April 27, 2018: Looking Beyond Healthcare in Effort to Improve Health

Panelists at Oregon Health Forum’s Social Determinants of Health breakfast forum said more data is key to addressing the ways society itself makes people sick.

By Courtney Sherwood

The United States has the most expensive healthcare delivery system, and the worst health outcomes of any industrialized country. And increasingly, leaders think efforts to fix the problem by only focusing on the healthcare sector itself are misguided. The subtle ways life experiences and the world around us affect our health – known as social determinants of health – were on the agenda the Oregon Health Forum’s Friday morning breakfast gathering and discussion.

Attended by more than 150 people including former Governor John Kitzhaber, the discussion was led by moderator Jesse Ellis O’Brien, OSPIRG policy director.

“We are in a health crisis,” said panelist Kent Thornburg, Ph.D., of OHSU’s Knight Cardiovascular Institute.

In his remarks, Thornburg delved into the ways a social environment affects not just people living today – but their offspring, though epigenetic changes. These are changes to the genetic code that happen as a result of environmental factors – so that the child of a parent raised eating heavily processed food, for example, may be more likely to develop diabetes, and the offspring of people of color who face discrimination may inherit the legacy of that stress through poorer health.

Understanding that reality can guide how Oregon responds to fast-rising rates of diabetes, heart disease and other chronic conditions.

“We will not be able to use medical care itself to find our way out of this,” he said. “What we have to do is reverse the amount of vulnerability that people in our society have for toxic stress and malnutrition.”

With the costs of treating chronic conditions rising at an astronomical rate, addressing social determinants of health may be the most financially responsible approach, Thornburg said.

“I would like for Oregon to be a leader.”

Panelist Dr. David Bangsberg , founding dean of the joint OHSU-Portland State University School of Public Health and Oregon Health Policy Board member, concurred with Thornburg’s assessment.

“I see this as a crisis, but also an opportunity – an opportunity to invest in the social determinants of health, which are defined as social, economic, environmental and political conditions in which people are born, work, live and age,” he said.

Bangberg noted that oregon’s Medicaid-funded coordinated care organizations are already starting to engage in this effort.

“The first round of CCOs have kept costs growing at under 3.5 percent, saved $8.6 billion over the last 5 years, and also improved outcomes,” he said.

“It’s an important step forward, but we can do better, and I know we will,” he said, adding that he expects the Portland State-Oregon Health & Science University collaborative public health program to play a critical role across the state.

“This could not be done in Massachussets and California,” he said. “Oregon has a special role to play for our nation in understanding.”

“We are already doing quite a bit, and we want to do even more,” said panelist Rebecca Ramsay, CEO of Housecall Providers, a subsidiary of CareOregon that works with CCOs.

Medicaid now allows CCOs to consider services that improve health but lack a billable code or Medicaid code as valid medical expenses, rather than as administrative costs, thanks to an understanding that “health outcomes are driven by much broader factors than pills, procedures, tests,” she said.

Housing has become one of the most crucial areas of focus for CareOregon, Ramsay continued.

“We don’t have enough affordable housing for individuals and families that are living in poverty,” she said. Living without a home increases the risk of becoming ill and makes its difficult or impossible to manage complex chronic diseases. So getting people into homes can be a critical step in improving their health.

Jackson Care Connect CCO is helping its members boost their fitness through a partnership with the YMCA, and Columbia Pacific CCO is partnering with schools to address the challenges of students who have survived trauma, she said.

“These are all things you can’t put on a typical bill,” Ramsay said, and it will take time, effort, and data collection to understand which approaches work best.

“We urge the Oregon Health Authority to collect more information on what investments are working,” she said. “This kind of research is very challenging. We have evidence about the problem. We don’t yet know what the solutions are that are outside the traditional medical environment.”

Kaiser Permanente is exploring the same issues and gathering data of its own, said panelist Dr. Colin Cave, director of external affairs, government relations and community health with Kaiser Northwest.

Screening of 11,000 patients to identify the social challenges that affect found Kaiser members often struggle with transportation, money, access to care at home, long term housing, food, and social support, Cave said.

That may offer hints of the challenges that need to be solved and tools that can address them – but there’s a long way to go, he said. “In addition to understanding needs, we need to understand assets available in community.”

For example, a program that aims to serve seniors and people with disabilities that has been cited as a tool for getting medical appointments had to turn down more than 24,000 requests for rides due to lack of vehicles and drivers.

By using its electronic medical records system, and expanding on its research into 11,000 patients, Kaiser hopes soon to be doing much more to improve social determinants of health, Cave said. “Stay tuned.”

The final panelist to speak focused on the non-medical providers who will be key to addressing the challenges raised Friday morning.

“It’s the safety net,” said Jennifer Stoll, vice president of government and public affairs for OCHIN, which develops and supports technology systems for safety net providers.

“The population that we serve are the most vulnerable, 5 percent are homeless or housing insecure, 70 percent are Medicaid covered,” she said.

Medical providers may want to help these patients stay healthy – but they don’t have the right tools.

“There’s nothing more frustrating for a provider to know there’s social complexity and not being able to do anything about it,” Stoll said.

“We need to fund the safety net,” she said. “And we need to really study the issue.”