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Long-Term Commitment to Addressing the Social Determinants of Health
For more than a decade, Cigna has been a leader in promoting identification of health disparities1 and influencing the development of solutions that will result in more equitable health among our customers, our workforce, and in the community. Cigna has committed to making health equity an enterprise-wide strategic priority, a long-term commitment to improving health equity2 in the marketplace by deploying strategic and operational resources to improve access to affordable high-quality health care while establishing and meeting organizational standards.
As a key advocate at the national level, Cigna actively shares best practices related to addressing health disparities and social determinants of health (SDoH)3 as well as advancing equitable health care with network providers, other health plans, employer groups, and clients.
Health Disparities and Health Equity
Health disparities are defined as avoidable and unfair differences in health status between segments of the population. Health disparities negatively affect groups of people who have experienced greater social and/or economic obstacles to health based on their:
- Income level
- Sexual orientation
- Gender identity/expression
- Cognitive, sensory, or physical disabilities
- Geographical location
Health disparities can lead to a state of health inequity in one’s business, community, region, or country. Health equity is “achieved when every person has the opportunity to ‘attain his or her full health potential’ and no one is ‘disadvantaged from achieving this potential because of social position or other socially determined circumstances.’ Inequities in health are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.”4
Social Determinants of Health
SDoH are the conditions and environments in which people are born, grow, live, learn, work, play, worship, and age that affect a wide range of health risks and outcomes. They help us to understand the factors affecting an individual’s health. Studies have shown that people with unmet social needs are associated with:
- Nearly twice the rate of depression
- A greater likelihood of having chronic conditions
- More than double the rate of emergency department visits and no-shows to clinic appointments
- 60 percent higher prevalence of diabetes and more than 50 percent higher prevalence of high cholesterol and elevated blood sugar levels5 Factors that impact Health and Well-Being [PDF].
In 2008, Cigna formed the Health Equity Council, the governing body of our overall strategy to address health equity. Composed of influential leaders from across the enterprise, the Council identified five key pillars to improve health equity among our customers.
- Leadership – Broaden and strengthen leadership at all levels to address health disparities and personalize care for each customer.
- Data, Research, and Evaluation – Identify and prioritize health disparities and evaluate the impact of initiatives to close gaps in care.
- Social Determinants of Health – Address the SDoH that contribute to inequitable health care among our customers and in the community.
- Health Care Services – Improve health and health care outcomes for racial, ethnic, and underserved populations.
- Cultural and Linguistic Competency – Improve cultural and linguistic competency of a diverse workforce and health care provider network.
An action plan has been created to ensure progress is made in each of these five areas. It is the council’s responsibility to formulate and oversee progress on our strategy.
In 2020, Cigna furthered our commitment to addressing health equity by launching the Building Equity and Equality Program, a multifaceted, five-year initiative to expand and accelerate our efforts to support diversity, inclusion, equality, and equity for communities of color. This program, among other initiatives, includes the acceleration of our efforts to recognize SDoH eliminate barriers to care, and improve access to care.
Cigna continues to recognize the importance of providing cultural competency resources and education to our stakeholders in order to better equip them to understand and address disparities among customers and within our communities. The examples below represent ways in which we engaged stakeholders, including employees, clients, and network providers, and equipped them with cultural competency education and resources in 2020.
We support our staff with cultural competency training and education, including mandatory training for customer-facing new hires. In 2020, we also launched two new courses: Conscious Inclusion Unconscious Bias Training and Spotlight on Poverty. The Conscious Inclusion course was designed to help our workforce recognize what biases are, learn where biases come from, and understand how individuals can take action to be more inclusive. In addition, the course is connected to the Cigna competencies – the desired behaviors for all employees. This training is now a part of our onboarding for all incoming hires in the U.S. In 2021, we plan to roll out the Conscious Inclusion training to our international employees. The Spotlight on Poverty training focuses on poverty, one of the most impactful SDoH. The goal of the training is to build awareness, dispel myths, and share information that can inform sensitive and supportive interactions with those impacted by poverty at work, or in their personal life.
In 2020, Cigna’s cultural competency training modules included a cultural competency series as well as multiple cultural trainings focused on subpopulations, including our transgender and gender nonbinary customers. Participants also learn how to comply with state and federal laws, including the Affordable Care Act, and gain the skills and the confidence to serve customers in a culturally responsive manner reflective of Cigna's mission.
