Healthy State: Practicing What They Preach in Louisiana

Am J Manag Care. 2024;30(Spec No. 10):SP775-SP777. https://doi.org/10.37765/ajmc.2024.89613

Mary “Toni” Flowers, PhD, DHL, MBA, the chief diversity and social responsibility officer for New Orleans–based LCMC Health, hinted at the obvious as she stood next to Eboni Price-Haywood, MD, MPH, director of the Ochsner-Xavier Institute for Health Equity and Research and Flowers’ cochair for the evening.

“Take a picture!” Flowers said, drawing laughs from an audience that brought together professionals from 2 large players in South Louisiana health care.

Competitors? Very much so. In the past decade, Ochsner’s hospital count has grown from 8 to 48 across 3 states, while LCMC Health, a nonprofit formed in the aftermath of Hurricane Katrina, operates 6 hospitals, including the 2.3 million–sq ft University Medical Center.^1,2 But the systems are united in Healthy State, an effort to move the needle in a place that is culturally blessed but cursed on every health measure under Louisiana’s baking sun.

The July 25, 2024, session, “Healthy State: Know It, Own It, Live It,” held at the Westin New Orleans, was the third installment in the Institute for Value-Based Medicine series focused on Healthy State, a multiyear, multistakeholder commitment to moving Louisiana from 49th in America’s Health Rankings (AHR) to at least 40th by 2030.³ July’s meeting came ahead of a larger meeting, the Healthy State Summit, scheduled for October 24, 2024, in Baton Rouge, the state capital.

Progress takes time, and Price-Haywood acknowledged that Louisiana may be improving residents’ health even if its relative position on some measures seems stuck. Other states, she notes, are working just as hard on their own health challenges. But there’s progress in some important areas, as AHR measures from 2020 to 2023 show the following⁴:

• Louisiana’s smoking rank improved from 48th to 43rd.
• In dental visits, the rank improved from 47th to 41st.
• Louisiana made smaller improvements in the percentage of adults with chlamydia, the percentage with high-risk HIV behaviors, food insecurity, physical activity, measures of clinical care, and measures of childhood trauma.

The decrease in smoking is important, given that the top drivers of premature death in Louisiana are cancer and cardiovascular disease, which Price-Haywood said “is pretty similar to the rest of the country, but take note that in Louisiana, a third of those deaths from cancer are related to lung cancer, which again is heavily tied to smoking.”

Amid the progress, Louisiana’s relative position slipped in some areas, including the percentage of adults with obesity and multiple chronic conditions, premature death, and the share of households with high-speed internet.

Price-Haywood focused on how poorly Louisiana ranked in obesity, economic hardship, and high-speed internet—all social determinants of health. “Note that 80% of what drives health outcomes has nothing to do with the health care system,” she said.

Moving to a payvider system. To launch the “Know It” segment, Phil Oravetz, MD, Ochsner’s chief population health officer, said US health care has reached “an inflection point” that compels stakeholders to look at the total equation of care delivery—in other words, the value.

Historically, he said, US physicians trained to deliver quality care but knew little about cost. That’s no longer possible, as health care has reached 20% of the gross domestic product due to the government’s historic reliance on a fee-for-service reimbursement system. Thus, both government and commercial plans are looking toward new value-based models that balance quality and cost.

Health systems such as Ochsner are learning to address both quality and cost by taking on risk; the delivery system is blurring the line between payer and the provider, hence the term payvider. Increasingly, Ochsner is participating in value-based contracts, which allow the use of claims, clinical, and social data to give a more holistic view of what drives outcomes—so health systems can get in front of the causes, including the social determinants. More recently, a focus on the Quadruple Aim targets patient experience, population health, cost savings, and provider well-being.

How does a health system become a payvider? Oravetz listed the concrete steps, which include investments in (1) technology and operations infrastructure, (2) analytics and dashboards, (3) population health management, (4) patient engagement, and (5) development of integrated workflows. More important, he said, is the promotion of a mindset that continually reinvests in quality: “You get to the point where your quality is so good—I really don’t worry about quality too much right now.”

In 2027, Oravetz said, a “20-year slog” will end when health systems will have access to their claims data, thanks to an act of Congress. When health systems can access these data, use of robust analytics—including artificial intelligence—will allow the savvy ones to combine social data and leverage community partnerships to transform the way they deliver preventive care. Oravetz is an unabashed fan of Medicare Advantage plans—which now account for 54% of Medicare beneficiary enrollment—and noted that CMS’ own strategy calls for all Medicare beneficiaries to be in a value-based plan by 2030.⁵

“We’re finally recognizing that more health care doesn’t mean more health,” he said. “We have to create health in other ways, right? That’s the genesis of Healthy State.”

Innovating with healthy food. To “Own It,” Healthy State looks squarely at a source of Louisiana’s struggles: its relationship with food. A reputation for world-class eating doesn’t mean everyone has enough food or appropriate food for their medical needs. Elizabeth Grush, MBA, PMP, Ochsner’s vice president for equity and Healthy State, led a discussion on these issues among Toby Comeaux, deputy undersecretary at the Louisiana Department of Children and Family Services; Sylvester Tumusiime, PhD, project manager for the Louisiana Public Health Institute; and Kimberly Williams, MPP, director, health equity and population health at Humana.

Williams first outlined Humana’s Food Is Medicine program, which offers 3 approaches: medically tailored meals or medically designed grocery packages, which are both developed with dietitians, or vouchers that allow beneficiaries to purchase qualifying healthy foods. Tumusiime’s institute is running a trial comparing participants who are given opportunities to purchase groceries in stores vs an online platform through Instacart. The study seeks to learn which leads people to buy healthier foods. Comeaux’s agency administers $200 million in benefits from the Supplemental Nutrition Assistance Program (SNAP) to 900,000 residents each month, and this year added distribution of summer assistance for families with school-aged children.

