Speaker 1:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft, and today I'm in conversation with Dr. Laurie Zephyrin. She's the Vice President of Health Systems Equity at the Commonwealth Fund. We're also fellows together in the inaugural class of the Aspen Health Innovators Fellowship. Laurie, welcome to Healthy Conversations.
Speaker 2:
Awesome.
Speaker 1:
We've known each other for a while. You're trained as a classic OB/GYN, but you've really branched out to look at a whole bunch of other elements that's impacting women and health equity. One of your big steps was to move to the Veterans Administration, the VA.
Speaker 2:
I've always been interested in thinking about how to ensure women have access to comprehensive health care throughout their entire lives. I actually spent a year as a White House Fellow in the VA. I left and practiced at Columbia for a few years, delivering babies, doing surgery, global health work. The VA actually was building out its women's health programs, saw an increased number of women veterans, and really had to undergo a transformational shift from taking care of predominantly male veterans to really transitioning sort of across the gender landscape to incorporate women as well. And so that was really very exciting. How do you provide care to a population that's growing?
Speaker 1:
And I imagine also the shift was happening within the military in general with more women even in combat roles.
Speaker 2:
Yeah. Imagine being a woman who served and coming to the VA and being asked, "Where's your husband? Where's your father?" when you're the one that's been serving in the front line. So really a cultural change and then also a systems change in terms of beyond just expanding gynecology services or thinking about obstetric services, like how to make sure that there's the capacity, from a clinical training perspective, but also from a systems perspective to care for the broad spectrum of new veterans that were coming into the health care system.
Speaker 1:
Given the VA's a big system and change sometimes takes a while, any lessons there from shaping your own perception and attitudes towards women's health and how to help shift those in a large organization or society writ large?
Speaker 2:
I spent a lot of my career at the systems level really thinking through how can we design systems that work better for the people in them. Our systems are designed to silo women's health into just sort of this bread box of these are the things you focus on for reproductive health, and then everything else may or may not get focused on. Being able to create primary health care centric for women veterans and being able to integrate teams that include primary health care provider, hopefully a gynecologist, a mental health specialist, proved to be very effective. And research a few years later just showed improved experience and some improved outcomes as well.
Speaker 1:
So in any health system, you often get what you incentivize or you get what you measure, but a lot of that, again, is aligned with what you measure as an outcome.
Speaker 2:
So our health system is designed in a way that separates women's bodies into reproductive organs and other parts, right? That's probably how you and I were trained as clinicians and how our health systems are organized, even how our reimbursement structures are organized. And so how do you align the incentives? One way is to align incentives around creating better opportunities for transitions of care between these silos, measuring differences or disparities between populations and creating incentives for health care leaders which attract those measures and intervene. And so for example, stratifying measures, let's say around diabetes based on gender, for example, hemoglobin A1c. If you're able to track that across institutions and you notice a difference, then what are some interventions that, from a system level, one can incorporate to narrow those differences?
Speaker 1:
And systems can learn, but ultimately it comes down to the team and the individual provider. Any sort of thoughts on how we might change medical education to understand both the disparities, maternal and women's health in general, for those who are not in that sort of day-to-day?
Speaker 2:
I do think that medical education plays a critical part in that. I've been very heartened by the conversations and the work that the AAMC, the American Association of Medical Colleges, how they're addressing structural racism and thinking about addressing it in medical education as well.
Speaker 1:
Spot on, and often we don't know where our blind spots are. So we talked about disparities, which has sort of been exacerbated in the setting of COVID-19. Any particular sort of examples or data you can point to that really highlight the racial disparities, particularly in maternal health?
Speaker 2:
Too many people die preventable deaths during pregnancy in the United States. By the CDC's estimates, about two thirds of pregnancy related deaths in this country could be prevented. And we know that black pregnant people are especially at risk and are about twice as likely during pregnancy to experience a maternal [inaudible 00:05:12] death or maternal morbidity. Our health care system doesn't work as it should for women and especially for black women. Startling facts, like if you're a black woman in America, regardless of your education, you're two or three times more likely to die during childbirth. And in some parts of this country, for example, New York City, you could be eight times as likely to die during childbirth. So there's definitely a need for us as a society to address this.
Speaker 1:
That's massive. I mean, eight times the difference. Are there sort of the 80/20 rule? Are there 20% of the situations that can be managed or better understood to impact that and bring down that massive disparity?