Cigna recognizes that our networks of providers are key partners in ensuring our customers receive culturally competent health care. Cigna's Cultural Competency and Health Equity website is free to providers and their staff and offers quick access to customer-focused cultural competency web-based trainings, white papers and tool kits promoting patient-centered care, and culturally appropriate communication techniques for diverse populations. Trainings include developing cultural agility to examine assumptions, unconscious bias, and cultural competency best practices to serve as a primer for the other trainings; in addition, trainings focus on including insights from the latest research and how implicit bias impacts patients.
In addition to training, the website includes:
- CultureVisionTM – An online database providing insights into more than 60 cultural communities.
- Translated Patient Forms – Commonly used patient forms are available in Spanish.
- Language Service Discounts – Available to Cigna-contracted providers for translation and interpretation services, including video/remote interpretation services, to support Cigna customers with limited English proficiency (LEP) and disabilities, including those who are deaf and hard of hearing.
Additionally, we regularly promote articles in the provider newsletters that are distributed to our medical, behavioral, and dental providers. These articles include health equity topics such as health disparities, unconscious bias, SDoH, and cultural competency.
Collaboration with Employer Clients
Cigna is committed to supporting employers in identifying, assessing, and addressing the social needs of their employees. Cigna developed its proprietary Social Determinants Index (SDI), so that we could better understand the potential health disadvantages an individual may experience, based on where they live. These findings are used to enhance our clinical program offerings, close disparities, and better serve our vulnerable customer populations. Clients have found value in this analysis, such as:
- Prevalence of behavioral health and other chronic diseases along the SDI
- Compliance with preventive health related to the SDI
- Emergency room utilization across the SDI
Cigna has also sought to improve engagement in preventive health among the customers associated with employer clients that participate in our Health Disparities Advisory Council (HDAC). The HDAC consists of employer clients with significant populations of employees from underrepresented communities. In 2020, a special meeting was held with our HDAC to present and discuss the information on disparities and COVID-19 and share salient resources.
Cigna also provides clients with resources such as white papers, presentations, videos, client reporting, and Aunt Bertha, a social care network that can help identify and locate local resources related to counseling, education, finances, and more.
New Strategic Goals
The Health Equity and SDoH Governance Council collaborated with key stakeholders to identify and commit to actions that will ensure progress is made in 2021 on each of the five new goals created to improve health equity among our customers:
- Improve our capabilities to identify customers impacted by disparities based on race, language, and SDoH risk, and create test-and-learn opportunities to close gaps.
- Evaluate the impact employee health plan benefits have on health equity, and establish opportunities for employers to address the SDoH that contribute to disparities.
- Improve customer health and affordability by creating benefits and enhancing our solutions that reduce health disparities and address SDoH.
- Institute models that pay health care providers based on improvements in equitable health outcomes as part of our value-based reimbursement initiatives.
- Commit to expanding digital solutions, without creating a “digital divide” and exacerbating disparities, to close gaps in access to care.
In 2021, Cigna will continue to work closely with clients, customers, and providers in the public and private sectors to address SDoH that negatively affect our customers and communities, eliminate barriers, and improve access to care for our customers.
1A health disparity is a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Defined as individuals who have experienced greater social and/or economic obstacles to health based on their race, ethnicity, education, literacy, income level, language, culture, age, sexual orientation, gender identity/expression, disability (cognitive, sensory, or physical), or geographic location.
2Health equity is the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.
3Social Determinants of Health (SDoH) are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. They include factors that influence our daily lives, such as economic stability; educational attainment; infrastructure (including housing and transportation); food access; access to health care; and community and social environment (with related factors including loneliness, stress and discrimination). Research shows that these factors play a significant role in health behavior and health status, utilization of care and health outcomes – even more so than clinical care.
4Centers for Disease Control and Prevention. (n.d.). Health Equity. Social Determinants of Health – Health Equity. Retrieved March 11, 2020, from https://www.cdc.gov/chronicdisease/healthequity/index.htm
5County Health Rankings and Roadmaps: A Robert Wood Johnson Foundation Program. (2019). County health rankings model. https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model.