Eager for Health Equity? Then Let’s First Change Health Policy

Updated on April 2, 2023
happy senior patient with friendly female nurse

Even as a once-in-a-generation pandemic has reshaped so much of the world, it remains too easy for those of us in the medical field — for doctors and nurses alike — to gloss over the subject of health equity in our work.

While extraordinary training and skill are required to tend to the medical needs of an individual, confronting the complex social and economic dynamics that drive systemic health disparities requires just as much sensitivity and care.

This is especially true as these same complex dynamics keep so many disadvantaged groups from having even their basic needs met.

In my own patient engagements, I make a conscious effort to avoid any approach to treatment that risks characterizing human beings as a collection of symptoms in search of solutions. Instead, I proactively embrace the notion of whole-person care.

What’s that? It’s a healthcare approach that considers not just the physical individual in need, but all components of their environment, background, psychology, and personal makeup. In so doing, whole-person care helps paint a fuller picture of each person in need — primarily by situating them in the real-world, everyday context in which they already live.

In other words, it treats people as people, not as numbers on a chart. It recognizes each of us is not only responsive to our bodies but to a web of habits, impulses, social connections, geographic locations, and sometimes just plain good or bad luck.

Ultimately, by deliberately honoring whole person care at every opportunity, I know I’ve sharpened my skills as a caregiver. More importantly, I’ve come to a deeper and richer understanding of how an array of disparate pieces fit together to shape each individual’s unique and precious life.

Meeting Ms. P

When my colleagues at Belong Health and I first met Ms. P, she was a 60-year-old woman living with several chronic conditions, including end-stage renal disease, anemia, hypertension, pulmonary fibrosis, arthritis, congestive heart failure, esophageal strictures, depression, and more. She qualified for a Dual Special Needs Program (DSNP) and required assistance for numerous daily activities. The DSNP population is eligible for Medicare and Medicaid. They are more vulnerable than the typical Medicare population but, inevitably, deal with more bureaucracy when trying to manage their health benefits. Needless to say, Ms. P was wary.

At the time of her initial engagement, Ms. P. was undergoing kidney transplant evaluation and out-of-network dialysis. 

But not all her challenges could be readily summarized in a tidy list of conditions and symptoms: she struggled with self-advocacy. She felt guilty for relying on her adult daughter for so many caregiving needs.

By her own admission, Ms. P felt like “a burden on [her] family.” We knew this kind of personal unease would require more than medicine and surgery to be resolved.

Caring for Ms. P

When we first sat down with Ms. P, she was resistant to any notion of a personal health plan at all. After all, she told us, a care manager was already helping her with dialysis. What more could be done for her?


Unbeknownst to Ms. P, her status as a DSNP member qualified her for a host of care benefits she hadn’t yet used. One such asset was the ongoing support of her very own care management team, which included a Medical Director, Registered Nurse, a Licensed Clinical Social Worker (LCSW), a Community Health Worker, and a pharmacist.

Together, the members of this curated care team worked harmoniously not only to help Ms. P get the resources she needed but also to answer questions about her health and to set achievable health and wellness goals for the weeks and months ahead.

Sometimes, care team members called up Ms. P just to actively listen to what was going on in her life and community. It was through this gentle methodology, in fact, they were able to offer her a sense of safety — one so reliable she finally began to share with them her most personal feelings of loneliness and hopelessness.

Care management team members reviewed Ms. P’s medication and explored options for home medication delivery and timely refills. They offered to connect Ms. P with a trusted behavioral health specialist.

Although Ms. P declined that last offer, she was deeply grateful to have secured so much control over the direction of her own health. In drawing from this newfound well of gratitude and optimism, an even deeper trust was established.

Care management ultimately directed Ms. P and her daughter to a primary care provider for comprehensive discussion of a long-term treatment plan that would keep Ms. P firmly in the driver’s seat of her own care. And, in the spirit of collaboration, her care management team alerted her provider that Ms. P had been receiving dialysis for a year — a detail she had not previously shared with her doctor.

Thanks to the LCSW on her personal care team, Ms. P was even set up with home health services — resources that enabled her and her daughter to explore a host of caregiver support options without stress. Together, mother and daughter benefited from the guidance of a Consumer Directed Personal Assistance (CDPA) agency, whose experts assisted in the submission of all necessary paperwork — and, consequently, in further reduction of stress for their family.

