The Value-Based Healthcare Podcast: Reginald Tucker-Seeley

We are back with another episode of The Value-Based Healthcare Podcast series! Our guest for episode 16 is Dr. Reginald Tucker-Seeley who is the Edward L. Schneider Assistant Professor of Gerontology at the USC Leonard Davis School of Gerontology. Dr. Tucker-Seeley discusses his career journey from majoring in accounting as an undergraduate all the way to getting his doctorate at the Harvard T.H. Chan School of Public Health. He also details the measurement of social determinants of health for an individual versus a population. Once that is measured, what do we do with that individual/group and how do we help those with financial hardship? Find out the answer to this and more below!

‍

Podcast transcription: 

Jay Ackerman:
Hello, I'm Jay Ackerman, CEO of Reveleer, a software company committed to providing health plans with innovative technologies to maximize their return from quality, risk adjustment, and compliance initiatives.

We're back again with yet another installment of the Value-Based Healthcare podcast where we engage with thought leaders and visionaries working across the healthcare ecosystem. Through our podcast we aim to widen the visibility and voice of people working to change how healthcare is provided and the impact it has on all those who participate in the care delivery chain. Let's get started.

Dr. Reginald Tucker-Seeley joined the faculty at the University of Southern California, USC, Leonard Davis School of Gerontology in June of '17. Prior to joining USC, Dr. Tucker-Seeley was an assistant professor at the Dana Farber Cancer Institute and the Harvard T.H. Chan School of Public Health. He completed master and doctoral degrees at HSPH and a postdoctoral fellowship in cancer prevention and control at HSPH and DFCI. Dr. Tucker-Seeley's research focuses primarily on social determinants of health, a hot topic such as the association between the neighborhood environment and health behavior. And, on individual levels, socioeconomic determinants of multi-morbidity, mortality, self-rated health, and health self-efficacy.

His current work focuses on financial wellbeing across the cancer continuum from prevention to end of life care. He has received R21 and KO1 grants from the National Cancer Institute to develop measures of financial wellbeing at two points along the cancer continuum: prevention and following diagnosis. He was also funded by the Academy Health Aetna Foundation Scholars in Residence Fellowship Program to develop measures of neighborhood economic wellbeing.

Dr. Reginald, I'm so happy to have you here today. I've been able to follow some of your work online and listen to some other speeches that you've given. And we're spending a lot of time in our company on social determinants of health and to have the opportunity to talk to you today is a delight and a treat for us.

Dr. Tucker-Seely:
Oh great, thanks so much for the invitation.

Jay Ackerman:
We're excited to have the time. So why don't we jump in and, first, to talk about your career journey. And I love hearing how people, such as yourself, kind of found their way into healthcare. And at what point in your life did you say, "Hey, you know what? I'm going to be a doctor and this is my calling"?

Dr. Tucker-Seely:
Yes, I share a similar passion in hearing how people got to where they are. Primarily, because my journey or trajectory was not so straightforward. So as an undergrad at the University of Tulsa, I majored in accounting and I spent about five years in the accounting field. First, I worked at a managed care company in the finance department, and then I was an internal auditor at St. Louis University. I didn't really enjoy accounting and I thought it would get better once I started working, and it just was not my calling. But I really enjoyed my social and behavioral science courses as an undergrad. But as a first generation college student, I had no idea what someone with a love for those topics did for work.

And so while an auditor at St. Louis University, I was able to take courses there and I entered the master's in counseling and family therapy program thinking I was going to get a PhD in counseling psychology. But realized I didn't really enjoy that either. But during that process I read a paper on the bio-psycho-social approaches to health. And that's where I first read the phrase "social determinants of health." And when I saw that phrase, I realized that I finally had language for what I was interested in. And when I read the paper I thought, "I want to do the work that this author is doing. So where is he working?" And it turned out, it was a paper by Dr. Norman Anderson who, at the time, was at the Harvard School of Public Health. So then, I was introduced to the field of public health. I didn't know public health existed, let alone social and behavioral sciences departments within schools of public health. And so I applied to the Harvard School of Public Health, I applied to get another master's degree and I was at Harvard from master's student to assistant professor.

Jay Ackerman:
So I imagine when you're together with doctors and you're talking about your backgrounds, you're probably standing alone there as someone who started their career in an accounting and audit.

