Keith A. Reynolds 0:00
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Speaker 1 0:25
You know it is a source, not just of challenge for patients, but also for clinicians who feel a degree of, I think, moral injury when they are not able to meet a need of a patient that is clearly leading to adverse health consequences.

Austin Littrell 0:52
Welcome to Off the Chart, a business of medicine podcast, featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Allison Luttrell. I'm the Associate Editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics Senior Editor Richard Perrichand sat down with two experts from the Physicians Foundation, Dr. Drew Kular, a practicing physician and associate professor of health policy and economics at Weill Cornell Medical College, who directs the Physicians Foundation Center for the Study of Physician Practice and leadership, and Paul Harrington, the former executive vice president of the Vermont Medical Society, and a current board member of the Physicians Foundation. They get into the five core drivers of health. Why a patient's zip code can predict life expectancy more than the care they receive, and how screening for social needs falls short when the support to act on it isn't there. With that said, Dr. Drew Kular and Paul Harrington, thank you both for joining us. Now, let's get into the episode.

Richard Payerchin 1:44
I'm Richard Payerchin, reporting for Medical Economics. With me today is Paul C. Harrington, a board member of the Physicians Foundation and former executive vice president of the Vermont Medical Society. He has served as an elected official and healthcare advisor to other policymakers, and is an expert in health care reform. Thank you for joining us today.

Speaker 2 2:06
My pleasure, Richard. Thank you for having me. And if I can just give you a little bit of background as to why we got involved in drivers of health, I think a pretty compelling story in the mid 2010 in that era, there was a lot of focus on health care costs, as there always has been, with us being spending more than any other industrialized country on health care, about 18% of our GDP, and the focus in the early part of this century was on the supply side. The theory was that if you had more physicians, you're going to get more care, because they want to stay busy, and, and there was there were a lot of physicians who frankly disagreed with that, that they weren't trying to drum up business, they had plenty of people coming through their doors, and really increasing numbers of people coming to get their illnesses treated, and there was a Dr. Buzz Cooper, who was the dean of the University of Pennsylvania School of Medicine, wrote a book commissioned by the Physicians Foundation, titled The Myths of I want to get the guy the title right, poverty in the myths of health care reform, and he looked at the reason we spend so much money on health care reform, not the function of supply but more on demand, and that people with lower incomes in areas of don't have access to healthy food, transportation is absent, housing doesn't say a lot of crime, demand more health care services because they are sicker, and so if you can address the root cause of why people are needing more health care, as opposed to casting blame on those providing health care, you're going to have a better solution, and you can engage physicians not only in treating illness but promoting wellness, and that book really got us involved in drivers of health and became an early proponent of not focusing so much on the medical care being provided, although it's a big part of our mission, but also, why is that medical care needed? Why are those people, particularly from those zip codes that have higher rates of poverty demanding more health care services, and the answer is the lack of, you know, again the key charges of health. What, what, what are the 80% of things that keep you healthy or cause illness and. Supposed to 20% of healthcare that is focused on treating those illnesses

Richard Payerchin 5:06
to go back to to the point you made a little bit ago about Dr. Cooper and his analysis of healthcare by zip code, but you know from the outside looking in, especially for example, I'm based in Northern Ohio, we have some great healthcare systems here, some, I mean, world class, truly. In you tend to think of, okay, well, maybe in rural areas this is a problem, because people simply, there's just not as many people, there's that means there's not as much demand, you may not have as many healthcare professionals. Where I'm going with this is, though, you mentioned a moment ago about the pit and inner city health care, too. Can you talk a little bit about social drivers of health, and maybe expand on that? Geography, this is not just a rural problem, it's not just an urban problem. Can you share your thoughts on that?

