GUEST POST from Arlen Meyers
We owe a lot to K-12 teachers. They, like others who work in mission critical industries, like sick care, have to deal with many issues to help their students. In fact,according to a recent survey,the greatest barriers to school success for K-12 students have little to do with anything that goes on in the classroom, according to the nation’s top teachers: It is family stress, followed by poverty, and learning and psychological problems. In many ways and in many places, the same is true for doctors helping patients.
Approximately 1.2 billion people in the world live in extreme poverty (less than one dollar per day). Poverty creates ill-health because it forces people to live in environments that make them sick, without decent shelter, clean water or adequate sanitation. While the official US poverty rate is 14.5%, some differ and claim it is as low as 4.5%. Still, a lot of people.
In addition,More than 16 million children in the United States – 22% of all children – live in families with incomes below the federal poverty level – $23,550 a year for a family of four. Research shows that, on average, families need an income of about twice that level to cover basic expenses.
After 50 years, The War on Poverty has been a stalemate, and , as you would expect, poverty rhetoric takes the stage every four years.
Between 2000 and 2015, the number of people living below the poverty line rose 36 percent, from just under 34 million Americans to over 46 million, and the poverty rate increased by two percentage points. But where one lives matters. High-poverty neighborhoods, defined as places in which at least 20 percent of residents are poor, can lock families and children into a cycle of poverty because they lack good schools, nearby jobs, and are often fraught with high crime. Unfortunately, the number of high-poverty neighborhoods has more than doubled in the nation’s 100 largest metro areas, with the bulk of that growth occurring in the suburbs.
I’ve worked for many years in “safety net” hospitals-city and county hospitals, university hospitals that take care of a disproportionate share of poor patients, VA patients who are homeless, and native American facilities located on reservations with a culture of poverty. In most instances, health success has little of nothing to do with what goes on in the examining room. Instead, the psycho-social and behavioral health context usually is a predictor of treatment success or failure. In most instances, doctors are ill-prepared to deal with those issues and live at the epicenter of medicine, the legal system, medical sociology and a very dysfunctional mental and behavioral health pseudo-system.
There is growing awareness and acknowledgment in the health care community that health outcomes and disparities, more often than not, are driven by social determinants of health than by medical care. Social determinants of health include social, economic, physical, or other conditions where people live, learn, work, and play that influence their health. Poverty and food insecurity are social determinants of health, and are associated with some of the most serious and costly health problems in the nation.
With the elimination of net neutrality, the internet becomes another social determinant.
The loss of net neutrality will force healthcare organizations to rely more on electronic health record (EHR) vendors like Cerner and Epic to provide them with the technological support they need to be able to move health records electronically, and consumers will pay for that cost, says Beatrice Mallory, SVP and managing director at Sensis Health.
It will also exacerbate the rate at which internet access is a social determinant of health, because there will now be entire communities with less access to preventive care, prenatal care and chronic disease management, she tells Healthcare Dive. “What you’ll see is more reliance on episodic care” and use of emergency rooms, she says.
These days, a lot of people are telling doctors what they should be and do. As if practicing state of the art medicine is not enough, clinicians are expected to be experts in health economics, population health, data analytics and business intelligence, spiritual medical sociology, behavioral health, community resource management, law enforcement, addiction medicine and much more. They are being measured and compensated using measures over which they have little or no control. And we haven’t yet gotten to the chief complaint.
In fact, doctors are no longer expected to just do what’s “right” by the patient. Now they are expected to serve two other masters-their employers and society at large.
I remember in medical school learning about taking a history from a patient. One part was the social history, inquiring about such things as education, occupation, marital status and a few things that regulators required later on, like being the victim of domestic abuse. I rarely asked about whether the patient had food and shelter for the night. Some medical schools are changing that, with the understanding that your ZIP code is a more important determinant of your health than your genetic code.
The two biggest contributors to rising global health costs are the aging population and poor health habits contributing to non-infectious chronic disease. Here are the factors thatcontribute to the success of public health interventions:
The factors that affect the successful implementation of such programs are: • national planning, political factors and capacity; • availability of data about the target population and intervention impacts; • influence of socio-economic factors and special considerations regarding the age of target population; • burden of the health problem to society, family and individual; • use of intervention in a multifactorial setting; • communication strategies through media and school to reach vulnerable and minority groups; and • engagement of all levels of the society (from government to individual) in the process.
