AHLA's Speaking of Health Law
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AHLA's Speaking of Health Law
Social Determinants of Health: Integrating Data, Law, and Whole Person Care
Eric Setterlund, Partner, Bradley Arant Boult Cummings LLP, speaks with Melissa Soliz, Partner, Coppersmith Brockelman PLC, Annie Harrington, Chief Legal Officer, Pyx Health, and Sarah Raybin, Counsel, Vanderbilt University Medical Center, about how to launch a successful social determinant of health (SDOH) platform for sharing data among a patient’s care team. They discuss the types of SDOH platforms, legal issues related to using these platforms, considerations when evaluating and launching these platforms, and barriers to participation in these platforms. They recently wrote an article for AHLA’s Journal of Health and Life Sciences Law on this topic.
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Speaker 2:This episode of A HLA speaking of health law is brought to you by A HLA members and donors like you. For more information, visit american health law.org.
Speaker 3:All right . Hey, everybody. Welcome to this A HLA podcast, and today we're gonna be puzzling, SDOH out. We'll be talking about social drivers of health. Um , and with me today I have Mel Sese , Annie Harrington, and Sarah Raymond . We'll make some introductions here in a second . But together , uh, we wrote an article for the A HLA Journal of Health and Life Sciences Law called the Missing Puzzle Piece, using health data to close the Social Determinants of Health Gap that's gonna be linked here , uh, with this podcast. Check it out. It's a really , uh, expansive article on the subject , uh, you know , so again, I'm Eric Sutherland. I am co-chair of the Privacy and Security Team at Bradley, and I'm also joined by Mel. I'll kick it off to you.
Speaker 4:Hi, I am Mel Solis . I'm a health data and interoperability attorney with Coppersmith Brockleman. Um, I'm based out of Phoenix, Arizona, and I have a national practice advising a wide range of organizations in the healthcare space on health data and interoperability laws.
Speaker 3:Annie?
Speaker 5:Hey, I'm Annie Harrington. I left my firm practice to go in-House, and I currently am fortunate to serve as the Chief Legal Officer of Pix Health, which is a healthcare technology company focused on supporting individuals dealing with loneliness, social isolation, and chronic disease management through peer mentor engagement. Uh, before joining the PS team, I served for several years as the chief legal officer and privacy officer of contextual , the largest health information exchange and health data utility in the Western us . So I've been grappling with these legal questions involving data privacy and interoperability, and introduction of new data sources and modes of exchange for quite a while. I'm excited to dive into this puzzle with you all.
Speaker 3:And Sarah .
Speaker 6:Hi, everybody. I am Sarah Rabin , and I currently serve as in-House counsel for Vanderbilt University Medical Center, a nonprofit hospital system in Nashville, Tennessee. I primarily advise on hospital operations and privacy, and prior to that, I served as the chief Compliance and privacy officer for the State of Tennessee's Medicaid agency.
Speaker 3:Yeah , and just a quick fact about me too, I was also the in-house , uh, privacy and data counsel and Chief Privacy Officer for a payer and health plan. So among all the speakers here, we really, you know, cover the entire gamut from government benefits payers, providers, health information exchanges, et cetera . And so, just kind of kick it off to the first question for everybody. So the real basic one , you know, what is SDOH and how does it relate to health equity?
Speaker 6:And Eric , I'm happy to pipe in here. So, social determinants of health, and sometimes they're referred to as the social drivers of health , uh, are basically risk factors that can affect someone's health outcome. They take into account daily living conditions, employment status, transportation needs, and access to basic necessities such as food and safe drinking, water access. These are all things that can significantly impact how quickly someone recovers from an injury or illness.
Speaker 3:Yeah, and I , and I guess I would say, you know, why is it so important? We're hearing a whole lot about SDOH these days, you know, both from physicians and, and also just from a societal needs . So just kind of kicking it to the group, you know, why do you think it's so important today? And I , I guess I'll , I'll , I'll start, I'll take this one. And so it's , it's really, you know, addressing these societal issues is, is it it can lead to better health, health outcomes for the whole person care. It's, it's, you know, the, the research has clearly shown that addressing SDOH issues is better than actually even providing more access to more various different types of treatment. And, you know, when you really think about it, it makes sense from some of the basic issues such as transportation , uh, which can be an exceedingly large roadblock for some , uh, you know, it might sound like a small hurdle for some of us, but it could really, such a simple issue can really impact the healthcare of somebody. They can't make it to their appointments. Maybe they don't have access to foods or, or other types of things, and they're , they're battling chronic conditions. Uh, you know, and this is also facing certain populations which are in need. And so you, you're kind of putting it all together. How do we help address these types of issues? You know? And , and Sarah , you know, you've been both at, you know, Medicaid and now you're in-house for a large health system. I mean, so what are your kind of thoughts about as it pertains to outcomes and, and how it works out?
