1 February 2019
Dear Interested Readers,
Poverty in the Midst of Plenty, Stress, and Health
When I look back on my professional life I realize that my practice was primarily populated by individuals and families that were mostly from the middle class. When Harvard Vanguard spun off of Harvard Pilgrim Health Care our CEO at the time, Glenn Hackbarth, thought that we should understand the demographics of our practice as part of a growth strategy. We engaged Lippincott and Margulies, a marketing consultancy, to help us understand just what populations were naturally attracted to us. What we discovered was that our patients were significantly wealthier than the average resident of Eastern Massachusetts. Our average adult patient also had more than a college degree which meant that they had also achieved a higher level of academic achievement than the average citizen in our market.
I was startled by these facts, but then the data made sense as I did a mental review of the employment and professions of the patients in my primary care and cardiology practices. In my practice there were many college professors, some with national and international reputations. There were many of my patients who were partners in prestigious downtown law firms. I saw patients who were engineers at Digital Electronics Corporation (DEC), Raytheon, Mitre, Polaroid, Bose and many of the other technology firms that had spun off of the innovations and discoveries at MIT and other local institutions of higher learning.
There were many state and local employees, including constitutional officers and legislators. I saw school teachers, education administrators, city managers, policemen, firefighters, judges, clerks, and social workers. There were many patients who were doctors, nurses, or managers working in the Boston teaching hospitals, medical schools, schools of public health, and affiliated healthcare industries. What I did not see were many members of labor unions other than those from public employee unions. There were a few Medicaid patients and a much smaller percentage of Medicare patients than you would expect in comparison to the population of Massachusetts. I reasoned that our Medicare population was low because when we had opened in 1969 most of our patients had been employed and we did not accept fee for service payment. Every patient had been prepaid and Medicare at that time was all fee for service. That changed when Medicare Advantage was introduced.
I was deeply interested in the data and tried to imagine the factors that had created the reality of who we were serving. My best guess began with the fact that the concept of prepaid medical care with a focus on prevention and management of chronic and complex medical problems in a teaching environment that was primarily marketed to large employers, universities, hospitals, and professional firms, would select an informed population. HCHP had begun as a “leftist” concept and the idea had attracted people who understood what we were trying to do and were politically aligned with our ideas. Many of our patients valued the benefits of a restricted integrated network that focused on quality in an academic environment.
In retrospect unions were focused on getting their members contracts with insurers like Blue Cross that would offer them much more choice from the community. Initially we did have many people at or below the poverty line because we had federal funding to reach out to the Mission Hill community in Boston near the Brigham where there was public housing. Minority populations were more often attracted to the very high quality federally qualified neighborhood health centers that emerged in Boston in the late seventies. Many of the minority patients we saw came to us because they were public employees. After the funding for our Mission Hill clinic was lost all of our sites were located in predominantly middle class neighborhoods.
What we desired and described in our mission statement was to serve patients from all segments of the community, and we did in small numbers, as was reflected in the story Doctor Dorsey told about Doctor Ebert which I reported in Tuesday’s post. The event in the story occurred a few years before we got the demographic data:
One day late in Dr. Ebert’s life, he was in the Kenmore Center seeing Joe Dorsey as a patient, “Dr. Ebert drew me back out into the waiting room where an ethnically diverse group of patients were preparing to be seen,” Dorsey recalled. “He observed that the Dean of Harvard Medical School, the wealthy from Wellesley, and the patients in the waiting room representing such diverse racial, economic and ethnic backgrounds could now all have the same physicians, the same facilities and receive the same respect. He was proud of the fact that this was no longer just an academic theory and/or idealistic vision of his, but a reality that he was witnessing right before his eyes.”
The event was real, and I had similar experiences and observations myself. One day in the late eighties I was ahead of schedule and my medical assistant was having a bad day because one of her colleagues had called in sick. I decided to “room” my next patient myself just to give her a little help. I looked through the glass door that separated the clinical area from the waiting room. My next patient, a middle aged African American single father with several children and suffering with a severe cardiac disorder who was trying to get by on his salary as a toll taker on the Mass Turnpike, was sitting next to the Governor of Massachusetts who had an appointment with one of my colleagues. Both patients worked for the state, and I assume that their medical benefits were identical, as they should have been. We had a one size fits all coverage. I know that once they got to our office their treatments were of identical quality.
