Discuss how employers must be as invested as the health care community and the government in ensuring equitable and responsible access to COVID-19 vaccines for their entire workforce.
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Aletha Maybank, MD, MPH: Hi everyone and welcome to Prioritizing Equity. My name is Dr Aletha Maybank and I am chief health equity officer at the American Medical Association. Thanks for joining us.
Today's discussion, we're going to explore how employers can really play a bigger role in making sure Americans get their COVID vaccines. We know that employers must be invested, as well as the health care community and government, ensuring equitable and responsible access to COVID vaccines for the entire workforce.
So, to help us really dig into this conversation further today, we have Dr Marina Del Rios, who is associate professor of clinical emergency medicine. She is director of social emergency medicine and emergency ultrasound research director. And we also have Dr Kyu Rhee, who is the chief medical officer at Aetna and senior vice president of CVS Health. Thank you both for joining us today.
So, my question that I usually open with, and we're now a little over a year now in our pandemic, is just kind of how are you all doing? How are you both doing, just you and your families and all of that? And where are you located?
Marina Del Rios, MD, MS: So, I can start. So, I live in Chicago, Illinois. I work at the University of Illinois in Chicago. Chicago was pretty hard hit, as a lot of the larger urban centers in the US. And so, I would say that I'm still in recovery. It's somewhat encouraging to see that more vaccines are becoming available and that case counts are going down, but I feel like most of us that work in health care have a little bit of post-traumatic stress disorder after such a hard year.
Luckily, I've had multiple people in my family get sick with COVID, but they've all done well. I have lost some friends, including coworkers. And so, that stays with you. Every time that you see a patient with COVID, you wonder what's going to be the outcome because although we have some sense of risk factors and who may get sicker, some of it actually has been very much surprising, having younger people that you didn't expect get very sick or even die from COVID. So, I'd say we're just working on cautious optimism, but still worried about what may come ahead of us if we're not adequately prepared.
Maybank: Absolutely. Thank you for that, Marina. Kyu?
Kyu Rhee, MD, MPP: Yeah. Thanks for asking, Aletha. I'd say it's been in many ways a challenging year, year and a half. Personally, right before the pandemic really hit the US, I lost my father. So, he had a challenging bout with cancer. And so, that was tough to experience that. And, of course, then my mother was living alone. And in the last year, she's been by herself because of the pandemic and because of all the challenges we face as a broader society. So, obviously, there's some light at the end of the tunnel. She just got her second vaccine. So we're excited, after those 2 weeks pass, to have her come visit and see her grandkids. I've got 2 daughters who are doing hybrid school. So, I think we're all used to doing this now virtually, for those of us who have the privilege of being able to work from home.
And then I made a transition myself professionally, after a decade at IBM, where I was very much engaged with the broader global COVID work and response for our workforce but also for our clients, came over to CVS just 6, 7 weeks ago. So, excited about the role that CVS Health has to play in addressing this pandemic and addressing equity. So, excited about the conversation here. Thanks.
Maybank: Thank you. And thank you for sharing. I completely empathize with a parent living on their own for the last year and how hard that is for parents, especially when they're used to being mobile and going around and about, and the excitement of being able to get the vaccine as well. So, I totally empathize with that. And thank you for sharing.
So, Marina, I want to talk with you because you and I had this opportunity to co-author a piece that was published in USA Today, and really focusing on how employers and what employers can do to help support their employees get vaccinated. And can you just speak to what was the thought behind us writing this? And I'll let you say it. And then kind of what were the key points from this piece?
Del Rios: Well, sure. I think that one thing that we've learned is that workplace outbreaks have been a major contributor to community surges of COVID. Essential workers are made vulnerable by their working conditions, people that are ... For those of us that can work from home, we've been able to overcome this pandemic relatively unscathed, but for our essential workforce, largely Black, Latino, Indigenous people, they had to show up to work to feed us, to keep us clothed, to keep our transportation systems running. And with that, they've been constantly exposed to COVID and experiencing very high rates of COVID.
So, we thought that it was important that as we plan for COVID vaccine rollout, that employers take the responsibility and the leadership in protecting their workers. That's the best way to save our economy and saving our society is ensuring that our essential workers are protected.
