Policies, Politics and Healthcare with Geoffrey Roche

Brian Urban: [00:00:22]
Yes, indeed. That is how you start our podcast. This is the health care rethink. I'm your host, Brian Urban. And today we're going to be talking about a very complicated subject, political determinants of health. And to help us navigate through the policy data business innovation side, we have Professor Jeffrey Roche from Harrisburg University here in Pennsylvania. Welcome to the show, Jeffrey.

Geoffrey Roche: [00:00:50]
Glad to be here. Thank you for the opportunity.

Brian Urban: [00:00:52]
So, Geoffrey, every show that we have, we would like to get our guests comfortable with our audience and them to know you a little bit more. So we'll do a quick, rapid fire question here just to keep you on your toes. Nothing painful. And then I really want to get into what we're looking at across our political and health care ecosystem and some things that we can see in the future as well. So quick Q&A for you to get to know you a little bit better. Are you ready?

Geoffrey Roche: [00:01:22]
I'm ready.

Brian Urban: [00:01:23]
All right. Pop or soda?

Geoffrey Roche: [00:01:26]
Soda.

Brian Urban: [00:01:27]
Mountains or beach?

Geoffrey Roche: [00:01:29]
Beach.

Brian Urban: [00:01:30]
Flying or driving.

Geoffrey Roche: [00:01:32]
Flying.

Brian Urban: [00:01:33]
Mints or chewing gum?

Geoffrey Roche: [00:01:35]
Chewing gum.

Brian Urban: [00:01:36]
You're in Pennsylvania. Steelers or.

Geoffrey Roche: [00:01:38]
Eagles? Oh, eagles, without question.

Brian Urban: [00:01:40]
All right. There's no wrong answer, so I won't hold that one against you. Last one. Value based care or fee for service?

Geoffrey Roche: [00:01:46]
Value based care.

Brian Urban: [00:01:47]
There it is. Nice. So I think our audience is warmed up to who Jeffrey Roche is, and I love doing that sort of thing. So let's get into the meat of this. So something that dropped earlier this year from NCQA is an innovative step in the right direction in terms of identifying needs at the individual level. So health plans going forward are expected to perform social determinants of health screenings at the individual member level, and they've yet to release their standards on how these measures will be looked at. So I want to know from your perspective, and you wear many hats to you're not just in the academia and research side, you're across the whole landscape. So I want to understand from your perspective, are we going in the right direction? A good pace to slow? Not fast enough. Want to get your thoughts to open this up?

Geoffrey Roche: [00:02:49]
Yeah, well, let me just say, I mean, I'm encouraged that we're starting to see this development. And I'm certainly not shocked, particularly when we consider this current administration certainly has individuals at CMS, at Health and Human Services that have had a long track record of really advancing health equity in a lot of the previous roles that they've been in. But I will say overwhelmingly, I think as a country we're very slow, particularly to adopt health equity and to really advance health equity and social determinants or sometimes called the social drivers of health. We've been too slow. And I think statistically and from a factual end, we've seen the unfortunate impacts of that, particularly during the COVID pandemic, where people were disproportionately impacted by the very disease virus of COVID 19, in many ways, just entirely on the social determinants of health. And so I'm encouraged that CMS and others are starting to take these steps, not shocked because of some of the folks that are at the helm there. But we've got to move it much more quickly.

Brian Urban: [00:03:56]
And I couldn't agree more. The pace is critical now, especially seeing all the things that have been highlighted from the pandemic. And we're not out of this yet either. So great way to start the conversation, Jeffrey. Thank you for that. Now, in looking at health care and innovations, Pennsylvania and the states touching it, Maryland, West Virginia, New Jersey, New York state, they're making a lot of progress in terms of community based organizations being pulled in as strategic partners, working with health care systems, working with community based hospitals. What have you seen in Pennsylvania or beyond that has really struck you as a faster move to really filling needs for people at the community level?

