When Health Care Goes Beyond the Office

By Heather Boerner
March 3, 2017

As health care providers are being asked to address population health issues as well as those of their patients, some physician leaders see opportunities to have an effect beyond the examination room. 

Joseph Chang, MD, learned to diagnose and treat asthma, identify heart disease and myocardial infarctions and even the basics of HIV/AIDS during medical school.

He didn’t learn that people living in neighborhoods with high levels of air pollution can experience epigenetic changes that increase their asthma risk. He didn’t learn heart attacks tend to cluster in neighborhoods with high concentrations of black residents, or that asking women about financial stress might be a better predictor of HIV risk than sexual behaviors. And he certainly wasn’t trained to address such health problems as lead-tainted water or poor public transit systems that might make follow-up visits difficult for his patients.

In fact, he chuckles ruefully just thinking about it. “You’re right,” he says. “The effect of socio-economic class on health care is not really taught in medical school, though it’s better now than when I was in school.”

Thousands of residents in Flint, Michigan, were poisoned by lead-tainted water after the city decided to switch suppliers. Physicians now must deal with the health effects of that choice.


When he arrived at Parkland Health and Hospital System in Dallas, Texas, he wasn’t prepared to address those problems. As the region’s safety-net hospital, he was seeing patients return repeatedly to the emergency department for issues more related to their lives than to biological disease progression.

Still, under the Affordable Care Act and other reforms to the Centers for Medicare and Medicaid Services, Chang, Parkland’s senior vice president and chief medical officer for outpatient and ambulatory care services, found his system increasingly responsible for population health — not just disease control.

He knew he had to do something, but that’s easier said than done under the current system.

“The health care system isn’t necessarily geared toward addressing social determinants of health,” he said. “As physicians, we are so focused on the individual encounter that we don’t focus on helping folks get rid of the external factors so they can come see us.”

Addressing those upstream policies that eventually show up as a list of complaints in the examination room might be the next frontier for physician leadership.

Paying for Value

Upstream policies always have affected downstream health. Manufacturing processes that belch smoke into the air always have affected community health. Decisions related to food additives, the purity of drinking water and the compounds in paint often result in maladies for people who live near contaminated streams, heavy factories and in older homes. These are not medical decisions, but they do affect the practice of medicine.

And under a fee-for-service reimbursement model, that’s been fine to a point. After all, no matter how often a patient comes in, physicians and hospital systems get reimbursed for their services. The problem with fee-for-service is that it’s unsatisfying for both the patient, who might need help beyond a prescription, and for the primary care physician, who would like to spend more than 15 minutes with a patient who constantly returns for the same medical conditions, says Alan Glaseroff, MD, founder of Stanford University Medical Center’s Coordinated Care Clinic, which deals with people who have multiple chronic conditions.

Patients become frustrated and hopeless about improving their care, and physicians become frustrated to the point of burnout because their care doesn’t seem to be helping, he says. That’s to say nothing of the burden on the health system and the increased cost of care overall, as patients flood hospitals for problems caused by things beyond medicine’s control, Chang says.

Thousands of residents in Flint, Michigan, were poisoned by lead-tainted water after the city decided to switch suppliers. Physicians now must deal with the health effects of that choice.

The Carrot and the Stick

But the ground rules have changed. Along with the expansion of Medicaid and the online health insurance marketplaces and insurance industry regulations, the Patient Protection and Affordable Care Act carried with it CMS reforms. Among them were new reimbursement models that asked providers to take on more risk with patients, attempting to address small-scale population health — that is, a given physician’s panel of patients — as well as large-scale population health — that is, health in an overall community.

One reform was accountable care organizations, which sought to find a better way to improve patient panel-level health by inviting physicians to share in any savings from reduced readmissions for key health issues. Another was to withhold reimbursements from medical systems that didn’t reduce the number of readmissions for those key medical conditions. For the first time since managed care in the 1980s, physicians were being asked to care for patients regardless of those external factors — driven by upstream policy decisions — that kept them sick and returning to the clinic. It required them to think outside the physician-led medical team and try new approaches to link public health to private practice.