Speaker 2 5:52
Sure, and we had, we just had the Physics Foundation just had a meeting in West Palm Beach, Florida, and I had given a webinar to the Palm Beach Medical Society a couple years ago, so I used that zip code as a basis for some study, and as you can imagine, Palm Beach County is one of the wealthiest areas in the nation, you know, President Trump's places on Palm Beach, there, and there's one zip code, there's a lot of beaches there, one area is called Jupiter Beach, and in that life, in that zip code, the life expectancy is 83 years, which is pretty darn good, I think, but within that same city of West Palm Beach, there's a zip code where the life expectancy is 67 years, and those two areas about 10 miles apart, and the the you know just the the income level in that inner city zip code with the life expectancy of 67 years is you know about half of what the zip code is in Jupiter Beach of 84 years, so to me that just hit me like a lightning bolt, that you know, Dr. Cooper's work, he focused on the, you know, the acuity of care that presenting patients would have going to a healthcare provider, I don't think he really looked at life expectancy, but what is more important than, you know, life expectancy? I mean, if you've got a difference of about 16 years, 10 miles apart, that just validated to be the importance of dealing with drivers of health to give, you know, everybody in this country the same possibility of leading, leading a health, healthy life, and not have it determined by whether you're not, you have access to healthy food, whether or not you're, you know, you're living near a waste dump, or you don't have access, you don't have job opportunities. The roads are in poor condition. You don't have access to transportation. There's domestic violence taking place, and so each of those people living in that environment, they are, you know, we talked about medical practices, you know, feeling that they're in the bottomless hole. I mean, I think those people would probably feel they too are in the bottomless hole, and they needed a ladder provided to them to climb up out of that hole. And I think we're trying to, through our focus on one of our priorities, German Smith, provide that ladder to those people

Richard Payerchin 9:02
for three quick hits, so to speak. Can you address something that works, something that doesn't, and what's coming for policy or practice from your own perspective?

Speaker 2 9:12
Sure. Well, again, I'm going to draw on the grant, draw on the grantees that we've already funded, so we have one grantee through the cardiology department at Rush University in Chicago, where the head of the program, Dr. Luger, is taking those cardiology residents and having them volunteer in local food shelves, so they are becoming familiar with the resources available to some of their patients that you know present with presumably a cardiac heart problem, but you know through the survey they fill out before they see the doctor, find out that you know they really are unable to get. Three meals a day, or foods are getting isn't as healthy as possible. This program started in Rush. It's now being picked up in Northwestern and other medical schools in the area. So I think just that going from the classroom to a food show to understand how important healthy food is, is really getting played out up in Chicago area. Another grantee we have is in Wichita, Kansas, and Dr. Moore, who leads that, is working with the physicians in the Wichita, Kansas area to have through their electronic medical records a screening tool to screen for deficient drivers of health, and then have the availability through a director of social service agencies, how those needs can be addressed, and then not only how other, how they can be addressed, but are they being addressed. So it's one thing to identify a deficiency, be aware of a resource, but actually has has the resource been taken advantage of, and is there remediation ongoing to address those drivers felt, so I know those things are those are good examples.

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Richard Payerchin 12:27
Can you briefly introduce yourself and the work you do for the foundation?

Speaker 1 12:31
Sure. So, my name is Ruth Kullar. I am a physician, a practicing physician at Weill Cornell in New York City. I'm also a health services researcher at Cornell, and so I work in the Department of Population Health Sciences here, and as part of that, I direct a center that is sponsored by the Physicians Foundation, which is called the Physicians Foundation Center for the Study of Physician Practice and Leadership, and we have a number of different focuses in terms of the type of work that we are doing, and the underlying goal of it all really is to try to bring about the conditions that allow physicians, other clinicians, and patients to thrive in the current healthcare system, and what can we do to nudge the system in the right direction. So we think a lot about issues around incentives in healthcare, a value-based payment, but also consolidation and corporatization of various parts of healthcare, we think about physician well-being and medical professionalism as levers to improve the quality of care, and an issue that's very dear to both the foundation and to the center is drivers of health and the meeting the social needs of patients, so that they can have the best health outcomes and well-being in their lives.

Richard Payerchin 13:46
I always tell people, in full disclosure, I'm not a physician myself, so if I ask a silly question, I appreciate your patience, but from kind of a journalistic perspective, a consumer or patient perspective, and yourself as a physician, you encounter some of the same, you know, advertisements, for example, that your patients do. Where I'm going with this is, is that there are certain elements of medicine that become kind of conventional wisdom. They're really ingrained in the system. At other times, patients and even physicians may hear about news that may sound like the latest fad or trend in healthcare. What I wanted to ask about was that establishment of that sort of data or evidence that establishes social drivers of health as a real contributor to a patient's health, and that this is not necessarily brand new. Doctors aren't just pulling this off the shelf hoping to find a solution, but there has been real study behind this.