And so, we came up with a list of recommendations, everything from hosting onsite vaccinations, partnering with health care systems or even with pharmacies like CVS and Walgreens to ensure that there is vaccines onsite. Make it as easy as possible for people to access the vaccine.
But in the absence of that, also offering opportunities for, if you can't host an onsite vaccination, which would be the ideal thing, maybe you can work to ensure that your employees have the paid time off so that they can take the day off to go get the vaccine and recover. Also, maybe partnering with transportation companies to ensure easy access so that people can actually get to locations where vaccines are being distributed. Also, ensuring that people don't have to worry about the costs related to accessing the vaccine. We know the vaccine itself is free, but what it means to take the time, the day off and keep the kids ... have to find someone that watches your kids while you're taking the day off to get your vaccine. Or paying for transportation to get to the vaccine or covering maybe other administrative fees, whether it's paid time off and so on, just to ensure that people don't see their economic stability as a barrier to accessing the COVID vaccine. And along with that, also providing information to workers about it, how to protect themselves, what's the importance of it and provided in a language-concordant and culturally competent way. Those were some of the highlights that we kind of included.
And I'm happy to report that in Illinois, we've started seeing some companies take charge with that. There's a—
Maybank: I was going to ask that question. What has been the reception of the piece?
Del Rios: Yeah. I mean, I think we had a car company, which I think it was out of Kankakee, a car manufacturing company. I can't remember which dealer, but they did actually partner with Swedish American Hospital and had onsite mobile units where their employees were able to access the vaccine.
And we're working now with other companies locally. We're actually trying to start to have some conversations with some manufacturing companies that are just outside of Chicago in the suburbs in Cook County to see if we can get Cook County Public Health mobile units or else other mobile units from local hospitals to just park outside and just be willing and ready and available for anyone who wants to get vaccinated. So I'll let you know how that goes, but I think the reception has overall been pretty positive.
Maybank: Great. Great. Thank you for that. Kyu. So CVS has been doing lots of efforts as it relates to COVID vaccine and vaccine equity specifically. Can you talk a little bit about that, and what you've been leading up in your six to seven weeks of being there?
Rhee: Yeah. Well, look, part of me feels very blessed to be part of this amazing team across CVS Health of nearly 300 000 folks who are on the front lines of addressing this pandemic and vaccine equity. And so, part of me feels probably I haven't contributed much in the first 6 to 7 weeks, but I'm proud to reference the work we've done.
I think one thing I reflect on in my background and my history is as a primary care physician, it was so important to work in community health centers in the federally qualified health center system and how essential it was to connect with community-based organizations as you delivered care and you addressed health equity across populations that were often underserved.
And what I wanted to highlight is CVS has such a diverse population and our locations are in places that are known as socially vulnerable by the CDC vulnerability index. And so, I think nearly half of them are in high or very high social vulnerability indexes. So we in many ways, can be that partner, whether it's the federal government or state governments or local community-based organizations, to help deliver this vaccine. And I'm proud of the fact that if you think about equity and elderly populations, for example, we've delivered over, at over 40 000 sites, 4.6 million doses of COVID vaccine.
We've also through the Federal Pharmacy Partnership Program at over 1200 sites in 29 states and Puerto Rico, we've delivered an extraordinary number of vaccines that actually are vaccinating ... 34% of the populations that were vaccinated are from underrepresented minorities. I do think a big formula for success for that is the fact that our workforce, the pharmacy and the pharmacy techs represent 40% and 50% nonwhite populations. And I do think once again, speaking with pride about how diverse our population is, the people who serve and those that we serve.
And so, there's still a lot of work to be done, as you know, and I think we've also been looking at surveys and science. We've been surveying populations to see about the issues of vaccine confidence and hesitancy, because we know and expect in the future, once supply surpasses potentially the current demand, there will be populations and pockets, particularly, in underrepresented minorities. Our most recent surveys show 35% of African Americans do not plan to receive the COVID vaccine when first available, which is up 10% since our November survey and 22% of Hispanics, which is up 5% from that last survey. So we still have a lot of work to do in our communities and as a country to address this issue.
