What Is Being Done to Assess the Disproportionate Effect of COVID-19 on Minority, Rural Communities?

As the United States continues to manage the ramifications of the coronavirus disease 2019 (COVID-19) pandemic, minority and rural communities have been ravaged by significantly disproportionate health and economic consequences. Notably, the mortality rate among African Americans has been indicated to be 3 times the rate of white people.

Although some may attribute this increased mortality rate to comorbidities such as diabetes and hypertension, which disproportionately affect African Americans, Gloria Wilder, MD, MPH, vice president of Innovation and Health Transformation at Centene, highlights that even after controlling for chronic illness, statistics still expose significant health disparities.

Recently, Centene and the National Minority Quality Forum (NMQF) announced a research-based partnership to examine underlying factors behind these disparities. In an interview with The American Journal of Managed Care^®, Wilder, along with Gary Puckrein, PhD, president and chief executive officer of the NMQF, speak on the implications of this partnership for underrepresented communities and how it can increase the availability of attributable data for minority populations.

Transcript

AJMC^®: Hello, I'm Matthew Gavidia. Today on MJH Life Sciences News Network, The American Journal of Managed Care^® is pleased to welcome Dr Gloria Wilder, vice president of Innovation and Health Transformation at Centene and Dr Gary Puckrein, president and chief executive officer of the National Minority Quality Forum. Can you both just introduce yourself and tell us a little bit about your work?

Wilder: Well, I'll start, I'm Gloria Wilder, and I helped to lead our Innovation and Health Transformation initiatives across Centene’s platform. Centene, we're a health care insurance company that focuses on really taking local actions and making sure that our health plans on the local level have control so that they can impact patients very directly. Centene has always been interested in how to improve the health outcomes of the populations that we serve, and not just for our members, but for our members’ families and the communities in which they reside. So, it's a pleasure to be here with you.

Puckrein: I’m Gary Puckrein. I'm president of the National Minority Quality Forum. The National Minority Quality Forum is a research and educational organization based here in Washington, DC. A lot of our work centers around collecting health data. We've been collecting health data now for about 20 years. We have a database of over 5 billion patient records. We collect data of about 130 million lives a year. We are particularly focused on what's happening to minority and underserved communities in health care, looking at both the quality of care they're receiving, as well as of their health status.

AJMC^®: Gloria, can you discuss the heightened impact of the pandemic in minority and underserved communities? And may current statistics be understated due to a lack of available testing?

Wilder: To talk about the COVID-19 pandemic in relation to communities of color and underserved communities, rural communities, marginalized communities, is to really talk about how our nation has historically dealt with health inequities. COVID-19 is really unroofing what has been a long-standing boil in health care, which is that there is disparity, and disparity has long existed, and there are certain populations that are unequally affected by the outcomes of disease and disorder.

What we see time and time again is that these communities tend to, if they're being heavily affected by 1 chronic illness, the other one will come along, and COVID-19 just shines a light on that. So, in terms of the pandemic, yes, I believe that there's underreporting that's going on. We know that there's a number of states in the United States that still don't even ask for demographic data. When screening for COVID-19, they're not asking race, they're not asking ethnicity, and that tracking is critical to getting the real numbers. But it is still striking, even with those deficiencies, that we're seeing such a high level of mortality and morbidity in African American communities, Hispanic communities, our native tribal communities, rural communities, and all of this has to be addressed.

Puckrein: Yeah, I think the moment of urgency is upon us. I think one of the things that I’m most taken aback by is the absence of a national strategy, a sense of urgency around the fact that Americans are dying. We've got almost 120,000 people who have been affected by the virus, and estimates are that it's going to get to 200,000. As a doctor, I always suggested it's impacting rural and minority populations disproportionately.

I think it's an important moment for industry, as well as government, to take a look at themselves and say, should I be standing on the sidelines when Americans need me most? That’s a really important question that they have to ask themselves about. I'm an old dog, right? I grew up in the 1950s when people thought of corporate responsibility to the communities that they served and lived in. We're at that moment now where corporations have to step forward, and that's why we've been so pleased with the way Centene has reacted to this situation and has shown some real leadership. But Centene and NMQF, we can't do it on our own. It's really important that others now come off the sideline and really help. Tthere's a big help sign that's out there, and I think it's needed.

Wilder: Yeah, and with that, Matthew, I'd say, for Centene, we recognize that we're serving 1 in every 15 Americans through Centene from a health care perspective, and we're trying to deliver on the highest level of quality, but you can't do that without looking at the greater good. These moments of public health urgency, where there is a population health crisis going on, it needs to be a moment of all hands on deck. So, we invite our entire industry to come and work on the solutions collectively.