Geoffrey Roche: [00:04:40]
Yeah. Well, I mean, obviously, I'll speak more to Pennsylvania. I mean, I think without question, to your point, we've seen some other states that have been certainly advancing a lot of this critical work. Massachusetts is certainly one, Rhode Island is another. So obviously, in the commonwealth of Pennsylvania, we've been fortunate in the current administration under governor. Wolf, to have actually taken a lot of steps forward when it comes to social determinants of health and health equity, particularly, as you know, Brian, I mean, in Pennsylvania, we unfortunately do not have by statute an Office of Health Equity in the Pennsylvania Department of Health, but we do by executive order. And it's important to recognize that that actually is a political determinant of health. We would love to see that we actually have that by statute. But but the legislature obviously has a different thought in mind there. Why that's important is that since actually Governor Corbett, former Governor Tom Corbett, who I give credit to, he actually started that office. Hopefully other other future governors will see the reason why Governor Corbett did that. And Governor Wolf obviously continued it because we've had an immense focus through all different state agencies Department of Health, Department of Human Services, Department of Aging, Department of Public Transportation, even dcnr to actually focus on social determinants of health and do it in a health equitable lens that's critical. So we've seen incredible work, particularly at the Pennsylvania Department of Human Services, to to think of how we do this with our managed care population, our Medicaid managed care population. We've seen the Department of Health do a lot of work with hospitals and health systems to really think about what we do to address social determinants of health and do it in a manner that advances health equity.

Geoffrey Roche: [00:06:24]
And we've also seen the Department of Health take a specific stand and say, you know, we've got to be mindful of of systemic racism in our health care system. And if we don't take steps to be mindful, we're never going to actually achieve health equity. So there's a lot of work occurring. In fact, during COVID, we had a COVID 19 Health equity response team, which I had the privilege of serving on the leadership team of. And in that effort, we actually broke it down by community based needs rural, suburban, urban, and we responded to those very needs. Well, that effort hasn't stopped. I mean, yes, we're kind of on the other side of the pandemic, but we've now actually moved into what's called a health equity action team. And that Health equity action team is working very much boots on the ground, filtering information up to up to the Department of Health under under now Acting Secretary Denise Johnson, who has continued to have a tremendous focus on health equity. But I've got to give credit, if there's one person who certainly took took the charge in Pennsylvania to really lead and ensure these efforts were going for many years is Dr. Rachel Levine. And so obviously, Dr. Levine is now at the federal government level, hence why we're seeing a lot of health equity work occurring at the federal government as well.

Brian Urban: [00:07:36]
I love the additional note on Dr. Levine. I think courageous comes to mind because there's a personal touch to everything that Dr. Levine has done and really leading conversation through dialog that touches individual lives, not just mass populations, but really populations that need to be more represented at the state and at the federal level. So it's amazing to see Dr. Levine continuing.

Geoffrey Roche: [00:08:03]
Well, let me tell you, when I first met Dr. Levine and Dr. Levine knows the story because I tell people all the time, and sometimes I think she says, why is he continuing to tell it? But, you know, I first met Dr. Levine, actually, when my brother passed away of a heroin overdose. And it was Dr. Levine who came to our county shortly after and our health care system at the time, which was Polk Health System, asked me if I would represent the hospital. And they knew what I went through. But they they asked me first if I wanted to do that, which obviously I felt compelled. And I will never forget the moment of sitting there in the room with other individuals that had been impacted. And the whole effort was to talk with our lawmakers and Dr. Levine, then the physician general, about what we could do to better address these issues. And I will tell you that I never saw someone who had more compassion, but also was entirely focused on not only helping me deal with what I just faced, but more importantly, what we could do to to deal with it as a as a commonwealth.

Brian Urban: [00:09:03]
Wow. Thank you for sharing that. And I think that alone says a lot to the character of Dr. Levine and yourself in terms of the audiences and the lives that you serve as well. So I really appreciate you being able to share that. And I think you bring up a really good point, whether whether you were thinking this way or not, but being able to help populations that have needs that you can't see, and that's looking at information outside the doctor's office, knowing the person in a more of a 360 view. And Medicaid populations are often a target of saying, well, you know what, we don't make a lot of money on serving Medicaid lives. They're very transient. They're very challenging. Those are all objective excuses in my mind. So when you look just beyond the lines of business, Medicaid, Medicare, commercial, looking at the hot spots and cold spots across the state and a zip code plus. Your analysis is really telling. And I think CMS has done a great job in being able to share their data tables publicly as well. So what I'm getting at here is data being a centric tool for government and also pulling in strategic partners. So I want to get an understanding of your perspective recently how key data, whether it's raw, unstructured or however supply to government, how have you seen that be helpful in driving new programs that that help that help address needs and communities?

