Horizon Blue Cross Blue Shield of New Jersey piloted Neighbors in Health to address Social Determinants of Health. What started with two community health workers is now a $25 million program. In this interview, we talk to health equity strategist Tracy Parris-Benjamin, who oversaw the program. She lays out eight ways the payer prioritizes health equity, creating the fertile ground for this program’s growth. This special episode was recorded at Future of Mental Healthcare East.
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The 8 Building Blocks
Ground Yourself in Purpose: To drive meaningful change, align your organization’s goals with your community’s needs.
Look Inward: Your leadership team should reflect the people you serve, and equity needs to be infused into everything you do.
Address Implicit Bias: Acknowledge that it exists in your organization and develop training to address it.
Dig Deeper into the Data: Focus on metrics that matter to your organization and its mission. Use disaggregated data to identify specific subgroups affected by disparities.
Start Small: Pilot programs offer learnings and proof points when requesting resources.
Engage Allies: Create a team of champions within your organization and partner with nontraditional partners, such as clergy and community leaders.
Take the Long View: Health equity programs are ongoing, not episodic.
Help People, Don’t Just Treat Illness: Successful programs must address the root causes, including social, economic, and cultural barriers to care.
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(edited for clarity)
Chris Hemphill: Thank you for tuning in to another Meeting of the Minds. Today we will talk with health equity strategist Tracy Parris-Benjamin, the former senior director of Health Equity and Community Health at Horizon Blue Cross Blue Shield.
Hi, Chris. Thank you so much for having me.
What’s really exciting about Tracy’s work is the specific program we will dig into, the Horizon Neighbors in Health program. It puts boots on the ground in terms of community health. We’ll also talk about how to maintain these types of programs, make that business case, and work along with the data metrics and leadership to make these plans happen and grow.
Chris, I think what’s so important is everyone understands that this is a journey, that this is not something that happens through one particular program. But working towards equity and equitable care requires a multifaceted approach. It requires organizations to take a look at themselves and align with the needs of the community and then determine if the goals of that organization actually meet and address what the community actually wants.
Well, we’re eager to dig into that subject. But before we do that, Tracy, I just wanted to hear your background and what led you to where you are today.
The first thing I think is important for people to understand is that we have to ground ourselves with who we are and why we do what we do. At Horizon, one of the things we always talk about is improving the health of our members. But I am a member. I’m a member of Horizon. And what’s important is what’s happening to our members, patients, and clients are happening to us.
When I went to social work school and started working with patients/member/clients in the field, I realized that fear can be something that debilitates people, doesn’t allow them to pursue their dreams, doesn’t allow them to reach whatever happiness looks like for them, or develop a sense of contentment. And I really made it a passion that wherever I went or whatever field, I would work with people to help them push past their fears.
A lot of the fears that exist today are fears that we can’t go into a church and pray. We can’t go to a school without thinking about a mass shooter coming in. That’s a real fear that impacts people’s health. And I felt that I really needed to be an advocate. So as I moved throughout my career, I found myself in areas where I was consistently being an advocate.
And that made me decide that talking about health equity was something that now is the time to really be the forger and the person that pushes forward and has those uncomfortable conversations primarily with leadership.
That’s an extremely important angle to come from. I’ve spoken with people even in the upper echelons and health care boards–we’re talking about people with a C in their title–but they are still afraid to be real about the issues that they find important and still afraid to be that voice and that light within their organizations.
It’s not easy. There are things I think everybody has to know about their organization and has to identify when the organization decides that they want to create a pledge or a commitment around health equity. It is very much a buzzword. Let’s admit it, right? And then, you can make some decisions about what organizations you want to partner with.
Getting the voice of the community at the head of the table. That, I think, is where structural changes start to occur. If you really want to tackle health equity.
You drive a strong point there because a lot of the fear that prevents people from getting started from all kinds of equity initiatives is the fear of admitting that certain business processes, certain economics, are biased. It seems very hard for organizations to take that first step in admitting that they were doing wrong in the first place. So how do you bring those conversations to light?
I think one of the things we did at Horizon was really start by looking at the fact that traditional care was not working. So when you look at the costs that continue escalating in healthcare, you have to identify the right system of care to change and modify behaviors. And if you consistently provide a program, and let’s say the program really doesn’t understand the root or the causes of the condition, then all you’re doing is putting a Band-Aid on it.
