Welcome to my 2020 year-end newsletter. You can find past newsletters with additional background materials, and different stories and initiatives on my website and in my LinkedIn articles or posts. Join me in identifying and coordinating initiatives that advance health, health equity and community and healthcare redesign.
Shannah’s Insights and Reflections
Yearend of a year we could not have predicted and that will have impacts for many years to come feels unsettling. There are many opportunities to make fundamental changes that will promote health equity and upstream investments in living conditions. These could strengthen our country and communities if embraced and sustained. There is enormous work to be done if we choose to take a bold path, but the benefits would be worth it.
Two year-end inspirational highlights. The first is the story of Jack Geiger MD who sadly recently passed away. It shows that with determination, enabling improved living conditions as a part of the healthcare mission can and has been done in more difficult times than ours. In the early 60s he established and transformed community health centers in South Boston and the Mississippi Delta with a social medicine model that addressed social and economic needs.
The second highlight is community fridges to help feed hungry neighbors. The number of community-led stocked refrigerators has increased at least 500% in the past 8 months and the movement shows a combination of contributions and partnerships that include volunteers, restaurants, stadiums and financial donations coming together to make everyone better off.
In other positive news, Ochsner Health and Xavier University with a little help from the Drew Brees foundation are committing $100 million in the first 5 years of a 10 year-commitment to increase healthcare access for people in Louisiana. They will open 15 community health centers in underserved areas in the first 3 years. Although the amount is small relative to total state healthcare spending the focus is on the critical gap and disparity of who has access/coverage. In 2020 LA ranked 49th in the US for healthcare.
I came across a very exciting Hospital Toolkit on Investing in Community Health that distinguishes investment from spending and emphasizes leveraging investments with other community partners. Hospitals can do so much more with the same dollars following the six steps that include having a strategy! The report is definitely worth a careful read and here is a last tidbit to get you interested:
“This toolkit will zero in on the last of these approaches, also known as community investment (see Box 3). Community investment (sometimes called impact investment) can be used to create the social and physical environments that support community health over the long term. Health care organizations have an array of assets—land, financial resources, relationships, expertise, etc.—that can be harnessed to support community investment.”
The approval and distribution of two COVID vaccines is a good way to start the new year, but not without challenges, particularly for the very people that are already being hardest hit by the pandemic. A Politico article highlights many of these issues:
“People can’t or won’t get the shot if they can’t get a ride to a vaccination site or face language barriers. For those who lack access to smartphones and other technology, it’s harder to make appointments or receive reminders about when to get the second dose weeks later.
Hourly workers may not be able to take time off during the day to get to a clinic — particularly if it requires a two-hour bus ride. If they don’t have paid sick leave, they may be afraid to miss work if they have side effects for a day or so. There’s apprehension about cost, because the message hasn’t gotten through that the coronavirus vaccine is free.”
States and the new administration have their work cut out for them to bridge distrust and administrative hurdles. Taking vaccines to the people and offering free transportation to the vaccine sites should be part of the delivery models.
The AMA is explicitly recognizing racism as a public health threat and recognizing race as a social construct. This cannot take hold soon enough as we just witnessed the likely preventable death of Dr. Susan Moore, an African American physician who was not treated equitably for COVID-19. If a physician is hard pressed to self-advocate, imagine what happens to patients without medical training.
Increasingly associations, health systems and thought leaders are recognizing SDOH as a team sport requiring all-hands-on-deck and many partners. The question arises who should take the lead? I come back to my strong preference from my last newsletter — Community, Community, Community; It should also strive for improvements and solutions that pool investments at the community level, rather than those driven by individual health systems or plans.
A recent article by Sachin Jain and Pooja Chandrashekar in the American Journal of Managed Care takes the opposite approach, i.e., recommending targeted interventions for individuals. This may yield near term improvements for individual patients but doesn’t address long-term upstream barriers for the community and future patients. The following characterization can be turned around.
“…a clinical trial conducted at 2 clinics in West Philadelphia, Pennsylvania, showed that patients offered rideshare services missed the same number of appointments as controls. Upon further investigation, researchers found that other factors (e.g., caregiver role for family members, stress, pressure to be at work) posed a greater obstacle to some patients than transportation.4 These findings caution against the broad, and sometimes blind, application of SDOH interventions.”
One could argue that the outcome lens is too narrow and short term. If rideshare is broadly offered/subsidized for all daily living needs – grocery shopping, timely arrival at work and medical appointments and other supports were in place, e.g., respite for caregivers to allow them time for appointments, the patients might make more appointments or need less healthcare. Is the healthcare appointment really the highest priority for the patients evaluated in the study? A separate statement in the article is where our views realign in that it is not the primary responsibility of the healthcare system to independently address the broader social needs. This brings us full circle to the concepts in the Toolkit mentioned above.
More and more Healthcare CEOs are calling for a Commission to address racism and healthcare coverage, but the suggested participants are largely healthcare providers and plans. We need broad multi-industry and community stakeholders involved who are often more knowledgeable about unmet social and community infrastructure needs.