Speaker 1 14:42
Oh, absolutely. I mean, I think in the past it was not as recognized as it should be. This idea that, of course, the community that you live in, the kind of social factors around healthcare, those contribute in an enormous way to the health and well-being of. People, by some measures, much more than the medical care that's being delivered in clinics and hospitals, and so I think there has been a growing understanding of how important these drivers of health are, but I think there has been still a challenge in integrating and meeting patients' social needs once they are in the healthcare system, in some way, and so I think that is what, over the past decade, decade and a half, has increasingly become a focus of policymakers, academics, and clinicians. Is once we know that patients have these needs, it's very clear from the evidence that an almost every health outcome is in some way influenced by a patient's social status, how do we then intervene on that to to try to support them on their health journey, and that I think is where there's still a lot of open questions, and that's one of the reasons that we're having this panel is to learn from people who are kind of at the forefront of integrating social drivers of health into care delivery to try to understand what are the most effective interventions. What has been tried in the past that hasn't been particularly effective, and if they could design a system, kind of a moon shot to move forward, what would that look like?

Richard Payerchin 16:18
The Physicians Foundation, and this has even come through in our coverage, but the foundation has identified four core driver, I'm sorry, five core drivers of health around food security, housing stability, transportation access, utilities access, and interpersonal safety as some of those really clinically significant factors for patients in your own experience, which one maybe gets the most attention, which one has been neglected.

Speaker 1 16:48
Well, I think, depending on the community, one or more of those things could be more relevant than others. So, there are places that are, you know, benefit from a lot more public safety. People don't feel safe in an area, another part area might be struggling with food insecurity. So, I think there are different areas that struggle disproportionately with different aspects of those five drivers that that you mentioned. You know, I think, of course, a very powerful driver of health is stable housing. If people don't have a place that they can call home if they're not kept, you know, sheltered in some way that will have a devastating effect on their health and well-being, but probably a broader challenge that many people, millions of people in this country face is the idea of food insecurity, and so people don't have access to regular nutritious food, and then the quality of the food is also an important part of things, so you know many people live in food deserts where they don't have access to fresh food, food that is, you know, high in nutrients and not just high in calories, and so I think changing the food environment, I think, is going to be a really important high-level policy challenge, but at a more granular level, clinics, hospitals, communities can work on, I think, making sure that people have at least access to stable food over time.

Richard Payerchin 18:17
But for three quick hits for us right now, can you address something that works, something that doesn't work, and maybe what is coming next for policy around social drivers of health.

Speaker 1 18:28
Absolutely, so you know we know that to a large extent when systems and clinics have resources, partnerships with community organizations that can meet some of the needs that we're talking about, whether it's food or housing or other social needs, those types of connections can be very valuable. So, when a doctor, a nurse, another clinician has a set of resources around them, they are able to connect patients with the types of services that they might need. You know, one of the challenges is that that is not always available, so often it is the case that there are communities where there are very few resources in that way, and, and you know, we have a system in which we're increasingly trying to get health systems to screen, for instance, for drivers of health to understand, at least at a very fundamental level, who in the community could benefit from support, but if there aren't actually those supports in the community, then that screening often doesn't go a very long way, and so I think part of the challenge really is to ensure that once we know the first very fundamental step is just knowing that patients and which patients could benefit from additional support, but then having the resources available to connect them is a really important linkage and part of it, you know. I think going forward, we need to think about how to incentivize both health outcomes themselves, but also health-related social needs. You know, what types of payment systems and other incentives. Will allow and incentivize health systems to do what they often want to do, but may not have the resources to do so. I'm very interested in the ways that we can bring payment and policy together to make sure that physicians and clinicians have the opportunity to meet patients, drivers of health.

Richard Payerchin 20:17
One of the things that you did talk about, though, was finding ways to incentivize and to integrate that into actual daily care, and I know that the Physicians Foundation in the last few years, particularly, has been really supportive and wanting to promote the billing code that would allow physicians to integrate that into their care. Can you talk a little bit about the latest research on that? I know it's still new. Has there been any formal study or documentation about how effective that has been?