Dr. Tucker-Seely:
Yeah. But one thing that I think people with varied backgrounds bring to any conversation is they pull the things that they learned from those fields to their current work. So, I think my work in accounting, and especially my work in higher education administration as an auditor, I learned a lot about how large organizations make decisions, and I learned a lot about financial management. So, I think those skills are very helpful in my research work, in my community-based work, I wouldn't choose a different path.

Jay Ackerman:
just to share, I actually started my career in that direction as well. So, I graduated undergrad as an economics major. Not sure what I was going to do with that. And then, got hired by one of the big eight firms and immediately went to business school for my master's in accounting, and joined the audit path of a big eight firm. So, we can do the secret handshake offline.

Dr. Tucker-Seely:
(Laughs) Yeah. That sounds good. Hopefully, I still remember it.

Jay Ackerman:
Yeah. So, so let's talk about your current position and focus. Can you share a little bit about that?

Dr. Tucker-Seely:
Sure. So, my program of research is focused on financial wellbeing across the cancer continuum. So, thinking about how do we think about socioeconomic circumstances beyond just education and income? In particular, the measures that capture how socioeconomic status is actually lived by people. And I think measures of financial wellbeing do that really well. And so when I was at Dana Farber Cancer Institute and the Harvard School of Public Health, my program of research focused on how do we think about, how do we measure financial wellbeing concepts across the cancer continuum from research and prevention throughout detection, diagnosis, survivorship, and end of life care?

In 2017, I was recruited to the Leonard Davis School Gerontology at the University of Southern California. And I've expanded that focus not just on across the cancer continuum, but the chronic disease continuum. So, thinking about financial wellbeing, our concepts of financial wellbeing, such as financial hardship, financial stress and strain across the chronic disease continuum. So not only just focusing on cancer, but thinking about how these concepts, how do we measure them and their influence on outcomes across other chronic diseases as well.

Jay Ackerman:
Would be great to hear how you think that the ability to measure and track that has changed in the few years that you've been focused on it.

Dr. Tucker-Seely:
Yeah, so I think when I was at the Dana Farber Cancer Institute, I think it was the term that has now gained a lot of popularity in the cancer world, was just being introduced. And that term was called financial toxicity. This notion that navigating cancer care can be financially toxic to the household. And so that term seems to have gained a little bit more popularity and traction among medical oncologists. But, at the time, first we didn't really have a good measure of this experience and we didn't really have anything to do once we measured it.

So a lot of pushback, or questions that I would get is, yes, we can measure this experience, but what do we do if we determine that a household is indeed experiencing financial hardships? So, there was no script to write or no prescription to write to alleviate that particular symptom. And one thing that I realized doing work in this area is that we used various terms interchangeably. So, we would use terms like financial hardship, financial stress, financial strain, economic burden. We would use all of those terms without a lot of conceptual clarity on what they meant and even less clarity on how we measured them.

And so at the start of this work, my goal was to dive in, and to develop measures, and get some measurement clarity in this space. But I realized that we weren't even using the same terms when we thought we may have been talking about the same experience, when maybe we weren't talking about the same experience. So, I think we need to first get conceptual clarity, that is figure out what is the experience that we're actually talking about when we use terms like financial hardship, or financial stress, or financial strain, or economic burden. And then, get more clarity on how do we measure that experience? And then, I think with that conceptual clarity and with that measurement clarity it's easier to develop interventions because we have clear targets on what we're intervening on.

Jay Ackerman:
So getting alignment on terms in an industry as broad and as vast as healthcare, it must be pretty daunting. Can you share maybe some of your thoughts on how do you embark on that?

Dr. Tucker-Seely:
Yeah, it's interesting you mentioned earlier in my introduction that I'd received some funding from the National Cancer Institute to develop measurement tools. And so, as part of those grants, I conducted a systematic literature review looking at the various way’s concepts related to financial wellbeing had been defined in measure across multiple fields. Across psychology, sociology, public health, medicine, family and consumer science, which those of us of an older age will remember that as the home economics field, and public health and medicine. And what I realized is that across fields there was no consistency. Sometimes in some of the articles we reviewed, we would note that the authors would use different terms in the same paper.

