Christina Mattina

 is speaking with 2 experts to discuss the root causes of racial inequities in cancer care. Dr John Carpten, professor at the University of Southern California Keck School of Medicine, outlines what needs to happen to improve cancer outcomes for minority populations and support minority scientists, and Dr Russell Ledet, president of The 15 White Coats and medical student at Tulane University School of Medicine, explains the steps to breaking down the barriers to medical school for those from marginalized communities.

 Welcome. Can you introduce yourself and tell us about your work?

 Hi, my name is John Carpten, professor and chair of the USC Department of Translational Genomics. I’m also program co-leader for the Norris Comprehensive Cancer Center, Translational and Clinical Sciences Program. My research interests primarily center around human genetics and genome science.

Throughout my career I’ve had a strong focus in the area of cancer research, including cancer genomics, cancer cell biology, precision oncology, and I’ve also spent a large portion of my career trying to understand what we tend to consider or call cancer disparities, which are cancers that disproportionately affect underrepresented minorities and the medically underserved.

 What are some root causes of racial inequities in cancer care?

Some of the root causes of inequities and cancer care, again when we look at underrepresented minorities or the medically underserved, tend to sort of center around socioeconomics and limitations in access to quality health care. A lot of this, of course, is due to systematic racism, which has sort of created this built environment, this environment that many individuals, particularly those from underrepresented communities, reside within, where there’s limited access to quality care, there’s no strong focus on actual health care itself, on being a healthy individual. When we think about access to detrimental environmental factors, you think about certain areas where you see a significant increase in signs for cigarette smoking, signs for alcohol, and so this built environment that many individuals live in contributes significantly to these inequities that we see in health care, particularly cancer care.

Of course, the financial issues, financial toxicities, when we think about something like cancer care, can be typically really expensive. And so when we think about access to the best diagnostic methods, the best treatment options, in many cases, those things are dictated by access to private insurance or access to specific types of insurance or access to significant financial resources, which we know in many cases are not in alignment with these communities and these population. So a lot of this is socioeconomics, financial issues, financial toxicities. And then I think, of course, a lot of this is brought about through just sort of overall systemic racism and social injustices in America. I think we should also consider additional issues, when we think about these sort of inequities that we see, that again are just related to aspects, just the overall systematic limitation in resources, right, overall resources in general, play a huge role. Now, I think we can also point to policy, and the lack of push towards policies that will sort of lead to improvements in these environments and in these communities, which could then perhaps turn the table and provide individuals with the type of health care that they deserve as citizens of this country.

 How do racial inequities in research lead to disparities in outcomes and mortality?

So racial inequities in cancer research, right, also contribute to some of the differences we see in incidence and outcomes. When we think about cancer and we think about cancer disparities, I think there are a number of things that we can point to. I think one is sort of this whole issue with a lack of diversity in clinical trials. I think that’s one place where we can start, where many of the therapies that are developed, whether they’re therapeutic modalities that are based on sort of improving standard of care in combination with chemotherapy, or whether they’re clinical trials to test some of the latest and greatest types of cancer therapies. In many cases, we know throughout the continuum of clinical development from the model systems that are used for early testing of these agents in animal systems, the actual tumors that are growing in the mice are typically not derived from a diverse collection of individuals. Most of the tumors are going to be derived from individuals of largely European descent, and then we move on to phase 1 clinical trials, which are small trials, typically, that are in most cases going to take place within cancer centers, academic medical centers, and in many cases, the patient populations there are just not diverse at all. And then of course, we move on to the phase 2 and phase 3, the larger trials, those trials that actually are going to be those definitive clinical trials that are going to lead to an FDA approval.

We know that particularly when we look in cancer, the overall number of underrepresented minorities in those trials is infinitesimal and this is even for cancers that have known disparities and incidence and outcomes: prostate cancer, triple negative breast cancer, colorectal cancer. We see typically numbers below 5% and sometimes below 3% in terms of the sort of the minority individuals that make up the clinical trial cohorts. So I think that that’s one of the big problems.

And just to expand on that just a little, I think we don’t necessarily have to look at it as “Oh, we, we want to diversify the trials just because we want more minorities.” I think we have to look at it from the standpoint that by diversifying the cohort, we learn more about the efficacy of the therapy, right, or perhaps the toxicity profile. We shouldn’t have to wait until the drug is approved and then used in practice to say, “Oh, we see a difference in sort of toxicity profile or we see a difference in the effect of this drug across different populations.” That should be built into the trials and from my perspective, by diversifying trials, we help everyone, right.

It’s not just diversifying trials just so that we can potentially help individuals from these underrepresented minority populations, but by studying a sort of broader group of patients from the standpoint of populations, communities, perhaps we gain a broader breadth and depth of the activity of that therapy when it’s being used to treat patients with cancer. So I think that whole concept of lack of diversity in clinical trials is one of the things that hampers our ability to really eliminate and deal with some of these disparities.

I think the same thing can be said for the tools and the reagents that we use in biomedical research to understand the biology of cancer. Again, going back to some of the comments I made about clinical trials, the model systems that we use, the cell lines that we use, in many cases, are cell lines that are not diverse. They weren’t derived from individuals from diverse backgrounds. So the understanding of the biology of cancer tends to be derived from a relatively homogeneous set of reagents. And so expanding the diversity in the biological reagents that we use for cancer research, again, could broaden our understanding of cancer and get us away from this concept of generalization if we, whatever we understand here is going to generalize over here, and that may not necessarily always be the case. I think we also see this in, for instance—I have a tremendous amount of interest in cancer genomics and genome science&mdash;and so one of the other things we know is that many of the large genetic and genomic studies that have been performed to try to understand the genomic alterations and changes that occur in cancer. Many of the tumors, again, were derived from largely European individuals. And we know that the diversity of those biomedical research cohorts is also significantly limited, again, even when we think about tumor types that disproportionately affect African Americans, Black and Brown people, Hispanic Latinos, and so on and so forth.