Around the same time President Barack Obama signed the Affordable Care Act, California Gov. Arnold Schwarzenegger signed an executive order directing the state’s Strategic Growth Council to establish a Health in All Policies Task Force. Its mission was to coordinate with 22 state agencies, including transportation, housing, education and environmental protection, “to support a healthier and more sustainable California,” according to the task force’s website.

In 2013, the private California Endowment health foundation, the American Public Health Association, the California Department of Public Health and the nonprofit Public Health Institute produced a guide that state and local governments

could use to assess whether upstream policies on issues seemingly unrelated to health might affect health. Around the same time, the Institute of Medicine (now known as the National Academy of Medicine) produced another report on the topic, addressing how departments and sectors can collaborate to improve health outcomes down the line.

Meanwhile, actual health emergencies caused by policy decisions began to emerge.

The lead-poisoned water supply in Flint, Michigan, didn’t happen because of intentional actions. It was the result of the city’s decision to get water from a cheaper supplier. Forty percent of Flint’s residents live in poverty, and that was part of the city’s desire to find less expensive water. So when the city switched in 2014 from Detroit Water and Sewerage to its own service, officials saw only the upside — $200 million for the city’s dwindling coffers.

But the decision to draw from the historically poor-quality Flint River resulted in lead leaching from the city’s aging, corroding pipes into the water supply. Untold thousands of residents have been irreversibly injured.

Public Health, Private Practice

To fix that problem and many others, doctors such as Abdul El-Sayed, MD, find themselves sitting in on legislative and policy decisions constantly. El-Sayed has both a medical degree and a degree in public health and always has been interested in, he says, “the ways in which the social world shapes the biological world.”

When he was tapped to run Detroit’s public health department, El-Sayed, a Detroit native, jumped at the chance. As a public health doctor and official, he focuses on how “the experiences of poverty fundamentally yield health disparities.” His work is around addressing the policy decisions that create poverty for Detroit residents, especially around seven factors: infant mortality and health; teen pregnancy, lead exposure, vision, asthma, nutritional imbalance and elderly isolation.

The goal in Detroit, he says, is to “leverage health to disrupt intergenerational poverty.”

To do that, he finds himself at legislative committees and other meetings. He is the human bridge between policymakers and patients, and small-scale and large-scale population health.

And while this has been largely the domain of public health officials such as El-Sayed, it’s not reserved for them. He called private physicians public health’s “collaborators.”

“We’re all in the same business,” he said. “When health is done best, it’s done together and coordinated. We are not the best provider for a number of services; physicians are. Hospitals are not the best providers of a number of services; we are.”

So what does that look like in practice? Consider Chang in Dallas. Four years ago, Parkland hired an army of social workers to fan out into the community and help patients who commonly visited the emergency room or were on a regular rotation of readmission to the hospital to get connected to existing services so they could address the real needs that were driving their medical conditions.

Chang says the program has evolved into a combination of social work and collaborations with public agencies and local nonprofits to meet patients’ needs. Together, the hospital and community organizations make sure patients who need it have food, vouchers for transportation and discounts for other things for which their economic circumstances don’t provide. One successful program offers house calls for seniors; the catch is in the reimbursement, he says.

“We don’t code for it — that’s the thing,” he says. “We know that to keep a geriatric community healthy, and at home and out of the clinics, means we’ll have fewer admissions.”

But they see rewards through improved population health. And if they could get more support from CMS for this kind of care, it would be even easier.

On the Horizon

Politically, the United States is on the verge of a number of drastic policy changes. Along with ACA repeal, federal legislators have introduced bills to do away with the Environmental Protection Agency, and to allow mountaintop excavation, from which runoff could enter waterways.

Each policy change before legislators nationally and locally has the potential to affect patients downstream, and the health system needs to be prepared to address it, Chang says. “Really, what it’s going to take to solve these big health problems is for all the hospitals and hospital systems to come together,” Chang says. “In the end, it’s going to take physician leaders and health care systems willing to do what’s necessary for the community.”

 Heather Boerner is a freelance medical and health care writer based in California.

Topics: Leadership Journal

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