So I introduced a conceptual model to sort the many terms that we use in this space into three domains. So, first, I think there's a material domain, so this is on the financial resources you have or that you don't have, so that is your struggle with making ends meet, specific hardships that you might have in a specific area. So that's the material. Then there's the psychological or psychosocial area or domain that focuses on how do you feel about those resources, or how do you feel about the lack of resources? So specifically thinking about financial worry, how much time are you spending thinking about your finances, financial stress or strain? Are you stressed about your lack of financial resources? And then thirdly, a behavioral domain.

So I will state that at the beginning of that research process, I really only thought about the material in psychosocial, which was really informed by the research and health disparities that talks about either the material or other psychosocial explanations for why health disparities exist. But this behavioral domain was really something that had been left out is, what do people do with their financial resources? What kinds of financial adjustments are they making in response to financial hardship? Are they cutting back on their meds? Are they not paying for their basic necessities? Are they missing doctor's appointments? I think the material psychosocial and behavioral conceptual model sort of helps us to sort the many terms that are used in this space that I then think is helpful for us for measurement and also for intervention.

Jay Ackerman:
That's really helpful to understand that construct. Now with that construct and the work you're doing there, can you share a little bit about how you see health plans maybe responding to that and how that will influence the way they operate?

Dr. Tucker-Seely:
I think this is a really interesting time because I think for those of us who are either trained in, or who have been doing research in the social epidemiology space are really excited that now, health plans and health systems are focusing on social determinants of health. And so, as they're focusing on social determinants of health, I think one of the key spaces is going, one of the key areas is going to be what do we measure and how do we measure it? And I think that's where for the thinking that I've been doing around financial hardship or financial wellbeing will be most helpful. But it's being very clear about what aspect of financial wellbeing that the health plan, or the health system is most interested in. And I think thinking about it in the material psycho, social and behavioral domains is helpful because it also gets you closer to thinking about not only, yes, this is what we're assessing, but then also helpful in thinking about who to partner with in efforts to attempt to intervene.

Jay Ackerman:
And Reggie, what do you see as the kind of industry trends that will accelerate a kind of movement here with either the plans or providers/health systems?

Dr. Tucker-Seely:
Yes. And so, I think this sort of goes back to my excitement around social determinants of health. I think the recognition that health no longer is just what happens in the doctor's office. It's actually what happens when we're not in the doctor's offices. And so, I think this trend towards trying to figure out sort of what are the social determinants of health are actually... I think too, this is another space where there's been some discussion around what do we call the social environment that is influential to our health behavior? So, is it social determinants of health? Is that social risk? Is it social needs?

And so I think in that space of trying to figure out sort of what do we call it, it's also going to be helpful for us to think about yes, after we figure out we're calling it social risk, or social needs what does it do we need to measure in those things that are most associated with poor health and poor health outcomes and for whom? For what specific population groups, for what specific context so things that are relevant in one area, geographic area, may not be relevant in another area. What issues might be relevant for one population may not be relevant for other populations across the life course. So I think I'm really excited that we're now starting to talk more about the social factors and how those social factors impact not only our health but how we navigate healthcare.

Jay Ackerman:
So as you, as you mentioned a minute ago, there is a lot of dialogue about what do we call this? And we're spending a lot of time on the measures. So, to the extent that you get to determine what we call it, where do you land on this SDOH, social risks, social needs?

Dr. Tucker-Seely:
Yeah, so I'm landing more on the social needs if we're focused on individual patients. I think one thing that those of us in academia are really great at is identifying what the problems are here. And so, it's consistent with being an academic, I think one of the other problems is how do we go from talking about populations to working one on one with individuals? And so I think if we're focused on the individual patient, then yes, the social needs of that particular patient, and being able to adequately navigate healthcare and address his or her health needs than social needs, I think, is the right term.

If we're talking about communities, if we're talking about populations, then I think social determinants of health I think is the better phrase. So that is, if the intervention is about how do we change the social context in neighborhoods, how do we change the social context for various populations, then I think social determinants of health is the most appropriate phrase there.

Jay Ackerman:
That's great. So, in this kind of movement and momentum building in this area what do you think will be the biggest barrier, biggest challenges that are going to affect kind of momentum and real change?