Maybank: Thank you. And I'm going to come back to you to talk a little bit more about kind of the addressing social needs. Marina kind of mentioned it already in her initial comments, but I want to speak specifically about Latinx communities and employees and employers, Marina, and what is the experience that's happening now? And what's just not being told and what's not being done and what needs to be done in order to support the community?
Del Rios: Yeah, I think that the reality is that the experience of undocumented and migrant workers is very different from those workers that are citizens, right? And this is independent of the language barriers and poverty barriers related to tech barriers. And so on. This is just the fact that you are a noncitizen is almost an automatic assumption that you're a second-class person.
And so sadly, what we've seen played out in the pandemic, is that a lot of these workers have been exploited by employers, have not been protected adequately. They've been denied personal protective equipment. They've been denied adequate spacing in their place of employment to ensure that there's enough physical distancing to keep themselves protected. They're afraid of taking time off for fear of retaliation or being fired, or just the fact that they can't bring money to their home, right? Many of workers that are citizens can access some federal relief dollars and some unemployment benefits that can bridge a little bit of the financial gap left from the pandemic. A lot of our migrant workers or undocumented workers, obviously don't qualify for those federal relief dollars. And so, they've had to choose between going hungry or going sick.
And going hungry almost always means not only for themselves, like for an entire household. And so many of them have continued to put themselves in harm's way. And then, when you add to that the fact that many of them, when they finally show up at our doors in emergency departments or in clinics, which in and of itself is already a difficult decision to make, because if you don't have insurance and you don't have money, then you think about what is it going to mean to show up at a clinic, at an emergency department, what's that going to cost? But many of them also have in addition confronted the language barrier of being able to fully explain the severity of their symptoms.
And unfortunately, not all hospitals, not all clinics have been equipped in the same way to be able to communicate appropriately with people. Many people have been sent home when they probably should have ended up being in the hospital and taken care of that way. So what we've seen is that when you look at age adjusted mortality rates, in Latinos, it's been higher than almost than any other group in many urban centers. And largely, it's because this workforce that is getting sick, exposing themselves constantly, showing up late to the hospital. Or when they show up, being turned away and dying at home.
Maybank: Thank you for that. And so, you just mentioned a little bit about the COVID relief bill or the American Rescue Plan and I was on another conversation just talking about it. And we were saying part of the success of the plan we would say is that it moves beyond just focusing on the health care system, but definitely considers the social context of how people live. However, what you just elevated, there still are gaps, right? And it's kind of that intersectionality that often is kind of not described well, but this layering of oppression that happens based on what access, what power you have within this country. And so, can you just speak a little bit more on the relief bill and the way that you think it has been helpful and not helpful?
Del Rios: Well, again, I think that it's helpful for people that have permanent residency and they have citizenship, right? Because you can access some unemployment benefits. There are some benefits there that have to do with childcare. So for those essential workers that have had to continue to work throughout the pandemic, there's some child relief dollars. There's also some rental relief dollars, which we know are so welcomed by so many people who are on the verge of being evicted because they've lost their job. And how many would keep up with rent? Right?
So those are all great things, but again, who is it going to benefit? Our undocumented workforce contributes billions of dollars in taxes, in income tax and tax of goods that they purchase. And yet, they're completely left out of any of our social safety net. There's no, to my knowledge, no inclusion in that letter of the law of how can we protect this huge portion of essential workers? Right? So many of our home health aides, who have been continuing to put themselves at risk, our nannies and childcare providers. And again, a lot of migrant farm workers, a lot of the people that work in factories, in food packing plants, in shipping companies. They're all immigrants. Not only Latinos, but a lot of Asians, a lot of African immigrants and they're being left out. And yet, they've been taking care of us throughout this pandemic.
Maybank: Thank you for highlighting that again for us. So Dr Rhee, Kyu, can you speak now ... We just talked about kind of the social context, the realities of that, the realities of where gaps in policy still exists. As an employer at CVS Health, I know you're considering and doing work around addressing the social determinants of health to improve health equity. Can you speak a little bit to that of kind of what maybe your vision is around that?
Rhee: Yeah. I do want to highlight, look, we are a country of immigrants. I was born in Korea. My parents worked hard, as I was reflecting on my father who passed away last year. And my mother, they came to this country with barely anything and they made a future for my brother and I.