The common thread is community partnerships: Comeaux credits Ochsner with helping beneficiaries enroll in SNAP, and Williams said physicians from Terrebonne Parish, in the bayous southwest of New Orleans, sounded the alarm about hungry patients coming to their clinics. Humana worked with entities such as Second Harvest to distribute food. For the many successes, the panelists were candid about the barriers they face: Comeaux said older people are the least likely to enroll in SNAP, despite having high levels of food insecurity; Tumusiime described the resistance from some study participants to putting their personal information into an online platform. And Williams said Humana had to figure out how to get food to older patients in the most remote areas.

Long term, she said, the goal should be consistent messaging to children from a young age about eating healthier food and adopting healthier habits. “I hope that in the future we are doing comprehensive, culturally responsive communications and health education with people who need access to healthy food,” she said.

“We’re Louisianans, we love our food, we want to eat a certain way,” she continued. The right balance must respect the area’s traditional approaches to food, “but also understand that we have a huge issue with obesity, and we have a huge issue with food insecurity, which is heartbreaking to be honest. And so, my hope is that Food Is Medicine will be a key tool among providers, and that it will be the go-to gold standard for people with chronic conditions, obesity, hypertension, and diabetes.”

New meaning to engagement. The “Live It” segment gave meaning to the concept of “meeting people where they are,” because in New Orleans, the “where” could be a nightclub or a bar or even a Mardi Gras parade route. According to New Orleans Health Department Director Jennifer Avegno, MD, and Yvens Laborde, MD, Ochsner’s medical director for global health education and public health, whether it’s getting people vaccinated against COVID-19 or screening for prostate cancer, nothing is off the table.

In a discussion led by Taslim van Hattum, MPH, LCSW, chief program officer at the Louisiana Public Health Institute, the physicians offered lively examples and advice on how to gain the public’s trust. “I think one of the things specifically is being humble when you approach the community,” Laborde said. “Ask and listen. Sometimes that’s one of the things that’s overlooked. We tend to come from a place of arrogance, where ‘we know’ and we’re going to come and figure out what’s wrong with the community. I think it’s really important that you ask permission, that you’re humble, and that you listen.”

Avegno agreed and said voices from the front lines must be constantly feeding into data sets or documents such as community needs assessments. Use of data, she said, must be structured in a way that is community centered. “It’s also important to be decentralized,” and leaders must be “willing to share the space and to share the power.” Finally, she said, “it has to be diverse, and diverse in all aspects.”

Laborde and Avegno shared some unusual partnership ideas, including the “shot for a shot” promotion in the spring of 2021 that gave bar patrons a drink if they got the COVID-19 vaccination.⁶

“If I have any legacy,” Avegno said, “it’s so intuitive to New Orleans.” On a serious note, she said public health professionals should work with all willing stakeholders, conventional or not. A separate campaign gave bars free naloxone and trained staff to use it to reduce opioid overdoses.

“Is that the solution? No,” Avegno said. “That’s not a normal partnership from a public health perspective. But if it gets our overdose rate down, that’s a win.”

In a similar vein, Laborde said the historic Black all-male Mardi Gras marching corps, the Zulu Social Aid and Pleasure Club, offered the perfect target audience for prostate cancer screening. “People just want to be asked,” he said. “We’ve had partnerships with the social aid and pleasure clubs, and with bars and with churches and with gun range owners and libraries. There’s always a health angle, because health is everything.”

If New Orleans’ community linkages can be tapped to improve health, they will be powerful, Laborde said. “When I go to other places, I see we are actually far more interconnected than most other communities, and proud of it. So if we could keep that connectivity in what we’re trying to do in health care, then we’re ahead of the game.”

Flowers said the lessons of COVID-19—that we are all in this together—should carry forward. “How can you work with your community partners, seeing things from different perspectives?” she said. “We hope, as you leave us today, now you know it, we want you to own it, and ultimately, we all have to live it.”

Author Information: Ms Caffrey is an employee of MJH Life Sciences, parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. Woodruff E. Ochsner’s growth exploded under Warner Thomas’ tenure. What happens next? NOLA.com. September 18, 2022. Accessed August 15, 2024. https://bit.ly/3SMIYGQ
2. Healthcare with heart. LCMC Health. Accessed August 15, 2024. https://www.lcmchealth.org/documents/content/LCMC-Health_Fact_Sheet.pdf
3. Caffrey M, Klein H. How Ochsner, Xavier are working together to make Louisiana a Healthy State. Am J Accountable Care. 2022;10(4):42-46. doi:10.37765/ajac.2022.89288
4. 2023 annual report: Louisiana. America’s Health Rankings. Accessed August 15, 2024. https://www.americashealthrankings.org/learn/reports/2023-annual-report/state-summaries-louisiana
5. Freed M, Fuglesten Biniek J, Damico A, Neuman T. Medicare Advantage in 2024: enrollment update and key trends. KFF. August 8, 2024. Accessed August 15, 2024. https://bit.ly/3WPu4ks
6. Lorell C. New Orleans bars and restaurants join COVID-19 vaccination effort. Eater NOLA. April 21, 2021. Accessed August 15, 2024. https://nola.eater.com/2021/4/12/22376260/new-orleanss-bars-restaurants-join-covid-19-vaccination-effort-shot-for-shot