Speaker 1 20:49
It's a great question. Physicians Foundation has been instrumental in those billing codes and getting them on the maps. I think you know, because they are so new and a lot of physicians are not yet aware of them, I think they're not being used to the full extent that they could be. This isn't a really important advance to help patients, health systems, clinicians, and policy makers understand the degree of social need that exists, and potentially focus interventions on the people who could most benefit from them, but what I think needs to happen going forward is we need to have a system in which people know that these codes are available, that they should be documented, and ultimately that we should be able to pay for these types of codes in some either direct or indirect capacity, such that there is the right incentive for people to both log them and then act on them,

Richard Payerchin 21:46
you know what, Doctor, and it's another great segue to a question I wanted to ask about, because obviously you're a physician, you get to get into the exam room, talk to patients, and you talk to your peers, to boil it down even more at the physician and practice level, when a doctor is in the examination room with their patients, what are the best, some of the best ways or some effective techniques you have used or encountered to broach the topic about social drivers of health between doctor and patient?

Speaker 1 22:15
Well, I think the first kind of principle is empathy, is trying to understand what it must be like for people who are struggling with those things, and asking about them in a way that's respectful, but also helps people feel comfortable sharing that they are struggling with one of these drivers of health, and so I think building that type of trust is a really fundamental element of making people comfortable and connecting them ultimately to the resources that they need, you know. I will share, you know, this is a real challenge for a lot of my colleagues. It's a topic of conversation when we are working together in the hospital or the clinic, you know, it is a source not just of challenge for patients, but also for clinicians who feel a degree of, I think, moral injury when they are not able to meet a need of a patient that is clearly leading to adverse health consequences. So, I think both for the health of patients, but also for the sustainability of the workforce, this should be one of the prime issues that we're talking about as we're trying to reform the healthcare system,

Richard Payerchin 23:25
you know, Doctor, and a few minutes ago you had mentioned about looking for the different ways and techniques to not only learn about a situation but to operationalize how to put solutions into place in a real practical sense, and a moment ago we talked about how physicians interact with their patients to do that to expand on maybe some solutions. What are some ways that physicians, other clinicians, maybe even hospitals and health systems can reach out to the social networks, maybe that might be in a position to help their patients with different factors around social drivers of health.

Speaker 1 24:04
Part of it requires first understanding who needs help, and some of that happens with relationship building and the conversations that you're having with patients. Some of that might happen through technology and using things like AI to evaluate, you know, who could benefit from some of these resources, and we want to be careful around using algorithms in a way that doesn't lead to harm or to bias, but I think there is a real opportunity to identify people who could respond and benefit from some of these social programs through the use of technology. I think the second part is to develop those relationships with community organizations, and that is not the work of a few months or even a year or two. Often the strongest relationships are ones that develop over a number of years and decades, and I think investing consistently in those linkages between the health system and surrounding community organizations is really important. I think the third part is funding social services at an adequate level. I think there's only so much we can do, there's only so many band aids we can apply if we do not have a robust safety net that supports people who have these needs, and I think ultimately a lot of the challenges that people face come down to there just not being enough resources in their area to access, and so I think at each of those levels we have work to do.

Richard Payerchin 25:28
When you talk about the resources, particularly, and I'm kind of bear with me a moment while I sort of formulate a question, because I'm only thinking I'm thinking about adequate funding, both for the social resources that are needed, and one of the topics that comes up a lot in our coverage area is adequate funding for primary care. We have come across different studies and evidence that make it clear that by preventing illness, even though that costs money up front, it seems like generally speaking saves a lot of money in the long run. How do you make that economic argument in favor of both additional funding for primary care and adequate funding for those social support services?

Speaker 1 26:10
I think it's a matter of willpower, as you mentioned, both adequately investing in primary care and adequately investing in social services. Those are things that have an enormous payoff in the long run, even if there is a kind of requirement to distribute resources in a different way, or to make large upfront investments. Those things have an enormous ROI that I think just require the social and political will to implement. I think part of it is making that financial or economic case, and part of it is making a moral case. You know, of course, dollars and cents matter, but at the end of the day, if people have a better, healthier experience by greater investment in primary care or greater investments in social services, that in and of itself should justify more attention being paid and more resources being devoted to those two areas.