Speaker 2:
So there are many reasons why we may have these disparities. Let's say the top four, black women, for example, don't get the care they need before or after pregnancy, but disproportionate number of black women are uninsured. So how do we address social inequalities that are upstream, for example, and also downstream? The third is when black women seek care, they're often not taken seriously. Regardless of how educated we are or how much money we make, black moms don't get the same respect or attention, and there's data to show that. And so take for example, Serena Williams' health care providers ignored her complaints for shortness of breath.
Speaker 1:
So we have a lot to learn and a lot of improvement to make. We know that the United States, despite spending the most per capita, is ranked quite low, particularly in maternal-fetal issues, but we have lessons from around the world, some spending far less per individual.
Speaker 2:
So it's really interesting. When we look at data, women in the US are more likely to die before, during, or after childbirth, and women in high-income nation, white women, black women, Hispanic women, Indigenous people, disaggregated categories as well. Our health care system is failing women and we need to do better. When we looked at 10 other high-income countries, we just see more investment in primary health care, which has the foundation of a health care system. So one is if you have a foundation of primary health care, after you give birth, you're sort of seamlessly integrated back into a health care system. Now, with the American Rescue Plan, there's new legislation to extend postpartum Medicaid up to one year, which is really important.
Speaker 1:
Any sort of best practices for those who are listening that could be more easily implemented at their community level?
Speaker 2:
Well, sometimes it's really important to ask the questions and to really understand how people's living environments and working environments could impact their health. I mean, I remember having a patient once, and she just was missing multiple, multiple visits. In her note from her primary care visit, it was saying, "Non-compliant and not listening." And when I finally got her in and spoke with her, I mean she was working three jobs and living on her brother-in-law's couch, having to bury her mother in the prior year. No one had asked her those questions. And so in her medical record, it's just non-compliant patient. So we as clinicians need to better understand why is it that people may not be coming into our practices? Can we reach them through a phone visit? Would another type of telehealth visit be an option? Are there other providers that can see her at a different time?
Speaker 1:
Yeah, we talk a lot about social determinants of health, but we often really don't even document or ask the questions about what's the patient's sort of sociome. We don't often ask if they're hungry and don't have enough money for food. So sometimes asking the simple questions, it might make a massive difference.
Speaker 2:
It's important for people to question their own assumptions about people that come to see them. I mean, it's challenging. It's not fun. But it's important to do and it's important for growth as well.
Speaker 1:
Can you tell us a bit more about the Commonwealth Fund in general and its mission?
Speaker 2:
So we function as a think tank. We've just launched a health equity fund to really focus on advancing health equity and addressing structural racism within the health care system and from a policy perspective as well. Primary health care is the foundation of any health care system, and so really thinking of ways to help improve that and increase that. Medicaid expansion is one example. As I mentioned, postpartum extension has been included in the American Recovery Act, which is very exciting. Medicaid, instead of ending at 60 days now in terms of coverage, birthing people can have Medicaid coverage up to a year. That's an important first step.
Speaker 1:
So it's one thing to identify systemic gaps and barriers, and it's another thing to address them.
Speaker 2:
From a policy perspective, we're providing technical assistance to states who are interested in addressing, within their Medicaid RFPs, specific aspects of primary health care, incorporate high quality, comprehensive primary health care from a payer perspective that incentivizes how delivery systems and providers provide care. I think that's really important to be able to really think about, one, the reimbursement and driving the incentives.
I think on the health systems side for models of primary health care, it's really looking at the population that you are serving. I mean, it's probably serving more than 50% women. You're probably serving a diverse population. And so one, does your leadership represent that? Two, is that built into your culture and ethos of the organization? And three, how are you centering that population within your walls? I think that's another way to address that as well.
Speaker 1:
We've had in the last year the pandemic, the Black Lives Matter movement, the importance of vaccines, for example, on the communities of color and others that might have felt distrusting, let's say, traditional medicine and therapies.
Speaker 2:
Very early in the pandemic, we didn't have initial data in terms of who the pandemic was affecting, but as the data came out, we see that black people, Hispanic people, Indigenous people are most affected. And the question is why is that? Do people have access to health insurance coverage? Do they have access to jobs where they can work from home? At no other time in my life... I mean, I'm just hearing more conversations, and I think we're also in a prime policy moment where that can also be addressed. That's really, really important to understand how structural racism impacts people's lives and impacts their health.
Speaker 1:
Any meta lessons you've seen at the VA and Commonwealth that really could help catalyze that further across the planet?
