A Business Imperative and Long-Term Company Commitment

For more than a decade Cigna has been actively engaged in the effort to address and eliminate disparities in health care.1 As a key advocate at the national level, Cigna actively shares best practices related to addressing health disparities and social determinants of health (SDoH)2 as well as advancing equitable health care with network providers, other health plans, employer groups, and clients.

At the same time, we continue to work closely with our stakeholders to improve health equity3 among our customers, our workforce, and our communities. Our company has made a long-term commitment to improving health equity in the marketplace – deploying strategic and operational resources to improve access to affordable high-quality health care while establishing and meeting standards of health equity and cultural competency within our own organization.

In 2019, Cigna received its fourth Innovation in Advancing Health Equity Award from the National Business Group on Health (NBGH), a nonprofit organization devoted exclusively to representing large employers’ perspective on national health policy issues and helping companies optimize business performance through health improvement, innovation, and health care management.

Case Study: How Health Disparities are Identified and Prioritized through Data and Research at Cigna

Data, research, and evaluation are used at Cigna to identify and prioritize health disparities and evaluate the impact of initiatives to close gaps in care.
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Case Study: Increasing Cultural Competency and Inclusion through Training

Cigna recognizes the importance of providing cultural competency education to stakeholders, in order to better equip them to understand and address disparities.
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Where Health Disparities Often Occur

Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.4 For example:

  • African Americans/Blacks are 20% more likely to develop colorectal cancer than non-Hispanic whites.5
  • Women of color are up to 50% more likely to give birth prematurely, and their infants are 130% more likely to die.6
  • Depression is more than twice as common among older adults who identify as Lesbian, Gay, Bisexual, or Transgender (LGBT) than among older adults in general.7

The Factors That Contribute to Health Disparities

Factors that contribute to health disparities are low health literacy, language barriers, cultural beliefs and practices, access to quality care, bias in the medical profession, and SDoH such as physical environment or educational achievement. Both individually and collectively these factors can present preventable health care barriers to achieving optimal health status and outcomes for certain populations. Despite significant improvement in overall health outcomes over the past decade, many sub-populations, including under-resourced communities, continue to experience substantial health disparities.

Why Addressing Health Disparities is Critical

As the U.S. becomes increasingly more diverse, it’s no surprise that Cigna's clients reflect this diversity within their workforces. This demographic shift requires different health service models to offer culturally responsive care. We know that to be a more effective health advocate for our customers, we need to understand cultural differences, recognize changing population demographics, and address gaps in care relative to health disparities.

Disparities can result in worsened health outcomes, added health care costs, lost work productivity, and premature death.8 Health disparities are all too pervasive, not to mention costly to our country and our economy. Analysis estimates that disparities amount to approximately $93 billion in excess medical care costs and $42 billion in lost productivity per year as well as economic losses due to premature deaths.9

Health Equity Strategy

Cigna’s Health Equity Council, launched in 2008, is the governing body of our overall strategy to address health equity. Comprised of leaders from across the enterprise, the Council’s purpose is to:

  • Increase awareness, share knowledge, and exchange ideas about health equity.
  • Integrate health equity into every business area and promote collaboration.
  • Monitor progress on the strategy to promote health equity.

Following a similar framework as the Department of Health and Human Services’ (HHS) National Partnership for Action to End Health Disparities, the Council identified five key pillars to improve health equity among our customers:

  • Leadership – strengthen and broaden 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 social determinants of health 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 Competence – improve the cultural and linguistic competency of a diverse workforce and health care provider network.

Cigna has created a detailed action plan annually to ensure progress is made in each of these five areas, and it is the Council’s responsibility to formulate and oversee progress on our strategy.

In 2019, the Health Equity Council formed the SDoH Governance Council, which is composed of a group of stakeholders from across the enterprise who are working to build a shared strategy to address the SDoH that influence health outcomes and contribute to health disparities among our customers and in the community at large.

health-equity-chart

In 2019, we continued to shift our understanding of, and approach to, what constitutes whole person health, with the goal of better addressing the SDoH that negatively impact health status, outcomes, utilization, and costs. To this end, we completed a comprehensive evaluation of our U.S. Commercial Book of Business to better understand the impact that SDoH have on chronic disease condition prevalence, engagement in case management, emergency room and inpatient utilization, and primary care alignment. Additionally, a comprehensive mapping analysis was completed using our proprietary Social Determinants Index (SDI), which helps us to identify populations and communities at risk based on their geographic location. And finally, we completed multiple focus groups of physicians across the U.S. to better understand how SDoH impact their patient populations and how they are assessing those patients’ needs for support.

This analytic work has enabled Cigna to undertake evidence-based dialogues within our organization and across varied industries to encourage collaborative efforts to mitigate the SDoH that may be contributing to negative outcomes. In 2019, we become a member at the Steering Committee level of the National Alliance to Impact Social Determinants of Health (NASDOH) and engaged with staff and members from various Department of Health and Human Services agencies, including: Medicaid; Medicare; the Centers for Medicare and Medicaid Innovation (CMMI); the Office of the National Coordinator (ONC); the Office of the Assistant Secretary for Health (ASH); the Surgeon General; and the Chief Data Officer (CDO). Cigna also become a member of Project Link organized by America’s Health Insurance Plans (AHIP) – and participated in National Quality Forum’s SDoH Data Integration Action Team.

Individuals with unmet social needs are more likely to have:11

  • chronic conditions, including a 60% greater prevalence of diabetes
  • more than double the rate of emergency room visits
  • nearly double the rate of depression

Where Do We Go From Here

Many opportunities exist for the public and private sectors – including Cigna as a leading health services company – to help close the gaps between health disparity and health equity in the U.S. To this end, Cigna has been actively engaged in efforts to address and eliminate disparities in health care: collaborating with key stakeholders to identify and resolve health disparity issues within the workforce and the community. Essentially, we practice what we preach – establishing and striving for standards of health equity and cultural competency within our own organization so that we can continue to improve the health, well-being, and peace of mind of our increasingly diverse customer base.

In 2020, we will continue to work closely with clients, customers, and health coaches in the public and private sectors to eliminate the health disparities that continue to plague far too many people and populations. In particular, we are committed to cultivating a state of health equity in the marketplace by deploying strategic and operational resources to improve affordability and access to high-quality health 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.

2Social 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.

3Healthy 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.

4U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet]. Section IV: Advisory Committee findings and recommendations [cited 2010 January 6]. Available from: http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf.

5Colorectal Cancer Facts & Figures 2017–2019. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-andfigures-2017-2019.pdf (p. 4).

6March of Dimes. Fall 2019 Prematurity Research Centers Update.

7Promoting The Behavioral Health of LGBT Older Adults. May 2019. National LGBT Health Education Center. Fenway Institute.

8Disparities in Health and Health Care: Five Key Questions and Answers, KFF Henry J. Kaiser Family Foundation. Published: August 8, 2018.

9Ani Turner, The Business Case for Racial Equity, A Strategy for Growth (W.K. Kellogg Foundation and Altarum, April 2018), https://altarum.org/publications/the-business-case-for-racial-equity-a-strategy-for-growth.

10County Health Rankings and Roadmaps: A Robert Wood Johnson Foundation Program. (2019). Country health rankings model. https://www.countryhealthrankings.org/explore-health-rankings/measures-data-sources

11Berkowitz, et al. (2016). Addressing basic resource needs to improve primary care quality: a community collaboration programme. BMJ Quality & Safety, 25(3), 164–172. https://www.ncbi.nlm.nih.gov/pubmed/26621916.