FAIR Health Access Interview with Chima Ndumele, PhD, MPH

June 16, 2022

An associate professor of health policy at the Yale School of Public Health and a faculty associate at the Institute for Social and Policy Studies at Yale University, Dr. Chima Ndumele focuses his research on better understanding the factors that influence the way vulnerable populations connect with and access healthcare resources. He is also the Co-director of the Yale Medicaid Policy Lab, which conducts work funded by the National Institutes of Health and several foundations. Dr. Ndumele serves as an esteemed member of FAIR Health’s Academic Advisory Board, which is tasked with advancing the research potential of the FAIR Health data collection in keeping with FAIR Health’s mission to contribute to public knowledge. Notably, Dr. Ndumele is also currently collaborating with FAIR Health on an initiative, funded by the New York Health Foundation, that seeks to advance shared decision making among patients of color in New York State. He received his PhD in Health Services Research from the Brown University School of Public Health and his MPH from Tufts University. Dr. Ndumele spoke with FAIR Health Access about his research and how healthcare transparency and related efforts can help promote population health for vulnerable populations.

FAIR Health (FH): What led you to pursue an academic research career in health policy focused on vulnerable populations?

Chima Ndumele: Health and access to healthcare always felt, to me, like a fundamental piece of a productive and happy existence, and I felt the benefit should be shared equitably across populations. From my view, it appeared that this wasn't the case. I pursued a Master of Public Health degree to understand the systemic barriers to improving access to care and achieving equitable health outcomes. I then pursued a PhD to learn the frameworks and to acquire the tools to figure out how to respond to those challenges. I fell in love with the potential impact of informing policy through research during my PhD [studies], and specifically with thinking about how to make smarter and fairer policy for vulnerable populations, who often don’t have much of a voice in the policy sphere themselves.

FH: You are collaborating with FAIR Health on an initiative that seeks to advance shared decision making among patients of color in New York State. As part of the initiative, which is funded by the New York Health Foundation, a new set of decision aids with clinical and cost information for conditions that disproportionately affect patients of color recently launched on the fairhealthconsumer.org website.
     a. In your view, how does the grant-funded project seek to empower patients of color to better navigate the healthcare system and make informed decisions?
     b. What role might shared decision making play in improving care delivery and quality, and increasing access to high-quality care, for vulnerable populations?

CN: The healthcare system, as it relates to how we think about treatment, is evolving. I think there is a growing acknowledgment that patients should have more of a voice and be able to express their preferences and constraints, which shape the way they experience the healthcare system, and which should be considered in their treatments. This project is critically important to giving patients the tools to articulate their preferences and seeking to help them understand the trade-offs associated with their treatment choices.

When patients feel respected and heard, they are much more likely to be engaged in their treatments. Most research suggests that when they are more engaged in their treatments, they have better outcomes. Shared decision making is an element of a high-quality system, but it is also a valuable mechanism for building trust. It helps patients plan for the costs of their care and gives them the opportunity to express their fears and concerns about treatment options and the cascade of information coming toward them. This is especially crucial for vulnerable populations, who traditionally have felt disrespected in the healthcare system. Giving these populations tools that can help them feel that their opinions, concerns and considerations are important is a significant advancement for our healthcare system.

FH: As the healthcare and public health landscapes continue to evolve due to the COVID-19 pandemic, what policy trends related to coverage and care for vulnerable and lower-income populations—who largely experienced poorer COVID-19 outcomes—might be observed in the next few years? What role will addressing social determinants of health play in coverage and care for these populations?

CN: Above all, COVID taught us that we are all connected. [Prior to that,] it was easy to think of somebody’s health challenges as being their own. But, given the extent to which a single person’s illness impacted everyone’s lives, we learned that we were all connected in a way that required us to care about the health of one another. Second, I think COVID required us to reimagine what access to care looks like, particularly for vulnerable populations. The advent—in some places—and the expansion—in other places—of telemedicine, e-consults and other mechanisms that made it easier to connect with healthcare systems was important, particularly for low-income and vulnerable populations who traditionally have had trouble accessing the standard healthcare system. Even if these [modalities] are imperfect substitutes for in-person care, they represent an improvement that I hope informs a more accessible health system moving forward.

The role of social determinants of health, I think, was a crucial revelation during COVID. The transmission and progression of disease were affected by housing, access to the tools of daily living, the capacity to get tested—all things that were impacted by social determinants and that we had known impacted health but may not have understood so viscerally. My hope is that addressing social determinants doesn't just improve lives in the short term, but also potentially mitigates the effects of the next pandemic.

FH: Part of your research has focused on physician networks in Medicaid managed care organizations and how these networks can be used to improve care quality for and outcomes in lower-income patient populations. What are the implications of your research on expanding vulnerable populations’ access to nonphysician healthcare providers, e.g., nurses and clinical social workers?