So, thinking about clinical trials, thinking about these research reagents, and then finally, the workforce, right. We know that there has been a significant limitation in the numbers of underrepresented minority faculty members at large academic medical centers, where a lot of the health care innovation occurs. And then we can continue to move back in the career path trajectory as we go back to the early stage scientists, the postdoctoral fellows, the graduate students, undergrads, and then even high school students, right, who have access to internships in STEM [science, technology, engineering, and math] related fields. We know that there are disparities there, and so if we don’t break down those barriers, we’ll continue to have this relatively homogeneous, relatively nondiverse workforce, and so that also plays a huge role in the disparities. I think that we can point to a number of areas where that can impact, but when we think about things like having access to, for instance, patient navigators or having access to individuals who work in the health care system, who can help provide and communicate most effectively with patients to educate them to help them better understand their particular medical issue, can better help them better understand their diagnosis or the various treatment options. So because we have this workforce that’s relatively homogeneous, and we really need to do a better job of diversifying our workforce. All of these things, I believe, play a significant role in cancer disparities.

 Are there any other things that need to happen in order to improve cancer outcomes for minority populations?

Well, I think one of the main things, and without a doubt, even though my focus is biology and trying to understand the biological factors that are driving these disparities, I think it all starts with policy. It all starts with sort of resources and access to resources, right, and equal access to resources. And, so, of course, you know, we have to get out and vote, we have to lobby our Congressmen, we have to work with patients, patient advocates, right, who have relationships with those individuals who actually can create and change policy. I think that that to me is first and foremost. Again, I think, going back to the whole concept of doing a better job of diversifying the workforce, I think that’s another huge issue. When we look back over time, we’ve made some progress, but the progress definitely hasn’t been substantial enough, where we can really say that we’ve made a significant difference. Policy is a big deal. I think one of the other things is bridging disciplines, so bringing together individuals from various disciplines and creating transdisciplinary and multidisciplinary research programs where we bring in individuals who study the environment or environmental factors, individuals who study social stressors in the built environment, and how the environment and the societal pressures can impact physiology in a negative way, such that it sort of breeds an internal host environment, that if a cancer manifests, it’s in the perfect environment to thrive. And so I think the whole concept of interdisciplinary and transdisciplinary research will probably be part of the answer. And we have to break down the barriers, break down the walls, and break down the silos, and begin to work together and come up with novel study designs that bring to bear various disciplines to address these issues.

What specifically can cancer research centers do to support the needs of minority scientists?

 So, one of the biggest issues in terms of cancer centers and minority scientists is that there just aren’t enough of us. I think we can look at this in 2 ways. We can look at it from the standpoint of the pipeline, right, and really working harder to increase the size of that pipeline—providing the types of educational programs for underrepresented minority students to get access to innovation, to be involved in innovation, to be a part of innovation.…And I think one of the problems is when we see many of these programs, in many cases, the students are separated, right? You may have a special program for underrepresented minority students, but you don’t have mainstream students involved, right, so we tend to see these siloed programs. I think we need to develop programs where the students are all working together and learning how to collaborate and how to communicate with each other, and how to come up with innovative and novel ideas on how to solve problems. So I think coming up with better ways to build a more robust and effective pipeline, so that we can feed the students into the process, but I think we also have to look at the back end of the pipeline when the students become graduate students, and then postdoctoral fellows or faculty members, that we provide the type of environment to support their career development, again at the fellowship level, as well as at the faculty level, that they have the appropriate mentoring in place, that they have the appropriate role models in place, that resources are available for them to support their careers. So, we have to work on building a more robust pipeline, but at the same time, we have to ensure that the appropriate environments are being created in those cancer centers to support retention of the faculty that we hope to recruit into these centers.

 Can you introduce yourself and tell us about your work?

 Yes. So my name is Dr Russell Joseph Ledet. I’m currently the president and cofounder of The 15 White Coats. And I’m also a third-year MD/MBA student at Tulane University School of Medicine and Freeman School of Business, respectively. I live here in New Orleans with my wife and 2 children.

Great. Can you tell us about how The 15 White Coats evolved from a photo into an organization with a larger mission?

 Basically, The 15 White Coats was formed after a very unique experience happened between my daughter and I. So essentially last summer, my very best friend came down to visit me from New York. He was getting his PhD at the same lab as I, and so we both went to historically Black colleges and universities—he went to North Carolina A&T and I went to Southern University in Baton Rouge, Louisiana&mdash;and so Black history is important to us. And so when he came down to visit, and we decided to go to the Whitney Plantation, and I brought my daughter along, and it’s about 45 minutes outside of New Orleans, so on our ride back, about 15 minutes down the road, my daughter sort of interrupted me and asked this question, she was just like, “Dad, you know, it’s interesting that we just left a plantation, and, you know, I’m riding in the car with 2 Black doctors.” And I’m like, “Well, why is that such a big deal?” And she’s like, “Well, just think about it.” Like there was a time when we couldn’t do that. There was a time when we couldn’t be lawyers, accountants, firefighters, any of those things, right? So she really understood the moment and also the historical context. And so, essentially, from that, I looked over and I was like, Yeah, I got an idea….I think we should get together a couple of my Black classmates, and we should go and take a photo.