Geoffrey Roche: [00:10:36]
Yeah, Well, I think in Pennsylvania, one example that comes to mind is Dr. Doug Jacobs. So, Doug, Doug had served as the chief innovation officer at the Pennsylvania Department of Human Services, now serves as the chief transformation officer at the Centers for Medicare and Medicaid Services. And when Doug was here in Pennsylvania, one of the things that he did, which obviously he had he had this knowledge from his time in Massachusetts, was looking at the Rhode Island model, which was Rhode Island had set up very successful, very impactful health equity zones. Now, in Pennsylvania, as Dr. Jacobs was doing this work with his incredible team and in collaboration with the Pennsylvania Department of Health in the Office of Health Equity. What was interesting and pretty telling was they had set up with with managed care providers and health systems kind of regional committees that would be chiming in and sharing kind of best practices, etc. community health organizers, community health engagement, etc.. But when Pennsylvania drilled into the data, what was really telling was that we Stoll saw significant health equity issues particularly, and social determinants of health in areas of Commonwealth that were redlined. And that's what's really important here.

Geoffrey Roche: [00:11:52]
When you look at the United States of America, a lot of different portions of different states have faced redlining. And so when we go back to the civil rights era and talk about redlining, you can still see the impacts of those decisions back then on the health outcomes of the individuals who live in those regions now, which is which makes sense because unfortunately, a lot of those individuals have family members and others that were impacted disproportionately and have continued to be impacted even after all this time. And so data is incredibly important, not only from the perspective of new programs, but also for the perspective of how do you actually address a community. And so in this type of a situation, it proves that you've got to do a lot more community health organizing, you've got to do a lot more work around ensuring better access to care. And I will tell you, this work was occurring right around the time when we were also doing more work in the Commonwealth to vaccinate the community, and particularly with COVID 19 also disproportionately impacting this community and these communities. The work was more important than ever.

Brian Urban: [00:13:00]
You bring up such a great point. And actually it's a societal tragedy. Redlining activities dating back to the 1930s and forward. So for our listeners out there, I highly recommend you even go into MEDCOM. You type in redlining. There's amazing research on it that highlights the social tragedies that we in America have have had going on for almost a century. And it's it's based for populations that are near high traffic areas, poor quality building, chemical plant areas. And actually, it's kind of touching now even more rural areas when you think about fracking as well for gas wells and the maintenance of wells and how not many of them are are kept very well going forward. So another subject to get into, but that's a great example of political determinants of health right there and how do we change that? And I think there's been some interesting models, but they're not really well thought through. So there's some great organizations that are building new buildings, good materials in these red line areas, but the follow through is really important. You can't just build these multimillion dollar complexes and expect everyone to just be okay. You have to have a maintenance and follow through so that there's good health journeys, not just outcomes. So kind of getting into that space, there's a lot of health plans, there's a lot of government agencies supporting improved homes, improved access to foods. Have you seen any food distribution centers working really well with health care or government in Pennsylvania that's kind of really taking food access to another level or any other examples? I'm curious because you see a lot of this quite frequently.

Geoffrey Roche: [00:14:44]
Yeah. I mean, I mean, obviously, you know, in the Philadelphia region, we see incredible work by Philabundance Philly, I guess it's called Philabundance, Philly Abundance. You know, a lot of collaboration that they have, particularly with all the different health care systems. You know, obviously, Geisinger has been well recognized for their fresh food pharmacy, and particularly the impact that that has made in a more rural community that I think oftentimes we we are are kind of in an assumption type manner to say that it's more urban communities that face some of these most disproportionate impacts. But but rural America, which obviously, you know, majority of Pennsylvania is rural, we have significant inequities as well in rural Pennsylvania. And so the work of Geisinger and the fresh food pharmacy is critical. I think certainly I think across the board we've seen much better collaboration from health care to food and other types of providers to really understand that food is health, food is medicine. And frankly, the more work we do to collaborate, the better we can truly address really the social determinants of health. I think too, we've seen better, better coordination too, even in the housing area. I mean, I always tell the tell the story that in my hospital days we were a hospital system that was doing some incredible work in the community, really through a partnership that we had with East Stroudsburg University, Wilkes University, as well as the Commonwealth Medical College, where we would bring together students who were pharmacy students, medical students and then actually undergrads and those that team of student professionals would actually go into the homes of patients and would sit with them and talk about what they were just in the hospital for, to try and help reduce readmissions and really an early stage of value based care, because we even worked with Blue Cross at the time, got telemedicine, you name it, so that the physician and the nurse could still see what was going on.

Geoffrey Roche: [00:16:48]
Well, that program was so impactful that it started to actually peel back the onion of some of our frequent fliers to the emergency room who ended up having significant chronic issues. And in one case in particular was a patient who lived in a public housing or I shouldn't say public housing, but lived in an a landlord type of situation, private landlord situation, but was very low income. And unfortunately, the landlord was truly actually taking advantage of this individual, but also taking advantage of other individuals who live there. And there were significant mold in that home. Now, we didn't find that out until numerous visits, thousands and thousands and thousands of dollars. But ultimately, once our social work team and such, we're able to figure it out.