Speaker 6:I think it's from the payer perspective, when I worked for Medicaid, there was a lot of research put into determining why is it that when you have patients that seem to have identical health conditions, have such disparate health outcomes, and we continually saw that over and over again. So it's nice to just see , um, more involvement from all of these different , um, sectors of the industry as far as healthcare , um, community-based organizations, of course, like we have food banks, homeless shelters, just a whole myriad of participants coming together to address a more holistic , um, approach to patient care.
Speaker 3:Yeah, I mean, it , it is all about whole pace patient care. And, you know, it clearly takes an , an , an entire community approach, and it , it requires engaging the community to help address these types of needs. And, you know, I think kind of the one thing that we're seeing, of course, across in every state are all these various different types of platforms that are popping up to help kind of solve these issues. You know, Annie, you've worked with a lot of these, you know, what kind of platforms are out there, and if you can kind of provide an overview of what they look like.
Speaker 5:Yeah, absolutely. Thanks, Eric. I'd say it's a , it is precisely against the backdrop that Sarah just described, that's growing body of evidence that factors outside of healthcare, of the healthcare sector have a greater influence on an individual's health , uh, than we once , uh, understood , um, that we've started to see an influx of these SDOH platforms or technology tools enter the market. Um, and to address these issues, these social determinants of health issues, clinicians and health plans have to be able to identify across their patient populations. Um, they have, they have to have the data , uh, and they have to be able to exchange the data so that they can understand factors that are impacting health and healthcare and , and then properly address them . Um, and so I think, you know, given that that's such a data intensive endeavor that requires data sharing capabilities, it's no surprise that we've seen , um, a growth in this market sector and this sort of social determinants of health tools as we refer to it . Our platforms, I think I'd broadly categorize them in four or five general buckets , um, really starting with tools that just simply help screen patients for SDOH issues. So using various screening methodologies like the prepare method or the prepare tool. And sure , this could be done on paper, pen and paper in a client in a , in a patient's chart , um, at a doctor's office setting. But we're increasingly seeing digital tools that assist in the , the , in the collection of this data directly from the patients . I would transition down the spectrum to really point solutions or consumer facing applications that are designed to engage patients for the purpose of helping them address a specific SDOH need, like you just mentioned, Derek , transportation , uh, food insecurity, and that connect patients or health plan members as the case may be to resources , uh, to help them address such things. Moving even further along the complexity spectrum , uh, on the tool side are , are really what we refer to as referral platforms, where a patient that's experiencing an SDOH issue can be referred either directly or by their physician or care manager to a participating community-based organization that can help assist in addressing the SDOH issue, like housing or transportation or even things like domestic violence support. Uh, these referral platforms that we'll refer to over the course of this podcast , um, offer are increasingly offering closed loop, what we'll refer to as a closed loop capability , where the result of an SDOH referral, in other words, when they are sent to A CBO , um, if they actually show up at a CBO appointment or visit A CBO, then that referral , um, then gets sent back to the clinician, to the referring clinician or to the care manager once the patient has received assistance. Um, and that can be captured at the patient's chart. And then finally, the, the most robust, what I'll refer to as sort of an enterprise level solution or a social health information exchange, not only offer the closed loop referral capability that I just described, but also integrate directly into a clinical EHR , um, so that the referral data or the SDOH screening data can be incorporated into a patient's clinical record. All of those have varying complexities when it comes to legality of exchanging this information. Uh, and so I think I'll throw it with that . I'll throw it back to , um, the rest of you to help our listeners , uh, think through some of the legal complexities involved with selecting one of these tools and then navigating use of these tools.
