity, then eliminate disparities, and then grow equitably. On that embedding equity piece, it’s really thinking about, not just are we looking at the disparities down the line, like “do well on this thing and then we’ll get to looking at that.” No, what’s that equity imperative from the beginning? Take for example, annual wellness visits. You could say, “do really well on annual wellness visits, and once you’ve got that down, then we’ll talk about the disparity aspect of it and then we’ll talk about the equity aspect of it.”
But really you want to be laying that foundation from the beginning. So, the 101 level for a practice who is new to starting to think about health equity might be, “ok let’s make sure that at the end of the annual wellness visit, that we are collecting demographic data in a robust way.” And then the 201 level would be saying, “ok we have got those demographics, we can look at that data and now we can mitigate against it.” But if you wait and say, “nope we got to get the scale all the way down before we get to the equity topic”, then you may never get to it.
JL: Tell me about how you have approached something like engagement, and recruitment of clinicians, and thinking about how that recruitment and engagement can work on health equity from the beginning?
KD: We’ve started a lot with the willing. There are two ways here and this is not just in medicine, I think this is everywhere. There are some folks who are passionate about health equity and they are looking for it and they want to see it on an organization’s website, and they want to know what folks are doing. So, we have our strategy and plans for folks to see.
And then there are others who honestly don’t understand it, are too busy to care, and haven’t thought about it. But they don’t get a pass, they don’t just get to not do health equity work just because it’s not exciting to you. So, there is a level of hiding the vegetables in the spaghetti sauce, of what are those things that we want to make sure all of our practices are doing? Are they robustly collecting demographics on patients? Are they understanding the basics of implicit bias and cultural competency, and even going back a level, to just cultural humility? How can we start to embed that into just the work that we do, so it doesn’t feel like an add on, and trying to be intentional from when practices are outreached?
In some of our pitches to practices, we include some of what we’re doing on health equity. When practices are being initiated into Aledade, we are working to try to incorporate the language on what we’re doing on health equity so it doesn’t feel as a surprise. Embedding it into our quality metrics around hypertension, so that we’re looking at the disparities there. So, there are drips along the way to really feel like we’re moving the needle, incorporating it into the curriculum for our practices and for our field teams. All of these different ways to help to move folks along and help to be more knowledgeable on what equity means, and why it’s important for our patients and for our practices.
JL: Do you find that your approach has been different depending on the populations or communities served by clinicians? On the hospital side we have these designations such as essential or safety net hospitals to signal organizations that serve a high proportion of certain marginalized or other at-risk communities. As you’re thinking about your work on equity, have you seen that in how you’re engaging or recruiting clinicians?
KD: I mean, you certainly need to be reflective of the area where you are. So, the approach that works in New York or California is not going to be the same approach that works in Mississippi and Alabama. We have practices in 35+ states and the approach needs to be reflective of that; so how we frame things up, how we talk about equity, how we talk about social determinants of health. But there is also a boldness of saying, this is what we stand for and that equity is for everyone. It isn’t always just along racial lines, we have practices in rural West Virginia, rural Virginia, along the Appalachian Trail who are very impoverished, and health literacy is an issue, and transportation is an issue. Those are things that we also need to be thinking about in our equity strategy.
JL: Tell me about ACOs, which is really one way in which payment incentives get connected to delivery models, and hopefully can be applied in a number of different settings and communities. How are you thinking about equity in rural settings [and how that] may differ or look distinct from other forms of equity?
KD: One is just making sure rural practices are a part of ACOs and they have an opportunity to be a part. When we look at where ACOs tend to be, they tend to be in places that are richer, more urbanized, have folks who are more highly educated, folks who tend to be Whiter. But we also know that our vulnerable patients benefit when their doctor is part of an ACO.
So, we need to fix that mismatch. If patients who are in vulnerable communities really benefit from having a doc that’s part of an ACO, then we need to make sure that our ACOs are intentionally going to those places so that those patients get the opportunity to benefit as well. So that means going to rural areas, that means going to practices that are serving minority communities, and sometimes that means changing the incentives, providing additional upfront support, providing more ongoing support, practice management, revenue cycle management support, to really help them to be successful.
So, we do that in our recruitment for bringing practices on board, and I would say, we also do that in our advocacy; in our policy arm. Advocating for things like telehealth which has greatly benefited our rural practices and our rural practice providers and with that, that means advocating for broadband access so that those clinics and those patients have access to it. Sometimes it’s thinking a little bit more broadly than just the health care delivery, but also what are those things that are going to enable successful and strong access for patients to their primary care physicians.
JL: On that note, do you think that there are certain policy levers or policy deign elements that are most conducive to promoting [flexibility and freedom to adapting to the local community]? What are some policy changes that you think would really help expand ACOs and their benefits to rural communities?
KD: To this core question of, “where does policy play a role?” I think it’s creating the same benchmarks, everybody has to be getting to the same level. But recognizing that people are starting at very different places on that line. So how do we strive for the same standard and also support those folks who are starting from way far back from the line?