Dr. Tucker-Seely:
Well I think there are a couple of barriers. So, I think one of the barriers is awareness sort of making sure that everyone in the healthcare is aware of the fact that social factors do indeed impact our health and our health behavior. So, I think there's going to be... not that everyone needs to be trained in social epidemiology, but I think everyone sort of that engages with patients needs to be aware of the social factors that can impact how individuals navigate care that's going to be important. And then the measurement piece, sort of what is it that we're actually going to assess, and how are we going to assess it? Where is it going to fit in the typical or normal clinical flow so that we don't overwhelm our current clinical staff with having to assess one more thing?

And then, I think another challenge is going to be, so yes it's very consistent with my earlier work in financial hardship, once we measure the thing then what do we do, where do we refer? And so making sure that the community has the capacity to absorb the social needs that are assessed in healthcare because it's not really fair to the patient to assess something and not have a place to either connect the patient to assure that we can address those needs, those social needs that are addressed that are potentially impacting his or her health, behavior, health or health behavior.

Jay Ackerman:
So in those three barriers or challenges, any thoughts you would share on how we can address them and kind of work through them?

Dr. Tucker-Seely:
Sure. So, I think it was great that the National Academy of Medicine had a recent report out on sort of integrating social needs into healthcare delivery. And so, they sort of talked a lot about how do we raise awareness of these issues? And I think reports like that sort of highlighting the issue help. I think the Robert Wood Johnson Culture of Health initiative that is focusing on this notion that health happens where we work, live, learn and play. So I think those kinds of when big players are highlighting the issue, that helps to raise awareness.

I think in the area of measurement, there are several research teams that are working together now that are... a couple of programs I think in Northern California are working on what do we assess in this space and what's been shown to be most effective? There's also a recent supplement in the American Journal of Preventive Medicine that I haven't gotten around to reading, but it's focused on assessing social needs or social risks in healthcare delivery. And one of the papers that I'm really excited about reading is related to patient acceptance of this new initiative. So, are patients willing to talk about and have their social needs assessed in healthcare delivery? So it's going to be a space where they may not necessarily be as accustomed to the healthcare delivery system addressing those needs.

So I think sort of continuing research in this area to make sure that we are asking the right kinds of questions, asking them in the right way, and ensuring that they fit well within the current healthcare delivery space. And then, for the third barrier that is making sure that we have community at the capacity to address these issues. I know there's The John A. Hartford Foundation has an initiative where they're working with community-based organizations to prepare them for engaging with healthcare delivery. So I think there are efforts that are underway and, hopefully, those efforts will be successful and sort of help us to better understand how best to navigate the landscape of addressing social needs in healthcare delivery.

Jay Ackerman:
Yeah, I've been hearing and reading a lot about organizations being launched to kind of bridge the gap from care to call it delivery into the community and kind of helping connect and solve the need kind of, outside the doctor office. So, it'd be interesting to see what emerges at scale that's not just local community but can do it across the state, across a region, across the country.

Dr. Tucker-Seely:
I'd be remiss if I didn't mention an effort that I'm involved in here in Los Angeles County. So, it's a collaboration with the Department of Public Health, the Department of Mental Health and the Department of Healthcare Services to address healthcare, to address social needs of patients as they're navigating care in Los Angeles County healthcare facilities. And we're in the early stages of trying to figure out how to make this work, and evaluate those efforts as well. So, I think in addition to implementation, we also have to think about ensuring that we have the necessary evaluation tools in place to evaluate these implementation efforts. I think, we're all really excited that these healthcare delivery and social determinants of health are sort of coming together. But I think we also have to make sure that we are adequately evaluating the implementation of these new efforts.

Jay Ackerman:
I appreciate you sharing what's going on inside of LA County. So, let's say, you got brought into the C-suite of a national health plan, and they said, "Reggie, we're going to want to hear your thoughts on what we should be doing to navigate and kind of lead progress in the area of social determinants of health?" What would you suggest to them? What would you kind of urge them to do? Yeah, can you share some thoughts there?

Dr. Tucker-Seely:
I recognize that it can feel like a very large area to try to tackle, sort of thinking about how every aspect of our social lives could potentially impact our health and our health behavior. So I think one of the first tasks would be to figure out what areas are you going to focus on? Are you going to focus on housing. Are you going to focus on food? Are you going to focus on social isolation, loneliness? Sort of prioritizing the social factors that that organization wants to focus on. In particular, I think sort of getting an assessment of what are the issues that the patients in that particular health system are struggling with? And what are the social factors that are being shown to most influence the health outcomes of interest?

I think it can be such a challenging task to not only figure out the social factors, but then how do we link that to specific health outcomes. And what are the process outcomes and what are the health outcomes to focus on? So I think my strategy would be sort of a brainstorming session around what are the social factors we're going to focus on? What are the health areas we're going focus on? And trying to ensure that we can create a system that allows for small successes early on because I recognize how challenging it can be to change large organizations. And so, trying to figure out what are the low hanging fruits in the area of social needs that the organization can focus on to begin to see some successes improving the health and health behavior of the patients.

Jay Ackerman:
Yeah so, it brings you back to the data again, right? Understanding the data for their members.

Dr. Tucker-Seely:
Most definitely. And I think trying to figure out what are the data needs? Because I think this is a new area for some health plans. So, figuring out what data do you have, and what new data do you need to begin to think about how does the social factors impact the patients in that particular plan?

Jay Ackerman:
All right, so we're talking about some larger organizations like health plans. So let's talk about a really large organization like CMS. If you had a chance to visit with CMS and talk to them about regulatory changes what would you really like to see from them?

Dr. Tucker-Seely:
Well, that's a really good question. I'm not sure I would know sort of what regulatory changes should happen. And I'm going to take this time to be a little bit selfish about my own research program, but I would really like sort of adoption of my sort of conceptual model of hardship and recognition of financial challenges of navigating healthcare across the life course. So, encouraging organizations to have a consistent definition and measurement of financial hardship so that across settings we can know that we're talking about the same experience, we're measuring it the same, and then we are sort of designing interventions that are focusing on the areas that we've clearly measured. So not sure that I have any regulatory recommendations, but it would be great if this sort of nebulous term of financial hardship could get some big players to say, "This is the term we're using, this is how we're defining it and measuring it, and all organizations working with us go forth and use these measures to assess this experience."

Jay Ackerman:
Yeah, that's perfect. Let's talk about the public and about recommendation to the public. Really kind of a little bit of a different twist, but if you kind of recommend to the public, like what can they do regarding their ownership of their health?

Dr. Tucker-Seely:
That's a great question because I think, oftentimes, we know that there are disparities in access, there are disparities in quality and experience, and outcomes across various groups as they're navigating healthcare. So, I think a few recommendations, like I said, I would have to the public is asking questions, making sure that your provider recognizes that it's a partnership in providing your healthcare. I often joke with some of my friends that whenever I enter a healthcare setting, or I'm meeting with a provider I make sure that she or he knows what I do for work. And so that they are aware that I study this and I'm aware of the fact that there are health disparities that are present in particular for people who look like me as an African-American man. And so, I want to make sure that we are in a partnership to address whatever health issue I'm there to address.

And so, I would encourage the public to sort of take that approach. One thing that we sometimes, as researchers or academics, sort of fall a little short in our sort of discussions what should patients do as they're navigating care? I think sometimes we assume that folks have the kinds of flexible schedules that we, as academics, have, or have the financial resources that we have. So, I think also recognizing that there are some individuals that are navigating care, but they're constrained by resources, they're constrained by time, they're constrained by a series of things in their respective communities. And so, I think sort of meeting patients where they are, but also encouraging patients to be active participants in the healthcare that they are receiving.

Jay Ackerman:
I'm just curious on the point about making sure that the provider understands your line of work, and that you're coming in as a more than informed consumer. How have you found them changing their reaction to that now versus a year ago and five years ago?

Dr. Tucker-Seely:
Yes. I would say at the beginning, let's go back 10 years ago, I think when I first started sort of making sure that my personal providers were aware of what I did for work. I think, physicians are under an enormous amount of pressure to see as many patients as possible. So, they're trying to cram as much in into the visit, into that short span of time. So, for me personally, I want to make sure that I'm seen as a person and not as sort of a set of characteristics. So that is a 40 plus, black man that is presenting for whatever health issue, but as a 40 plus black man who studies this. And so, who also may have or who does have input on his health and healthcare. And the thing that I hope that that does to the provider is that it not only helps him to see me as a person, but also the next patient as a person and not just as the set of demographic characteristics to help make sense of the behavior that the physician may be seeing.