Speaker 3:Yeah. Uh , I mean, I think you kind of touched on the , the main point, right? Which data is paramount to the , to a successful platform, to a successful system. We're talking about exchanging information with regulated and non-regulated entities, you know, subject to disparate laws. Uh, and quick plug again for our article, 'cause we cover this excruciatingly in depth in our article <laugh> , so feel free to, to take a look. But, you know, with that comes also all just the strings of data protection, right? Maintaining privacy, making sure you're complying with various laws and that everything is done above board and , uh, in compliance. And so, but the biggest issue again is , you know, how do you move that data from point A to point B? And there's tons of legal hurdles that, that face that. And so, you know, Mel, I'm gonna kick it to you. You know, when, when talking about and working with these platforms, I mean, what are some of the issues related to sharing information on , you know, using disclosures , uh, disclosing protected health information, you know, what are just the key laws that pre present obstacles for all, all of clients and stakeholders?
Speaker 4:Yeah. Well, as a health data privacy attorney, I really wanna focus on the data privacy laws. And I wanna specifically focus on some of the most complex SDOH platform solutions, which is what Annie was referring to as a community health information exchange, where you have not only screening tools, but you have the referral mechanism, and then also you have the network data sharing where you're sharing information, not point to point , but with a whole care team associated with the particular individuals. And , and those are the most complex because there's so many different data privacy laws involved. And a lot of these laws don't happen at what we call like the data element level. That means they don't necessarily protect like social determinants of health data or a particular type of screening. It really depends on the source of the data. And within these complex SDH data sharing platforms, you have a lot of different sources of data. You have data coming from HIPAA regulated entities, entities that are subject to 42 C ffr , part two , the Veterans Administration. You have them also coming from community-based organizations that might be subject to the proliferation of state consumer data laws. So I'm gonna specifically focus in answering this question, I think on the health data laws. So I'm talking about HIPAA 42 c FFR part two , the type of laws that apply to HIPAA covered entities and their business associates and part two programs. Um, but it's not just HIPAA and 42 C ffr part two , if you're working with the Veterans Administration, for instance, you might also need to worry about the Federal Privacy Act, which is more restrictive than hipaa. If you're working with a family planning organization, for instance, that gets Title 10 funds, they're going to be subject to title 10 confidentiality requirements. And then you really can't forget about the, the literally hundreds of local and state health data privacy laws that are gonna vary depending on the institutional licenses , um, and the provider licenses and might be dependent on the type of healthcare services or the type of healthcare data provided. Like, there's a lot of complexity here, but your minimum, if we're talking about health data, most folks are going to be HIPAA covered entities and business associates. And even if they're not , uh, HIPAA really is kind of the standard of care throughout the healthcare industry. So it's important for that to be a floor. And, and Eric's had a lot of experience working with organizations and how do we meet the minimum HIPAA compliance for these complex data sharing platforms, and how can HIPAA covered entities and their business associates disclose protected health information to these community-based organizations that are not subject to hipaa? So Eric, do you kind of wanna walk us through that ?
Speaker 3:Yeah , and I was just gonna say, it's Mel, we have this conversation all the time, right? And I think it, it , it was actually kind of solidified more with the 20 20, 20 21 NPRM that was outstanding for the privacy rule. But with hipaa, you still have the traditional treatment and healthcare operations exemptions to the individual authorization requirement to share that information. Uh, obviously if you have a provider who, you know, they see nutrition or potentially housing affecting a treatment issue , uh, you know, they can make a referral , uh, pursuant to the treatment exception and when a health plan does it, right, that would be healthcare operations. You know, if , I think that one of the issues, and this was reaffirmed in the, you know, the, the new NPRM that we've been waiting forever and ever I'm in for , uh, is well, how far does that go and what can we do? And , and I think that HHS and had to, you know, essentially learn that people were not disclosing this information. They still were trying to seek individual authorizations, although they could make those permissible disclosures for those purposes. And so, you know, in that guidance, you know, I think everybody should know and feel comfortable that they have reaffirmed those traditional pathways and are also planning an additional exemption that's at least , uh, at the individual level to share with non, you know, covered entities or other providers in the CBO space , uh, on that individual capacity. Um, you know, so we have those traditional frameworks that already exists today. I think that one of the issues though, because of the confusion and , and some of the, the, you know, security , uh, just like it , I guess, expectations related to, to the individuals, right? Should you still leverage consent or an authorization when you're, you're using these systems? Uh, you know, and I think Bell , you and I would both agree that if you can get consent or, or obtain an authorization to participate in these platforms, that's great. It's not always possible that you can get a written authorization. So you can rely on the exemptions. But if you can obtain consent or get an authorization, I mean, that's a great way to go. It meets everybody's expectations and they understand how they can use and disclose data, but it's not completely necessary at the same time. I dunno if you wanna add anything .
