Abstract
Health equity is a key focus for health care providers, government entities, and employers nationwide. While much research has been done to understand and address the long-term effects of health inequities in populations that traditionally might not have reliable access to health care, little research has been done to understand the impact of Social Determinants of Health (SDOH) on commercially insured employee populations. Now, however, employers are gaining a better understanding of how social factors can lead to ill health and health care inequities among their employed populations covered by the organization’s health insurance program. 1
Even in employed and insured populations, health inequities such as bias and discrimination negatively affect employees mentally, emotionally, and physically. Additionally, these inequities can negatively impact productivity and health care costs for the employer. The W.K. Kellogg Foundation estimates that “disparities in health in the U.S. today represent US$93 billion in excess medical care costs and US$42 billion in untapped productivity.” 2 A National Institutes of Health (NIH)-funded study found that “in 2018, racial and ethnic health disparities cost the U.S. economy US$451 billion, a 41% increase from the previous estimate of US$320 billion in 2014.” 3
One employer, Metro Nashville Public Schools (MNPS), a large metropolitan school district, has committed to understanding and addressing SDOH through a whole health benefits strategy. As early as 2006, the Trust that manages the teachers’ health plan adopted a mission to “look beyond health care costs alone to the impact of poor health on the total health and productivity paradigm.” By taking steps to understand employees’ needs and barriers to care, the district can better provide tools and resources to support overall health and well-being, job satisfaction, and performance in the classroom, thereby supporting the district’s overall objective to optimize students’ educational achievement.
Understanding the MNPS Population
Metro Nashville Public School’s population includes public school teachers in a large urban school district, most (79%) of whom are female with an average age of 41. The population is 67% White, 26% Black, and 7% other.
Despite having college degrees and a consistent salary structure and benefits package, many are struggling. While seemingly homogeneous (in geography, salary/benefits scale, educational background), the teacher population is comprised of diverse communities influenced by micro-geography, race, culture, age, and personal history.
A Five-Pronged Approach to Health Equity
The MNPS Certificated Employee Health Plan is founded on the district’s core belief that healthy employees are better employees. Metro Nashville Public School has committed time and resources to help its population get and stay healthy, find job satisfaction and fulfillment, and be fully present in their classrooms to support students’ success.
To achieve these goals, MNPS first prioritized 3 domains of health equity: 1. Removing barriers/improving access to care 2. Boosting preventive care/screening practices 3. Addressing high-cost/high-prevalence obesity/cardio-metabolic conditions (e.g., diabetes) and associated comorbidities (e.g., obesity, mental health concerns)
With these domains as a foundation, the district developed a five-pronged benefits strategy targeting high-risk and high-need employees in their population: 1. Integrated Data Warehouse 2. Simple Low-cost Health Plan 3. Value-based Benefits 4. Focus on Population Health 5. Employee Health Clinics
Integrated Data Warehouse
In 2012, MNPS partnered with Benegration, a data warehousing firm, to provide a framework for analyzing clinical, financial, and administrative data to provide a better understanding of the covered population and their needs. Based on an analysis of SDOH in the employee population, 3 SDOH tiers (low need, medium need, and high need) were created through a process that began by dividing the region into geographic census tracts, which are smaller areas and more geographically homogeneous than ZIP codes. These census tracts were then classified into the 3 SDOH tiers based on 10 indicators of social need categorized into criminal justice/safety factors (crime rates, incarceration rates, etc.), economic stress (unemployment rates, poverty rates, social vulnerability index, per capita income), and the built environment (risk of lead exposure, access to food, etc.).
Additionally, drawing from sources such as medical claims, electronic health records, lab results, health history, participation data, and employment data, the district has been able to mine data to better understand the health issues affecting various communities and subsets of the population.
The data partner analyzed employees and the association between SDOH tier, health care costs, health risks, and other measures. By combining race and ethnicity data drawn from HR records with payroll data, they developed an employee profile that includes job, work location, home location, educational background, tenure, salary, age, and sex. Additionally, the integration of data associated with TN census tracts provided key data on SDOH in various locales across Nashville. Now the district knows who works and lives where as well as their demographic profile.