And there’s policies that we can put in places in terms of payment, extra upfront money, forgiveness, borrowing against shared savings that can be very helpful. Also thinking about how we are setting benchmarks and quality targets, and so does the practice get penalized for not hitting the quality target and what are the implications for that. For example, let’s say we’ve got two practices and the same asthma control measure that they need to meet, and you have one practice where the patient population is in a suburban area with lots of green space, and you have another practice that’s in an urban area and the patients live next to an oil refinery, or close to that pollution and lots of environmental toxins. That doc whose patients live in an area that is exposed to lots of environmental toxins is going to have a really hard challenge of trying to meet that same asthma control metric as the doc whose patients live with lots of green spaces. It doesn’t mean that we don’t want those patients to exhibit the same level of health or be striving to get there. But the one doc (they could both be excellent docs) through no fault of their own, is at a disadvantage because of where that patient population is.
And so, how do we give that doc additional supports, additional resources to be able to reach those patients and improve their health goals. A lot of times that’s what that takes, the difference between equity and equality - equality and being equal. Equal is everybody gets the same thing. Equity and equality is recognizing that sometimes folks need a little bit more to get to that same outcome. And that’s OK. If we want to be breaking down disparities and if we want to be breaking down these health barriers, we really need to start being more intentional and giving folks that need extra, the help that they need to get there.
JL: A lot of these models, ACOs and otherwise, really focus on cost efficiency. From my view, sometimes I think that is appropriate. But there’s another facet where sometimes there is underuse for certain populations and maybe to get the health outcomes that we all want, you need to do more (not less) of certain things.
Do you agree with that idea? And if so, can we get there – can we increase use and do more particularly for certain historically marginalized groups to get them to a place of better health, under the current design of models? Or do we need to see models evolve in a certain way, away from its current [focus on] total cost of care, episode cost, population cost, to achieve that end?
KD: Certainly, ACO REACH is starting to get us there. It’s not perfect, but that’s certainly on the road to trying to be able to change how we invest upfront to help folks get to those metrics and targets. That’s certainly a step in the right direction. I think another thing to consider is the timeline and horizon that we allow for change. We are often stuck on a one-year cycle when you look at Medicare shared savings, “in year cost savings.” Did it move the needle this year?
But when you’re talking about equity, it’s a much larger, much longer time horizon that you’re looking at. And because of that we have seen plans hesitant to make that investment because the savings may not come back to them. So, when you think about something like hypertension, if I can prevent the heart attack or stroke, that’s a huge cost savings. But the work that I do today, that heart attack that I prevented, was probably going to happen 10 years from now.
So how do we make sure that folks are getting credit for that up front work now? Right now, we don’t have a good way to do that. We don’t have a good way to realize or reward that work. Other than doing the process measures, like what type of hypertension control measures, diabetes control measures today, that is continuing to prevent the leg amputation down the line. You think about the cardiologist who comes in and saves the person from the heart attack, gets all of the credit, but the primary care doc who cared for the patient for 20 years and the person never has a heart attack, doesn’t get celebrated. It’s similar to that when we think about payment models.
JL: Are there a few areas that you think are particularly ripe for multi-payer alignment, where you say, “these I think we can clasp hands and work towards together”, as oppose to other features that are more unique and really cannot be translated across populations?
KD: Certainly, chronic diseases like hypertension, diabetes are things that because they’re over the life span, they have that potential for crossing payer. A lot of complicated childhood illnesses. You see this as we start to think about biologics and new medications for muscular dystrophy and sickle cell disease. Who bears the brunt of that cost? We get to the point where we have a medication that can greatly curtail the side effects of sickle cell disease for a kid. Who should pay? Should that insurance company bear that whole cost when had they not had that medication, the cost of sickle cell would have been borne out over several different insurers over the cost of their lifetime? How do we think about spreading that benefit around?
The savings that we see when we think about our dual eligible [beneficiaries] or folks who have Medicaid and may transition to Medicare as they grow older, or our commercial patients who may transition to Medicare, what’s the incentive for the plan to invest in that patient at 63 when they know they’re going to not have to bear the cost of whatever poor outcome could potentially come at 65 or 66 when they’re on Medicare?
I can’t say that I’ve necessarily seen good models that exist now, but I think there are folks who are thinking in that way and looking at how do we do it differently. I think that the conversation on drug cost has been a big impetus for sparking that conversation.
JL: Is there anything else that we haven’t talked about but that you feel that we, the collective we, need to focus on to advance health equity?
KD: I think in a lot of ways it still comes down to the basics of the data. Collecting patient demographic data in a robust way, you know, gold standard is self-reported data. How do we get our practices to do that well? And when they’re not doing it, what can we use as proxy for that and there are companies out there that help with that. But for folks that are just trying to start, just having that, just starting somewhere I think makes a big difference. And then how we use that data. One, in looking at core performance metrics but also ACOs can be a part of the community so there’s an opportunity there to use that data and share that with communities, state and local partners, to help them improve their communities where they sit. I think that’s an opportunity that most ACOs have not started to explore: what does that community partnership look like? The ACO benefits if the patients in their community are healthier. So, can we start to use that data as a way to move some of those conversations forward? I think that takes me back to the beginning - communities should be better because of the primary care practice that is there. A community should be better if there’s an ACO there, and how do we start to build on some of those partnerships and start to create them. I think that we are in the very early phase to start to look and leverage ACOs in that way.
JL: Dr. Kisha Davis, thank you again for joining us for today’s conversation. You’ve given a lot of perspective for me to chew on, and I think for our listeners as well. Thank you for the work that you’re doing in a number of different roles.
KD: Thank you Josh, it was a pleasure.