If I told you I planned to close a quarter of the country’s cardiac catheterization labs, how would you react?
You would probably express outrage and accuse me of mismanagement of our entire health system. And that is to say nothing of all the harm that would come to patients. But as docs, we reason in a prejudiced fashion. We do medicine. We write prescriptions. We look at blood test results. That is our profession after all. It is how we extend lives and improve people’s well-being. If we can measure, see, or manipulate a variable, anything attached to it must have value. We have been trained to infer from that ethos with everything else taking a back seat.
However, what if I then said I would reinvest every dime saved from those closures above and direct them towards all the people in our communities. How many more lives might we protect or individuals made better off? It is all about tradeoffs and the only go-to fixes we know–referrals, technology, and pharmaceuticals–are often not cures but remedies to move us from one setback to the next.
Have you ever seen below:
* 2000 B.C. – Here, eat this root.
* A.D. 1000 – That root is heathen. Here, say this prayer.
* A.D. 1850 – That prayer is superstition. Here, drink this potion.
* A.D. 1920 – That potion is snake oil. Here, swallow this pill.
* A.D. 1945 – That pill is ineffective. Here, take this penicillin.
* A.D. 1955 – Oops . . . bugs mutated. Here, take this tetracycline.
* 1960-2015 – 39 more “oops.” Here, take gorillacillin.
* A.D. 2016 – The bugs have won! Here, eat this root.
It’s about the basics. The root is the low tech stuff we don’t do–and it triumphs most of the time. As providers, unfortunately, and as I alluded to earlier, we don’t have the training, and thus the mindset, to make the mental shift. But think. Is it possible, if making people healthier remains our first principle, if not at least applying tools that may seem foreign to us, can we at least make an attempt to understand how these same tools fit into a much larger order we don’t appreciate?
Recently, you have noticed an increase in attention paid to care transitions, bundled payments, and neighborhood services availed to people following an institutional stay. Further, terms such as “built environments,” healthy communities and population health (you can check your region’s ranking here) have come into vogue not because we need new ways to spend government funds, but because the wheel we have been trying to reinvent does not need a rebuild. It spins just fine.
And that gets me to the real purpose of this post. I am delighted Lauren Taylor agreed to answer a number of questions linked to these and other issues related to how the social determinants of health impact our practice in the hospital. Her outstanding co-authored book with Elizabeth Bradley, The American Health Care Paradox, will turn minds on how we misallocate our system’s resources and produce results much lower than we should be achieving.
As a lead in, and so you get a better sense of why learning what she has to teach us has such salience for our work on the wards, read some of the foreword penned by Harvey V. Fineberg, former President of the Institute of Medicine:
For decades, experts have puzzled over why the US spends more on health care but suffers poorer outcomes than other industrialized nations. Now Elizabeth H. Bradley and Lauren A. Taylor marshal extensive research, including a comparative study of health care data from thirty countries, and get to the root of this paradox: We’ve left out of our tally the most impactful expenditures countries make to improve the health of their populations—investments in social services.
In The American Health Care Paradox, Bradley and Taylor illuminate how narrow definitions of “health care,” archaic divisions in the distribution of health and social services, and our allergy to government programs combine to create needless suffering in individual lives, even as health care spending continues to soar. They show us how and why the US health care “system” developed as it did; examine the constraints on, and possibilities for, reform; and profile inspiring new initiatives from around the world.
Offering a unique and clarifying perspective on the problems the Affordable Care Act won’t solve, this book also points a new way forward.
Our conversation follows with remarks edited for clarity:
BF: First off, thanks so much for spending some time with me today. If you mention determinants of health or use a catch-all phrase like the “safety net” to a provider, the first and probably only thoughts that will come to their mind are folks having no insurance, or Medicaid coverage, or living in a “bad” neighborhood. What’s the biggest misunderstanding of how providers see non-clinical determinants of health?
LT: Ah, language! Always tricky. For me, the terms “safety net” and “social (or non-clinical) determinants” actually call to mind different populations and challenges. I think of the safety net much like you described. On the health care side, Medicaid, federally-qualified health centers (FQHC), disproportionate share (DSH) hospitals, etc. On the social services side, the safety net includes things like Women, Infants and Children (WIC) program, nutritional support and public housing. In short, the safety net system is a system of last resort.
Social determinants, on the other hand, are inputs to health that most Americans grapple with every day. Social determinants is a catch-all phrase for things like food quality, smoking and exercise habits, aspects of our built environment and the degree to which we feel welcomed in or excluded from our community. So one need not be poor or receive benefits from the safety net to be deeply affected by social determinants. We all are.
The reason we so often conflate the safety net and the social determinants conversation is, I think, because the safety net is publicly funded. My sense is that Americans across the socio-economic spectrum probably over-utilize health care and under-prioritize social determinants – but we only get upset about it (and call people frequent fliers) when they have publicly-funded health insurance. Hence, the safety net discussion has become a sort of social determinants conversation.
BF: Understanding community organizations and ancillary staff by default have dealt with social issues in the past, should docs have this responsibility as well, and if so, what should that role be? It is such an important subject and history taking focused on financial, transportation, and home safety issues could probably get us a better return on investment beyond other things we ask.
LT: I am a fan of docs having conversations with patients about social determinants. I recognize that physicians feel like they’re drowning in paperwork and metrics but we know that words coming from a physician can have impact that the same words coming from other providers do not. Now, the more complicated system design question is who does the actual handoff or connecting of patients from physicians to the required services. This, I sense should not fall within a doctor’s scope of practice.
I suspect a lot of this hinges on individual providers’ identities. If physicians see themselves as “health” professionals, then I think the ask for them to address social determinants is natural. If, on the other hand, they see themselves as “health care” professionals, then addressing social determinants of health can seem out of scope.
BF: Continuing on the above point, should we educate or urge providers to take on these tasks if the supports to engage the right people do not exist or are weak?
LT: Frankly, I am still wrestling with this issue. I know it comes up quite a bit in relation to ACE (Adverse Childhood Events) screenings. I’ve heard some physicians don’t like to do these screenings because if and when an ACE score turns out high and the physician is unable to make the appropriate referral, they run the risk of (a) compromising the doctor-patient relationship and (b) facing moral distress.
Despite these concerns, I think I’m still in favor of providers asking the hard questions. And this instinct comes from my training as an oncology chaplain. Even if there is nothing you can do, I think hearing the patients concerns and validating their challenge as real (with all the social authority of that white coat!) is an intervention unto itself. I realize this runs contrary to the dominant ethos of medicine – which is to fix things – but that would be my vote.
BF: Knowing the prominent deficiencies we have in our support system outside hospital walls, how accountable should hospital-based docs be for them and the readmissions they likely cause?
LT: I would be skeptical about pinning responsibility directly to individual hospital-based docs. But I am interested in exploring what it would look like to pin responsibility for health outcomes to organizations like ACOs. I think readmissions penalties have already heightened health systems’ interest in what is going on outside hospital walls – and if it spurs some investment in the community to shore up the deficiencies, I’m happy. Do I think that should be the primary role of health systems? Of course not. But I’m a pragmatist in this sense. And more social service spending, particularly from the states, has been difficult to come by so long as health care spending has been growing. So if we can construct an incentive scheme that redirects some health care dollars into the community, I’ll take it.
BF: With the dearth of social service and community provisions that await patients post discharge, how would you advise an inpatient group to use a non-clinical FTE that dropped out of the sky or a new found $75K to better bridge their patient’s care transitions back to home? Also, if you had your fantasy, what intervention would you want to see in place before discharge, again, to facilitate a better transition? You have an open checkbook.
LT: This is a tough question to answer without knowing what the patient population of this inpatient group looks like. A team that I am on from Yale recently published a literature review that aimed to answer the question: which social service investments create the greatest returns to health? And what we found is that nutritional support, income support, housing and care coordination all have a reasonable (though certainly not infallible) evidence base. The challenge is that in many cases, the return on investment that these interventions generate seems highly dependent on the patient population on which they are evaluated. A housing intervention may create big returns to health for people who are homeless but less so for a middle-class patient who is already safely and stably housed. Similarly, a home-delivered meals intervention may make a substantial difference in the health of an older American who is home alone most days but very little to a low-income single Mom who works three jobs and is gone all day.
I think this is what makes this issue deceptively complex. It’s not difficult to imagine what categories of things are critical to being healthy. But it can be complicated to figure out how to meaningfully provide that support to diverse populations.
BF: Tell us a bit more about your work and to take advantage of your wisdom, would you leave us with some key take home points.
LT: My work these days is mostly focused on operational models by which health and social services can come together. If anyone is interested, do feel free to e-mail me.
As for take homes, there might be two. First, I would clarify that I am not interested in needlessly making more work for providers by dragging them deep into a realm that they are not trained to handle. Rather, my interest is in linking health and social services in such a way that providers are able to make referrals so that non-medical challenges can be addressed by non-medical providers. I’ll never forget this one physician we talked to in writing The American Health Care Paradox. She was reflecting on her own participation in this coordinated health-housing intervention and said “Now, I really get to be a physician. And that’s refreshing.” I would love for all physicians to be able to say that.
Second, I always like to remind physicians what extraordinary social influence they have. Many people have noted that this is something of a ‘zeitgeist’ moment insomuch as everyone in Health Affairs (the leading health policy journal) and the like suddenly seems to be talking about social determinants. But I’m keenly aware of the fact that my, and all, wonk influence is limited. If we really want greater attention to social determinants of health to take hold in the psyche of the American people – who are patients, payers, and policymakers – then it’s ultimately physicians who will have to be out in front of these national conversations. For better or worse, you are who people look to when it comes health.