Speaker 4:Yeah , yeah. And , and again, it goes back to who are the data sources that are gonna participate in your exchange. Like we kicked this off talking about how HIPAA is the floor, but what if you want substance use disorder treatment providers that are subject to part two to participate in this networked environment? Well, that's where you're gonna see a push towards using more authorization and consent based SDOH platforms because you need to comply with the more stringent privacy laws like 42 CFR part two. Uh , if you wanna allow those part two programs to participate, and you're gonna need a consent management function to do that, and you know, healthcare organizations should be aware. Or if you're on the developer side and you wanna develop one of these platforms, is the tech out there? Do you have the tech out there to have the consent management functionality to be able to do things like allow for consent based exchange? How are you gonna manage revocations? If there is a revocation? How do you suppress that data from further closures? And that can be exceedingly challenging to build and to implement. And I think the impact we see on the community is we're not seeing a huge uptake of participation by providers that are subject to more stringent health data privacy laws, like the Park two programs. And it's not just limited to these federal laws. It happening at the state level too, like domestic violence shelters, for instance. In most states, there are state laws that make that dv, the domestic violence data confidential if it's coming from those domestic violence shelters. So they might not be able to participate in some of these networks, or if they do participate, it might be at a more limited capacity. Um, and you don't just have to worry about the data privacy laws , like that's what I've been, or the health data privacy laws , uh, because these are CBOs, as I said, they might be some subject to consumer data privacy laws. And then there's also a whole host of laws having to do with how you're communicating the data. And also, is your SDOH solution, your platform, does it have consumer facing functionality where you're engaging in consumer communications or directly interacting with those patients and health plan members? And I was wondering, Eric, could you walk us through some of the, the legal challenges there?
Speaker 3:I mean, I think just, I'll just give it just a real basic example, but texting, right, presents an issue, right? So making sure if you wanna reach out with somebody , uh, via text message, you know, the TCPA was kind of rolled back with the Facebook decision , uh, one of the, the few unanimous Supreme Court decisions we've had recently. But, you know, you still have to make sure that you're obtaining consent for the carrier guidelines and depending what , uh, you know, contractual restrictions you've also , uh, leaned into for those various platforms. And then in , in addition to some of the many TCPA and other texting laws that have also proliferated in the state space to kind of fill the gap , uh, that was left by that Supreme Court decision , uh, you know, limiting the definition of auto dialers , um, you know, I, I see that one as , that's probably the most common one I see every day is, you know, how do we outreach? 'cause part of the key to the solution is meeting people where they are. I mean, mail is not effective. Email is becoming increasingly ineffective. It's it's phone and text. And so I think you just always have to kind of kick the tires to make sure you're compliant at both the federal and the state level on those laws. And again, you know, with all the , all of these types of issues, you know, consent cures all ill, right? So you, you, I still think that's the best practice. And if you can't obtain some sort of consent, then you have to look at what you legally can do with the type of consent you had. And there's various, there's differences, right? There's express written consent, and then there's implied consent based on business relationships, et cetera . Granted, a lot of those laws apply specifically to solicitations, but that is still a gray area , uh, as it pertains to some of these new state laws, right? Uh, because services could be provided, you know, remuneration could be received even though it's for a healthcare purpose, right? So just making sure you're compliant with, with those and , and, you know, checking 'em up . Y you know, I , I think that we talked, we've kind of covered a lot of these topics about what are some of the best practices when, when thinking about S-D-H-S-D-O-H solutions, you know, how do you maintain, how do you start a program or how do you begin to advise related to some of the legal hurdles that are here? You know, again, we've all talked about this and it's covered in our article as well, but it , you know, you really do have to kind of take stake of , of what your business goals are, what data you have, and what laws apply to the business processes that you're doing . I mean , that's really step one . And working with council who's familiar with this space is obviously, you know , a , a great to helping to , to helping you design your program in such a way to avoid some of these pitfalls. And we kind of discussed the, the closed group referral system too, and leveraging those authorizations at the outset , uh, you know, to kind of taking it away from HIPAA or, or clearing those hurdles. Uh, again, I think that if you can kind of, you know, I won't, I guess it's just kind of not blowing past it, but just making sure you're checking those boxes and, and limiting it and allowing data to be shared as freely as possible by obtaining consent or necessary authorizations. I mean, that's the way to go. So Mel , you have anything you want to add to that?