So, as we reflect on the importance of what makes us unique as a country, a country of immigrants and innovation and creativity, I do think it's essential to recognize the disparities that exist and how health is such an essential component of providing that value to this country and its future. So I just wanted to emphasize that. And especially with a lot of the challenges that I've experienced in my career as an Asian American, I think I can resonate with much of what Marina was referencing in the heterogeneity and the cultural diversity and the linguistic diversity that like, for example, Asians have ... We've got to be thoughtful about how we address disparities as it relates to immigrant populations.
So, I just wanted to emphasize that and re-emphasize what was just referenced. As far as what I view, the opportunities that we have partly with this pandemic and social determinants of health. I believe that every now organization is a health organization. So previously you might've said, oh, hospitals and health plans. But now I think this pandemic has made everyone realize that we have a responsibility to assure a culture of health and equity, as companies, as organizations. And so one piece of work that I'd love to references with Dr Howard Koh and Dr John Quelch. We did some work around a culture of health and what are the dimensions of that for companies, as they now all have to be health companies or organizations.
And it's typically in these four areas and dimensions. One is employer health, which I know we're focused on and that's so important. And the culture of assuring health and safety as it relates to that. But then the consumer health. We live in this world now that so much of the challenges of opening up borders and opening up businesses are going to be connected to how confident a customer feels in taking a flight or going into a hotel or going into a store. And so, it's going to be important that we think about consumer health. And one of the things I'm proud of at CVS and from a consumer health perspective, we became tobacco-free in 2014 and stopped selling tobacco as a product. And I believe there was a great study in the American Journal of Public Health that highlighted how that decision led to decreased rates of tobacco for many of our customers in many of the communities where we were very prominent.
So this is an important thing, consumer health. The other areas are what I would call community health and also environmental health. As you think about the challenges of climate change and also the opportunities we have to think about as it relates to the communities in which our workforce has come from, but also where our customers come from and how we need to think broader than just what we sell. But making sure that the communities from which our customers come from and our employees come from are healthier.
And I'm also proud of the work we do called Project Health, where we've made an investment of $600 million. We have promised over five years to address inequities in communities. And what I love is health to me is housing, education, access to healthy choices, labor and transportation, as well as health care. So when I think of health, I think this pandemic is making us realize that while health care is essential, we need to be thinking broader than just health care and going to those areas of health.
Maybank: Absolutely. Thank you for that. I think that's one of the big hopes of this COVID time that there is going to be a narrative switch, an evolution of what grades health in the first place. And that it does go beyond just the health care system and the hospital walls in this greater context and really that health care embraces it. Public health clearly understands that, but that health care embraces it and all the kind of the ecosystem related to health care better embraces that as well. An opportunity to push just a slight shift, because at the American Medical Association, we were clearly an employer and this has been a tough time. I think we at least spoke at the top of the call of the toughness of this, the emotional kind of roller coaster potentially this year has provided for many of us.
And so, I just wanted to speak to Marina, any thoughts around emotional supports and mental health supports that employers are able to provide or should be providing during this time, or examples that you may have seen that have been meaningful?
Del Rios: Well, I can only speak about my employer directly, and I know that even early on in the pandemic, it became clear that we were going to need some additional support than just here's a phone number. And so there was a conscientious outreach to the medical staff. Check-ins, both just on a daily basis at the work site, just acknowledging the difficulty of how shifts were looking for us during those days. And reiterating, the fact that this is a marathon, not a race so we need to take time for ourselves and our families. And I think an acknowledgement of just being kind to people and being kind with people's time and not asking why you need time off. And if you need to get out of a shift, we were aggressive about having extra people on deck, in case somebody needed to take time off, whether because they got sick with COVID or just because they needed a break. But I think that what I would like to see is that that holds on beyond pandemic years, right?
Because what we've learned is that in health care, mental health is a stigma, carries a negative stigma. And we tend to hide our emotions and not admit that we need help, that we've seen at therapists, that we've had to be on antidepressants or antianxiety medications. And I think what I'm hoping moving forward is that in learning how to be kind to each other in the last year, because it's been so difficult on all of us, that we accept that the brain is just like any other organ and needs to be taken care of. And sometimes it needs a break, and sometimes it needs therapy and sometimes it needs medication. And that we don't carry any stigma or any prejudice against health care providers who have sought out help. So that's one thing. I think it's easy in the health care field.