Geoffrey Roche: [00:17:32]
We were able to get that patient into a new home. We were able to also report that landlord appropriately to have that solution be identified. But ultimately, unfortunately for that individual, it was a little too late because they already had COPD and they had medical issues that that in many ways the physicians felt came on because of that living condition, because they lived there for for so long. And I think that's another example of really political determinants. Of health. We as a society have to remember that housing, health care laws, zoning, you name it, all impacts the social determinants of health. And until we recognize and understand that we all have to be in this work together, we're going to continue to set up a system that has haves and have nots. And and frankly, we're not going to achieve health equity because people just have this belief that we don't have to deal with those issues. But the reality of it is, is that our health care system is always going to have to deal with those issues, even in value based care. They're going to come through the emergency room. It's going to be very expensive and everyone's going to still be impacted. Until we all recognize our opportunity to do our work here.

Brian Urban: [00:18:44]
Great examples that you laid out there and at the individual level. And I didn't realize that you were in the field so much in your hospital days as well. And I did want to talk about the education, the academia side of your world. But a quick shout out to Geisinger Health. You are right. I think Brian ever saw and Allison has that team out there that leads that sdoh work. Love the fresh food pharmacies Scranton, Pennsylvania, and Kingston. I believe they have locations, but that's how you embed yourself in a community and do it with purpose. I love that. So shout out to Geisinger Health.

Geoffrey Roche: [00:19:19]
Well, don't forget Dr. Murphy, You know, don't forget Karen.

Brian Urban: [00:19:23]
Karen's awesome. What a champion. What an innovator as well. You're right. The whole the whole crew, even even back in the days of Dr. Feinberg. And he's off to different world now. But yeah, what a great rich history they have. So anyway, let's get into the academia side of your world. So you shape young lives and you have quite a reach. Are you seeing trends now getting more high volume public health focus for skills in education, more strategic partnership, developing different types of business models that are more purpose driven and less hard profit driven? I mean, that's what took me into public health. Are you seeing that as a trend in formal academia?

Geoffrey Roche: [00:20:10]
You know, I think without question we're seeing a lot more interest in social impact. And so how can individuals that serve in public health really be mindful and intentional about social impact in the greater good? So one of the things I think that's been really interesting is that in public health, population health, we started to see not just from the from the practitioners of of those fields this full adoption and strong endorsement of addressing issues of health equity. But we've also started to see them really understand the political determinants of health. And so we've started to see a lot more questions get asked about that. Now, I'm a firm believer, and to your earlier point, I was fortunate to serve in a community hospital that that health care also has to remain local. And so I will continue to say that the larger our health care systems become can be very challenging When we're talking about issues of health equity, we've got to ensure that our health care systems still identify with the local communities that they serve. One way to do that, Brian, is to actually have a system called an anchor institution framework. And so from an academic level, particularly, I'm completing a fellowship right now on this exact model, I have continued to believe very strongly in the anchor anchor institution framework. And there are several health care systems that have been strong adopters of this framework that we have seen tremendous success. Atlanta Care is one actually in Atlantic City, New Jersey, where they have been incredibly intentional about the work they do in the community to serve them from a public health lens.

Geoffrey Roche: [00:21:46]
But at the same time, they've been intentional about dealing with issues of supplier diversity so that at the end of the day, you can't just do business from a partnership level and do business with all white owned businesses. You've got to do business with diversity, equity and inclusion in mind or we're never going to lift lift all tides in this type of system. So that work has definitely become more and more important than ever. And Johns Hopkins certainly has been involved as another anchor institution. And there are several others, obviously, in New York City and other parts of the country. So that's definitely encouraging. I think if there's there's another element to me that's incredibly encouraging and that is that, you know, at the federal level, for example, the CDC just announced that under under Dr. Walensky, Dr. Walensky is asked to have a review of the CDC. And one of the things that was really exciting to see was that she actually selected Dr. Mary Wakefield, who's a nurse. That's incredibly a positive thing, because public health, like other aspects of health care, has always looked towards our physicians. While we love our physicians, we have to remember that nurses are also. Integral to every aspect of the public health system. And so for Dr. Walensky to select Dr. Wakefield is is a huge bonus, certainly to the nursing workforce, because we know the backbone of our public health infrastructure, our nurses.