Obviously, there was more to it than just taking a photo. There was also the experience itself. And so, after we had this experience, and we took these photos, the idea behind the photos was for us to capture just how far we’ve come, and even more so our resilience with coming back from that. And so we released those photos, those photos got a ton of attention, and because of that, we realized that we had an opportunity to leverage that attention for good. And so, because of that, we formed the company and the idea behind the company was to promote cultural imagery and learning spaces, because we realized, it’s kind of hard to be something that you’ve never seen before. Right, that’s half the challenge. And the other part is too that it was kind of like, we’ll get past these issues anyway. Like, we’ll get past these circumstances, the systemic racism, institutional racism, systemic oppression, like we’ll get past it anyway, and we’ll still get to where we want to be, because, I mean, everyone’s knowledgeable of the esteem doctors are held to in the United States specifically. And so I think that’s what really captivates a lot of people’s attention is that they saw 15 budding, bright minded student physicians, and they just so also happened to be Black.

So that was really captivating for a lot of people, and because of that we formed the organization. We put the photo up in classrooms around the country. We sell the photos, and nobody earns any of money from the from the proceeds; we take all of that and put it towards scholarships for minorities applying to medical school, high schools, students graduating high school, medical students, and we also use the money obviously to buy more posters to send out to classrooms, so schools can go to our website, sign up for a poster, and we’ll mail it out to them for free.

What are your hopes for the organization?

 Yeah, so the hope for the organization is for us to eventually be able to pay for someone’s medical school, specifically someone from the minority community, to raise enough money to offset some of the costs that come with applying to medical school. You know, if you take into account the historical economic perspective for marginalized communities, we know that those communities are well behind in terms of opportunity to gain wealth, opportunity to maintain wealth, especially with things like the 

 and things of that nature, we know of all the situations in which even when marginalized communities tried to gain wealth, it was stifled. So we have to do something to try to offset that economic barrier. People don’t even know how much it costs to apply to medical school; in general, costs between $3500 and $10,000. That’s a lot of money just to apply. So if you take that into account, right, and then you take into account a lot of your students are already in debt from undergrad, where you can come up with that kind of money from? And so we want to try to take some money that we have and alleviate some of those costs. Then the other part of it, too, is that once you get into medical school, there are a lot of costs that come with being in medical school, whether it be some of the learning platforms you need in order to learn the material you need for school, or having professional attire, living costs, all these things. And so that’s really our hope is to try to offset some of the economic burden, specifically for marginalized communities, when it comes down to the medical school process.

What’s the importance of representation in the media for young Black children and teens, especially in a field like medicine?

Yeah, I think the importance of representation is multipronged, obviously. I think if you think about it, just from a visual perspective, the reason why a lot of people especially, you know, Black men can aspire to be great basketball players, is because we’ve had so many Black great basketball players. If we never saw them, it’d be kind of hard for us to imagine it, right. It’s the same thing in medicine. We need to see representation in order for us to see to this even possible. I’ll never forget, I had this one experience. I was shadowing a child psychiatrist. And he went to go get a patient, a young African American boy, and when the young boy walked into the room, his eyes just lit up. It’s like he, I don’t know, it’s like he saw Jesus or something. And he sat down, and I knew why he was looking at me like that. Because he probably had never seen, you know, a Black male who looks like me with the hair, beard, in a white coat or sitting in a room, you know, almost as if to say, like, do you belong here? Like, are you supposed to be here? Is it okay for you to be here? And I finally got an opportunity to talk to him, and he just poured out his life in front of me. And so I think that representation goes far, just from a visual perspective, but I think there’s an underlying experiential perspective. We know that representation matters in terms of how the doctor’s visit will go, and because of the cultural understanding that that is very possible in an environment where there is some sort of congruency in experiences as well as a culture. So, that's not a secret.

And then more so I think, you know, if you take into account the history of medicine and marginalized communities, it’s not pretty, right. I think her name was Harriet Washington, wrote the book, 

, and she talked about the atrocities that have happened for a lot of medicine to progress. And now this was done on the backs of a lot of Black people, a lot of the experiments, a lot of these falsehoods that are out there that Black people experience less pain. The experimentation has been done on Black folks for eons of time have contributed to some mistrust, right, and so how do we try to overcome that, or at least to some degree, try to fix it? You got to have some people who understand the history, some people who understand the culture, but also some people who have come from those communities, providing care, because they know they know their people, they do, they genuinely do. And so accessibility in the medical school will help with that, and also accessibility when it comes to positions of influence and power within medical schools, within academia, within hospital systems. It’s not just medical school; it’s got to be institutional change at a lot of different levels. Obviously, with me being in med school, my interest right now is med school, but I’m certain that will change over time, and it will expand.

 So what needs to happen in order to change to break down these barriers to medical school?

 Right, so I think there are a couple things that need to happen for accessibility to medical school. I think you need to get some different people selecting who goes to med school. I think you have to get some people in the room who value people from minority communities as people, and not just because they’re trying to fill a quota, but because they genuinely value their culture, their experiences, what they bring to the table, and they’re willing to institute antiracist policies that kind of go against has been done for a long time. And I always say this because we, as a human race, we have accomplished some very lofty feats. Some very lofty goals like sequencing the human genome, identifying PD-L, PD-L1 as therapeutic targets for cancer. We’ve done a number of things that were absolutely incredible and pushed humanity forward. I think we can achieve true diversity and inclusion, because we can’t forget about the inclusive piece, by relearning a lot of things, unlearning some things that we utilize the status quo for how we go about selecting people for medical school, but also learning new ways to value people as people. And I talk about this inclusive piece because, you know, it’s no point in you recruiting me if you’re not going to include me. So if you’re going to bring me to your building, but then it’s clear that I’m not welcome, but you’re kind of doing it to check a box, I mean, am I really gonna want to stay there? And even if I get through, am I really gonna want to contribute afterwards? Most likely not. And so, I think another big piece to changing the paradigm is changing the culture. I think it says something that a lot of faculties in general may have 1 or 2 Black people on the faculty. That’s not good. Like, that’s just fundamentally not good. If you’re graduating a lot of Black medical students, don’t you think you should have more Black faculty? I mean, you’re producing doctors, you should be getting them back, or you should be getting some from somewhere, and so that speaks to culture. I heard Roland Martin talk about something this morning with ABC, and one of the issues was it was a culture problem. And I will say that there are some cultural issues in medical school around there not being enough antiracism being taught.