From this data, the district found that half of MNPS teachers live in areas of high social need, with minorities representing a 30% greater saturation in those communities. The data showed that home and work locations impact health to a much greater degree with Black employees than with White employees. It also showed that Black employees have the highest rate of comorbidities, driving the highest health care costs.
Using the data and information gathered, MNPS was able to identify those employees deemed most at risk according to SDOH. Understanding the different tiers of employee need, they were able to develop a whole health benefits strategy that addresses these at-risk employees, care gaps and inequities across its population.
Simple Low-Cost Health Plan
The district offers certificated employees a simple, low-cost health plan that includes medical, dental, vision, and hearing coverage in 1 package and for 1 premium. Despite the popularity of high-deductible health plans to mitigate health plan costs, MNPS instead opted to make coverage affordable and straightforward and, in many cases, to provide care with zero cost share to ensure cost and confusion are never barriers to care access. It offers members a preferred provider organization (PPO) with a low deductible, low office visit and pharmacy copays, and US$0 cost prescriptions for asthma, COPD, diabetes, and cardiovascular conditions. Enhancements (described below) have been added as the district has learned more about the needs of its population.
For example, the plan prioritized easy access to behavioral health (BH) care by eliminating cost share for BH office visits in 2019, adding a no-cost virtual counseling program in 2020, and eliminating cost share for all in-network mental health care (inpatient and outpatient) in 2022 with remarkable outcomes. In 2019, 27% of health plan members had a BH diagnosis while 44% who filled a BH prescription were not actively engaged in therapy. Today, though BH diagnoses have increased to 36%, the number of members who filled a prescription but who did not also actively engage in therapy decreased to 22%, indicating that more people are taking advantage of therapy options available.
Additionally, the plan provides value-based bundles through Vanderbilt Health to provide comprehensive care for conditions such as pregnancy, cancer, musculoskeletal conditions, and weight loss. Members who utilize these bundles pay zero cost for covered treatments and receive concierge-level care from a dedicated patient care navigator. The district has seen impressive results. Across all bundle categories, members living in areas of highest social need are 15% more likely to participate in the bundles than those living in areas of lowest social need.
Value-Based Benefits
The third prong emphasizes a benefits design that focuses on achieving better health outcomes for all members by eliminating disparities in access to care.
Preventive Care
Boosting preventive care practices — with age-appropriate screenings and vaccinations — is at the core of this strategy. The district examines screening rates across race and gender to inform efforts to close gaps. Additionally, the health plan offers zero cost-share for follow-up screenings or diagnostics to encourage members to act on positive results. As a result, the district has seen high primary care attachment along with high associated preventive care metrics (screenings, vaccinations, etc.). For example, preventive visits/1000 increased from 486 for calendar year (CY) 2017 to 529 for CY 2022, and breast cancer screening rates increased from 75% for CY 2017 to 84% for CY 2022.
Premium Discount
In 2017, MNPS began offering an US$800/year premium discount for taking a Health Risk Assessment (HRA). The HRA provides valuable data that informs the implementation of wellness programs and gives employees a snapshot of their health. Offering a means of reducing premiums on an already low-cost plan helped ensure affordable health coverage was more accessible to all employees.
Program Offerings
Metro Nashville Public School’s value-based plan design includes a vast array of programs, many of which are designed to “meet people where they are” and appeal to different cultures and backgrounds. Programs cover a variety of treatment/healthy living options such as metabolic management, health coaching, telenutrition, behavioral health care, and chronic pain management. From 2017 to 2022, 73% of health plan members participated in 1 or more of the core programs.
Incentive Plan
In 2018, the district funded an incentive program called MotivateMe. It rewarded employees who got key preventive screenings (e.g., wellness visit, mammogram) and who completed certain health coaching programs. Today, 60% of members participate in MotivateMe.
Telehealth Services
Understanding that teacher schedules often make it difficult to see medical providers in person, the district expanded access to low or no-cost medical and behavioral telehealth services. The convenience of telemedicine ensures that enrollees have access to care regardless of their socio-economic status, location, or other environmental factors.
