Dr. Bechara Choucair | The Next Great Health Crisis

Jennifer Tescher:
Welcome to Emerge Everywhere. I’m Jennifer Tescher, journalist turned financial health champion. As founder and CEO of the Financial Health Network, I’ve spent my career connecting forward-thinking leaders to the growing fin health movement. Now I’m sharing these conversations with you. Discover how these visionaries are challenging the status quo and improving financial health for their customers, employees, and communities. Dr. Bechara Choucair is the chief health officer at Kaiser Permanente and one of the most influential voices on the role of social needs in improving people’s physical and mental health. Dr. Bechara Choucair’s upbringing during the Civil War in Beirut, Lebanon and his early experiences with patients as a family physician opened his eyes to the factors affecting people’s health, like hunger and housing insecurity. At Kaiser, he is a force behind a monumental shift to provide patients with access, not just to doctors in medicine, but also to community social services providers. Dr. Choucair, Bechara, welcome to Emerge Everywhere.

Dr. Bechara Choucair:
Thank you for having me, Jennifer.

Jennifer Tescher:
Absolutely. I’m going to dive right in because we could talk for several hours. You’ve had such a fascinating career and you’re doing such an important work. In a recent op-ed you wrote, you said that, “Financial insecurity is the next great health crisis.” Say more. Why is that?

Dr. Bechara Choucair:
Well look, Jennifer, financial security is at the core of nearly everything that drives conditions for health. Your finances determine access to healthcare and insurance. It determines food security, housing security, access to education, beginning and very early childhood. They determine where you can afford to live, the conditions of your housing, whether unexpected circumstances or natural disasters. In many ways, the way I look at it, economic opportunity is a super driver of health. It’s the upstream issue that has a tremendous effect on every other social factor that influence health outcomes.

Jennifer Tescher:
And why the next great health crisis? I mean in a way, you could say it’s the crisis we’re already living. Yes?

Dr. Bechara Choucair:
Well, here’s how I’d look at it. If we see an increase in financial insecurity, then you would expect that we would see more barriers to health outcomes up and down the line. And that’s why organizations like us have more and more interest in understanding economic opportunity in every community that we serve. We know that less than a third of Americans are estimated to be financially healthy, only less than a third. That means 65% of people in this country are stressed out about money and the economy this past year. And this is not an issue that’s impacting thousands of even hundreds of thousands of people. This is impacting the majority of people in our country. It’s very easy for us as health system to focus downstream, to focus on the symptoms of poverty. Housing and security, homelessness, food and security, transportation challenges, access to care, healthy behavior. All of those are really important and we have to do that. But there’s a real opportunity here to get at the issues that are driving all of those social needs. And that’s where focusing on economic security is an important part of thinking about improving health.

Jennifer Tescher:
So you talk a lot about this intersection between physical, mental and what you often call social health. And you’ve come to this experience, this understanding through a variety of experiences. You are a family physician, you are the public health commissioner for the city of Chicago where I live. You are the COVID vaccine coordinator for the Biden administration, and now you’re the chief medical officer for Kaiser Permanente. I wonder if you could tell us about some of the seminal experiences you’ve had across those roles that have helped you think differently about the problems we face and how to address them.

Dr. Bechara Choucair:
Well, Jennifer, let me take you back to one of my patient stories. And one particular experience that helped me expand my thinking around health came from one of the wonderful people I’ve worked with as a family physician, practicing as part of a healthcare for the homeless program. Actually back in your neck of the wood in Illinois. So I’ve met Judy, she was in her mid-thirties when I met her. She was smart, she was engaging, she was charming. At the same time she was dealing with mental health issues. She dealt with bipolar disorder and she was in and out of homelessness for the five years that I’ve worked with her as her primary care provider. So sometimes she’ll be excited and full of hope and energy and other times she’d be hopeless and depressed. And as her primary care doctor, there were so many things I could work with her on to support her on an individual basis.

I could listen to her, I could develop treatment plans with her and I could address all her medical issues. But the system she and I were both working together in was not designed to improve the biggest barrier to her physical and mental health. And that’s truly being able to maintain and sustain stable housing. When you think about my engagement with Judy, when I think about where I could have contributed the most to support Judy, I feel like I have failed her in being able to support her in finding affordable housing. So when I think about how do we support people in today to, and how do we support people to help them improve and optimize their health, we have to be thinking about their physical health. We have to be thinking about their mental health and we have to be thinking about their social health. And that’s, I think the important part of expanding how we think about health as health systems across the country is going to be critical.

Jennifer Tescher:
So let’s talk a little bit about what Kaiser Permanente is doing about that. You have 12 million members and you sit on both sides of the table, right? You’re both the provider and the payer, which makes you unique. How are you in your role there, how is the system thinking about making these broader connections?

Dr. Bechara Choucair:
Well the way I think about it is we have to start incorporating asking about social health from our members the same way we ask about their physical health, the same way we ask about their mental health. We are an organization that takes care about 12.6 million members. We have been doing… We’ve been providing integrated care for the last now 75 plus years. And we’ve built a primary care practice, we’ve built a mental health practice, and now we’re in the process of building a social health practice. So what does that mean? It means basically that we engage with our members, we ask them about their social need, and we figure out a way to connect them to those social needs so that they can get those social needs met. We surveyed 10,000 of our members recently, and three out of five of our members have at least one unmet social need, three out of five.

And think about the fact that the majority of our members get their insurance coverage through their employer. That means these are folks who are employed and three out of five have at least one unmet social need. One out of five have three or more unmet social need. So we have the responsibility to build that social health practice with the same rigor that we’ve built our physical health practice and our mental health practice. And our work really around this area is divided into three big things. One, you’re going to have to screen for social need. Two, you have to be able to have networks of providers from community-based organizations that are out in the community that are ready and available to support those members. And two, you have to be able to connect those members to the organizations that are available to provide the services. And that three big pillar approach is truly what defines our social health practice. You screen for social need, you build networks of providers that are ready to support people with their social needs, and you create systems to be able to connect those two together.

Jennifer Tescher:
And so I think you’re referring to something you call Thrive Local. Am I right?

Dr. Bechara Choucair:
Absolutely. And that is the name for our social health practice, the Thrive Local Network is what we’ve been working on for the last two to three years.

Jennifer Tescher:
I think this is fascinating. I want to dig deeper here for a moment. So how do doctors and other health professionals in the Kaiser system feel about having this extra burden, if you will. This extra thing they’ve got to do when a patient walks into the office? It’s assuming this is now part of the intake process, this screening that you do for social needs. How have you trained your physicians and health professionals and how do they feel about it?

Dr. Bechara Choucair:
Well, there are multiple ways that we can screen members. Absolutely during your encounter with the healthcare system is one way that we could ask you about your social need and try to connect you to services. And over the last couple of years, we’ve built standardized tools to screen people that we’re trying to disseminate across the system. But there are also some non-standardized tools that are already existing and we’re trying to shift all of those tools to adopt the standardized tool. That’s an integral part of how we interact with our members and our providers truly value that this is an important part because they are seeing the impact of social needs on their members not being able to get to the optimal health that they could get to. So it’s an integral part of how we think about optimizing the health and wellbeing of our members.

But make no mistake, that screening in the care delivery is only one tool or one venue to allow our members to screen for social need and give them the opportunity to connect. For some other members, they might not prefer to have that conversation in the exam room. For some, it’s very comfortable for them to go on their own and do a self screen. That’s why we built those screening tools in our kp.org app. We’ve put them online and we’ve put the resource directory also available online so that our members could refer themselves. Could identify their need and be able to identify the organizations in their community to be able to tap the resources that they would need. So thinking about how do you create multi modes, different modalities for people to be able to screen is really important. And at the same time, we are doing more proactive outreach.

We’ll talk a little bit about food insecurity for example. We know that many of our members are dealing with food insecurity. We know many of our members qualified to are eligible for SNAP, the supplemental nutrition program, and they just don’t have it. So we’ve engaged with those members. We’ve actually identified about 4 million members that we’ve proactively reached out to through a texting mechanisms. And we’ve asked them about their food insecurity, and we’ve helped nearly a hundred thousand member complete those applications for food stamps.

And what we know is that type of engagement led to more than $35 million of actual cash coming to the pockets of our members so that they can buy food and put at their dinner table those 35 million dollars now, they don’t have to worry about how to get food to their dinner table. They can use their money to be able to pay their rent, they can use their money to be able to pay the copay for their medication. It’s just the right thing to do. And that’s the type of engagement that I’m expecting to see more and more from health systems across the country.

Jennifer Tescher:
That’s an incredible story. I mean, what’s incredible is not just the success in getting a hundred thousand people to sign up. It’s the fact that you have 12.6 million members and your data sources suggested that as many as 4 million of them might actually qualify. That’s a third. That’s stunning.