So I think that that’ll help. Definitely the economic piece, definitely getting the right people in the room to choose who should who should be in a medical school class, and lastly, the culture. The culture needs to be overhauled, not just fixed, it needs to be overhauled. We need to be teaching about medical apartheid, and the history of how obstetrics and gynecology moved forward, how pain management moved forward, how all these different fields like surgery moved forward, and the ugly history behind it. Because if you aren’t teaching doctors that or if you aren’t teaching student physicians that, then when are they going to learn it? When they get into their specialty? No, they’ll be too busy. So you’ve got to teach it to them at the foundation of their medical school education.

Right. That’s the end of my questions. Was there anything else you wanted to add?

 If you want to check out The 15 White coats, you can check us out on Instagram, Twitter, or Facebook at The 15 White Coats, or you can check out our website, 

. And we’ll always speak truth to power.

Great, thanks so much for taking the time to speak with us.

Videos

Today, The American Journal of Managed Care® is speaking with 2 experts to discuss the root causes of racial inequities in cancer care. Dr John Carpten, professor at the University of Southern California Keck School of Medicine, outlines what needs to happen to improve cancer outcomes for minority populations and support minority scientists, and Dr Russell Ledet, president of The 15 White Coats and medical student at Tulane University School of Medicine, explains the steps to breaking down the barriers to medical school for those from marginalized communities.

Key Steps to Reduce Racial Cancer Disparities Include Supporting Minority Scientists, Diversifying Medical Schools and Clinical Trials

Women with heart disease during their first pregnancy had a higher rate of maternal cardiac events and neonatal complications, especially if they also had pulmonary hypertension (PH), according to study findings published in 

. The study also identified factors that can predict which pregnant women with heart disease will develop heart failure.

Using a large medical record database of more than 45,000 women in their first pregnancy treated at 7 medical centers in Southwestern China, researchers identified those with and without heart disease, and further classified the women with heart disease into groups with valvular heart disease, adult congenital heart disease, cardiomyopathy, PH, and other cardiac diseases.

The women with heart disease (n = 508) had higher rates of arrythmia (14.6% vs 0.1%) and heart failure (14.4% vs 0.05%) than those without, leading to a higher rate of major adverse cardiac events (28.0% vs 0.4%) (all 

 < .0001). They also had a significantly higher rate of obstetric complications (54.8% vs 4.7%; 

 = .002), although there was a lower incidence of laceration in the group with heart disease, likely because these women were more likely to deliver via cesarean section.

Neonatal adverse clinical events, which included fetal or neonate death, prematurity, and respiratory distress syndrome, were more common among the infants of women with heart disease than of those without (23.3% vs 11.3%; 

 < .0001). The infants of women with heart disease were more likely to be born premature (12.7% vs 7.1%; 

 < .0001), contributing to the significant difference in rates of infants with low birth weight (2.0% vs 0.6%; 

In addition to these differences in maternal cardiac outcomes and the neonatal complications, researchers also identified that women with heart disease had higher mean total hospital costs (¥9581 vs ¥5212 [US $1368 vs US $744]; 

 < .0001) and rates of acute renal failure (1.0% vs 0.0%; 

The study authors noted that PH was associated with higher rates of adverse maternal cardiac events, specifically heart failure, and neonatal prematurity. Women with PH were more likely to develop incident heart failure (42.9%) than those with other types of heart disease (4.9%-25.8%; 

Multivariable models revealed that significant independent predictors of heart failure were New York Heart Association functional class of 3 or greater, heart rate of 100 beats per minute or greater, ejection fraction of 60% or less, and left ventricular end-diastolic diameter of 50 mm or greater.

The authors wrote that their findings could inform efforts to more closely monitor women with heart disease during their first pregnancy and ensure that they are aware of the potential risks of maternal and neonatal complications.

“Given the higher rate of these in-hospital complications and predictors of having [heart failure], women with cardiac disease should undergo evaluation of their disease subtype and cardiac function earlier and should be treated in centers with expertise on a multidisciplinary approach,” they concluded.

Wang W, Wang L, Feng P, et al. Real-world in-hospital outcomes and potential predictors of heart failure in primigravid women with heart disease in Southwestern China. 

. 2020;20:372. doi:10.1186/s12884-020-03058-9

Articles

Women with heart disease during their first pregnancy had a higher rate of maternal cardiac events and neonatal complications, especially if they also had pulmonary hypertension, according to study findings published in BMC Pregnancy and Childbirth. The study also identified factors that can predict which pregnant women with heart disease will develop heart failure.

Heart Disease in Pregnant Women Raises Risk of Maternal, Neonatal Complications

Today on MJH Life Sciences™ News Network, I’m speaking with Dr Mark Fendrick, co-editor-in-chief of 

) and director of the University of Michigan Center for Value-Based Insurance Design, or V-BID, on how the principles of V-BID can be used to make a real difference for the millions of American families financially struggling with the impacts of the coronavirus disease 2019 (COVID-19) and can help shape the new healthcare delivery landscape after the pandemic.

The concept of V-BID arose nearly 2 decades ago from an 

 commentary coauthored by Dr Fendrick and Dr Michael Chernew, also co-editor-in-chief of 

. In the commentary, they and their colleagues discussed the idea of a benefit-based co-pay for prescription drugs, in which the price paid by a patient is calculated based on the expected clinical benefit of a drug, not its acquisition cost.

“By linking the patient contribution to the estimated evidence-based clinical and economic benefit at a patient-specific level, a greater proportion of the population most likely to benefit from taking a medication will be able to do so,” they wrote.

