| 3 July 2015
Dear Interested Readers,
Inside this Week's Letter
I was tempted to use the letter this week to join the chorus of all the continuing celebration of last week’s landmark decisions from the Supreme Court. In the aftermath of King v. Burwell the President seems to be redoubling his efforts to invite a bipartisan improvement of the ACA. The question was never about whether it was perfect. It is not. It has always been a starting point. Someday we will have ACA 2.0. In fact, I expect that someday we will have ACA 10.0, but that discussion is not the focus of this week’s letter.
This week’s letter is about healthcare disparities and the discussion arises from my recent affiliation with the Whittier Street Health Center in the Roxbury neighborhood of Boston. The letter is full of links that I hope you will check out this weekend if you have a little extra free time. The links do include strategyhealthcare.com, the companion blog to this weekly letter. Also, for the first time ever, I have included some graphics in the letter. I hope that they prove useful to you and that I have not broken any laws with my good intentions. If you are reading this letter because someone forwarded it to you, you may sign up at strategyhealthcare.com to get this letter sent to you free every Friday.
Health Disparities and The Triple Aim
Last Saturday morning I was the keynote speaker at the Whittier Street Clinic’s Men’s Health Summit and Grand Opening Ceremony. I have recently joined their Health and Wellness Foundation Board and the CEO, Frederica Williams, has wasted no time putting me to work. For those of you who do not know the Whittier Street Clinic, it is a historic neighborhood practice in the Roxbury neighborhood of Boston that was founded in 1933 as a free neighborhood clinic for obstetrical care. It is now a Federally Qualified Health Center (FQHC) and Level 3 Patient-Centered Medical Home (PCMH), and is licensed by the Massachusetts Department of Public Health. The mission of Whittier Street Health Center is to provide high quality, reliable and accessible primary care and support services to promote wellness and eliminate health and social disparities.
Whittier serves 27,000 patients and community residents providing them with primary care, behavioral health, dental care, vision, and social services. Whittier’s coordinated care delivery model uses multidisciplinary teams staffed by physicians, nurses, and medical assistants. The teams are supported by clinical pharmacists, nutritionists, and case managers. Aligned with their mission, the practice provides free programs to improve the health and wellness of the surrounding neighborhoods, which are Boston’s most challenged in the struggle with poverty, violence, and the other social determinants of health.
One specific example of how Whittier Street is trying to make a difference is a support program targeted for young men (18-34) who face enormous challenges as they seek opportunities in a world where unemployment of their demographic is greater than 25% according to a report from the Gallup organization in April 2015. The article states that it is a sad reality that the problem is getting worse despite the efforts of organizations like Whittier Street where its program is directed at helping young men prepare for job interviews. The program even goes so far as to focus on the language and dress modifications that the men need to make to have a better chance of finding an excellent job. Whittier has also been supportive of the efforts to bring better nutrition to the neighborhood and they have applauded the opening of an excellent supermarket, Tropical Foods, around the corner on Melnea Cass Boulevard. Unemployment and poor nutrition are two of the greatest threats to the health of all ages, but especially to the health of the youth of the community.
Whittier has a new home that offers the residents of its community one of the most beautiful and well appointed ambulatory facilities that exists anywhere. The building has a palpable focus on the dignity that every patient deserves when getting care. Opened in January 2012, this Silver LEED-certified, 78,900-square foot health facility gives them the capacity to provide up to 220,000 visits annually which should allow substantial expansion to adequately care for up to 80,000 patients.
Whittier recognizes that the men of their community represent a very challenged population and part of the event at which I spoke was the opening of a fabulous new exercise facility (partially pictured in today’s header). This new exercise area is available to anyone, but the needs of men who are harder to reach was a central consideration and motivation for its construction. The new exercise facility is an extension of the holistic philosophy of the practice that provides, in addition to primary care and improved handicap access, an array of services in one location, such as a Community Resource Room for community events, an Urgent Care Clinic, expanded Dental Services, a 340B pharmacy, and specialized clinics for chronic illnesses prevalent among the patients of the community.
In the document from which I gleaned most of this information, Whittier Street Health Center proudly lists its top five accomplishments for 2014 and its 2015 goals:
2014 Top Five Accomplishments
- Served 27,000 people through clinical services, wellness programs, and outreach and education activities.
- Named as one of the Top 100 Women-Led Businesses in Massachusetts.
- Selected as one of 22 organizations across the state to receive a grant from the Attorney General's Office to increase access to Behavioral Health services.
- Reached over 2,000 African American and Hispanic community residents through cardiovascular education outreach program.
- Reached 1,300 public housing residents through health screenings, workshops, and programming as part of the Building Vibrant Communities program.
2015 Goals
- Expand access to wellness programs by completing construction of the onsite Medical Fitness Center.