Brian Urban: [00:23:14]
I love where you're taking this and you're making me think about the evolution of public health as we know it. And I don't know if I would agree with this comment that I'm going to say here, but it feels like public health always looking at the mass populations, looking at from an epidemiological lens, and now it seems to be becoming more of a precision model down to community level, down to household level. And it's even becoming a little bit more almost personalized. So when we think about just the disparities alone by race and then by gender and language preference, it seems like we have more of a precision public health model that's coming into place with the US. Would you agree with that or do you think we're not not there just yet? There needs to be more time for us to really kind of validate that.

Geoffrey Roche: [00:24:07]
No, I think we're I think we're getting there. You know, again, I would would would encourage that we move more quickly and I would encourage that we do it equitably, particularly in all communities and and just ensure that as part of that effort, we do a real strong focus on issues like health literacy. I think the more we do to personalize it, we've got to address those issues too, because statistics prove that a lot of medical decisions can cause a lot of challenges with with individuals that are disproportionately impacted just on health communication alone. And so in public health, just like in traditional health care, we have that same exact challenge. And so if we're going to see this movement, we've just got to ensure that we we also address issues of health literacy. We address issues of certainly of health equity or we're never going to achieve health equity if you don't address health literacy. And I think that's oftentimes one of the challenge that challenges that we face in society is we we we take good steps, but we don't address all the other aspects that actually will hold us back if we don't.

Brian Urban: [00:25:11]
I agree. I think we get innovation happy. Sometimes we come up with new things, we come up with new things, and sometimes we forget to be foundational or fundamental in our approach. This has been great. Jeffrey So I have one compelling question here to wrap up our conversation, if you will. So looking at the political term determinants of health and you look across the ecosystem, health care, health plans, pharmacy, even that high level of leadership, the influence that they have in our political system, what are the three things that you would say to leaders across that ecosystem that they could do to ensure that we're identifying people that have needs and we're starting to connect services and actually help change the way that their health improves?

Geoffrey Roche: [00:25:59]
Well, the first thing I would say is they should read Daniel Dodd's book. And Daniel doesn't Daniel doesn't pay me to say that. But the true reality of it is, is that I think Daniel has put together a prescription to understand how all of us can be a part of this ecosystem. The second thing is that as we know in our political system and you hear the shrug because it frustrates me, our political system is still very much, very much guarded and not guarded, but actually driven by lobbyists. And so oftentimes individuals that are very engaged in this important work don't necessarily have the same fundraising or same political action committee levels to kind of reach this message. And so what's critical or what's most important there is that we've got to create this ecosystem. So you talked about health payers, you talked about health care systems. Well, let's not forget pharma. We've got to bring all of them in and help them understand that it's great to have a corporate social responsibility initiative. But until you have come together as an ecosystem, all of health care with life sciences, to truly put our fork in the ground and say our fork in the road and say we want to achieve health equity, and we're actually going to make sure all lawmakers know we're all unified in this work. We're going to continue to face a system that is not entirely working together. And so that that would be my big, big element is that this is ecosystem work. And so people have to find the way. It can't be lip service. We can't say we're working towards health equity without actually intentional efforts of coming together. And then the third thing is where we started.

Geoffrey Roche: [00:27:45]
We've got to use data at the state, at the federal and at the local level more effectively. And I would encourage everyone to go out and check out the health equity tracker, which obviously is is offered by the Morehouse School of Medicine. It was done with. Google. It's an incredible tool. I had the privilege of serving as an adviser with Daniel Dawes team through the National Health Equity Task Force on it. And I will tell you that it was one of the most uplifting experiences of my life where I had to sit and learn from Dr. Satcher and Daniel Dawes and others who have really been pioneers in the health equity space. But Karen DeSalvo and others who led this process to ensure that for the first time ever, not only were we developing a tracker that would pull in data, but that we would actually do it with health equity in mind. And so I would encourage individuals to check that tool out. I think if you do, you will see that that if you use the data correctly, we can not only change lives, but we can also change how people think of this issue. And I just want to highlight that we'll never address these issues, too, if we if we sit here in the United States of America and don't realize that health inequities literally exist everywhere where we live. And we've got to acknowledge our brothers and sisters who live in our communities, who are on Alice in the Hills population, who are challenged by these inequities, because honestly, it impacts all of us. And so we've got to be willing to take that next step, as I call, to get into good trouble to address these issues.

Brian Urban: [00:29:20]
I love Well, you ended there. Being a good bully is something that I enjoy and aspire to be as well. Those three things is where I would love to stop our conversation. And with that, this is the Health Care Rethink podcast. I've been your host, Brian Urban. Thank you to a good friend and a leader across Pennsylvania and the academic world. Professor Geoffrey Rush, thank you so much for being on. For more insights and excerpts from our show, please visit finthrive.com.