The extensive partnership evolving in Utah that includes Intermountain Healthcare and United Way of Salt Lake looking for scalable approaches for the whole state may offer a multi-stakeholder model. Let’s hope they look to the local communities to help determine priorities and facilitate engagement.
Pharmacists are increasingly being seen as a recognized engagement point for individuals in need beyond healthcare. Aetna/CVS are leveraging the concept through their HealthTag program that delivers personalized messages from the pharmacists to patients and tells the patient about enrolling in UniteUs to access social services.
Wellcare’s community engagement and community connections team are supported through the Community Connections Help Line (CCHL)“… a resource not only for members but also for anyone in the community. If help is needed, call the CCHL number. “The Help Line is run and answered by people who are peer-based, so they have faced challenges before and have sought out help…” The information and referrals are followed up 2 weeks later to better understand community need. 15,000 social services referrals were made in 2019. Initial analysis indicates individuals receiving the social services help are “5.5 times more likely to schedule and attend their primary care visits, 2.4 times more likely to improve their BMI, and 1.4 times more likely to take better care of their diabetes-related complications”
Similarly, local hospital systems, Mercy Health and Saint Joseph Health System in Michigan established a social care hotline for any community resident in need for both health care and living conditions. Since the start in June they have help more than 5,000people.
I started looking at the latest HHS budget and was reminded about how lopsided our expenditures/investments are in what really matters for individuals and families. I wrote about the negligible funding for Area Agencies on Aging and the programs that support nutrition, transportation and housing in a 2016 paper and unfortunately it is a sustained funding trend for the elderly, rural health and low-wage workers who are disproportionately contracting and dying of the coronavirus.
“Federal funding for support services is miniscule compared with spending on health care. To illustrate, in fiscal year 2015, the federal government spent less than 2 cents on aging programs for each dollar it spent on health care for older Americans. Moreover, funding for OAA has shrunk dramatically in recent decades, despite growth in the ranks of older Americans.”
I am cautiously optimistic that the pressures of the pandemic, economy and racial reckoning will be the basis for changing these trends.
Humane eviction?! This NY Times article talks about how to address the anticipate flood of evictions once the moratorium is lifted. My heart sinks with the thought of this during winter and our second COVID wave. CDC’s eviction ban is in place until the end of January. Most state bans have ended. We should do better. A minimum should be to provide information for all forms of low cost and no cost housing. I recently came across Pallet Shelters’ a means to rapidly set up temporary housing. This sounds like something most communities with the combined challenges of homelessness and impending evictions should be exploring. Alternatively, repurposing hotels and office space that will not be quickly reoccupied or readily commercialized is another avenue to explore.
$3 Million was included for innovation funding of SDOH intervention programs in the omnibus bill funding COVID19 relief. Consider the amount in comparison to the Louisiana investment discussed above. “CDC will allocate funding to state, local, territorial, or tribal leaders to help fund social determinants of health work.” Perhaps this is better than nothing, but is $60K per state, forget breaking it into smaller amounts for other localities, really something to talk about? Once again, we should do better, particularly midst COVID19.
On the health disparities and structural racism front a recent study shows health inequality in infant care has increased since 2010. Sadly, it was on the heels of the prior recession that the reversal began and given the added burdens of the pandemic and current recession it will likely worsen. This is also a function of structural racism as discussed in a recent Washington Post article highlighting that black infant mortality rates are cut in half when babies are delivered by black doctors.
Yearend always brings new year predictions. This year is no different, although we might want to take a lesson from last year that we will be hard pressed to know given: the disruption of the pandemic; the new strains of the virus and the uncertainties involved in the vaccine distribution; the portion of the population that do not trust the health system or vaccines; and the continued unrest in our country. With this caveat, I will list my recommendations rather than my predictions.
I’m finishing this newsletter in the midst of the worst national insurrection since the early 1800s. We need to have a fresh start in 2021 for which thankfully the GA senate run-off elections have given our country more of a fighting chance.
1. The new administration should establish an advisory board on racial equity and the elimination of structural racism to parallel the COVID-19 advisory board with the same visibility and leverage to make quick and fundamental policy and investment recommendations.
2. Embrace ways across all federal programs to facilitate access to and investment in the social services and community infrastructures that will address basic human needs for all people living in the US. Let’s start moving the needle on more equitable investment that will ultimately help drive down healthcare costs. Perhaps start systematically looking at SDOH impacts of significant regulatory changes in all regulations across all agencies, with heavy emphasis on Housing, Transportation, Education, Agriculture, Labor, SSA, Justice and the IRS.
3. Use positive and negative incentives to counter the drivers of health disparities and inequities. Reward the states and communities that are making needed progress toward equity and penalize those communities and institutions that turn a blind eye towards structural racism and impoverished communities.
Please share the newsletter and connect via LinkedIn or email email@example.com with your reactions and input.
RECENT & UPCOMING EVENTS
Health Disparities Research Institute (HDRI) virtually August 9-13, 202, Applications will be accepted from February 1 – March 8, 2021! Designed to help aspiring early-career minority health and health disparities research scientists. Go to the website for more information.
Background and Definition
I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible. This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020