- Increase capacity in the Pediatrics and Dental Departments.
- Sustain mission-aligned grant-funded programs through a diverse mix of funding sources.
- Continue implementing the Health Equity Program and achieve improved outcomes for patients.
- Continue hosting successful community and fundraising events.
In that I have just recently become a part of the Whittier Street family, I had been quite surprised by the invitation to speak at the opening of the Men’s Health Summit and the opening of the fitness center. I shared the platform with the mayor of Boston, the Honorable Marty Walsh who was there to recognize the continuing service of Whittier Street Health Center to Boston’s most diverse and challenged citizens. The program also included the presentation of several awards that were given to professional staff, to board members and to members from the community whose efforts have made a difference in the Whittier Street programs to improve the care for men.
As I was contemplating what I might say to this very diverse gathering of dignitaries, employees and community members, I kept coming back in my mind to the speech that Dr. Robert Ebert gave on October 19, 1967 at Simmons College which is just a few blocks away in the Fenway neighborhood. Whittier Street’s new location on Tremont is also less than a mile from the Harvard Medical School and the Brigham where the bulk of my medical education occurred.
Dr. Ebert’s speech was delivered before I had finished my second month of medical school. Four things impress me when I read Dr. Ebert’s speech for the first time in 2008. First, he had accurately analyzed the state of healthcare in 1967. Second, things have not changed much over the past 48 years. Third, Dr. Ebert was on a mission to create a change in the way we train doctors and how we deliver care because he thought that doing so would be a major step in the direction of improving the health of individuals and of the community. This was a Triple Aim speech delivered 40 years before we had the Triple Aim. Finally, I suddenly realized just how much Dr. Ebert’s intent and wisdom had impacted who I am today. Those ideas would affect my training and determine more of what happened in my professional life than I could have ever imagined as a 22 year old who had just arrived in town from a childhood and college experience in a world that was still deeply divided along lines of race and economics and where even today many people cling to a perversion of history that allows them to fly an offensive flag as an expression of “heritage”.
In retrospect, it appeared that in that speech, The Kate McMahon Lecture at Simmons College, Dr. Ebert was describing once again the deficiencies of the current state of healthcare and medical education and he was also advocating for the trial of new approaches in delivery, finance, and education as steps that could be taken to resolve the problems as he had so eloquently summarized two years earlier with his admonition:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
The personal impact for me was that part of his solution was to create socially responsible physicians. Let me rephrase what I said above for emphasis. When I first found the speech in 2008 and read it, it was almost as if I had discovered a well meaning plot with me as a target and that the script or screenplay that contained that plot became the story of my forty years as a physician. Almost everything that I would do and would be, the focus of what I cared about, had been revealed or predicted in that speech.
Dr. Ebert did not try to hide his intentions about redirecting the training experience that my classmates and I were about to receive. Near the end of his speech he says:
Above all, the student must actively participate in such programs. He can learn from lectures and seminars but he must experience a new kind of social responsibility within the clinic if he is to be influenced in the future. He must see experiments in the delivery of health care. He must be made aware that the practice of medicine is now a group responsibility and he must learn to work closely with others. He must be made as aware of the social problems of medicine as he is of the biological problems.
In essence what he was describing was the Harvard Community Health Plan which would be launched two years later as a teaching practice of the Harvard Medical School which is a role that Harvard Vanguard Medical Associates continues to play even now.
What made the speech particularly important to discuss at the Whittier Street Health Center was Dr. Ebert’s concerns about how difficult delivering adequate care to the “urban poor” would be. Once again his thoughts from a half century ago read like an editorial from the most recent issues of Health Affairs or the New England Medical Journal. Read below and see for yourself. I have included his concerns also for rural America. I also serve on the board of Guthrie Health, a system in the “twin tiers” of Pennsylvania and New York that delivers care to rural and small town communities.
In this speech Dr. Ebert offers many solutions that have been adopted if you realize that care in community hospitals is now supported by the ability to transfer the critically ill to larger hospitals by helicopter as he invisions and suggests. What is most important, and I have put this and other significant points in bold face type that is not in his presentation, is that I wanted to show his thinking and emphasize the fact that he considers the problems of the urban poor to be even greater than the medical problems of rural America. He discussed these ideas in the sections of the speech following his review of the fragmented care in hospitals and the inadequacies of the current medical training. They are in sections entitled “The distribution of medical care” and “The organization of health care”. Please read them! I have posted the entire speech on strategyhealthcare.com as a resource for you since a clean copy is hard to find on the Internet.
The distribution of medical care:
Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions. Most of you are familiar with the problem of the rural community. Here the general practitioner is the mainstay of the medical care system, but as he grows older he is not being replaced. Community after community attempts to recruit new family physicians only to find that young physicians do not wish to practice alone in a small town. The reasons are not hard to find. Most young physicians specialize and are unwilling to practice alone; they are more and more dependent upon the well-equipped modern hospital, and finally their wives worry about the availability of good schools. [This reference to “wives” and his use of male pronouns in reference to doctors may be the only pieces of evidence that the document is almost 50 years old.] Once again, curiously little imagination has been exercised in seeking solutions to this problem. In an age of modern transportation, when the evacuation of wounded from the jungle by helicopter is routine, [Those of you old enough to remember know that war in Vietnam was producing evidence on the evening news on a nightly basis showing wounded soldiers being taken from the jungle by helicopter with IVs running.] it should not be too difficult to plan the care for rural communities. It would take a different kind of organization of physicians, however, and would require a kind of teamwork with other members of the health professions which physicians have been reluctant to provide except within the walls of the hospital. It also would demand a new role for the regional community hospital. The central city presents a different problem and one of greater magnitude. Few of the general practitioners who practiced in the city have been replaced, and the modern specialist serves the suburbs more than the city. The city or county hospital or large urban voluntary hospital provides most of the care for the urban poor. Often the actual medical care is good, particularly for the acutely ill patient, but too often it is care without dignity. Service is frequently fragmented among different hospitals for members of the same family, and even when paid for it tends to retain the trappings of charity. [My audience at Whittier Street shook their heads in agreement when I read these lines to them.] It is not surprising that the urban poor have sought a different kind of solution. The medical programs sponsored by OEO [Office of Economic Opportunity] can be criticized on many grounds but they have endeavored to give the community itself a voice in how it is to receive care — and the community does not want the charity clinic. Columbia Point [the first Federally Qualified Health Clinic] is too expensive to replicate, and it has not solved the problem of its relationship to hospitals. But it has demonstrated a number of important points.
First, the health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.
Second, more than the physician alone is required to provide these services; a well-organized team is essential.
Third, the community itself profits from a sense of active participation in the project.
These are important lessons, and the physician can display a new kind of social responsibility in contributing to the solution of the problems of urban health.
The organization of health care:
The provision of medical care in the rural community and in the central city will require a different kind of organization of medical resources than has existed in the past. The physician must learn to work more closely with social workers, nurses, visiting nurses, in fact all of the members of the health professions. There must be a sensible division of labor so that the physician performs those services which only he can do, and other duties are delegated to appropriate members of the health team. To a degree this has already been accomplished within the hospital, but team effort must be extended to provide care at all levels. This is not an easy problem for it will be necessary to make the most efficient use of expensive manpower and still maintain the personal nature of medical care. I believe this can be done but it will take innovation and will require of the physician a new kind of responsible social action. Care for the chronically ill and for the elderly, who so often suffer from chronic disease, is a particular case in point. Chronic illness is increasingly common and it cannot be handled effectively if it is thought of as an exclusively medical problem. The social, emotional and economic impacts of chronic disease must be understood and intelligently dealt with. Here the physician must share the responsibility with others who have special skills to offer.
As we consider the cutting edge thinking of our time, what has he left out? He describes with great clarity the social issues that determine health and that are still so hard to manage today. He envisions teams with new “standard work” for physicians and nurses and suggests how we should make sure that professional responsibilities are assigned for efficiency, effectiveness and as an exercise cognizant of the growing scarcity of clinicians. His answer to the professional shortages that are most significantly felt in the inner city and rural environment is for everyone to be working at “the top of their licenses”, doing only what only they can do and allowing other members of the team to share the work. He anticipates the need for innovation to solve problems and he basically describes the Wagner approach to the management of chronic disease decades before it appears in the literature. He is empathetic of the need for dignity and stresses that charity or municipal hospitals usually provide good care on an incidental and not in a coordinated fashion, and this care may be demeaning to the recipients of care who deserve more. He recognizes that better care for the diverse populations of the urban core is not a “copy and paste” reproduction of what works in the suburbs. He understands and is concerned about the plight of the underserved, recognizing their need to be participants in articulating the solutions that will affect their care.
