This month, Sanjay Basu, Waymark’s Head of Clinical, took the opportunity to speak with and learn more about Monica Soni, a Waymark advisor. Monica describes her experience in primary care, working with health systems to improve care access and quality, and recommendations for Waymark when engaging with providers, with social determinants of health, and with health equity topics.
Sanjay: Can you tell us a little bit about yourself, how you ended up in primary care, and what you're doing now?
Monica: I'm originally from Los Angeles. I trained in San Francisco at UCSF in the primary care track based at the county hospital. That was the mothership in some ways, because I was surrounded by like-minded folks taking ideas that had been theoretical when I trained in Boston at Harvard and teaching me how to implement those ideas practically. What does harm reduction actually look like? What is patient-centered care in action? When the formulary doesn't allow for somebody to have an insulin pen, you pre-fill those syringes on your own until the prior authorization goes through. I was taught by faculty who could really support me in learning the fundamentals that have carried me through my career.
I came back to Los Angeles, after the Affordable Care Act (ACA), to the Los Angeles County Department of Health Services. That safety net institution had been doing 80% uninsured care, and after the ACA we flipped to nearly 80% managed Medicaid. So imagine a wholesale flip from building out an electronic health record, to creating population health platforms and panel management systems. If you think about Bodenheimer’s building blocks, we had zero.We had to do all of that building, while trying to care for incredibly ill, complicated patients. I ended up not only practicing as a primary care physician, but also running primary care, urgent care and transitions-of-care clinics. I was not seeking to get 10 years worth of experience truncated into three, but that is what I got by necessity. I became a utility player, just because of having been in a resource-lean setting. I don't mean resources from the dollars perspective; LA county has money to do the care. It's really from a team perspective. We didn't have a bunch of folks who could do informatics, population health and community engagement. There were only small pockets of experience.
I then transitioned to serving as Director of Specialty care for Los Angeles County, which is second in size to New York, supporting four hospitals, about 25 ambulatory centers, and about 200 Federally Qualified Health Centers (FQHCs). We were one of the largest eConsult implementations and used eConsultation in sophisticated ways rather than traditional prior authorization or utilization management. There was intentionality about having a primary care person in that role, thinking about how specialty care is in service of primary care, which actually remains a fairly progressive idea.
Finally, I progressed to the role that I am in now, serving as Associate Chief Medical Officer for New Century Health, a national company that manages specialty care, with depth in oncology and cardiology–both expensive specialties with high complexity and gaps in equity. I again function as a utility payer thinking about how to achieve the elusive quadruple aim of improving quality and equity, patient experience, cost, and provider centeredness. And again bring that safety net primary care perspective to the work we do to ensure we are making systems better for our most vulnerable.
Sanjay: One thing we want to talk about is you had a lot of experience with improving primary care. What should organizations like Waymark think about when engaging with primary care providers?
Monica: I think we–as primary care providers–are a little bit of a paradox. We say “we're too busy. Don't do that. I can't be bothered with that.” And then we also say: “you better not do that without telling me.” I think both things are true. Anybody who wants to interact with primary care really needs to have operational efficiency at the core and understand the workflows.
Primary care providers will always go out of their way to do what's right for patients. But if it's perceived as a waste of time, we won’t do any of it.
The onus really is on folks outside of the micro-ecosystem to understand what's in it for the provider. And what’s in it for primary care providers is usually what's in it for the patient.
Sanjay: In terms of improving care for Medicaid populations, tell us a little bit more about what success looks like for organizations that try to care for patients in community settings in particular, outside of the doctor's office.
Monica: I think there's the standard answer, which is from our vantage point: metrics, metrics, metrics. So you've curbed costs and you've got some patient satisfaction numbers and provider satisfaction numbers. Yes. Right. Of course. We must do that. The expectation is that you do that.
But I actually think more comprehensively the question is: have you made the community better? Is there a sustainable change? Both of us have been strongly influenced by Paul Farmer and there's his idea that you are only a piece of the solution. Everything that you're doing should be making the infrastructure better so that the community itself can continue to have health and wellness.
I don't think we measure that very well at all. To me, that is what I hope is going to come out of Waymark’s work.
Sanjay: Linked to that question, I have a bit of an obnoxious question. A lot of people are passionate about addressing social determinants, particularly as a strategy to address health equity. What should we be careful about when engaging in this space? What wisdom do you have for those of us working on these topics to ensure we are meaningful and productive?
Monica: I sit on the board of Mercy Housing California, an affordable housing organization, and they shared with me a study from the 90s, the Moving to Opportunity Study [a study to randomize low-income families to receive a voucher to move out of their neighborhood to a higher-income neighborhood]. I read it with fascination because I thought to myself: did people really think this was a good idea?
This is what I worry about. Are we actually doing co-creation of programs with community members? We believe that we have the answers, then we do what's easiest for us to pick off, without actually addressing the core issues. There are definitely going to be bad ideas to address social determinants of health, and the bad ideas mostly come from us. So how can we make sure that we are getting at least some cross-section of ideas from the communities that we get to serve?
Some of the ideas will be local and some of them will be scalable, but they will still be potentially impactful, and we have to be willing to do co-creation. It's tricky in the United States to advocate for differential use of resources. We all have social determinants of health, but not all of those social determinants of health lead to disproportionate outcomes like death. So when it's life or death for some populations, how can we not be willing to give some specific resources, whatever they may be, to address differential risk? There's a study that came out of Chicago, looking at AML [acute myeloid leukemia], and the title was ‘Structural racism is a mediator of disparities in acute myeloid leukemia outcomes’. I don't know any of those authors, but I am so proud of them. They just called it what it was. You won't be surprised, essentially the predictive factors for death weren’t genetics. They weren’t co-morbidities. They weren’t insurance. They weren’t the treatment plans. The disparate outcomes in death were due to census tract factors. How segregated your neighborhood was. Affluence or lack thereof. Things that we all know. But tell me, what are we doing to address any of those things?
When we talk about social determinants of health, what would it even mean to integrate? To reallocate? We're going to have bad ideas in that space, back to my opening point about the Moving to Opportunity study. We're going to have bad ideas, so let's actually work with the folks that are living and breathing these experiences. Let them help inform our strategy.