Richard Payerchin 27:10
Federal policy, and right now Department of Health and Human Services has certainly gets a lot of attention nationally. I always like to say, there are 50 other, you know, sort of experiments going on, if you will, in healthcare policy, and that's around the different 50 states, you're well familiar with that, and I guess, could you comment a little bit about how important it is for state policy to, to, for physicians, maybe to get involved, how can state policy maybe be creative to address social drivers of health.

Speaker 2 27:46
Well, you know, they.. I am.. I appreciate your pointing out the federal as well as the state roles, and you know, when I was, as I mentioned earlier, I was in Washington back in the early 90s, advocating for state flexibility under national reform, and you know, the phrase that states are the laboratories of democracy was what I believed in, or tried to articulate well, and I was, you know, based on my background, both as a legislator, as a member of the executive branch at the state level, and then as an advocate on behalf of physicians heading in medical society, I sort of feel like sat in most of the chairs around that particular table, and I always, I knew, as this, as a member of the House of Representatives, that we always look for when I was working on bills related to health care, the views of physicians, and because you know they, they were carrying out, you know, they would have to carry out the policy we were working on, and as we've discussed, they're already overwhelmed. You don't want to add to their burden. You ideally want to improve their situation, and their, you know, the care their patients are receiving, so I think I think I would say with all confidence that any elected official would welcome the feedback from physicians on health policy or what the existing situation is, and I think they should work through their state medical society or professional organizations, let those organizations know that they're available, because they will be called on. I can guarantee that they will be asked to share their views.

Richard Payerchin 29:57
You know, I think I mentioned hopefully before, but are. Main audience, you know, traditionally has been primary care physicians. What would you like to say to them, or what would you like them to know?

Speaker 1 30:08
Well, I have tremendous respect for primary care doctors. I trained as an internist and practice mostly in the hospital now, but I think there's nothing more important than having a longitudinal relationship with a patient or a community, and that is something that primary care doctors are at the forefront of, and I will also note that it just seems to be harder to practice primary care in this country year after year, and so unless we make substantial changes to how healthcare is financed, how administrative burden influences people's desire to go into primary care or stay into primary care, or how we support not just clinical but also social needs for patients. I worry that the health of the primary care workforce is going to take a hit, and so you know this is a, this is a tremendously important issue. We need to be supporting primary care doctors more than we are now, and my hope is that this conversation is part of moving in that direction.

Speaker 2 31:15
First, I'd like to say, thank you, and I believe, and many believe that primary care physicians are the bedrock of our healthcare system, and in many ways an under appreciated and underfunded bedrock of our healthcare system. So we're trying, we, the Physicians Foundation, is trying to help address that and raise the profile of the needs of primary care physicians and the final role they play in our nation's healthcare system, so thank you. And then for those in rural areas, you know you're the cornerstone of people's lives, and they, you, you got into the field you're in because you, you're compassionate, you care for the people, you care for your neighbors. I used to spend a lot of time talking to primary care physicians in rural areas, and they tell me stories about being in the grocery line in the local supermarket, and seeing one of their patients, and actually having consultation in that, you know, HIPAA compliant consultation, but, you know, they're so embedded in their patients' lives, and such a cornerstone of the structure of those communities. I just say we're enormously grateful for the work you do. We're trying to help you out. We know you're overwhelmed by a lot of the administrative burdens that are imposed upon you. We're trying to remove some of those, and we know you care about your patients, drivers of health. We're trying to work with you to address those, but we're sensitive that the way we go about doing that can't make your life, your practice life, harder, but hopefully easier, and have you have healthier patients coming in your front door in the future.

Richard Payerchin 33:21
I'm Richard Payerchin, reporting for Medical Economics. Thank you for meeting with us today. Thanks so much for having me.

Speaker 2 33:28
Thank you, Richard. I really enjoyed it

Austin Littrell 33:42
once again, that was Dr. Drew Kullar and Paul Harrington speaking with Medical Economics senior editor Richard Parishen. You can find more on the Foundation's work on social drivers of health@physiciansfoundation.org On behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask you to please subscribe, so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories, and solutions we can practice. You can find us by searching Off the Chart wherever you get your podcasts. And if you'd like the best stories that Medical Economics and Physicians Practice published, delivered straight to your email six days of the week, subscribe to our newsletters at Medical economics.com and Physicians practice.com Off the Chart of Business and Medicine podcast is executive produced by Chris Massolini and Keith Reynolds, and produced by Also Mattrell. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai