I shared this graphic from the Robert Wood Johnson Foundation earlier in the month it is an elegant portrayal of the fundamental difference between equality and equity. Health insurance exists because of the uncertainty of health risks. Healthcare is heavily regulated to help ensure quality and equity. These concepts often get lost in the cost driven political discussions.
Welcome to the monthly newsletter. You can find past newsletter in my LinkedIn articles. They have some additional background materials with different stories and initiatives that might be of interest. My goal for the newsletter is to inform improved and coordinated initiatives that advance health, health equity and community and healthcare redesign.
This month you can read about: A family’s escalating challenges to have a viable living environment; the benefit of community intergenerational programs; the Administrations reorganization plan that could undermine social supports in contrast to two state initiatives that seek to address the needs; the medical communities’ need for tools and resources to address living conditions; AAFP’s population health profiler and MedPac’s recommendation for a single Medicare hospital incentive program that would risk adjust for living conditions.
Please share the newsletter and connect via LinkedIn or email email@example.com with your reactions and input.
A personal story
This excerpt is from an article by Sarah Rigg Untangling The Complex Issue of Health Equity in Michigan part of State of Health a new series examining health disparities.
“Imagine this: Your child has tested positive for lead poisoning, so you request a city inspection of your home. At the same time, you receive an eviction notice. You follow up with the city to find out when the lead inspection will occur so you can use it to fight your eviction notice, but the city has canceled the inspection because of your eviction. In the same week, you have your second child, who will grow up in transitional housing after your eviction.
It sounds like some sort of nightmare scenario, but it’s the story of a very real Grand Rapids woman who Jeremy Moore met in his work as director of community health innovations at Spectrum Health. Moore uses the story to illustrate the concept of health equity, and the differences in the quality of health people may experience due to a host of factors known as social determinants.
For example, that Grand Rapids woman’s first child was already at a health disadvantage due to the social determinant of an unsafe physical environment. Her second would face potential health disadvantages due to social determinants including income, housing, access to services, and stress.”
I attended a local American Society on Aging event on Intergenerational programs that benefit all program participants. The panelists were: Donna Butts, Executive Director of Generations United, Leah Bradley Senior Director at Heyman Interages Center Jewish Council for the Aging and Joseph McCarley Temporary Emergency Residential Resource Institute for Families in Crisis, Inc. Washington, DC
All spoke about a broad range of programs that engage older adults with children and teens in novel ways that have dramatic impacts including substantial improvement in education outcomes for kids, creating purpose and enjoyment in the lives of older adults and addressing age segregation and ageism. Organization and facilities that provide senior services or support volunteer programs often partner with schools to set up these programs, but there are many more novel approaches including one example in which an old nursing facility was revamped to be assisted living and a nursing home with a preschool run in between the two facilities and programs for the seniors and kids to interact. It was life changing. All three organizations represented on the panel are happy to discuss their programs and Generations United has many resources and ideas on its website.
Government Initiatives Federal and State
On June 21st, The White House released a plan to reorganize and merge agencies and programs much of which would consolidate and potentially limit safety net programs. Many of these programs are the very heart of maintaining some minimum standard of living for individuals and families who live in poverty. The fundamental needs being supported like housing and food are also the living conditions that when absent result in poor health and increased medical expenses. Most reactions to the plan temper the concerns with the unlikelihood of any congressional action during an election year. Read more.
Meanwhile HUD and State of New York cut a deal on homelessness and housing that is designed to address some of the same living conditions to intentionally improve health. Similarly, Oregon’s Medicaid Advisory Committee issued a report focused on social determinants of health and Coordinated Care Organization Models that fundamentally recognizes the importance of Medicaid managed care plans working with communities to address living conditions that undermine health.
Health System and Community-based Services
Forbes May29th blog post Are Social Determinants The Missing Key To Improving Health? written by Chief Medical Officer of Humana Roy A. Beveridge, M.D., underscores how food insecurity, loneliness and isolation, particularly for the elderly “may be equally or more important as our physical determinants and genetic makeup.” He then goes on to say, however that “Our medical community needs the time, tools and reimbursement to proactively screen for social determinants of health, and this requires evolved payment models that codify and compensate physicians for these screenings.”
Research, Metrics & Technology
HealthLandscape, part of the American Academy of Family Physicians (AAFP), released its new Community Vital Signs Population Health Profiler tool, designed to help provider understand their patients living conditions.
“We created this tool to allow physicians the ability to easily upload a list of ZIP codes and counts of their patients in those ZIP codes to see the health and social characteristics of the areas that they serve,” said Mark Carrozza, director of HealthLandscape.
Physicians are encouraged to look at ZIPs covering 70% of their services area along with uploading their zip codes and patient counts and search on characteristics.
The Medicare Payment Advisory Commission’s (MedPac) June report to Congress recommends a consolidation of the four current hospital payment incentive programs into a single quality based payment program. The existing programs would be brought “under a single hospital value incentive program (HVIP) that would be patient oriented, encourage coordination across providers and time, and promote change in the delivery system. It also would account for social risk factors by adjusting payment through peer grouping.” Read more in chapter 7 of the report.
There is hope and the potential to transform aging in the intergenerational initiatives, but investments are limited and thus far it is largely a collective of grassroots efforts; perhaps this will change with more investment in improved living conditions. The White house proposal is likely dead on arrival, but the concept that we will in essence abandon or marginalize our responsibility to those less fortunate seems to be a hallmark of this administration. The silver lining is that most states, regardless of political leanings, are striving to improve living conditions. These kind of crosscutting policy changes could benefit from global health assessments similar to the cost-benefits assessments that are standard requirements for new or significant regulatory changes.
At the risk of becoming a broken record, I think the concept that the medical delivery system should screen for and then address social determinants will increase the likelihood of failure. Physicians and their staffs already are stretched to the limit. The solution lies with our communities and their social programs being supported and enhanced to help both screen and provide services that refer to the health system as needed and not the other way around. The tools and incentives again seem to anticipate the expanded medical system model, but potentially healthcare providers will have a greater incentive to find the right community partners.
Share your personal or community stories by connecting via LinkedIn or email firstname.lastname@example.org I welcome suggestions in all topic areas, particularly community driven models.
The 2nd Annual Payer and Provider Summit on Social Determinants of Health for Complex Populations September 11-12, 2018 Washington, DC
3rd Annual National Summit on the Social Determinants of Heath, October 8-9th, 2018, Sheraton, New Orleans, Louisiana Root Cause Coalition
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