Since the publication of that commentary in 2001, the journal has published research and commentary on the evolution of this idea to encompass clinical services, not just prescription drugs, and a focus on eliminating wasteful low-value care while promoting cost-effective preventive drugs and services.

Recent editorials by Dr Fendrick published in 

“precision patient assistance programs”

 to help with the cost of precision medicines. Now, as the healthcare system confronts the unexpected global challenge of the coronavirus disease 2019, or COVID-19, pandemic, Dr Fendrick and coauthor Beth Shrosbree have contributed a very timely editorial calling for expanded coverage of essential care during COVID-19 and beyond.

Dr Fendrick explains why it’s important to reduce costs for a broad range of essential health services, not just COVID-19 care, and highlights which changes he sees making a permanent impact even after the pandemic abates. Stay tuned for the interview, and read the full commentary online ahead of print in the May issue, at 

 Welcome to the MJH Life Sciences™ News Network. Can you introduce yourself and tell us about your work with the V-BID Center?

 Hi, I’m Mark Fendrick. I’m a practicing general internist and I direct the Center for Value-Based Insurance Design at the University of Michigan. We work to increase access and affordability of essential healthcare services and try to pay for it by reducing care that doesn’t make Americans any healthier.

 So for those who might not be familiar, what are the principles of V-BID?

 So in America, most people with public and private insurance, they pay the same out of pocket for the services that are highest value or I beg my patients to do, or the services that don’t make them any healthier. Value-based insurance design has a clinically driven or clinically nuanced approach to cost sharing, in the fact that instead of setting what my patients pay out of pocket based on the cost of the service, we set their out-of-pocket costs on the clinical value. So the high-value services, there are little or no out-of-pocket payments; and for the services they really don't need, they should pay a lot.

 Right. In your recent AJMC® commentary, you write that the pandemic has uncovered a flaw in current benefit designs that do not provide affordable coverage for critical services. What are these flaws, and how are they exacerbated by the COVID-19 crisis?

 Thanks for highlighting that key point. We've tried for many, many years, and AJMC has been a key outlet of our views that even if you have an insurance card doesn’t mean that you’re covered and that your coverage will allow you to get the care you need. Most Americans now with private insurance have deductibles over $1000, families approaching $4000, and 40% of Americans don’t have $400 in the bank. So there’s a rub there in terms of what you’re actually able to get in terms of your clinically necessary services. So the COVID epidemic comes around and we realize that close to two-thirds of Americans are fearful of not having the money they need to pay for COVID testing and treatment. And it ultimately exposed the fact that even if you had insurance didn’t mean that you would have the resources available to get emergent care say like COVID testing, or even worse, COVID treatment.

So we were able to work very quickly with the federal government to allow legislation to be passed that all health plans had to cover all Americans who had a visit that led to a COVID test. But we fell a little bit short for those few patients who actually needed COVID hospitalizations. Fortunately, there has been a large majority of private and some public insurers who decided to waive cost sharing for COVID treatment in its entirety. So this brought to bear the issues that we saw for decades for people with cancer and diabetes and mental health and substance abuse disorders, even though they had insurance, they did not have coverage of the care they needed. And we’re hopeful that these some mandatory and some voluntary policies that removed cost sharing for high-value COVID services will be extended in the post-COVID era to the services to treat other common chronic conditions for which million Americans cannot afford the care that will improve their quality of life.

 What role can V-BID play in providing relief to families who are struggling now with the impacts of COVID-19?

 Well, specifically for COVID, I think it’s really reassuring to know that our work and the work of our many, many colleagues have removed any concerns that people might have to get tested for the coronavirus and hopefully get financial relief for treatment for COVID-19 illnesses. Some of the policies are mandatory, as I mentioned, others are voluntary. But I do believe that as the entire country turns to common themes of abating the spread and hopefully the clinical negative implications of people who are infected, we will understand that there is actually a common societal element that will emerge that would be beneficial to not only individuals who may or will be sick from COVID, but those will be reassured that if they were to become sick that they would not have to go into financial hard times.

 Why is it important to expand coverage and reduce costs for a wider range of essential health services, not just COVID-19 care?

 Well, at least 1 in 4, maybe 1 in 3 Americans say that they don’t have the money to get the essential healthcare that they need. That includes doctor visits, diagnostic tests, and drugs. So we’ve known these issues of what is now called underinsurance, or having an insurance plan that does not cover you adequately for the care you need, has been around for decades. No surprise, the patient populations that are impacted most by these costs are those who are socioeconomically challenged and those with multiple chronic conditions. Lo and behold, these are the same populations that we’re most worried about, for those at highest risk for COVID-19. So there is again some confluence to the larger public health issues of COVID-19, and our need to think about better, more clinically driven benefit designs that allow patients to get the care they need, but also make it harder to get the care that they previously had access to that wasn't going to help them very much in terms of their health.

 What are some recent regulatory or policy changes we've already seen to implement V-BID principles in response to COVID.

 Yeah, we were very fortunate to have quick inclusion of V-BID principles in several of the coronavirus-related relief packages. The first package, the Family First Act, removed cost sharing for COVID-related telehealth and allowed high-deductible plans to cover COVID-related testing on a predeductible basis. The larger package, the CARES Act, the $2.2 trillion COVID relief package, that extended the telehealth V-BID benefits beyond COVID-related care and that all telehealth, regardless of its clinical reason, could be provided on a predeductible basis. It also importantly amended section 2713 of the Affordable Care Act, the V-BID portion of the ACA, in the fact that when we have a COVID vaccine, within 15 days, all plans have to make that vaccine zero cost sharing to clinically indicated beneficiaries. So not only did V-BID deliver on COVID now, regarding testing and related telehealth, but it also is a gift that keeps on giving in the fact that when we hopefully get an effective vaccine, patients won’t have to worry about paying out of pocket to receive it.