CN: Our research team has done a considerable amount of work on physician networks in Medicaid managed care plans, wherein states contract directly with private managed care organizations or health plans tasked with facilitating access to services and contracting with a network of providers to do so. About 70 percent of the approximately 85 million Medicaid recipients are enrolled in Medicaid managed care. While much of managed care is standardized, these health plans have quite a bit of latitude in constructing and adapting provider networks, which are a hypothesized pathway to greater efficiency on one end. But on the other end, they are the primary pathway through which recipients access healthcare.

Our research has looked at this trade-off and at how states can better regulate these plans so that improved efficiency doesn’t impact recipients’ access to care. Health plans’ networks change in ways that are challenging for individuals to navigate. Our recent work showed that about one-third of providers listed in networks delivered care to fewer than 10 recipients annually; about 50 percent of those providers didn’t deliver care to anyone. Identifying mechanisms to provide efficient healthcare that is also accessible is one of the key areas of focus for our group.

There may not be a silver bullet to completely fix long-standing access challenges in Medicaid. That said, we need an all-hands-on-deck approach to expand access to care, including a network of nonphysician healthcare providers who deliver a considerable amount of high-quality care to Medicaid and other vulnerable recipients. Many states are grappling with the roles and scope of practice of nurses, social workers and other nonphysician providers. But the preponderance of the research suggests that these providers are already a significant part of the healthcare safety net and of networks that undergird Medicaid managed care plans; codifying that role may make it easier for beneficiaries to navigate the system.

FH: What are some gaps in research pertaining to the health of lower-income and vulnerable populations that should be studied in the future?

CN: Three things come to mind. First, how can we make fairer policy for vulnerable groups, who face unique challenges in navigating the healthcare system? Our broad approach to policy has been siloed and has not accounted for the fact that individuals’ lives are connected. My research group’s initiative, Building a Smarter Safety-Net, acknowledges that most people who use one aspect of the social safety net, such as Medicaid, food stamps or the WIC program [the Special Supplemental Nutrition Program for Women, Infants, and Children], often use multiple aspects of the social safety net. The question is, how can we derive policy that accounts for the fact that people don’t live in the silos we put them in for the ease of administration, and that the design and delivery of services in one program largely impact the experience that individuals will have in another program?

The second area is understanding what works in the Medicaid program and having a better mechanism for how states learn from each other. The most charitable articulation of the promise of the Medicaid program is one where states operate as laboratories, with programs innovating and learning, all designed to improve population health in their localities. But it won’t happen magically; the infrastructure, both to innovate and learn, needs to be in place and exercised. How do we know what’s working? How can states learn from each other and avoid reinventing the wheel? How do we reduce the likelihood that states do things that harm their enrollees? How do we take what works locally and scale it nationally? There is considerable work that we all, both researchers and policy makers, need to engage in to make sure that the promise of this program can be realized and that fewer people are left behind.

The third area is the conspicuous gap in research related to low-income populations: understanding how people’s lives—and significant disruptions in people’s lives, such as divorce, job loss and incarceration—impact the way that people experience care, and then constructing a healthcare system that is responsive to those unique challenges. The Medicaid program—for which eligibility is defined by a household’s income level and size—is uniquely positioned to measure and assist people dealing with the disruptions of life, especially because they often happen with greater frequency among low-income populations. I think Medicaid is uniquely positioned to prevent some of the downward health spirals that appear unrelated to healthcare and insurance, but challenge people’s capacity to navigate their health and healthcare systems.

FH: To what extent has cost transparency figured into the national conversation on costs and spending related to the care of lower-income and vulnerable populations?

CN: Not enough, is the short answer. In states that expanded Medicaid, healthcare costs for the lowest-income populations are defrayed or completely covered. However, inefficient use of healthcare and resulting costs still get transferred to the states, so Medicaid cost increases are associated with decreases in spending on public health, infrastructure and education—some of which are arguably more fundamental to health than Medicaid itself. Understanding how cost transparency can encourage more efficient, less costly use of care is key. In states that did not expand Medicaid, healthcare costs are crippling, especially for families on the lower-income threshold. For these populations, information about how to navigate the system, especially as it relates to cost and quality, is essential, in part because it eases some of the uncertainty associated with long-term costs of care—a factor that affects how these populations experience care and whether they forego care for reasons related to costs.

FH: FAIR Health has continued to lead as a source of independent and objective price and utilization information for all healthcare stakeholders. What role can FAIR Health data play in advancing research into the health of vulnerable and underserved communities? How might FAIR Health’s role in the healthcare sector evolve, especially as it relates to healthcare decision making and navigation among vulnerable populations?

CN: FAIR Health has been a critical partner for patients in helping them better understand the healthcare system. That said, most people encounter FAIR Health only when they are looking to interact with the healthcare system. Many populations for whom cost, and the trade-offs associated with cost and quality, are a challenge use the healthcare system as the option of last resort. I believe FAIR Health can have an enhanced role in outreach to vulnerable communities—particularly those who are not inclined to log on to the FAIR Health consumer site as a function of their day-to-day activities—and potentially change the relationship that these populations have with the healthcare system by allowing them to plan for healthcare costs and more proactively engage.

*FAIR Health interviews reflect the views of the interviewee in his or her individual capacity and not necessarily those of FAIR Health or other organizations with which the interviewee is affiliated.