CareFirst's 1st public health director: We have 'a moral imperative' to address health inequities

Djinge Lindsay, MD, is the new and first director of public health at Baltimore-based CareFirst BlueCross BlueShield. She spoke with Becker's about how she wants to leverage member data and industry relationships to achieve better health outcomes for the people and communities in the Washington, D.C., Maryland and northern Virginia region.

Question: You are the first public health director for CareFirst. Why is this position needed now?

Dr. Djinge Lindsay: There's a few different reasons why this position makes sense now. As a nation, we're seeing ever-rising costs in our healthcare spending without the equivalent in health outcomes, and in some instances actually seeing worse outcomes. Within those core health outcomes, what we have recognized within the public health community and across the nation coming out of the pandemic is that there are still vast disparities based on race and geography within those particular outcomes. There's a business imperative to get in control of your population and make sure that you're applying solutions to improve people's health, but I think there's also a moral imperative for us. We have to understand that there are systemic issues that have been going on for years: the structural racism that has led to issues with people not having opportunities to be healthy. From a moral standpoint, that also has to be addressed. I think the field of public health offers a framework for businesses, particularly in the healthcare space, to start to tackle these huge social challenges that are impacting our members in our communities.

Q: You're going to be leading a public health infrastructure team to improve health outcomes and equity for 3.5 million people. Can you explain what that will look like on the ground in the communities you serve?

DL: There's two ways that I look at us as a not-for-profit payer and as a huge business presence in our region. I think one is our role as a health insurer. For the public health team, our very first priority is to get a handle on our data. I think we all have a sense that there's definitely disparities within our membership. We know there's disparities within our community from data that's publicly produced, but we need to understand exactly where we're seeing those and start to unpack some of the factors we know are contributing to these inequities and to these poor health outcomes. 

Our first role for public health is to really provide some actionable data for our team to start to center around and say, we understand now what the problem is in an objective way. Once you understand the problem, then you can apply solutions. I think a lot of times in many spaces, people start to look for solutions without really having an idea of what we're solutioning for. 

Based on that public health framework, our first role is to assess what the problem is in an objective way, and then start to do policy development around how we can address the issues that we're seeing. When I say policy development, I don't mean specific legislation or policy, although that's part of it. There's also policy in terms of programming or approaches that we're taking to try to level the playing field and increase opportunities for good health for our members. 

The way that we're looking at this as a not-for-profit insurer is with three main focus areas that we can leverage. One is directly to our members — our benefit design, our wraparound support program offerings, our abilities to help people navigate through the very complex health system — what can we offer our members directly? Our second bucket of big intervention is our providers — how can we work with our providers to really support them, but then also have some levels of accountability for the outcomes they are producing, the quality of service they're providing and their ability to decrease disparities within their panels. That's things like value-based payments. Making sure they do a good job, but also how we are partnering with them to do that. How we are also leveraging those member-focused interventions to really partner with our provider community and support our patients. The third is — we are very focused on our members, but we also have a huge focus on our community and our role as a regional insurer in the D.C., Maryland and northern Virginia area. Where we are strategically investing in our community, and supporting our community at large and down the line to support healthier communities and healthier members. How we are also promoting equity within our company, within our workforce and our approaches as part of our local business system as well.

Q: What new strategies are you looking at to collect this data and how to best analyze and implement it?

DL: The big elephant in the room for all organizations is: How can you identify disparities if you can't identify people's race, ethnicity or language? There's a ton of articles out in the health space about the challenges that healthcare faces around being able to attach race to data so we can understand disparities. This year, we have an analytic tool that's going to help us to get some blunt understanding of our enrollees' race, ethnicity, language, as well as social risk, which are very closely tied in many ways. That's working with a company called Socially Determined. 

In the long run, where we want to go is doing better with direct data collection from our members. That's through Firstsource, but also through our provider reporting systems. There's also having some level of trust with both our members and provider community to say, "We don't want to use this data for bad. We don't want to use it to adjust your premiums. We really want to understand where we have opportunity for improvement, and we are going to have to do work as an insurer to have that level of trust with our communities and with our members as well."

Q: Prior to this, you served as medical director for CareFirst's D.C. health plan. How did that experience of providing oversight for vulnerable populations on Medicaid shape your plans for your new role?

DL: My career path and total trajectory has set me up for this role. My first career coming out of medical school was as a primary care doctor. I trained in a community hospital, where the patient population that I was seeing was largely publicly insured or uninsured. We provided safety-net services and tried to provide very high-quality care for marginalized populations. My career has been as a front-line primary care doc working every day with patients. 

The reason that I went into public health is because as a clinician, I understood very quickly during my medical school training that what I could offer to a patient on an individual basis is just chipping away at the problem. Where public health works is at that broad population level — looking at policy systems, environment, and looking at those kinds of root causes and systems to allow people to be healthier. For example, I remember having a woman with diabetes and she's overweight. We're talking about counseling for physical activity, and she tells me, "There's nowhere for me to walk in my neighborhood, it's not safe, and the recreation space nearby is filled with litter and isn't well lit, and I don't necessarily have that opportunity when I go into work." 

As a physician, you are stuck. I can write you these prescriptions, but the other interventions that you really need to support your health, I can't offer you. I wanted to pivot from that whack-a-mole game of primary care into how we are looking at more broad based solutions. The choices people make are the choices they have, and those choices are determined by the systems and the structures and the neighborhoods they exist in. 

My next role was working with the D.C. Department of Health and really looking at community programming for our populations. Coming out of that, I had experience as a provider and I had experience as part of the public system working for the government. What I really wanted to understand more is how, from a business lens, do you leverage your tools to improve health outcomes? Clinicians were not taught a lot about finance and healthcare costs, and I think that's part of our underlying issues in this country. Even in the government space, we're given a budget and we work with it how we can, but you're this one entity. There's this whole surrounding system that's really impacting people's outcomes more than the provider, the government or the public health department. Going into D.C. Medicaid, it was really understanding how a payer provides support for our members. From a business perspective, how we can deliver on lower costs with improved outcomes.

Q: It sounds like you're in favor of value-based, whole-person care models?

DL: It's been a business imperative for us at CareFirst. We're doubling down on our efforts to move to more value-based contracts. If you incentivize payment for widgets, people produce more widgets. We have to change that payment structure for us as a nation to realize better outcomes. I think payers (and to be fair, I have been a provider) need to be in lockstep with how we're moving together as a payer community so we're not making things more difficult or challenging for our providers. 

Q: How does your personal background lend itself to success in this role?

DL: I grew up in North Philadelphia. If you don't know about Philadelphia, it meets the textbook definition of a ghetto. It was a very low socioeconomic status. I remember as a child having to drive to a grocery store, and luckily my parents had a car. We didn't have fresh food sources in my immediate neighborhood and there were issues with walkability. I have a good understanding of what some of the challenges are for communities that have been disinvested in and how easy it is to lack opportunity. 

I'm thankful that I'm the child of a two-parent household, both of whom had college degrees. They fought for me to have opportunities, particularly around education. Had I attended my neighborhood school, they were looking at issues like not enough textbooks for people to take home. What kind of future do I have where I'm starting out without having adequate literacy? You're not even set up for a trade school career, let alone trying to rise to be a physician. 

I think that having come from the communities that we talk about, when we're talking about disparate outcomes and the results of redlining and other other historically racist practices — I think that gives me a unique perspective. Coming from that community, my sisters and I have all been very service-driven in how we want to approach the world. We were all blessed to have more opportunities than many of our peers that we grew up with, and now we're using that to do work that's in support of social good and social change.

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