So one of the things I would suggest to anyone considering starting to discuss this is to start by thinking about where your costs are generated from. The disease is, yes, one aspect of it in healthcare. Or the condition. But if you don’t address what’s impacting the person’s ability to manage their health effectively, then what you’re doing is you’re just creating a million different Band-Aids.
You’re just putting Band-Aids on things without hearing directly about the root of the issue. And that is something I think that’s so imperative here. So that’s the first step. One of the things we did was take a chance.
That’s the other thing: With these types of programs focused on addressing health equity, you won’t see outcomes tomorrow. We’re talking about structural racism that is embedded in the healthcare system for many, many years. To be able to say that one program is going to be able to change those outcomes tomorrow is really a fallacy. I think you have to be very real, and you have to decide whether it’s a pilot and where you’re getting the information from, from the community, from the community board organizations, from people who’ve had life experiences to develop one strategy towards this work.
The other piece I would say is really for the leaders of the organization to take a look at their organization and see how the organization is supporting the growth and development of diverse leaders. If you don’t have a diverse leadership team, you’re very limited in your scope and your approach. There’s to me, no other way around it.
Thank you for bringing that up. I think that a lot of our audience is tired of running back and forth between Band-Aids or chasing overly large promises that are doomed for failure. So to dig into something that focuses on the root causes of an issue, I think that’s a perfect time to describe the Neighbors in Health program and what that entailed.
It actually started with a pilot program. So two leaders within Horizon came together and said what if we developed a program that incorporated community health workers into the care teams? Now, community health workers are not a new concept. They’ve been used abroad.
Community health workers reflect the community. You can find community health workers at a school or church. They are those individuals that everyone seems to gravitate to, and they do 1,000,001 different jobs. But they do it so well, and they have this succinct ability to connect with people within the first 3 seconds of meeting them. There’s something about them that they’re naturally born to do.
And this small pilot really looked at one geography, Newark in New Jersey is an area I’ll describe as very urban. We decided to look at the population based on four particular ZIP codes, specifically on a commercial population. And I want to kind of preface that. A commercial population tends to be individuals who are working. So they have insurance because they work, and the likelihood is they don’t have the same burdens or the same social determinants that a Medicaid member may have.
Over a two-year period, the two community health workers who were hired engaged members at the point of contact in the hospital and really asked them, what are the things that are keeping you awake at night? It didn’t start with, well, you’re a diabetic and you need to go on this new treatment. It focused on the person. And what we heard from people who felt open and felt comfortable trusting that person was, yes, I’m having difficulty covering my rent. I’m having financial issues. It’s challenging for me to provide food on the table. And what that program allowed us to do was see, over the course of two years, a decrease in the total cost of care, as well as an increase in behavioral health services by connecting those members to resources within their community that they weren’t aware even existed or realize that were part of what an insurance plan would do. So it was a collaboration between the hospitals, the community board organizations, and the payer.
Ultimately, how did that evolve? And I’m curious about the use of data. One thing that was exciting to me is that there was a predictive model that was used to help the community health workers identify who to speak with. Could you speak to that?
So the pilot was called the Newark Initiative. That was with those two community health workers that I referenced. Because of those directional results, we were able to socialize this with our board, talk to hospitals, and really start to develop. What if we could scale this program? What if we could make this program bigger?
What we saw was a 20 percent decrease in the total cost of care and a 60 percent increase in behavioral health. The community health workers fostered trust and connected members to the appropriate resources so they utilize care appropriately. So the decision was made that we should dedicate $25 million to this program.
Now, Neighbors in Health, over the course of three years, required identifying partners, hospital partners, as well as coalitions that wanted to work with us. And Horizon covered 50 percent of the resources. So what that means is the hiring of community health workers. We covered those salaries, and the partners that worked with us covered the additional. The thought behind this is, in the future, these partners would be able to see the decreases in total cost of care and later work to build these programs into value-based programs.
So that’s tremendous. And it digs into the heart of what some people might be looking for in terms of getting a program started. So it sounded like a much smaller effort.
It was an extremely small effort. So these two community health workers started. We didn’t have a fancy platform. We didn’t have predictive analytics at that time. It was a small shoestring budget. And what we did was look at our high-utilizing members, members who were frequenting the E.R., and we used that as a predictor of identifying our population.