All good businesses do market studies to understand their current customers and locate new customers. There were several takeaways from our mid nineties market evaluation. The first was the realization that we had had a market share of about 15% of the Eastern Mass population. We also learned that our population was more affluent and better educated than the average citizen in the population. The most important takeaway for me was that in our desire to grow we had focused on the suburbs and the city neighborhoods where the population was more affluent and understood the value we offered. If growth and financial security were our only objectives we had done a pretty good job of competing with the established medical community in Eastern Massachusetts, but along the way our sense of social responsibility and desire to serve underserved populations had drifted down on the list of our priorities. Our greatest future opportunity for growth was in the population that we had largely ignored, the underserved. We needed to ask ourselves how to attract and better serve a Medicaid population if we were to remain true to our mission while growing. It was also obvious that it would be hard since we had located most of our delivery sites in the more affluent neighboring towns of the suburbs and the more affluent or middle class areas in the city of Boston.
Changing directions would take a lot of effort. Everyone in our practice said that they embraced the mission and we proudly proclaimed our intent to try to follow strategies that generated the financial stability that would allow us to be true to that objective. But, intermingled with the affirmation of our commitment to mission I frequently heard the mantra, “No margin, no mission.” We approached the challenge with a “Robin Hood” strategy. We moved resources from our most affluent sites to ones that were closer to areas of economic distress in the inner city. We provided more dollars per patient and richer staffing ratios and social services to the sites that had more socially challenged populations. Sometimes that process of “wealth transfer” was challenged by clinicians who felt that the money earned at a specific site should stay at that site. The other mission related decision that we made was to expand the budget of behavioral health beyond the revenue that they generated. In an era when most of our clinical services were asked to be self sufficient and the conventional wisdom was, “Every tub sits on its own bottom,” and other competitor group practices had stopped offering internal psychiatric services, we subsidized the budget of mental health. Not everyone agreed with the policy that was initiated by the board because by then we were measuring individual and departmental productivity, and almost 60% of the practice revenue had shifted from capitated contracts to fee for service income. Physicians were no longer on a straight salary and had substantial amounts of compensation based on RVU calculations of productivity. Our medical and surgical specialists often complained that that they were funding less “productive” sites and services. I soon learned that sometimes, even in organizations that have a charitable mission, “the right thing” is perceived differently based on how the dollars flow. “Mission” can be a real challenge to manage and maintain in a climate of declining revenue and increasing external challenges.
The current debates and the ones that will surely occur as we move toward the 2020 elections about public funding of universal access and the public policies that would improve the health of the nation rekindle my memories of those ancient organizational debates. The same questions that drove the internal philosophical controversies in our practice and were associated with the complex issues created by the tension between our mission, external market realities, and the concerns of individuals are still with us at every level. I see versions of what we experienced in many local practices and health systems. We feel those self protective emotions in the debates in state legislatures. What to do about extending coverage and maintaining the prohibition from using preexisting conditions as justification for charging more or denying insurance to every citizen will be our most significant domestic issue in the next election.
Those who want to cut taxes want to do more than build a wall on the border. They also want to redirect money from social programs to cover the deficits created by tax cuts. Immigration policy is important. What we will do with our foreign trading partners is key to our future wealth and national security. What we do to protect the planet and our environment should concern us all. Infrastructure is both a key concern and an opportunity to build for a better future. There are many important issues, but it is clear that we must have strategies and social policies that improve the social determinants of health if we are ever to live up to the promise of America. We can’t ignore that our current approaches to education, housing, income inequity, and access to health compromise the health and opportunities of 15 to 20 percent of our citizens. We have a problem with poverty and inequality that needs attention because in the end our current course will lead us to injury at every level of our society. We must face the reality that economic inequality that creates a burden for the poor is a problem that will eventually harm us all.
My interest in the intersection of poverty, health, and public policy has been rekindled by getting active in my new community. It started by agreeing to be part of an after school program for children in the fourth, fifth, and sixth grades in an old mill town, Newport, that is ten miles from my home. Newport is on the exact opposite end of the economic spectrum from the affluence of my community. Some children candidly talk about their lives. I was quite moved when a child in the after school program announced to me that she was “defective,” but she quickly added that she was not as defective as her brother. They both had “pills” to take. I learned a lot about her world listening to her chat away while we worked on projects or played “Clue” with others in the group. One day she casually told me that her mother was only fourteen when she was born. There were other chatty conversations about the rotating men in her mother’s life. Her siblings had different fathers. Later, she told me that she would not be coming back. She was moving to another state to be with her grandmother. She was a very bright child with a dim future. Her only error in life was being born into poverty at a time when there was still an insistence that the poor accept the responsibility for their own plight and lift themselves up by their own bootstraps.