Jay Ackerman:
That's wonderful. I appreciate you sharing that. The dialogue's been great, but we probably need to start to bring it to a close so I can let you get back to your research. So, I love wrapping up with our kind of rapid-fire round, five quick questions top of mind. So, what keeps you up at night?

Dr. Tucker-Seely:
Well, I'm new to Southern California, so I would say this is my first time being in a space where the ground can be on fire. So that's been sort of adjusting to Southern California, the great weather here, but then also the impact of climate change in this area is pretty evident. So, I think I would say the impact that climate change is going to continue to have on our environment is something that keeps me up.

Jay Ackerman:
Yeah. As beautiful as Southern California is, it is hard to say that we're not going through climate change based on fires, and droughts, and mudslides that we all experience now.

Dr. Tucker-Seely:
Yes.

Jay Ackerman:
All right, so when you're kind of up at night thinking about that, what book might you grab from your nightstand and maybe you can share why you read it?

Dr. Tucker-Seely:
So it's interesting. The only books I read are sort of books for work, but sort of pleasure I'm sort of addicted to Audible at the moment. So all of my books are through that app, and so I'm listening to a book called White Fragility at the moment, which I found to be really informative around how white folks talk about issues related to race.

Jay Ackerman:
Interesting. I'll have to look that one up. I find myself in an interesting place as a white man, but with two adopted African-American children. So, my world straddles a bunch of circles and it's caused me and my wife to have to deepen our understanding of a number of different lives.

Dr. Tucker-Seely:
Yes. Well, I highly recommend White Fragility it's a really great text.

Jay Ackerman:
Yeah. Thank you. I'm going to go deep on this one, if you'll indulge me. If you can redo one decision in your life, what would it be and why?

Dr. Tucker-Seely:
Oh, that's a great question. I generally like to look back at... I mean as you heard from my career trajectory, there are a lot of sort of decisions that didn't necessarily stick, but I generally don't necessarily like to look at those kinds of decisions as mistakes because I wouldn't be the person I am if I hadn't done accounting, or done mental health, or decided to move to Boston for graduate school. So I don't necessarily look back at past decisions. There's things that I should've done differently, but more so is, what did I learn from those decisions that didn't necessarily work out as intended?

Jay Ackerman:
I was glad we didn't get to you sharing that moving from the East coast to the West coast that you've adopted the Lakers, so stick with your New England teams, I hope.

Dr. Tucker-Seely:
I'm not really a big sports fan and I think that's actually one of the things that has been an adjustment of now being at USC, which is a really big, big sports school is just having to learn about all of the big sports at my new school.

Jay Ackerman:
Yeah, I bet. Now, we're going light. What's your favorite app on your mobile device?

Dr. Tucker-Seely:
So I would say the app that I use the most now that I live in Southern California is Waze, is trying to get around LA. I can't imagine navigating the city without it.

Jay Ackerman:
Yeah, I think we can compare how many Waze points we've earned based on our miles, like feedback we've give and received.

Dr. Tucker-Seely:
Yeah.

Jay Ackerman:
All right. Last one for your Reggie, how do you invest in yourself?

Dr. Tucker-Seely:
I really enjoy spending time with my family, with my husband and my two dogs. So, the year before coming to USC, I spent a year in Washington DC, and my husband stayed here in Los Angeles, and that was our first time living apart. And so, I think now that I'm back we spend as much time as we can together. And we just bought a house here so we are sort of trying to make this house our home here in Southern California. So I would say investing in myself by making sure that I carve out time.

Jay Ackerman:
Lovely. I appreciate you sharing that. Reggie, this has been fantastic. I've enjoyed talking to you.

Dr. Tucker-Seely:
Thanks, you too. And thanks so much for having me.

Jay Ackerman:
We were in hot pursuit to carve out time on your calendar and you didn't disappoint.

Dr. Tucker-Seely:
Great. All right, well I look forward to hearing the podcast, so thanks again for inviting me.

Jay Ackerman:
You bet. Thank you, Reggie. And this will bring our Value-Based Healthcare podcast to a close.

Thank you for joining us today. Listen to more episodes at reveleer.com or find us through your favorite podcast platform. For episode updates, follow Reveleer on LinkedIn.