 So you think that these changes with telehealth will continue even after COVID is over?

 So I’m a silver lining guy and you know, we never let any crisis to emerge without an opportunity. We have been bullish about telemedicine for quite some time. Telemedicine is a key component of what people at CMMI called V-BID 2.0, which is the recent expansion of the Medicare Advantage value-based insurance design model test. And it’s been very interesting to see that those of us who felt telemedicine would have a key role for both patients and providers in terms of getting patients the care they need in a setting that’s most reliable, has gone on kind of superspeed now, in the fact that my own patients I see through telephone and visual visits, and hopefully we will be able to set the new normal in the fact that the people who need to come and see us will see us in person, but those patients who could get highly satisfied, high quality care through a telemedicine visit, I believe will be here for quite some time in the future.

 Great. What further steps would be most impactful for helping Americans afford care?

 Well, I think what’s kind of interesting, Christina, as you know, through this V-BID journey is value-based insurance design has been bipartisan and multistakeholder, and who’s going to be against spend more on the good stuff and less of the bad stuff? I think what’s important, and what many people call the second or third coming of value-based insurance design, is our ability to engage purchasers around action to reduce the use of what some people think is several hundred billion dollars in healthcare spending every year that doesn’t make Americans any healthier. So we’ve moved forward this idea of benefit design that includes more of the good stuff and less of the bad stuff, which we call V-BID X. The X is designed initially for the exchanges or the individual marketplaces. But now, we have a template of a plan that will make high-value services less expensive and predeductible. This is many classes of chronic disease drugs, some visits, and durable medical equipment. And it’s paid for not by raising premiums on everyone, or raising deductibles and cost sharing on sick people, but instead is paid for dollar for dollar by raising cost sharing or noncoverage on care that is clinically not indicated or in most situations clinically not indicated. The good news and bad news is there’s a lot of waste out there, and hopefully we could eliminate that to provide some headroom to allow more generous coverage of the high-value services that are not being accessed and are not affordable to many people, even those with pretty good health plans.

 Right. That’s the end of my questions. Was there anything you wanted to add?

 for providing us an opportunity to provide information to key constituencies in the healthcare workplace. I think that many people are thinking about COVID now; we in 

 and myself are thinking about what the new normal will be in healthcare. And I think that it should allow us an opportunity to get rid of some of these older ideas and programs that promulgate the use of services, regardless of their clinical value. And we’re extraordinarily hopeful, as we emerge into a new type of healthcare delivery, that stakeholders come together about providing more of the services that we know make Americans healthier, and we could have the courage to hopefully eliminate a large portion of the billions of dollars we spend on things that don’t make Americans any healthier.

We spoke with Dr Mark Fendrick, co-editor-in-chief of The American Journal of Managed Care®, and director of the University of Michigan Center for Value-Based Insurance Design, or V-BID, on how the principles of V-BID can be used to make a real difference for the millions of American families financially struggling with the impacts of coronavirus disease 2019 (COVID-19) and can help shape the new healthcare delivery landscape after the pandemic.

Dr Mark Fendrick: Incorporating V-BID Into Our COVID-19 Response and the "New Normal" to Follow

Today on MJH Life Sciences™ News Network, 

) is diving into the role of Medicaid, the insurance program for low-income individuals, in the coronavirus disease 2019 (COVID-19) crisis. With unprecedented numbers of people losing their jobs and healthcare coverage, Medicaid plans are preparing for a massive influx of beneficiaries, which will require information technology (IT) readiness, social service coordination, and of course financial resources.

We spoke with Russ Fendley, former Medicaid commissioner for Kentucky, about the financial and technology strain of COVID-19 on state Medicaid programs. He mentions the importance of communication to keep new enrollees informed about their benefits and the resources available to them. He cautions that the still-unknown aftereffects of the virus will lead to additional demand for services that will remain even after new infections level off.

We also spoke with Patrick Sturdivant, president of the Amerigroup Texas Medicaid plan, about the solutions, both new initiatives and ones that are already in place, to welcome new members into Medicaid and help them navigate the healthcare system. Key efforts include telehealth platforms, online portals, and member service coordinators who stand ready to help with healthcare needs and social determinants of health.

Stay tuned for our full conversations with Russ and Patrick.

 Welcome to the MJH Life Sciences™ News Network. Can you introduce yourself and tell us a bit about your work?

 Sure. My name is Russ Fendley, I’ve been in the healthcare field for 30 plus years running MCOs [managed care organizations], running hospitals for HCA; I was Medicaid Commissioner for the Commonwealth of Kentucky and served as a fellow with the National Governors Association and the Center for Health Transformation on public health policy and Medicaid.

 Great. So as we’re seeing these massive job losses from COVID-19, what will be the financial strain on state Medicaid programs?

 Really, you can’t calculate it yet. It’s going to be significant. The closest thing I can come to as an analogy was, I live in Kentucky, and our experience here was when we did the Medicaid expansion, that added about 425,000 lives at about $2 billion a year in total cost. Don’t have any idea though, with this new population, we don’t know what preexisting medical conditions they have. We don’t know, if they’re joining into a managed care program, which eligibility classification they would be in, so there  would be different premiums associated with that. And we don’t know what costs would be from any COVID-19 related. So it’s hard to calculate that right now. We’re estimating, I’ve seen several estimates, about anywhere from 10 to 20 million people nationally, rough estimate, will join Medicaid. Obviously, that varies from state to state based on their employment numbers. Here in Kentucky, I can tell you we’re looking at about 300,000, 350,000 people, so it’s gonna have a significant impact.