About the same time I started volunteering in the after school program I joined the “wood ministry” at my church. We get donations of logs from various sources like contractors or from people who need to take down a tree to build an addition to their home or do a landscaping upgrade. We cut and split the wood in the summer and stack it to age for the winter. During the winter we get calls from people who need wood for heating. It is rare to deliver wood in New London, but we get calls from people living not far away down a road in the woods, or in one of the less affluent villages and towns of the area. What I have seen making deliveries are the squalid living conditions of proud people who are working hard at multiple minimum wage jobs and are still not making it. It’s hard to pull yourself up by your bootstraps when you have no boots.
This year I gave up working at the after school program because the schedule conflicted with new opportunity to participate in the Kearsage Regional Ecumenical Ministry. KREM is a collaborative program that distributes emergency funds to families in need. I hope that you click on the link to learn more about us. At any moment two members are “on call” to administer aid. I see some of the people who get wood from the wood ministry getting emergency help from KREM. We help with car repairs, overdue propane and electric bills, gas, groceries and almost any other concern that presents as an acute need for cash. Our church and others nearby maintain food pantries. One of the biggest jobs that KREM does is help clients find their way to other resources that are difficult for them to access. New Hampshire is famous for its motto, “Live Free or Die.” We don’t pay income tax and we don’t have a sales tax, so we have a public social services safety net with many big holes through which children, families, and the elderly can fall, especially when it is cold. KREM is a bandaid that struggles to cover deep wounds. Currently a group of us are trying to determine how we can move beyond being a bandaid and become “bootstraps” or an ongoing resource for those who are trying to lift themselves up.
It occurred to me that as a physician I never really needed to focus much on the social determinants of health. I was quite busy and satisfied taking care of people who were largely drawn from my own social circle. In retirement I am experiencing more exposure to those dealing with poverty than I ever had to encounter in practice. In practice if a problem did arise I could easily refer my patient to great social workers that we employed and quickly get back to “working at the top of my license” telling people that they should schedule their colonoscopy, should not smoke, should exercise more, should eat less salt, should limit their alcohol consumption, and be sure to remember to take their hydrochlorothiazide, lisinopril and atorvastatin.
A few weeks ago I published in a list of “key points” for physicians and healthcare organizations form an article in the Canadian Medical Association Journal entitled, “Taking action on the social determinants of health in clinical practice: a framework for health professionals” written by Anne Andermann, MD of McGill University where she leads a program to study and improve the social determinants of health. Here are some of her comments again because they are worth your second look and they lead into my next point:
There is strong evidence from around the globe that people who are poor and less educated have more health problems and die earlier than those who are richer and more educated, and these disparities exist even in wealthy countries like Canada. To make an impact on improving health equity and providing more patient-centred care, it is necessary to better understand and address the underlying causes of poor health.Yet physicians often feel helpless and frustrated when faced with the complex and intertwined health and social challenges of their patients. Many avoid asking about social issues, preferring to focus on medical treatment and lifestyle counseling. [ Here and below I have added bolding for emphasis.]
She offers a list of “Key Points” that include some things that physicians can do to make a difference.
Key points
- Although physicians generally recognize that social determinants (e.g., income, education and social status) influence the health of their patients, many are unsure how they can intervene.
- An increasing body of evidence provides guidance on a number of concrete actions that clinicians can use to address social determinants in their clinical practice to improve patient health and reduce inequities.
- At the patient level, physicians can be alert to clinical flags, ask patients about social challenges in a sensitive and caring way, and help them access benefits and support services.
- At the practice level, physicians can offer culturally safe services, use patient navigators where possible, and ensure that care is accessible to those most in need.
- At the community level, physicians can also partner with local organizations and public health, get involved in health planning and advocate for more supportive environments for health.
- Growing numbers of clinical decision aids, practice guidelines and other tools are now available to help physicians and allied health workers address the social determinants in their day-to-day practice.
She is writing to Canadian colleagues, but her conclusions are valid worldwide:
…physicians and other allied health care workers at the frontlines of clinical care are nonetheless important players and potential catalysts of change. They are well-positioned to support their patients in dealing with their social challenges; raise awareness of the human cost and suffering that results from poverty, discrimination, violence and social exclusion; and advocate for better living conditions to reduce health inequities and for more responsive health and social systems to care for those in need. Missed opportunities for prevention and inequitable access to care have been identified as major factors leading to inefficiencies in the health system. Therefore, leaders in Canadian health care increasingly recognize the need for a social determinants and population health approach “in reducing healthcare demand and contributing to health system sustainability.” Physicians are encouraged to implement their own creative solutions in their local context, measure the impact and share their successes in this important area of practice.