Dr. Bechara Choucair:
Well I mean, when we’ve asked people about food insecurity, I think 30% or so of our members reference that they might be dealing with food insecurity. And when you look even at the breakdown of the members based on that survey that we’ve completed for 10,000 members, the social needs are not equal amongst our members.

Jennifer Tescher:
No.

Dr. Bechara Choucair:
We know there is, Black members are twice more likely to be dealing with housing insecurity than white members. The Latino members are twice more likely to be dealing with food insecurity than white members. So these types of efforts, they truly lift up the importance of keeping equity at the center of everything you do.

Jennifer Tescher:
Am I right in understanding that I think health systems are going to have to start doing more of the work that you’re already doing? I’ve heard that they’re going to have to start asking patients a screener question about whether they can afford to pay their utilities as part of a government effort to encourage more focus on social determinants of health. Is this something you’re familiar with?

Dr. Bechara Choucair:
I think this discipline of advancing a social health practice is becoming more and more of a movement across the country. And I think now we’re starting to see regulatory push to standardize this and add it to the part of your care model. We’re starting to see some of the organizations that do accreditation and design standards that are starting to incorporate that. And I think that’s a movement that we’re going to continue to see to grow. And we’d want to be prepared for that as a health system. And we’d want to be able to support the social services space, the industry there to be able to support the response to the needs that we’re seeing in our communities.

Jennifer Tescher:
Right. And that’s where I wanted to go next. When we talk about systems change, especially in healthcare, we’ve really got to talk about incentives. I’m assuming that one of the reasons why we’re seeing this push and this shift in healthcare is because increasingly insurers are paying doctors, not based on how many tests they run, but on the actual results. Am I making my patients healthier? So that’s really where I wanted to go next, because when we talk about systems change, we really have to talk about incentives.

And my sense, this is that one of the reasons why healthcare is moving further in this direction is because increasingly doctors are being paid for results in terms of their patients’ health as opposed to simply being paid for tests or office visits. In the case of Kaiser, you’re both the provider and the payer. And so what I’m curious about is when someone is being referred, if you will, by the doctor for fresh food. Or they’re self-referring from your website and you send someone to a Thrive Local partner, who’s paying that partner for the work they’re doing with your patients on their social health needs?

Dr. Bechara Choucair:
Well it’s important to remember that the social service organizations that are part of our social health networks serve communities at large. And it’s not just Kaiser Permanente members. So funding comes from multiple sources. It comes from grants from philanthropic support from the private sector, or as part of the states and federal programs that already exist. And you’re right, so much success depends on aligning the right incentives for the organizations providing services, the healthcare providers who are screening for the needs and the individuals and families who could benefit from resources that are available to them. And if you think about an organization like Kaiser Permanente, that alignment process starts with researching what works in improving health outcomes. So for example, there’s a lot of buzz right now about food is medicine movement and what’s the type of work that we should be funding and supporting when it comes to food security.

And one role we believe that we can play as an organization is to help build the evidence and the business case to understand what effective food is medicine interventions need to look like. We know that we need more evidence to understand what works under what conditions it works so that we can deploy these interventions more effectively. That’s, for example, is one area that we’ve committed to. We’ve committed to that work as part of our commitment in response to the White House conference on hunger, food and nutrition. And we’re really supported and excited to support this work moving forward.

Jennifer Tescher:
Do you imagine that there could be a time when the federal government, at least for Medicare and Medicaid users would be willing to start paying for these kinds of social health services, that it would be part of the reimbursement process?

Dr. Bechara Choucair:
I do believe so. And I think we’re starting to see that we are getting signals from CMS and some of the interventions at CMMI. And then I think we’re going to see a lot more of that coming down the line.

Jennifer Tescher:
That’s really interesting. So as humans in a complex world, we tend to use silos as a way to organize things to make sense of the world. And a lot of our systems are organized as silos. Certainly that’s been true in much of medicine. And what you’re suggesting though, around the intersection of physical, mental and social health really requires a more integrated approach and it requires a much broader set of actors at the table. It requires working across systems. And so that’s a really tall order. It’s a big deal for a company, an organization the size of Kaiser Permanente to do it on it’s own. What do we need to do to change it systemically so this is just how healthcare works, period? Who else do you think needs to be at the table and what other roles are needed? Because to your point, the doctor has a very particular role to play and a set of skills, but can’t do it all herself.