The bigger impact though, Christina, is not just on Medicaid, it’s going to be downstream. As the state tries to balance the budget, which is a requirement, and even though the federal government’s increasing the match by 6.25%, the FMAP [Federal Medical Assistance Percentage], you’re still gonna have that gap in the current budgets, and even next year’s budget, from this medical expenditure. And they’re going to have to take from other programs to fill that gap or increase taxes, which you really can’t do when there’s severe unemployment. So you would expect there to be impacts on transportation, hopefully not but potentially education, parks, pensions. Hard to say.

 Right. We’ve recently learned that HHS will be reimbursing hospitals for the care of uninsured patients with COVID-19. How do you think this will affect Medicaid signups?

 I don’t think it will. If it does, at least not significantly. Most of the people who are going to have or have COVID, or have become Medicaid eligible, they may have other healthcare conditions that require home health, medical physician services, so even though it’s good that they’re gonna pay the hospital portion of this, which will alleviate a big part of the burden, you’re still going to have to, the people are still going to need that medical coverage for other services, pharmaceutical services, those types of things. I don’t think it’s going to impact it.

 Okay. What differences do you expect to see in states that expanded Medicaid compared with states that didn’t?

 What’s really going to be interesting is those that didn’t have it. There’s been such a contraction in the companies that are selling through the exchange, I don’t know what’s available. I haven’t kept up with what’s available in the exchanges now or what the cost would be. It depends on who’s going to be eligible for the income assistance through the exchange. So for those states that have expanded their Medicaid, a big chunk of those people are going to fall within that 138% of federal poverty level, it’s not going to be everybody, so you’re still going to have some that don’t meet that income criteria because your unemployment insurance counts towards your income. So we don’t know yet, but I think it’s gonna be far easier for those states that expanded Medicaid than those that did not.

 How will an influx into Medicaid impact the programs’ IT systems and workflow?

Way back when I was Medicaid commissioner, everything was based on these old COBOL hardwired systems. I shudder to think what it would have been like to make the changes that are being made right now to accommodate this new crisis in that old system. Most of the new systems that are that are out there now, you know, are all SAS and modular and they’re just configuration; there’s not a lot of coding that has to be done. But there’s still going to be a significant amount of change that has to be made. You can’t just implement the change, you’ve got to implement it and then test it and make sure it works right. So I know the eligibility systems are going through a major reconfiguration change for the eligibility rules that are being loosened. You know, claims payment systems are being modified. And so there’s a heavy lift there for the IT department, but it’s a much easier—and this is easy for me to say because I’m not an IT person&mdash;but it’s a much easier lift now than it would have been 15 years ago.

What do states need to do to make sure that they can accommodate all the new Medicaid beneficiaries?

Yeah, there’s a number of things, and most of the states I’ve talked to so far, they’ve all got access points up for their potential new enrollees, numbers to call, but it’s going to be a matter of, you’re going to have to have almost a constant line of communication with your MCOs. The providers are going to be a huge key, because a lot of eligibility comes from the hospital admission process. That’s where a lot of Medicaid enrollees wind up in the system. And then some communication back and forth, or you’ve got to have a lot of external vendors who are placed here, people who supply things to the Medicaid program. You know, call centers are going to have to be set up or running and maybe additional staff put on, so there’s going to be a lot of a lot of points of contact that are going to have to be made with these new enrollees, not only to identify, let them know what their coverage is, what their benefits are, who the providers are, what the rules and regulations are, what they should and shouldn’t do with COVID-19—there’s a lot of that kind of communication. So that’s going to be the key, just entry. Just the communication with a variety of sources, from the MCOs to the members to the providers.

Right. Well, that’s the end of my questions. Was there anything else that you wanted to add about the situation?

Well, you know, the one of the things that’s going to be a key going forward, we’re almost to a point in the curve now where, you know, identification of new cases is still important as if you think of COVID-19 as an accordion. I did a war game exercise with the CDC about 15 years ago on a viral pandemic like this in the United States, and it is like an accordion starting with either coast and working inward. So we’re not over by any stretch of the imagination, but people need to realize this does not end when we see the infection leveling out, because you’re going to have a lot of people with the lingering effects of this disease, far beyond their initial sickness. If they’re on a ventilator or in serious medical condition, they’re going to have lung damage, potentially heart damage, other organ issues; they’re going to have to be followed for years. So there’s going to be a lot of that, and there’s so much we don't know about the disease yet, and what the recurrence rate is and the reinfection rate, those things we don’t know. So what people need to know is we’re only in phase 1; phase 2 will be kind of looking at how you treat the people going forward and in preparation for what we’re being told will be the next phase of the pandemic, which will be this fall, if everything’s correct in the modeling so far. So, this is not over by any stretch of the imagination. This is just, for lack of a better way of saying, this is just the end of the first beginning, and we’ve got a long way to go until we get to the point where there’s a vaccine and other ways to prevent a recurrence.

All right. Well, thanks for taking the time to speak with us.

Can you introduce yourself and tell us a bit about your work?

Sure. I’m Patrick Sturdivant. I’m president and CEO of Amerigroup Texas, one of the many Anthem affiliated health plans across the country. We have the privilege to serve more than 760,000 Texans in our health plan. We started in 1996, and now we serve 230 of the 254 counties in Texas, which covers 236,000 square miles of this beautiful state.

 Great. Amid the COVID-19 crisis, millions of Americans are facing unprecedented challenges and turning to social supports like Medicaid. What changes are you implementing to prepare to welcome new members who are not familiar with Medicaid? And how can you help them navigate the healthcare system?

 You know, honestly, we’re going to continue to do what we do each and every day. We’ve worked with millions of individuals and families from all walks of life, who face very unique situations and challenges. We understand that it takes just one job loss, one accident, or one turn of events to change lives. Whether it's helping someone to find a PCP [primary care provider] close to them, or making sure they have all the DME [durable medical equipment] items they may need after a hospitalization, we’re there to help. It reminds me of a young man here in Texas a few years ago, who was injured in an accident and became paralyzed. He was in the hospital for a number of months and the family, when he was discharged, realized they weren’t prepared for him to go home. So we connected him with our service coordinator and his own service coordinator and the teams worked to make sure that he had a hospital bed and all the needed items there to make sure he could comfortably move back home and be in a safe environment and not have to return to the hospital. So that’s the type of stuff we do each and every day, whether it’s in a crisis or in our everyday, day to day activity.