Speaker 4:No, I, I think you hit the nail on the head, but I would like to hear, I think more from Annie and Sarah about some of their lived experiences with either operating one of these SDOH platforms or working and evaluating different vendors for operating a platform. What have been some of your observations in terms of good solutions for SDH platform that are, or that are done and to support compliance with these laws, given all the complexity?
Speaker 5:Yeah, I'm happy to start. I , um, I, I would say it starts with the contracting phase . And , um, I hate to answer with such a lawyerly <laugh> in such a lawyerly way. Um , but I, I think I found both from the technology vendor side of the aisle, but also for the customers that you're serving on health plans or on the provider side, that clarity upfront being extremely clear in your legal terms, what you can and cannot and will and will not do with their data , uh, that you are flowing through your systems as the business associate , um, is absolutely essential. And I think that I, I can speak from the, the, the vendor side of the house. Um, when we have good contracts upfront , it leads to better outcomes on the implementation side because when my teams go to roll out a solution in the market, they are not then having to deal with roadblocks along the way. What can we and can't we do? Because we've dealt with those upfront in the , in the negotiation side. So while that can prolong the negotiation of the contracting phase, it pays dividends down the line on the implementation side , um, relative to, to rollout , uh, in the market. Sarah, any any thoughts or things to add?
Speaker 6:Sure. I would love to add in , um, from the government side of things, when I worked at tencare, they did procure a closed root loop referral system , say that three times fast. Um, and there's just not a whole lot of vendors out there given the specific needs of the system. There are going to be a couple of major players that you're going to be dealing with every time. And from our end, what we found was that our health plans use different platforms. We had the CBOs and other organizations using different platforms. And for us, we looked for a way to streamline that. And that came with our state Medicaid agency procuring the platform and then having all participants basically signed up to use that platform.
Speaker 3:And I think that makes sense. I mean, so, and you know, what are some of the three, the , the considerations that a healthcare organization should look for when evaluating, you know, a platform?
Speaker 4:Well, what I advise organizations look at and remember this is coming from a data privacy and interoperability perspective. Um, if you are a stark or an anti-kickback attorney, you might have different top threes that, that you might wanna look at. Um, but from my perspective, first and foremost , uh, you wanna look at the platform's data privacy and security practices, and to do that, as Annie said , uh, in terms of contractual PO promises. But you also wanna see what their policies are, both the policies that apply to everybody who's participating in that SDOH platform, as well as maybe their internal policies to see if it backs up and supports legal compliance on the, on the platform, as well as understanding if they're actually using industry standard security practices. 'cause a lot of the data is heavily regulated data. And do they have industry standard security certifications? Like do they have a SOC two certification or high trusts certification? And I think at a very bare minimum, the platform has to operate in compliance with the HIPAA privacy rule and security rule . And as, as Eric illustrated earlier, there's a lot of variety in how you might do that depending on who the participants are in the SDOH solution. And I also think that healthcare organizations, when you're looking at all of this, you really do need to pay close attention to what are the promises that you are giving to the organization? What type of data use license are you giving to the SDH developer or the operator of that platform? And you need to know that because depending on the laws that apply to you, they might be asking for a license that you either cannot give them, or that if you do give it to them, you might have to do additional administrative steps and expend additional resources to get appropriate consents if what they're using for consent or if they're not using consent that they're not already getting for the platform. So that's one. Uh, second, I do think you need to look closely as to whether or not that SDOH solution actually integrates or doesn't integrate with your existing internal systems. And is it possible for that platform to export out the SDOH data and what form and format are you gonna to get that SDH data? I don't wanna go too into the weeds, but you really need it in A-U-S-C-D-I version three content and vocabulary standard. And you want it via a fire , API, particularly if you're one of those CMS regulated plans, because your requirements as part of different CMS programs, whether it's a value-based care program, CMS interoperability mandates or other reporting requirements, you need to be able to ingest that data, manipulate it for the reports you need to give, or to facilitate some of these CMS mandated APIs. So that is why it's important to know what's the level of integration, how is the data , um, being formatted so that you can make sure that you can meet your other legal requirements depending on whatever government program you may participate in. And lastly, <laugh> , uh, I do wanna say pay particular , uh, per attention, sorry, attention to the functionality and usability of the platform. And that's important not only to verify regulatory compliance, like is it actually operating the way they say it's going to operate, but also does it support your, your business goals? And it's, is it something that your organization, the people in your organization are really going to use? Um, and then I'll, I'll kick it back to, to the group to see if there's, there's anything that I might have missed.