Dr. Bechara Choucair:
We are not there yet. Look, we are an organization that is committed to practicing evidence-based medicine. And the quality of our care and the outcomes that we track certainly reflect that as we pay close attention to the evolution of evidence in clinical care, we incorporate that into our model of care. And social health is no exception. So we are following that same rigor that we’ve done around quality metrics for physical health and mental health into our social health. There are still many evidence gaps about what work best in delivering care to people with social need as well as about screening. And that’s why, for those very specific reasons, this is why we’re engaging our research centers to help us address some of the key questions we need to know. And I think, Jennifer, we have to get back to that rigor of evaluating what works, what doesn’t work, so we can design interventions that make a difference in people’s life.

We’ve been funding a network of translational researchers who are using the research capabilities to help evaluate and test new social health interventions. We evaluate every social health initiative we undertake with our members to better understand how do we scale it and to build out the evidence-based to see if what types of these new initiatives work and what kind of impact they have on health and wellbeing. And as we test and scale our social health practice across the organization, not only we are supporting our members, but also we are increasing the knowledge about these important topics to the industry and to the discipline and building that discipline. And that’s, I think is really important. We have to bring that rigor to the work.

Jennifer Tescher:
Yeah, that’s really exciting to be on that part of the journey because certainly we know that having healthy food to eat, in general, is a positive factor in someone’s overall health. But being able to see the thread all the way through and understand it at a more granular level is an exciting opportunity and will take time. And that’s certainly just one of many social health interventions. But I think it’s a really good example and I’m looking forward to learning more as Kaiser and other researchers around the country. I wonder-

Dr. Bechara Choucair:
Yeah, I can’t agree with you more. And I love how you’re framing it. Because I’ve always pushed back on people that would always say, “Well, what’s the ROI on your social health interventions that you’re doing?” I truly believe this is fundamentally the wrong question to ask. Just exactly like you said, making sure that your members have food at their dinner table is the right thing to do. There’s no doubt in my mind about that. Now, following the thread all the way to see the impact of that on their health outcomes, total cost of care, their experience with the healthcare system are extremely important. We have to do both. But I don’t think we have to tie that work to just simply, if you don’t have an ROI, you shouldn’t be doing it. So I completely agree with your premise.

Jennifer Tescher:
I’m glad you said that because I sometimes forget that that’s not a given. I take it as a given, but I forgot for a moment where I was. So thank you for making that point. I want to end our conversation, coming back to you. You began your career as a family physician, but I wonder what it is you wanted to be when you were a kid growing up in Beirut, Lebanon. Was it a doctor, was it something else? And what’s really inspired the journey that you’ve been on?

Dr. Bechara Choucair:
Well, thank you for ending with this question. I grew up in Beirut in the midst of a civil war that took the lives of tens of thousands of people, including friends and family. And at that time growing up, I was more concerned about safety, about making sure that my mom and dad will end up coming back home safely at night. That when we are in school, we’re not going to get bombed and I’m going to get to play with my sisters and with my friends, during breaks and when we come back home. So as I was growing up, I was privileged to have had two parents who made sure that I stayed focused on education and not joined militias and not be part of all the other distractions that was happening. And I had the opportunity to go to college and ended up in medical school. And as I started my training, I’ve started realizing that I’m spending more and more time with my patients talking about their housing situations.

Where are they going to get their meal? Are they going to have enough money to pay their rent by the end of the month? And I’ve realized that this is an important part of who I am and what I was doing. And I got to a point where it was really important that I pay attention to my patients on an individual level but I started asking myself the questions, “Well, is there anything else I can do by going more upstream?” And are there policies that need to change or systems that need to change or environments that need to change so that we can give people the opportunity to live the lives that they’d want to live without having to deal with these systemic barriers. So it was a journey I think for me, Jennifer, that started from being a kid who’s trying to worry about safety and surviving the war, all the way to figuring out what can I do and what role can I play to create better environments that would allow people to live the lives that they’d want to live.

And I feel like I had the privilege to be able to immigrate to this country and do the work that I’ve been doing. And I have to tell you, I probably would’ve never thought in a million year when I immigrated to this country back in 1997 that I’ll be working from the White House and I’ll be working on vaccinating this country to get us out of the pandemic. And it was the most humbling experience you could ever have. And I’m so grateful to have had this opportunity

Jennifer Tescher:
Bechara, Dr. Choucair, thank you so much for joining me on Emerge Everywhere.

Dr. Bechara Choucair:
Thank you so much for having me. And thank you, Jennifer, for all the work that you and the Financial Health Network do every single day.

Jennifer Tescher:
This has been Emerge Everywhere, a financial health network production. If you like the show, please help spread the financial health message by leaving a review. And if you have ideas for future guests or thoughts on the show, please click on the link in the show notes to connect with us. See you next time.