 Are you concerned about possibly having to enroll an influx of new members as more and more people apply and qualify for Medicaid?

 We’re expecting that there will be an influx and we’re prepared to enroll new members and make sure they have access to the care that is required. There’s an increased need in our state, so we’re actively monitoring the situation; we have plans to expand as needed; we’ll continue to work on behalf of our members. You know, we, as many other organizations have done, have transitioned to moving people to home and have a work at home model. We’re doing that and promoting social distancing. But we’ve not slowed down. And we’re motivated to do more because this crisis hits home, and it’s personal for all of us. We also have innovative solutions in place that are ideal for overcoming these challenges presented by this unique crisis.

What are some of those innovative solutions that you’re putting in place?

 Yeah, a few things that I'll highlight for you: one, you know, we’re hearing about practicing social distancing. Part of that is remote care when possible, so telehealth has been a huge focus during this time. While others are scrambling to implement new telehealth programs, it’s not new for our members at Amerigroup Texas. We enhanced our Medicaid members’ benefits last year to give them the opportunity to take advantage of both physical and mental telehealth services at no cost. So as the COVID crisis began escalating, there was no need for us to implement changes to promote safe remote care. It was already in place. All we did was enhance the ability for more clinicians to offer virtual care to our members. With telehealth being an Amerigroup Texas benefit, it’s not something that’s going to go away after this crisis. It’s going to continue. Other things we’ve done in this crisis, we’ve donated money to local food banks. We provided thermometers to foster care providers. We’ve donated hand sanitizer to 239 nursing facilities across Texas. So we’re trying to do as much as we can during the crisis, just like everybody else.

Wonderful. Have you seen that members are actually taking advantage of the new technology that you’re offering?

Yes, we’ve seen an increase in members who have registered to use our live health online platform. We hope to see this continue to see this happen through the crisis and beyond. It’s a simple solution that our members can utilize anywhere at anytime. Members are also taking advantage of our mobile apps and our online member portal. These tools are designed to be easy to navigate. Individuals can take control their health, they securely log on to choose or change their providers, check the status of actions, locate resources, have information, and can access care. It’s empowering people to be involved in their healthcare and not have to wait on the phone to ask questions.

Great. For individuals or families who are new to Medicaid, what changes that they expect?

 Well, Medicaid will become their health insurance. They need to know Medicaid’s not subpar health insurance. In fact, those that are new may find that it’s just as robust as any other health insurance plan they might have been involved with or have heard about. We’re here to help navigate a complex healthcare system. Our mission is to make healthcare simple. The goal of a health plan is to break down these barriers that may stand between people taking control of their health and improving their lives. We’re here to help; we connect members to needs beyond their health but related; if their electricity is cut off, they need access to food, healthy food options, transportation, we can connect them to resources in the community. We know it takes more than seeing a doctor or accessing medication for a person to get and achieve their health goals. There are many drivers of health. And I’m sure you’ve heard the term social determinants of health. A lot of people are talking about it as if it’s something that’s new. It’s actually something that Medicaid health plans such as Amerigroup Texas have spent decades doing and addressing. It’s just now something that has come to light for many others. But we have options where members can contact their service coordinator and ask questions about anything that’s going on in their lives beyond their health, and we’re there to help.

We truly believe we make a difference in people’s lives each and every day, and that’s what motivates our staff. We’ve got story after story of things that we’ve done for people. Number one, we’ve got service coordinators, nurses, people on our Member Services line that are there to listen and listen closely, and it’s something they take seriously. One recent story that comes to mind for me, we had a member that was on the phone, their child is an Amerigroup member and on a medication; they’ve been our member for a couple of months, and as they were going through the assessment over the telephone, our service coordinator noticed that the medicine that the member had said was different than what they had been on previously, and actually identified a medication error that was made at the pharmacy. The pharmacist, when our service query coordinator called the pharmacy, said they transcribed it the wrong way and made a change and flagged the account, and the mom was very grateful that we caught that medication error. So it’s stuff like that that we do each day to make sure that our members are safe and that they’re healthy, and they’re living their best lives.

Great. What would you say is the role of Medicaid as a solution to this current health crisis?

 The role of Medicaid, it’s a tremendous resource. It’s there for people in their greatest need. I know many of our associates were actually on Medicaid at one time. I personally wouldn’t be sitting here today without Medicaid. My wife and I, our son is actually a Medicaid baby born in Northwest Texas Hospital in Amarillo, Texas, 26 years ago. So I would say Medicaid is not a handout. It’s a hand up, and it allows people to focus on other things in their life than where they’re going to get care, how are they going to afford that care, and is that care good. So it’s with that that brought me into this business and makes me passionate about this business. At Amerigroup Texas, we truly believe we make a difference in people’s lives each and every day. Our associates in Amerigroup Texas believe that, they practice that, and they do it with all their heart. And I’m truly blessed to work with our team and witness the great things they accomplish on behalf of our members.

 That’s great to hear. That’s the end of my questions. Was there anything else you wanted to add?

Thanks for taking the time to speak with us.

With the economic upheaval and unemployment brought by the coronavirus disease 2019 (COVID-19) pandemic, observers anticipate a large influx of new members into Medicaid programs. We spoke with Russ Fendley, former Medicaid commissioner for Kentucky, and Patrick Sturdivant, president of the Amerigroup Texas Medicaid plan, to find out how states and plans are preparing for this challenge and its lasting effects.

Author | Christina Mattina

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