Policy considerations
The research evidence shows that the most effective programes for children and young people are carried out at the government level, supported by society in general, and promote national policies to decrease poverty and increase social equality. The second most effective interventions are coordinated government policies such as pricing, legislation and other policies. (E.g. the most effective interventions against tobacco use are increasing the price of tobacco, banning tobacco product advertising, banning smoking in public places and legislation prohibiting the sale of tobacco products to young people.) There is also evidence that simultaneous, multi-dimensional inputs at national, local and individual level increase the effectiveness of general health promotion campaigns. The health promotion interventions that are least likely to work are ones that deal with single issues, are ‘negative in the message’, and delivered at only one level of society.
The research on social services, health spending, and health outcomes suggests strongly that it is no coincidence that the U.S. has this unusual combination of spending and mediocre outcomes.
Studies that focus on non-clinically directed health promoting interventions such as tobacco or sugar taxes, or placement of urban greenways are in short supply in spite of the fact that a robust literature has documented that health care’s impact on population health is dwarfed by social and environmental factors. Here is a research agenda to fill the gaps
Value-based care (VBC) is necessary to significantly improve health outcomes and to lower costs for children and others with chronic illness and complex medical conditions. One hospital reports, though, that a VBC approach can decrease the direct costs of care for a group of children with a chronic condition. However, transitioning to a VBC approach involves added infrastructure, training costs, and complexity of delivering care in an environment that mixes fee-for-service and value-based reimbursement. In addition, in order to deliver on the promise of improved health and reduced spending, VBC must be augmented with a structured approach to eliminate waste and be delivered in conjunction with a broad-based effort to address factors that are outside of the traditional boundaries of healthcare. The results might also mean less revenue for a hospital since it reduces fee for service interventions.
Here how different organizations are solving the problem.
Experts offer the following advice to leaders who want to reduce health disparities in their communities.
Use the community health needs assessment. Hospitals are required to complete the assessment every three years and can use the process to identify which health inequities to target, Weiss says. MaineHealth identified substance-use disorder as a priority after reviewing its own assessment. Leaders may want to conduct this assessment jointly with other providers in their community.
Ask for help. Health system and health plans may want to reach out to community stakeholders like criminal justice, transportation, and business organizations to talk about potential solutions. For example, leaders at Maine Behavioral Healthcare work with law enforcement to train officers on how to identify individuals with mental health needs, including substance-use disorder, Merz says.
Think about the next generation. In addition to helping adults by funding stable housing, CareOregon aims to change the trajectory for children affected by homelessness. Hunter says that homeless children often have higher scores in Adverse Childhood Experiences testing, which raises their future health risks. “Housing is a big piece of a family’s economic security and helps to change the long-term dynamic,” he says.
Be a catalyst for collaboration in your own organization. In many provider organizations, internal leaders in finance, population health, and community benefits may not have had opportunities to interact. But a health equity project can be a good place to start. “What financial leadership can help do is bring some of those conversations together,” Weiss says.
Focus on the problem and then think about incorporating technology. Providers need to consider their clinical needs before they purchase technology platforms to address health disparities, UMMC’s Adcock says. In addition, they should realize that one product will not address every issue.
Build healthy cities Most city leadership, urban policymaking or action on the ground prioritises the safe and efficient delivery of formal healthcare services in hospitals and the community rather than a wider focus on public health and healthy lives. This is cure rather than prevention. The Foresight Future of Cities project has identified a broader perspective that could be adopted – one that looks at urban health and wellbeing as a total ‘ecosystem’ to be embraced, rather than urban healthcare as a complex system to be managed and resourced.
Newark Beth Israel has hired 169 city residents for full- and part-time jobs during the past year and will hire locally for 250 more full-time positions over the next two years. The hospital plans to spend $610,000 this year with local women and minority-owned businesses. It also has invested $5 million in a Newark venture-capital project to develop local tech entrepreneurs and provided a $150,000 grant to a commercial-redevelopment program.
Population health is more about providing clean water, housing, mental and behavioral health intervention, opportunity equity, education and adequate nutrition than big data. The sick care system generally ignores it. Those that don’t not only improve care but save money doing it.
We need to do a better job of rebuilding civic social support systems and linking the sick care system with the public health and other social service ecosystems However,without seeing care in context, we’ll be missing the forest for the trees.
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