But very quickly, what we learned is by actually working with those hospital partners and socializing information about what social barriers were, we could get the care teams to also refer members into the program. So there was an educational experience going on here as well. A lot of it was speaking to physician teams about the impact of social drivers and social determinants on health, on one’s overall health outcome.
I’m curious about some of the social barriers that were identified in this process.
Our top barriers are food insecurity, transportation, and financial insecurity. The program’s been going for three years now, and consistently that has been the issue of the majority of our members. So with any of our members, we start with the crisis. Obviously, it’s hard to get people to think about their care from a preventive standpoint or go to the doctor when they don’t have enough food on the table.
So our main concern is to identify and remove those crisis barriers. But then, beyond that is to help individuals begin to see and identify goals for themselves. We’re not here to tell you how to live your life, but we’re here to say there may be a better way. So some of the conversations community health workers have with members are really focused on what brings them joy.
You know, tell me about your goals. Sometimes we have members who will say, my goal is to lose 10lbs. to go to my daughter’s wedding. And the community health worker works with the member and says, okay, if we’re going to do that, there needs to be some changes that we both are in agreement with. So once a week, I’m going to meet you here, or you’re going to do this, or twice a week, you’re going to do this, or we’re going to find healthier food. So it becomes a real shared relationship where this person has the ability to focus on empowering themselves when that relationship is over.
That speaks heavily to the power of being able to address real specific issues when you have the equipment to find out what’s really going on. So it leads to another question. Now that this effort is in place and there is funding behind it, can you talk about the metrics and communications you have with leadership to sustain the program?
I want to preface this by saying that sustaining a program like this doesn’t come without its hardships. So I want to be really honest to folks that are doing this. Whether you start out as a pilot, what you want to identify are some key metrics that matter to the company. So in New Jersey, we have a real problem as it relates to maternal child health.
We are 47th out of 50 states in terms of birthing outcomes. So when we think about building metrics into any of our programs, we want it to align with a couple of things. What’s important to the state of New Jersey? What’s important to us as one the largest insurers in New Jersey?
And if we want to reduce health disparities, how are we going to do that? So I would encourage anyone to look at their data first. Look at the pockets of the data where you’re beginning to see those disparities, and you have to really desegregate the data. In the past, a lot of what we did was look at data from an aggregate. It wasn’t looking at race, ethnicity, and language. And we’re beginning to collect that data to help tell the story as it relates to the work that we’re doing. So we’re in the initial phases of that.
So in terms of identifying metrics, you want to be able to say if you believe that this program is going to improve and connect individuals to resources, how are we going to do that, and how are we going to measure it?
You want to measure it by race, ethnicity, as well as SOGI (Sexual Orientation and Gender Identity) data because then you can determine if there are disparities. But what I would say is, if you’re looking to see if there’s been an improvement in outcomes in terms of getting to wellness visits or reduction in total cost or looking at a decrease in E.R. and inpatient, what you want to do is look at that based on those different criteria to help you determine if the interactions of the community health worker are truly motivating some of that.
And sometimes it’s hard to see that. But if you know that the large majority of the individuals that you’re engaging with, let’s say, are Latino, or they’re Black, you can begin to pinpoint how these points of care actually changed the trajectory of the outcomes that you’re seeing overall.
Without asking the deeper question of how efforts affect subgroups, maybe an overall metric that looks really appealing is masking something that’s going on with a specific group.
And the funny thing is that until you disaggregate that data, that’s when you can really also begin to respond and make sure your programs are effectively answering the questions that the communities need. I mean, we know that our members experience a lot of health disparities, primarily those in Black and brown communities. We see the outcomes in hypertension, obesity, and diabetes.
We know that. But I think when we want to develop a program that responds effectively, we need to determine if we need more physicians that look like the communities they serve. Or do we need to train physicians so that they understand the needs? You know, it’s a combination of all of those things rather than just going back to the Band-Aid statement saying that, okay, all physicians need implicit bias training. You know, that’s an aspect, and it’s important, but it doesn’t necessarily mean that it’s going to get you to the endpoint of what you need. After folks received training, then what? So it can’t be this episodic kind of planning. The data helps you to decide after you put these interventions in place what’s really working.
What would you say are some metrics that started making you proud of those broad efforts?