Speaker 2:
It's interesting, I was talking to someone at UPenn, and they've developed a really interesting sort of local tool that they're piloting to be able to address bias, where people can sort of enter into this tool experiences of bias, and that's discussed on a regular basis in real-time fashion.
Speaker 1:
I think it's a really exciting time in health care for sort of re-imagination and reshaping, and part of that is driven by emerging technologies. We've talked in the past about femtech apps to help you get pregnant or prevent pregnancy to wearables that can track the health of the mother and the fetus, all the way now to startups, addressing needs around menopause. Are there any particular new technologies, innovations, platforms that you've seen that you're excited about that are addressing gaps in women's health care?
Speaker 2:
There's really an increasing conversation about equitable care and women's health in the venture and technology space. There seems to be an explosion of models trying to address these various silos, whether it's menopause or infertility or contraception or maternity care. I'm just excited about continuing to see an increase in entrepreneurs of color as well, really tackling these problems in a really interesting and inclusive way, for example, Google and their work in product inclusion and diversity, YouTube and their health content reach, the entrepreneurs addressing silos and women's health from menopause to maternity. There's also an opportunity to think through how to connect these various ecosystems. What does it look like from the user's perspective? Is there a way to link all of these platforms, connecting them to form a unified comprehensive care model for women that truly recognizes the diversity of the people being served?
Speaker 1:
And what's exciting, we're both part of the Aspen Institute Health Innovators Fellowship, which brings folks from clinical sides, from policy, from venture, from the startup world together. It helps unleash the power of convergence and collaboration because you can't have siloed solutions, and often the magic happens when you bring folks together. A little interesting example, we have a pocket ultrasound now with AI that I could probably even do an obstetric exam at home and enable a nurse practitioner in a relatively rural area to do what an OB used to do in the past. Any favorite examples of convergence or cross-fertilization you could share?
Speaker 2:
Oh, goodness, there's so many. I love what Cityblock is doing. Their model is just very equity-centric in the middle, meeting people and patients where they're at. I love the work of Ashlee Wisdom and Health In Her HUE. It's a platform that allows people of color to access providers of color or culturally competent providers. I love the work that's happening in the menopause space, reframing life after 40. I'd love to see more innovation in the Medicaid space. I could say the last thing is around telehealth. With COVID, we've just seen sort of people flip the switch on telehealth. I'd love to see that continue and that have payer models and create seamless infrastructure. Hey, you need a tele-visit today? Great. You need an in-person visit next week? Perfect. There isn't a competing interest based on payer reimbursement.
Speaker 1:
But how do you blend those virtual models and in-person? And I think, particularly, in the setting of COVID, we've seen a lot more examples of even virtual care coming to the prenatal visit.
Speaker 2:
In the last year, what I think has been really interesting in the maternal health space has just been how we've reimagined the prenatal visit. I mean, it used to be you need X number, 13 prenatal visits. I remember when I was pregnant, having to go to so many prenatal visits can be challenging. Flip the switch with COVID, it's reinventing and saying, "Okay, well, you really need four or five in-person visits and these four or five tele-visits we can incorporate into that model as well." That's really exciting.
Speaker 1:
We're entering this era of big data, but not just data, the AI and the analytics to make sense of that, but they need to be informed by the best studies that are not just from white, European, Caucasian men as their baseline, which many of the guidelines around care, whether it's for statins or others, are still based upon.
Speaker 2:
The who at the table is important. Who's on your leadership team? Who's on your board? Who are your advisors? Where's the data coming from? It's really critical to think about all of those things from the entrepreneur perspective, but also from the investor perspective.
Speaker 1:
Speaking directly to health care providers, anything you'd like to add or any other subjects we haven't addressed you want to make sure we highlight and communicate?
Speaker 2:
There's just a lot more data coming out now just to show that black people aren't necessarily vaccine-hesitant. They're increasingly interested in getting the vaccine, whether we're talking about black and Latino and Indigenous people and other people of color, and so it's also thinking about where are vaccines given and is there actual access to vaccine, and are we providing access to vaccine to people in their communities and making sure that vaccine access is equitable? To your question around what do I tell other clinical providers, I'm also still a clinical provider. There's data showing that, for example, black people aren't listened to when they come into health care settings, and we all know that particularly in life or death situations, those can have dire consequences.
Speaker 1:
Lots of challenges, lots of opportunities. Want to thank you, Laurie, for joining us on Healthy Conversations. Thank you for your incredibly impactful work and lessons that you've shared that can hopefully help all of us bring a better, healthier future for all.
Speaker 2:
Thank you.