Focus on Population Health
A key component of the five-pronged approach is offering programs that address the health and well-being of specific at-risk populations and including them in the design of these programs. To best understand the varying populations and their specific needs, the district gathers comprehensive data through population-wide needs assessment surveys, Press Ganey patient satisfaction surveys, and a Patient Advisory Group that meets quarterly, composed of 15-20 employees, retirees and family members who have received care at the employer health clinics in the previous 2 years. It also draws data from its data warehouse, Cigna claims, and a robust internal quality dashboard powered by Epic and Tableau. Additionally, the teachers’ health trust, comprised of current teachers, retirees, and union members, is actively involved in plan design. Analysis of wide-ranging data points has enabled MNPS to identify high-risk areas and to work with health care partners to provide care and treatment for groups that need it most.
One identified focus is obesity and its comorbidities. Metro Nashville Public School data analysis showed that the most common health risk factors among its population were BMI ≥ 30 kg/m2, followed by high blood pressure. Additionally, since obesity disproportionately affects marginalized communities and racial and ethnic minority groups, and with 33% of the covered population falling into these groups, it was important that the district provide an effective and equity-focused solution.
Traditional models of obesity care and treatment were not producing the desired outcomes, so MNPS partnered with Vanderbilt Health to create a bundled care solution. The bundle, which offers both medical and surgical weight loss options, drives members to a center of excellence and includes comprehensive services needed to successfully lose weight and maintain weight loss (e.g., nutrition counseling, exercise, sleep, and psychological support). The bundle is offered to eligible members at no out-of-pocket cost.
Since launching the weight loss bundle in 2021, the district has seen tremendous results. • Employees have lost more than 7000 pounds, and co-morbidities such as diabetes and coronary heart disease have seen dramatic improvement. • Cardiometabolic spend for patients with diabetes has plummeted from 19% in 2018 to 9% of total cardiometabolic spend in 2022.
Employee Health Clinics
To support its commitment to remove barriers and improve access to care, the district looked for ways to ensure all members could receive care when and where they need it. Metro Nashville Public School warehouse data show that half of MNPS teachers live in communities of high social need (e.g., low income, limited food access, primary care deserts), and of this subset, Black teachers are 30% more likely to live and work in high-need areas than their White counterparts.
To provide convenient and equal access, MNPS established 5 employee health clinics, each no more than 15 minutes away from any workplace. These award-winning clinics are staffed by an integrated care team that provides primary care, behavioral health, health coaching, physical therapy, chiropractors, and acupuncture, as well as a pharmacy and fitness center at a central wellness center, all at no cost to members. Moreover, all 5 clinics are certified as Patient-Centered Medical Homes (PCMH) and provide integrated population-health tools like quality improvement dashboards, care coordination and clinical pharmacist support.
These clinics also include a full range of wraparound service providers including licensed clinical social workers, board-certified hospital chaplains, nurse navigators to triage patients and explain benefit policies, and telehealth services with on-call nurse practitioners, all without any out-of-pocket cost to the employee. Providing this large network of support ensures the whole person is being cared for, both inside and outside clinic walls.
The results: For health plan members attached to clinic primary care providers vs members attached to community-based primary care: • Overall medical costs are nearly 30% less. • Inpatient admissions are 38% less. • Emergency room utilization is 23% less.
Conclusion
Metro Nashville Public School’s five-pronged approach to promoting health equity amongst its population has produced impressive results. The district has seen increases in the diagnosis and treatment of behavioral health conditions, greater engagement in lifestyle and other anti-obesity interventions, and improved health and lower overall cardio-metabolic trend.
More importantly, promoting health equity for teacher populations can have a ripple effect in the community. Having a benefits package that supports their whole health can increase retention, decrease absenteeism, increase productivity, and improve mental and emotional outlook. This, in turn, results in positive classroom environments and outcomes. Furthermore, the economic effects for teachers and the district have downstream effects on communities and businesses as spending is shifted away from health care and into the community.
With health care costs expected to continue to rise, employers will need to look for ways to contain costs and support employees and their families. Metro Nashville Public School’s approach can serve as an example for other employers striving to address health inequities, achieve economic goals, and support the health and well-being of employees.
Footnotes
Acknowledgments
The authors thank Jon Harris-Shapiro of Benegration (Pittsburg, PA) for data preparation and analysis.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