Catching up with Ms. P

Today, Ms. P is thriving. She finally feels a sense of control over her own life and health. She takes medications as prescribed and regularly participates in her own care planning meetings. Because her care team continues to provide education on her conditions and needs, her daily anxiety has subsided.

Most importantly, however, Ms. P no longer hesitates to reach out when she needs help or guidance. She knows a member of her care management team is always just a quick message away. 

And she no longer feels like a burden on her family.

As Ms. P’s daughter is now being paid, through Consumer-Directed Personal Assistance Services (CDPAS), to provide Ms. P with care, their joint efforts to enrich and lengthen Ms. P’s life have only drawn the two closer together.

“This program and the care management team really knew how to help me,” Ms. P later told us. “I’m glad you would be there for me.”

Connecting personal successes to policy reform

Like so many tales of personal health, Ms. P’s story is both unique in its details and universal in its import. In every community across the country, people are weighed down by severe medical need but are reluctant, or too overwhelmed, to take that first step — to trust, to plan, to engage.

As we can’t expect to catch every individual before they slip through the cracks of our complex healthcare system, celebrations of unique success stories only highlight a need for change at systemic, policy-oriented levels

For many years efforts have been made to improve the care for dual-eligible beneficiaries who often deal with numerous medical, social, and behavioral health needs. A bi-partisan congressional committee recently sought input on what to do next. Below are three policy changes that would better support this growing population.

  • Increase incorporation of social determinants of health (SDOH) and socioeconomic characteristics when developing quality, risk adjustments, and STARS metrics.

Healthy living doesn’t occur in a vacuum, and there is no test case for the “perfectly healthy” human. We must consider nutrition, lifestyle, environment, income, race, and a host of other social determinants in the shaping of the ratings systems used to evaluate risk and performance.

This is exactly what was done for Ms. P. To get an accurate picture not just of her symptoms and history but of how she lived. Thoroughly screening her for several social determinants of health and conducting a full risk assessment that considered all aspects of her physicality, psychology, environment, and daily life. Only after performing such assessments could we fully address needs that lay outside the parameters of a ‘typical’ health plan. 

For example, an investigation of the Ms. P’s ‘neighborhood and built environment’ as well as her ‘social and community context.’ proved particularly illuminating. Even heartbreaking.

Ms. P’s physical ailments and challenges were never purely physical at all — they had been exacerbated, in fact, by a concern that ran even deeper than anything we could have measured on a chart.

Ms. P had long felt alone, frustrated, and wracked with guilt about the strain she imagined she’d put on her loved ones. And that suffocating sense of personal agony, we soon discovered, was among her toughest and most personal battles to fight.

But how — I found myself wondering, with no shortage of irritation — could this 60-year-old woman’s loneliness, frustration, and anxiety be recognized only now? How could the awesome power of medical expertise leave so much of her personal complexity overlooked for so long?

Truthfully, there was no excuse for it. But there was, thankfully, a solution. Ms. P’s personal care team swiftly connected her with community resources, reconnecting her and her daughter with a world she’d assumed had left her behind. 

As it so often does, that newfound community and sense of belonging rapidly became indispensable in lifting both her spirits and her health.

There’s a lesson to be learned here. Throughout her story, it was often the personal relationships Ms. P had built with each member of her care team, with her community (and, of course, with her daughter) that kept her moving towards a promising outcome. Absent this soft touch from a local and focused system of support, her healthcare journey may have ended very differently.

Where broader healthcare policy, thus far, comes up short in its consideration of social determinants of health (including community ties, as just one example) Such awareness is fundamental to truly transformative healthcare — the care all members and patients deserve.

Addressing a member’s social needs and the varied and significant impacts it may have on their health is vitally important. However, there is limited support for this work, and it often goes unrecognized in the risk scores and quality measurements that are used to evaluate the health plan.

  • Push for more interdisciplinary teams, higher levels of care integration, and maximized healthcare simplicity for every member.

My work stubbornly reminds me, repeatedly, of one simple truth: an increase in barriers to medical care leaves an individual discouraged by it. In other words, the more systems someone is left to navigate, the more daunting and impenetrable that whole process is left to seem. 