Since giving you the Andermann reference, I have reviewed Don Berwick’s IHI speech on the social determinants of health. In his speech Don recommended the book, The Health Gap: The Challenge of an Unequal World by Sir Michael Marmot. All of these resources make the same points.
- Health and Healthcare are not the same.
- Poverty and the social determinants of health are essentially one and the same.
- Medical practice, universal access, and sophisticated care for the individual are not enough to improve the health of the population.
- Physicians should better understand the social determinants of health so that they can understand the challenges their poorer patients must face and have insights into how they can contribute to the effort to improve the care of those patients.
- The United States is last among the developed nations in “health” while spending more than any other nation on healthcare because it does not have effective policies and programs to reduce the social barriers to health.
- The cost of care can never be reduced nor the health of the nation improved without addressing the social determinants of health through public policy and programs targeted to effectively reduce poverty.
Because of my interest in understanding poverty at the individual level most of my recent reading has been directed at understanding how poverty affects the individual, and especially children. One controversial resource which I have found to be very enlightening for the work that I am doing in my community was recommended by a friend who is an educator. It is Dr. Ruby Payne’s A Framework For Understanding Poverty. Many in education find reason to criticize her work, but I find it very helpful. She uses case studies to give a deeper understanding of the cultural issues of families in poverty and their lack of understanding and fluency in the “hidden rules” and language of the middle class. If you do not understand the rules of the game it is hard to win.
Another excellent resource for understanding how poverty affects the neurophysiology of the poor and has lasting impact on the brains of children in poverty is Robert Sapolsky’s Why Zebras Don’t Get Ulcers. Sapolsky is a well known Stanford professor of neurosciences. I have previously quoted from his book, Behave: The Biology of Humans at Our Best and Worst. In Zebras Don’t Get Ulcers he traces how stress impacts us to reduce our health and limit our ability to make good decisions when stressed. He explains how the fight or flight response to stress impacts the health of individuals, especially children, more creatively than I have ever read before. He demonstrates how poverty, economic inequity, and the fear of economic loss changes brain function and makes us less capable of exercising the frontal lobe executive function necessary to control impulsive behavior and make time discounted decisions. He explains why there is always a socioeconomic gradient of health in any population. He describes the same picture coming from the study of neuroscience that Ruby Payne paints coming from the classroom. Children of poverty have measurable deficits in neurological function by the time they get to an after school program like the one in which I participated. Chapter 17 of his book: “The View From the Bottom” should be required reading for all healthcare professionals and all members of Congress. Let me suggest that’s probably not going to happen, but l would encourage you to listen to Dr. Sapolsky describe it all in a recent interview with Ezra Klein. I have listened to the program several times and get something new with each investment of the time to listen.
It has been written that forty percent of Americans live so close to poverty that an unexpected bill of $400 would force them to sell something or get a loan. We learned a lot when President Trump shut down the government. Tens of thousands of middle class government employees turned out to be less than two paychecks away from financial distress. Food banks were stressed. People who appeared to be middle class were suddenly unable to pay their mortgages. Professor Sapolsky would point to the stress they felt and the continuing uncertainty of what might come next as a risk to their health .
I am beginning to think that I should rename this letter to “Musings on How Poverty Hurts All of Us.” I keep thinking about a quote that Don Berwick threw out in his speech from a physician in the UK, Dr. Jerry Morris:
A minimum income includes not just what is necessary for food and shelter, but what is required to live a life of dignity and to take one’s place in society.
There is so much to do, and tens of millions of reasons to encourage our efforts.
BuRRRR! It Is Cold
The high temperature on my walk on Thursday was a record for the lowest high temperature experienced during a walk. It was 5 degrees. It was a warm up from an overnight plunge to below zero. There were icicles in my beard! I was toasty in three pairs of gloves, a ski mask, and two heavy knit caps. I pulled on long johns, regular pants, and ski pants on my lower half, and covered my upper body with two shirts, a quilted vest, and puffy coat. I felt like a knight in armor. The sun was out, and the sky was a gorgeous bright blue.
Today’s header captures the feel of the day. It looks bright and cold with mist rising off of a frozen lake as the sun rises in the East. It is from a different spectacular cold, cold day, and is another lift from my neighbor’s fabulous drone photography. It makes the point that getting out in the cold can be a rewarding experience.
My advice for you this weekend is to get in a few miles on a walk on Sunday before the Super Bowl no matter what the temperature is. Once the game gets tense my diet will be the victim. Super Bowl Sunday is a good time to practice preventive exercise. Be out and about before you attack the nachos!
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
Note: The clinical vignettes in this letter have been modified to preserve privacy.