We started working with an independent researcher. That was separate from our internal analytics team that looks at the data. And what we’re seeing is very directional. So we’re seeing some results primarily in reducing hospital stays where our community health workers have actually engaged those members at the point of care. We attribute that to the decrease.
One of the barriers that we see a lot of times is transportation. When folks are in the hospital, sometimes transportation isn’t set up the time to make sure it’s an effective discharge. Sometimes the discharge occurs without taking into consideration the social barriers that are in the home. You know, you can prescribe a medication for someone, and that patient is so vulnerable, they’re like, yes, I’m ready to take it without realizing that it requires refrigeration.
Maybe this person right now is in between homes and is in a hotel. And this is actually a real case that we had, where we were able to identify that that served as a barrier. This person went to the hotel but was not able to keep the medication at the temperature needed.
And unfortunately, you see a cyclical effect where they then either have to come back to the hospital or become sick again. So that was really a good indication for us to see that as a result of those interventions, we believe that there was a decrease in hospital days.
The other, I would say, is the overall management of some chronic conditions. Many of the results we’re seeing right now were on a small population. So I want to be honest in the sense that it’s still very much directional. We have our research team taking a broader look now that the program is three years in. When they did that initial research, it was for a year. So now that it’s three years and we have more robust data, we’re looking to see what other points we can pull from the information we’re seeing.
Could you talk about the types of teams that you have to mobilize and potentially any pushback or resistance?
Well, I think these conversations around health equity are new. They’re new for people. The topic is not new, but talking about it is new. So it creates an uncomfortable space for a lot of individuals. Even for myself, it’s an uncomfortable topic because, you know, I am the person that is also seen as that marginalized community.
And I have family and friends that experienced the healthcare system through biases. So from the same perspective of thinking about it as a patient member client, it’s also thinking that now I’m in a leadership position, how do I mobilize that? And how do I engage others in the conversation? So I would say it’s really looking to leadership to begin candid conversations, and it requires some of us to be vulnerable or share stories about how this has impacted either your health or a loved one through the healthcare system.
That’s the first step. The other is getting a team of champions who believe in this work. And sometimes, it’s not always the C-suite folks. It’s looking for allies within your organization who believe in this work and can start building it into their day-to-day operations. So sometimes it starts with the language we use, identifying and talking about patients.
In the healthcare industry, we say many things are not always as easy as we would like them to be. So I’ll give you one example. It’s identifying patients as a diabetic. Like, this is a diabetic. This is a hypertensive. This is just the way a lot of individuals have always spoken in the healthcare field with no malice intended. It’s just a cultural thing.
It’s important that we start to identify this person as someone with diabetes versus identifying them based on a disease. That’s the first step. The other, I would say, is looking at your care teams and extending and working with nontraditional resources. This work required us to begin to engage with clergy. At the height of the pandemic, we started working with churches.
We started working with schools to be able to socialize the vaccine. Now you can get a vaccine anywhere, right? But at the height of the pandemic, there were communities that did not have access to the vaccine. And one of the things we had to do is be very nimble and flexible. And we started working with nontraditional partners again, churches, clergy, CBOs (community-based organizations), bringing the vaccine to the community, having folks come in and have conversations about why it’s important to receive the vaccine or how to make an informed decision about receiving the vaccine.
So it’s looking at who can be your allies, who can be your ambassadors, your champions around this work. But it took a lot of socializing and education within the organization, and it still requires more because the needs of the community are ever-changing.
So it might be today looking at specific access to medications and how certain physicians are prescribing them. Tomorrow, maybe we’re looking at your transportation and housing in this particular area as a barrier. So it’s multifaceted.
One thing that you touched on a little earlier was using this data and understanding, identifying where these challenges existed, and then working with these teams to start addressing these issues. I thought that was a really powerful point.
So there’s the Neighbors program that you launched, but I’m curious if there are plans around the expansion of this program or other programs that you might be looking into. We’ve talked about a program that’s in progress, but I’m just curious about where you think the health equity conversation will lead.
I think the first thing is the fact that we’re having the conversation about health equity in every area that’s important. So it doesn’t just live in a program that is the goal, that health equity becomes the company’s footprint, that it becomes part of the organization in terms of thinking about how they deliver on work that they’re doing.