Speaker 3:Well , I , and I was just gonna kind of delineate practically, right? I mean, I think the interesting thing about these types of, these , these systems , uh, specifically is you have these heavy regulated entities who are mu you know, very much concerned about privacy and security and the regulatory obligations, and they're trying to get the , the data to these entities that are community-based and volunteer run with very limited resources , uh, and obviously can't meet the same data protection standards, right? But it doesn't change the impact that still those regulated entities have to be mindful of these. They can't shirk their responsibility and sharing information in a secure and compliant way, even though the ultimate destination is a non-regulated entity right. Entity in , in certain circumstances.
Speaker 4:So Eric , I know you and I have talked about this a lot. Um, I just wanted to ask you, do you think the CBOs all need to be business associates of all the HIPAA covered entity participants?
Speaker 3:Uh , no, I don't. I mean, I really don't. And I, but because I guess it really depends if they meet the definition, right? I mean, if definitionally if they're performing services on behalf of a covered entity or another business associate, then you know, by default they do, you know, if they're churning data or providing some upstream services. But if this is a referral to a community based organization, right? Let's just use the example of transportation or food, right? We're gonna refer somebody to a food bank , uh, because they don't have access to, to food. No, I mean that's, you're, you're just making that disclosure for a treatment based purpose that you're both operating on your own behalf that does not make them your business associate. And I think, you know, we see that quite a bit, Mel , you know, where people are trying to, to push down those responsibilities, but at the same time, you know, the law permits those disclosures assuming you, you're doing it in a compliant way , uh, and they're just not working on your behalf, right? So I I would say no <laugh>, and yeah , I think you also wouldn't want to be responsible for those entities because they cannot , uh, they don't necessarily have the same resources to maintain the same level of security that like a large health system or a health plan again . Right.
Speaker 5:Yeah. I just wanna double click on something , uh, that Mel said. I think for three, you know, primary buckets that you listed are a hundred percent correct. And, and I , I wanna spend a second on the second bucket, which is ensuring that the SDOH platform that you select for whatever your , wherever you sit in the healthcare spectrum, that it can meet your data needs. I think the tendency , uh, in health plan side or provider side is to kick it to the attorneys to , and your security team to do the security and legal evaluation of a specific tool. But in parallel, you've gotta have your, your data teams, your, your, your program teams evaluating what you're going to get from that SDOH tool, the form and format of that data, and whether it's usable for your purposes, whether that's population health analytics that you wanna run on your member population or, or integrating back into the EHR. If that tool can't get you the data in the form and format that you need, it is ultimately not gonna serve and not gonna be a good investment. And I think sometimes , um, that valuation on that second factor that you touched on, Mel, happens after you've already spent a lot of time doing the security and legal analysis. Um , and really I think it should, should happen in parallel. Uh , 'cause I think it's just a critical component .
Speaker 3:Totally agree. I can , I mean, I, I think it is just such a , a , a critical point. I mean, so obviously there's, I think that, you know, setting aside costs , which is always a , you know, a barrier , um, you know, what are some of the other barriers to participating in these types of platforms?