I think it's easy to access, not easy to access health care, but there's more of an ease in accessing health care when you have insurance. I think the other thing that we have to think about too is how difficult this pandemic has been on essential workers that are often working low wage, minimum wage jobs that don't have health insurance with them. And how do we ensure that that population's mental health is being taken care of? And so I think that what I would like to see moving forward is that people have better access overall to getting mental health care, to getting access to medications, to therapy, to taking time off to recover from that just like you would recover from surgery. I think that that's something that we really need to be thoughtful of making plans for in the future.
Maybank: I totally agree and I think that's right. I think one of the opportunities I'll come back to the AMA as well, just because this is where I'm at, is that they were great in communication consistently, which was, I think really helpful. And then the employer, as an employer, they also launched a program called Thrive during the middle of COVID to make sure that those resources were accessible to all employees. So where there may be gaps in terms of insurance status or things of that nature. Most people probably have insurance at AMA, but nonetheless for their families also that as an extension of them as employees. There was access to services that they could call upon if they needed it.
And beyond just the typical EAP, we brought in folks to help support with just providing psychological safety and hosting sessions with some of our employee resource groups, just to talk through what was going on. When the public murder of George Floyd happened, we really were very intentional around that. So I think there's still is a lot that an employer can do in light of there being gaps in realities of access to health care. Kyu, any comments?
Rhee: I'm not yet as literate in terms of CVS Health, as it relates to what we were doing in mental health. So I'm kind of, I know there's a lot we're doing and this is a big priority for Karen Lynch, our CEO, and we've done some really creative initiatives as it relates to the communities we're in, where we looked at providing potentially access to mental health through telehealth or through the Minute Clinics or through now the health hubs. We have social workers in communities and so I know this will continue to be a high priority. I will resonate with what Marina has said and what you said, Aletha, is the importance of us standardizing and simplifying, and destigmatizing mental health. And recognizing that a blood pressure screening is standard or diabetes screening is standard. Mental health screening should be standard.
And my belief and hope, and part of this is my experience that I had at IBM over that decade, and thinking about the health of our workforce from that perspective and leveraging creative interventions, like mental health first aid. I mean, oftentimes the people are most likely to know that you have a health issue from a mental health perspective are your peers, the people you're working with. And so leveraging what I love is the acronym QPR, like CPR, Question, Persuade, Refer, as you noticed. Or you seem to be stressed or you seem to be short-tempered, questioning, persuading people to go deeper a little bit. You're not a health care professional, but your job is to kind of be a peer educator or a community health worker, a promotora, or … and then to refer people to the right resources.
And sometimes EAP is the right resource, sometimes your primary care clinician is, sometimes it might be a phone line. So this idea of referring people to the right resources. So I know we're very invested at CVS Health as we've seen actually the data during this pandemic that shows that mental health is becoming more of a prominent issue, higher utilization rates, higher need, a higher rates of diagnosis of depression and anxiety disorders. I would argue that the mental health issues have always been there, but it's now made us more aware of it, just like we talked about inequities. So now we have an opportunity to focus on it and address these issues that we're just talking about and make it standard in health and health care.
Maybank: Absolutely. Thank you. And thank you for bringing up mental health first aid, that reminded me of my health department roots. We had huge initiatives to train up our teams and community members in that opportunity. And I just saw, today there was an announcement by the White House of over $300 million to become available for community health workers. And so I think that that's going to be helpful. Very much to support vaccine equity, but I think also in the emotional and mental health context as well. So we'll see how that plays out.
So as we get ready to close out, just from both of you and you can do it quickly, or however long you want to take. What do you think are going to be the biggest opportunities for employers? I mean, Kyu, you mentioned some as it relates to this employer responsibility beyond just the health care aspect, but what are they doing broader to the community that they're serving?
But what is it that you would like to see employers do in the next year beyond COVID?
Rhee: Want to go first, Marina, or me?
Del Rios: Why don't you start, Kyu?
Rhee: I'll do—I wanted a little more time to think, but that's all right.
Maybank: I know. I tried to do this question.