So in your actuarial department, in your communications department, these are different areas where we’re starting to expand conversations around health equity so it’s socialized for the organization. Our CEO has been having conversations about how he is addressing health equity. So it’s not, again, just living in one particular area. My department happens to be community health, and that’s where it started.
But the intent is that health equity permeates throughout the organization. So how we contract with vendors asking them questions about how they’re promoting health equity and how they’re impacting workforce development? Hiring diverse populations is really important. And we should be able to ask individuals about their health equity stance. So collectively, this work becomes not just what Horizon is doing but almost contagious, like it’s a body of work that everyone’s working on. So I would say that that’s an important piece of this.
The other aspect is thinking about disaggregating the data that I mentioned based on what we find over time, it is going to continue to dictate new programs that we develop.
One of the things that we are most recently proud of is expanding the benefits to doulas, helping a birthing person through delivery. It’s providing them with insight and cultural support that meets that person’s needs during the delivery process, and they can be working with a birthing person or woman throughout the pregnancy. They serve as an advocate. They basically are the person that can be there throughout the delivery, making sure that this person is focused on the end point of what’s going to happen, which is a safe delivery.
And we believe that it’s one of the ways to bridge some of the health equity gaps that we see. We know often in maternal child health space that, unfortunately, people of color are not listened to. And that’s one of the reasons why we see some of the health outcomes that we see. And it goes beyond all socioeconomic. So it doesn’t have anything to do with whether or not a Black woman is extremely well-to-do or if this person is not doing as well financially.
The issue is that this person isn’t being listened to. So we believe that doulas serve as that support. It is not the only solution but one of the solutions. So those are some of the programs that we’re looking into. But I want to say it’s a multifaceted approach and ongoing that’s not just baked into programs. It’s baked into how you’re wired to think about contracting with physician partners, and programs that you develop.
It sounds like people are passionate about launching programs and identifying where they should start there. It seems there’s a mosaic of health equity opportunities in the data waiting to be discovered.
Definitely, and I think some people may not think that this is really attractive, but you have to put the care back into healthcare. That is the reality of what we’re doing, and it starts with identifying what people really need.
If we don’t understand that structural racism is what dictates how individuals are not only treated but how they utilize the health care system, then every program that you develop will be just that. It’ll be a program. It won’t get to the root. You won’t see a change in the outcomes. You won’t see the improvements that you’re looking for. And this is the way that we have to begin to look at care.
We can’t address structural racism with our heads in the sand. When we start to look at that type of data, then we start seeing what the ethnic breakdown is, how certain populations are impacted, and ultimately the level of the population that is unwilling to self-report because of a lack of faith in that system’s ability to have their interests at heart.
But there is a major question that we ask everyone. I’m excited to hear your answer because of all the work that you’ve done so far. If you had a magic wand that could change anything about our healthcare system today, about the way healthcare is delivered, what would that be?
I think the first thing is recognizing that people, regardless of race, regardless of ethnicity, or language spoken, that they deserve the right to be treated equitably and recognized as an individual that deserves care, that it is their right. We all have rights. I’ve seen cases where people provide more care to animals, and I’m not taking away from animals. But the reality is, is that there are humans, and there’s a life behind the person. You see beyond their skin. There’s a human there. And my thought would be that no one should be afraid to go into a doctor’s office or to go into a hospital because they fear that the color of their skin is going to determine how they’re treated.
I would love for the four walls of the doctor’s office or the hospital to be that welcoming place that, yes, you go to when you’re sick, but you don’t have to fear or think about what’s the story I’m going to tell so I get the best care possible. And this is real. I’ve spoken to friends and family that look like me, and they’ve rehearsed what they’re going to say to the doctor so that they self-report in a way that seems honest, that they come off as their best self because they already feel like they’re being judged.
So I know that’s not a one-word answer. It’s not necessarily focused on payment reform. I think those things come. But I think first you have to see people as people, and you have to think about who that person is as your mother, aunt, sister, husband, wife, and significant other. If people start to see people as humans, then I think care would be rendered in a way that would be so much better.
And I think where we are at a point where we can not penalize folks for having biases because the reality is we all have them. But when they permeate how you deliver care, that’s where the problem exists. So I am all for making individuals aware that implicit bias exists in healthcare. I’m all for making programs that focus on addressing and educating people.
But you have to make sure that those programs meet the needs of the individuals that they serve. Once you identify that you have those biases, what are you going to do to address them?
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