Speaker 5:Yeah, let me , let me start with that one and I'll kick it over to you, Mel and Sarah . I, I think , um, when you control for costs , there's a bunch of states doing cool stuff in this space. You all in the Medicaid context. So we've got states like North Carolina, Nebraska, that are, are working to sort of roll out a social health information exchange or to procure tools to help providers to control for cost . Um, I'm most familiar with the , um, Medicaid agency in Arizona who has rolled out a community cares program, which is effectively a , a state incentivized tool or state subsidized, I should say, tool , um, to, to , uh, to try to incentivize uptake in the market and what we saw in Arizona, even when you're controlling for cost . 'cause often cost is the biggest barrier, right? You have , uh, low, low budget community based organizations in many cases that can't afford new fancy tools, or you have providers that are also similarly situated. But when you control for cost , there are still some barriers that I think are worth calling out here and thinking through creative ways to, to , um, to approach it to ensure that whatever's SDOH solution is introduced in a given market is ultimately successful. First is making sure that whatever you introduce on the provider side doesn't force providers to go outside of their workflow. I think increasingly providers don't want to be bombarded with many, many technology tools. They want something that integrates directly with the EHR that they're using day in , day out to provide patient patient care , um, and , and tools that don't allow for that type of integration. Um, I've seen some reticence , uh, in the market to , uh, to, to adopt. Uh, I think the contracting , uh, barrier is real, and Mel can speak more to that 'cause she has just a , a plethora of experience in this space, trying to put in place contracts that don't overwhelm community-based organizations who simply don't always have the resources or the lawyers at hand to review the material and get up to speed. Um, yeah, I , I think, I mean, in , in my experience, those two, our, our prime and then ultimately in order to be successful as a closed loop referral platform, you've gotta have a critical mass of CBOs and providers who are participating in a closed loop referral system who are making the referrals on behalf of their patients in order for it to be useful. And that takes time. Um, that takes, just takes time and rollout in communities. I don't know, Eric, Mel , Sarah .
Speaker 3:Yeah , I mean , I , I was just gonna say, you know, the contracting thing, you know, it's, especially when you think about physician networks , uh, you know, whether ACOs or other things, and they hire these business associates who provide care management case management services, the contracting can be significant because you have one entity that's kind of the managing entity in the spoken wheel model. Uh, but then they, you know, you might have platforms who say, no, we need a contract with every single provider, and you're talking about 60 to 70 providers within a state. Uh, you know, and it , it, it can become a lot and, you know, addressing these issues from the provider or payer side is not necessarily, you don't see those dollars come in in the benefit. It's about improving whole person care, reducing overall cost , right? In some sort of risk-based model. And so it's, it's also having to justify those costs and continuing these programs. And that's where, you know, for and Sarah's experience, you know , Medicaid mandating that these or Medicaid agencies mandating that these things be done, right, because they need to be done. You know, one thing I wanted to talk about just briefly with Sarah , so full disclosure, Sarah and I both operated in Tennessee and, you know, I was worked at a large payer while Sarah was the , uh, chief compliance and privacy officer at the state Medicaid agency at Tencare . And I, I think we had tons of discussions about some of these and, and working on some , uh, contracts together. But one of the biggest issues outside of just the costs , it's also those resources for the CBOs and getting them on board , right? I mean, you're talking about the places where you're targeting for these types of programs. They have a , you know, population who have tons of need and, but there's already existing limiting resources, for example, those food banks are stressed , the, you know , there's not enough housing. Uh, and so it really just takes, takes an entire community-based approach. I mean, Sarah , I can think about certain communities, both rural and urban and, you know, Tennessee, which are just, you know, so hard , uh, to outreach to, right? I mean, absolutely . I don't know if
Speaker 6:You have from , you have these organizations that are stretched so thin and here we are, we're asking them to do one more thing, become familiar with one more system, and then let's just add some contracts on top of that for the non-existent time that they have left. So what we found to be helpful was to start outreach early, fill in these community based organizations on what exactly we're gonna work with, what we need from them , and pick contracts with easy to understand terms. Don't send them a 20 page contract. Make sure you streamline those agreements and basically do everything you can to help these CBOs just overcome some of these hurdles so that they can participate and do what they do best as link these individuals to resources for housing, food, transportation.
Speaker 3:Yep . I mean, I think that that's , yeah , go ahead Mel.
Speaker 4:Yeah, I just wanted to add on, on the CBO side, one of the things that I think is make it more successful with CBO uptake is if you have the budget for it, for instance, if this is a , a Medicaid driven project, for instance, or you have grant funding or legislative funding for the SDH platform, is to the extent you can give incentive payments to CBOs for uptake or to give dedicated dollars for them to assign personnel to do it. Because it's not even just about signing the contract or integrating the system. It's who is going to do this? We're gonna have to train somebody on it . They're gonna need to spend time to do it. And paying the person to do that work or to provide the volunteers at that CBO to help do that work is one of the ways that you can increase CBO participation.