The room was full of members of the Whittier Street Health Center’s community. They had come out to celebrate what had been created with them and for them. They responded with affirmation to Dr. Ebert’s words from across time as if I was reading to them from Holy Scripture. The Mayor sitting on the front row responded with affirming nods. When he rose to deliver his words following my presentation he echoed many of the same sentiments and then produced the most startling piece of evidence for the cruelty of health care discrepancies that I have ever heard. The life expectancy of a resident of the Roxbury community is 58.9 years. The life expectancy of a resident of Back Bay is 91.9 years. Hopefully those numbers will improve and that 33 year discrepancy will narrow substantially as we get further into healthcare reform in the aftermath of Chapter 58 in Massachusetts and the ACA in all of America. You can read the data for yourself at:
Here is a graphic from that work:
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| | | The presentation goes into a description of all of the issues that Dr. Ebert recognized and that continue today as reasons why just expanding access to care alone will not close the gap or create healthier communities or achieve the Triple Aim. The chart below that I copied from the reference puts it out there in much the same way as Dr. Ebert described the problems half a century ago. When I had referred to these issues in my presentation there was general agreement among those in the room for whom the neighborhood is their home. They agree that these are the issues that make the road to health much more difficult than my road as a member of the upper middle class or the road of those in almost every other demographic outside the diversity of the urban neighborhoods. |
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Dr. Ebert’s speech reveals that we have been concerned about the issue of healthcare disparities for a long time. Concern alone and the efforts and hard work of organizations like the Whittier Street Health Center are not enough. Don Berwick tried to address these issues in his failed campaign for governor and he has been a champion of the need for more focused and effective attention to these issues for many years. The concept of the Triple Aim is a start but we need to be realistic that if we are ever going to raise the life expectancy in our economically challenged neighborhoods to match the experience in wealthier neighborhoods that are just a few miles away geographically but worlds apart in the experience of health, we will need to do a lot more than just extend coverage that gives the possibility of a “suburban” like benefit package to residents of these challenged neighborhoods. Leaders like Mayor Walsh understand the problem and I am convinced that he understands that Boston’s collective expectations require vast improvement in the quality of health and life in these neighborhoods.
I was delighted to discover the federally supported program, Healthy People 2020. I encourage you to click on the link where you will read:
Although the term disparities is often interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen to a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health. It is important to recognize the impact that social determinants have on health outcomes of specific populations. Healthy People strives to improve the health of all groups.
I frequently receive notes from readers who are frustrated with the pace of change and who wonder if we are headed in the right direction. My own sense is that the landscape is dotted with wonderful examples of progress and places like Whittier Street Health Center where one can go to see real progress tackling enormous problems. There you can see a glimpse of the best we currently are doing and begin to imagine what “good would look like”.
I believe that the four legs of the “Triple Aim plus one” are not all of the same weight. The care of the individual is paramount, but unless we insure that the care of individuals is free of disparities we have not accomplished the real goal. Unless we eliminate disparities we will not achieve the second objective of healthier communities, nor will we realize the full benefits that we project will accrue to us all in terms of the lower cost of care that healthy communities generate. I will delay my comments on the fourth leg of the “Triple Aim plus one” until next week’s Musings. The achievement of that leg has operational, ethical and professional considerations that are definitely connected to the future resolution of healthcare disparities but the discussion will be a letter of its own.
I close with the words of Dr. Martin Luther King, Jr. If you visit his monument as I did recently, you are drawn more to his words that are carved into the walls of the monument that flank his statue than to his powerful image that the sculptor has tried to hew out of stone. I was disappointed that among the quotes that have become so familiar, his words about healthcare were missing. We need to say these words to ourselves again and again until we do away with the injustices of healthcare disparities. Whittier Street Health Center is on a mission to make a difference. Are the rest of us equally dedicated to the goal?
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
My Favorite Fourth
My favorite Fourth is one that I do not remember but I have home movies made by my father to suggest that we had a big time. I was three years old. My maternal grandfather is standing at a picnic table in his backyard in his starched white dress shirt and bow tie and is cutting watermelon. It is 1948 and that is the way many men were back then. I do not ever remember him in anything but a starched white shirt and tie or in pajamas shortly before he died at aged 64 following a massive heart attack and the subsequent month of declining status. Many times over my career as a cardiologist I have wished that I could have taken the technology of our era back to him in 1953 when he died.
Another big Fourth in my memory occurred at a family picnic with my father’s parents and siblings at the state park on top of Paris Mountain outside of Greenville, South Carolina in the early fifties. As an adult I will never forget the extended festivities of 1975 and the bicentennial. I am fortunate to have only positive memories associated with this most American of holidays. I am sure that it would not take long for you to bring up your own memories of family events, parades, fireworks and good times with good friends. It is a day when we easily focus on all that we have accomplished together. On the Fourth we are less likely to think about the issues of those who are not in the mainstream of American life and culture, but perhaps we should because as Hubert Humphrey said:
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
I can remember the chill that ran down my spine when I first read those words carved on the wall of the lobby of the Hubert Humphrey Building, the offices of HHS just a few blocks down Independence Avenue from the Capital. I had gone there to ask Don Berwick’s advice. I think that we can substitute culture, people, or a society for “government”, since these days so many seem to not recognize themselves in “government”. On the Fourth we all could realize that we are individually accountable for our share of how things work and that we and our children will be safer, happier and healthier when the day comes when everyone enjoys the same safety, the same opportunity for happiness, and the same access and equivalent support for good health. That day will be a real day for fireworks and joyous music on the Esplanade in Back Bay where the life expectancy exceeds 91 years!
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