In contrast, medical care that is distilled through a single point of contact, and with a single set of reliable benefits, is routinely proven to be the best way to reduce patient burden and to facilitate a seamless medical experience.

An experience rooted in true equity and deeply cognizant of socioeconomic disparity.

A single set of “one-stop shopping” health benefits — including medical, behavioral, pharmaceutical, long-term services, and support for social needs — dramatically reduces each member’s stress and boosts their health outcomes.

That reduction of friction, in turn, reduces fears around seeking medical aid. And that reduction of fear and confusion ideally leaves each member empowered to enjoy more benefits and resources that address their whole person.

Extending this approach to all health systems would benefit each individual in need and would also mark a powerful shift in our cultural mindset about the healthcare system itself.

Perhaps we could finally begin to prioritize lifetime care — healthcare built not solely on chasing discrete medical solutions to immediate ailments and challenges but, instead, on shaping whole-person health via long-term planning and strategy.

To incentivize a focus on lifetime care, and to limit headaches for individual members, I recommend, as policy, default enrollment into healthcare plans — and plans who rapidly enter and exit geographies should be penalized.

While Ms. P always had multiple voices (including her daughter’s) involved in her care, there was initially no cohesion or connection between any of those stakeholders. Offering a streamlined and deeply personalized approach to care management, effectively established the stability and communication Ms. P had always craved.

That consistent system of care not only boosted Ms. P’s healthcare outcomes, it lowered her healthcare costs. With the support of her on-call care management team, Ms. P was guided through Medicare and Medicaid in ways that saved her time and money. 

That’s the kind of healthcare experience all patients, regardless of their backgrounds or circumstances, deserve.

  • Recognize social determinants as fundamental to healthcare for the DSNP community

Although Centers for Medicare and Medicaid Services (CMS) currently requires all its healthcare plans assess psychosocial issues through health reimbursement arrangement (HRA), this has never been a uniformly applied policy. That needs to change.

For Ms. P, a thorough psychosocial determinant screening meant a world of difference. It unlocked our ability to finally put her on a path towards community, belonging, and better health. It helped us see what had otherwise been overlooked.

In the current healthcare landscape, benefits related to social determinants (nutrition, exercise, social community, as just a few examples) are too often treated as “add-on” features within Medicare Advantage plans. We urgently recommend each of these elements be considered fundamental parts of healthcare — not just accessories to be casually tacked on to the traditional baseline DSNP care of hospitalizations, medications, and visits to a doctor’s office.

After all, it’s little wonder so many members of our DSNP population, especially those from multiply marginalized communities, often expect negative outcomes from the care they receive. Once a member’s world is pressurized by pills, surgeries, and hospital visits — once every doctor’s visit is defined by a “problem” — control over personal care naturally seems less and less achievable.

In 2023, a socially conscious redesign of healthcare is not only achievable but necessary, nationwide. It’s time for us to broaden DSNP healthcare beyond treatment to include proactive prevention that doesn’t just save lives but enriches them, too.

Crucially, a strengthened and welcoming primary care practice must live at the core of this redesigned system. Friendly, frequent, and open dialogue between medical professionals and plan members — just as was illustrated in the story of Ms. P — will naturally become the heartbeat of long-term, whole-person care.

I love my work and won’t be satisfied until the feelings of doubt, strain, and personal shame felt by Ms. P and so many other DSNP members are no longer commonplace across the healthcare landscape. 

No one should be made to feel purely like a patient. A collection of ailments. A burden to their loved ones.

I’ll stay committed to meeting every community and member in the language, style, and circumstance that uniquely suits them best.

I can only hope national healthcare policy soon meets that challenge, too. Because try as we might, we know we can’t reach everyone on our own.

Portrait of Natasha VanWright by photographer John Keatley
Natasha VanWright

Natasha VanWright RN MBA MS MA CCM is a healthcare executive who is dedicated to advancing health care equity through the development of care management programs using a whole person framework. Natasha has 20+ years of experience across the healthcare ecosystem including inpatient care, community health, business development, and nursing education. Additionally, she has developed health plan care management programs for Commercial; Medicare, Medicaid, D-SNP, and underinsured/uninsured populations. She earned a B.S. from Fordham University, a B.A. and M.A. in nursing from Pace University, an M.S. from Weill Cornell Graduate School of Medical Sciences, and an MBA from Cornell University.