Speaker 3:Yeah. And, and , and you also, 'cause you definitely don't wanna just shoot those referrals out in the dark. You wanna make sure those they're closed, right? You wanna see the outcomes, right. And so I think that's completely right, Mel . Totally agree. Well, you know, I guess I'll kind of cap it off with this one. Where do we see SDOH headed in, in the industry? You know, Annie, I'll kick that one to you. You know, where, where do you see this, this going in the future?
Speaker 5:Oh , goodness. I think that this, that we're, that this , in spite of the, the barriers that we have identified today, that we are just at the very beginning of this type of data exchange. There is no question given the information available on impacts. So social determinants of health impacts on a patient's lived clinical experience, there is just no way that we're, that this is not going to take off and continue growing the , um, types of data exchange types of tools being offered directly to patients. Um, and they're then being integrated back into the clinical record are only growing and increasing in number. And so I think that that , um, hopefully we will see some potentially federal legislative legislation that can help us streamline some of the complexity when you have to compare federal laws versus the specific state laws at issue that create complexity for practitioners and companies who are practicing across multiple states. Um, but ultimately I think , uh, that we're just at the beginning of this space. Mel,
Speaker 4:How about you ? I agree with that. I a hundred percent agree with that. There's so much need and there's so many tangential governmental programs that really require you to have this SDOH data to prove that gaps have been closed, that you've closed that referral, that they're getting those needs, and you need the data to be able to report on that. And that is going to happen through SDOH platforms. And it might not be this full blown SDOH network we're talking about. It might be the digital SDOH screening tools that you have integrated into the EHR or the health plans care coordination platform. Um, but it might be those more robust referral and network platforms. In fact, I think it's worth pointing out that California, through the, the data exchange framework, which requires hospitals and certain health plans to participate in data sharing net in a data sharing network. It's not just clinical data. They're also talking about the social services data as well. So this is definitely on the radar for different state. And I also think maybe federal government , um, in terms of increasing the amount of data sharing to meet social needs. So that's not gonna stop where I see a lot of , um, issues on uptake. And are we actually gonna see more use of it is really gonna come down as to what's the business model for this? How is this gonna be finance, where's the money gonna come from? And you've already flagged the complexity with the data laws. There needs to be some sort of solution there because of the amount of complexity. So I do see greater uptake. I see continued challenges though with, with making it work. What about you, Sarah ?
Speaker 6:Sure. So from my end, I think SDOH is here to stay. Absolutely. Our healthcare systems are stretched so thin right now. They're basically to, their limit costs are skyrocketing, and SDOH platforms are a way to curb some of those costs by addressing health issues more holistically and not just based on one or two symptoms. And I think the data is there to show that we need SDOH to improve health outcomes.
Speaker 3:Yeah, I , I mean, I , I agree with everything that everybody said, surprise <laugh>, but , but I would just say it's, I think, you know, Mel , you kind of hit on one thing, which I think it's just where the money is, is going and how do you show return on investment? Because you're talking about, you know, if you're a payer, you're looking at a whole statewide population or , or focusing on some specific rural or, you know, or specific urban areas and communities. And , uh, you know, it's really trying to show that our ROI , but it makes the data so imperative, right? And so I just think that we're just gonna continue to see all of these platforms that share information and then increase funding incentives to, you know, once we see how it all shakes out over time, but increase funding to address these, this whole person care issue to keep costs low , right? I mean, I think 'cause all of these issues, the , the research has shown that it , it's, it's better for the individual and it increases their overall health by addressing these issues. So there's the ROI ON investment, but how do you just implement it and, you know, where do those funds come from for those CBOs and other types of entities? So I think we're gonna see more targeted efforts to increase dollars in this space, no doubt. So. Well, I think that that's our time, everybody, and we appreciate you guys taking the time for this A HLA , uh, podcast. I wanted to thank , uh, Mel, Andy and Sarah for participating. And again, check our article that was published this year on SDOH issues. It's, it's one of the most comprehensive articles out there. Uh, but thank you guys so much. We really appreciate it. Thanks for taking the time.
Speaker 2:Thank you for listening. If you enjoy this episode, be sure to subscribe to a HLA speaking of health law wherever you get your podcasts. To learn more about a HLA and the educational resources available to the health law community, visit American health law.org .