Rhee: So look, I go back to the whole principle that Howard Koh and John Quelch talked about. Every business is a health business and I feel fortunate to have played a role in helping facilitate that work with the Robert Wood Johnson Foundation. There's a great book called “Building a Cultural Health: A Business Imperative” that's available that tells that story and gives really great examples of how employers are addressing those four areas of consumer, employer, environmental and community health. So I would start there.
There was a piece I wrote in Fortune, and I know you and I, Aletha, were able to be on a panel on equity and the importance that hospitals typically don't measure equity and we need to create equity measures. So I'm fortunate to have partnered with Josh Sharfstein and Hopkins and the Center for Health Equity, Lisa Cooper's group, to look at how hospitals should have a measure of equity as a standard. Whether it's the IBM Watson's hospital rankings or the US News and World Report, this should be standardized. I would suggest that equity has often been the Rodney Dangerfield of health care quality measures.
Rhee: Safe, timely, effective, efficient and patient-centered. So in this space, I would suggest employers have extraordinary influence as it relates to four areas and one is your workforce has to be diverse. You need to represent the populations you serve throughout your workforce, but also at the C-suite. Marian Wright Edelman talked about you can't be what you can see when she was referencing all white children's books for the Children's Defense Fund. Similarly, we have opportunities and challenges in health care and technology to address the diversity of our workforces, to make sure that you can be what you can see.
I would also suggest data collection is also important, but data collection from a perspective of trust is essential. As we're doing this important vaccine effort, we are collecting race and ethnicity data, which I think is important. You can't talk about which lives matter if you don't know which lives are Black versus Hispanic versus Asian versus poor. So a key piece of this is data trust and collection and transparency. So that would be a second area that I think employers can suggest that it's really important, voluntarily, of course, to encourage why do we need this data to address the disparities that exist?
The third area I would suggest is related to this topic of as employers purchase care, they should seriously consider the role of equity as a measure they expect delivered in the broader health and health care system. So I call this equity dashboards. In the same way we have safety dashboards or readmission rates, if you compared readmission rates about Blacks and whites, shouldn't that be a disparity we should reduce as well as reduce the overall rate of readmission rates of all the employed population and dependent? So the concept of equity dashboard.
The last piece I'd say is and I saw this and witnessed this at IBM, I mean, AI is here to stay. There are no more AI winters to come. If you're a Game of Thrones fan, no more winter is coming. So the importance of thinking about transparent AI and machine learning, AI is being leveraged all around us. It's being leveraged as it relates to our retail choices, our financial choices. So as we think of predictive analytics to better predict and prevent disparities, it's important that we're making that transparent and we're addressing ethical and equitable AI. So I would suggest employers as they apply AI technologies have to seriously consider that and request that transparency.
Maybank: Thank you. Marina?
Del Rios: So those are all great points and certainly great things to strive for. I think the one thing that I would like to see more employers do, moving forward, is really engage their workers in any plans that are related to health and safety in the workplace. I think that what we learned throughout the COVID pandemic is that fear of retaliation is real, that there are some workers that are protected better than others.
I would like to see that some of these bigger companies would start looking into engaging the trusted messengers within their workforce to keep people healthy, whether it is to ensure, as Kyu was talking about, that people's mental health is okay and that people don't fear talking about how stressful their life is. Or ensuring that they're keeping up with their usual just general health measures, whether it's getting your flu vaccine every year, the COVID vaccine now, that you're taking time off when you're sick and that you're not coming in when you have symptoms. And that they truly do this in a way that people don't fear speaking out when they're not feeling well, that we, again, encourage people to really take care of themselves, because it's in the best interest of the employer to have their workforce healthy.
Maybank: Absolutely. Well, thanks to you both. Those are great, in-depth and thorough answers that I'm very thankful to have. Really, thank you both for your time and for your leadership throughout this. I mean, throughout your career, but really especially throughout this year. Both of you have been very present, very visible, very directive. I think it's been extremely helpful during this time and I've appreciated your voice in partnership. So I want to thank everyone for tuning in and joining us for this series. This will be available, and it will be available for CME credit, moving forward, and just to remind people that you can visit our health equity resource center on the AMA website as well. So, see you next time and take care.
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