This is a moment where there should be no competition in health care. Hospitals should work with other hospitals, and FQACs [federally qualified health centers] should work with other FQACs, and managed care companies should come together collectively to say, why is this happening? Why do we see in certain communities, like in Louisiana, a 6 times higher rate of mortality in African Americans than non-African Americans? Why is that occurring?

State, after state, after state, we're seeing those same kinds of numbers. What we know to be true, and Gary has spoken of this many times, is that it's not just chronic illness that's causing this mortality rate, because when you control for chronic illness, we still see these types of numbers.

AJMC^®: Gary, just to build off that, to address health disparities, Centene and the National Minority Quality Forum announced a research partnership to assess the impact of COVID-19 in these communities. What does this partnership entail, and when and where will studies take place?

Puckrein: As the virus started to unfold, there was a quick response to why were African Americans and Hispanics in rural communities being disproportionately affected. So, the quick response was, well, they have asthma, they have diabetes, and so it is these comorbid conditions. Some of it underneath, you kind of blame the victim, in light of if you did not have diabetes, you wouldn't die. So, it released everyone from being responsible, because in effect, they sort of brought it on themselves.

When the studies started to come out, as Dr Wilder suggested, where you control for diabetes and you control for asthma, you control for hypertension, you still see these high levels. So, the question became really, what is the science? Where is the science? That helps us, and the minute you started to look for the science, what you found is that minority populations weren’t in the science, they weren’t in the studies, we have no science. So, we were really pleased in enrollment with our initiative and Centene’s initiative. They came to us and said, we think there needs to be some science here, and we agreed with them.

So, what the study is doing, it's doing what is necessary, which is to begin to look at these populations, using them as the reference point, as the reference population, and trying to understand are there biomarkers? What's driving the risk? So, we are collecting data, testing those to see if they have the virus, to see if they have antibodies, doing genomic sequencing to try to understand what's the biology here.

AJMC^®: Can you discuss what data will researchers collect and analyze through the partnership?

Puckrein: So, in the data collection, we are assuming no knowledge. So, we are starting with the PCR [polymerase chain reaction] test to see if people are positive with the virus. Then we're also screening for the antibodies, and we're using different platforms to screen for the antibodies. The reason is that there's data out there to suggest that antibodies present differently in populations.

So, the example would be that if you are a senior, you may not produce as many antibodies as a young person. So, we want to make sure that as we screen, we're looking at the cohort that was screening for the antibodies, and then we're going to try to associate that with outcomes meaning the antibody tests confer immunity, and the only way to do that is to look over time, as Dr Wilder suggested, so we'll be looking over 5 years. Does the virus itself impact metabolic processes? There’s data to suggest that it triggers the onset of diabetes, that people may have been prediabetic, and so we want to know that.

There is a suggestion that it could impact cardiovascular health, and so we want to take a look at what it's doing to people with varying degrees of cardiac health. But the point is, what we've done is we've pulled together specialists in cardiology, endocrinology, neurology, pulmonology, and each one of them is looking at the virus from the lens of their specialty and helping us to follow the patient.

So, this is probably the most comprehensive look at the virus in diverse populations. The findings that come out of this, hopefully, will tell us a lot about this particular virus but also begin to help us understand that homogeneity is a hard way to learn. Heterogeneity is the way in which you learn quicker, and so, when you try, which you're just looking at a homogeneous population, you can't pick up the signal, right? Because you're just looking, and then you're trying to apply that to everyone. So, we think that we're setting a whole new way of beginning to look at the way in which we produce science for the American population, which, of course, is growing more and more diverse.

Wilder: When Centene reached out to the National Minority Quality Forum, we reached out to them because we knew their long history of being able to produce really stringent and rigorous research. This is one of those moments where I think we need to say that our commitment to a longitudinal study, that will last over 5 years, reflects our commitment to all of the communities that we're serving. That we know that COVID-19 is not a 1-day event, right? It's not a go get screened and either you're positive or negative.

We know that this has changed lives. Unfortunately, this has ended lives, and this will continue to change not only lives in our communities, but as a pandemic, it is changing the world and how the world views health. Health will never be seen again in the same light that it was before COVID-19. And that might be a good thing, because there were some mistakes we were making in ignoring people's needs or not addressing health equity and health inequities properly, and hopefully, this will be a drumbeat that heads us in that direction of being able to look at every single disease now and really start to count difference, and understand that difference matters. You should not ignore race; you should not ignore gender differences or gender identification differences. You should not ignore poverty as an impactor of health outcome or the social determinants of health as an impactor of health outcome.