The Work

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Every day since Tuesday feels like walking a plank. Stepping toward a jagged and uncertain future with hands bound by the votes of neighbors, friends even. How deep do these dark waters go? When no bridge spans the troubled reaches, where is the solace for what lies beyond the edge?

To those of you who are now, just 2 days later, shrugging your shoulders and saying, “It may not be that bad.” Or “Let’s wait and see what happens.”

Stop.

I get that perhaps you do not wake to the terror and nausea that I do. That you must not have felt personally accosted by the toxic insults that diminished your love, your color, your nationality, your body, your traditions, your abilities, your rights, your neighborhood, or your God. You must not have felt your physical safety threatened, trivialized, or commoditized for a political punchline. But the wounds I carry weren’t opened 2 days ago. These wounds predate the president-elect, but are pained all the more by his malicious campaign, growing crowd of supporters, and electoral win. That pain is inflicted on old scars, shared scars, some more vulnerable than others, and the process to heal them will require more than mere distance from Tuesday.

The 2016 election is personal. While we can await the policies and procedures that empower the president-elect and embolden the unveiled hatred of some unhooded supporters, the toll the weeks and months of unfettered attacks on American values, American people, and American diplomatic relations, has already begun.

It is here that I depart from calls for insta-unity.

To quiet the disquiet that illuminates the darkest recesses of America and Americans is to turn away from our problems at the moment they fully surface. No, the lines have been drawn. They are stark. They are real. And they must be confronted. While the unrepentant divisiveness of the republican nominee’s rhetoric and thin political strategies may have stoked an old fire of racial, patriarchal, gendered, economic insecurities – make no mistake about it, what is set aflame is the roof that covered existing, widening, engrossing tensions that divide America down the middle. And to reconcile those tensions we, you and I, must look them in the face and make some decisions. One decision was made on Tuesday. But more decisions are coming.

White people who call themselves allies, now is the time to do the work. And that work does not mean organizing black and brown people. It means talking to other white people. Go home, go to class, go to work, and have difficult conversations about what Tuesday means for many Americans. Look honestly at the rationalizations of “small government” idealism and “anti-establishment” deviance and explore what it means to prioritize those values above the safety and inclusion of people of color, homosexuals, transgender individuals, people with disabilities, women and particularly those who have suffered sexual harassment or assault, Muslims, immigrants and the wealth of diversity that calls America home. Examine how the freedom to vote on ideals when the rights of fellow and marginalized Americans are at stake, is a privilege that comes with responsibilities, the least of which is identifying as a liberal, or a conservative.

To republicans, especially those who depart from the president-elect’s divisive words and claims, your congressional and local power and proximity to constituents may be all that stands between some and their future. While Obamacare may be a contentious policy, its repeal without swift and comprehensive replacement of a structure to insure and assure Americans affordable access to baseline health services, will almost certainly result in rising ranks of uninsured, increased health disparities, and more untimely deaths. This is avoidable and should be prevented. Also, as immigration reform is likely to be an early priority of the incumbent administration, please deeply consider what the separation of American families, children from parents and siblings from caregivers, means for those who remain. Immigration is the foundation of this country. When the vote arises, we will call on you, republicans, to honor that value for all of us. More decisions will certainly come, but let us start there.

And lastly, to black women. To the black female voters, more than 90% of whom voted for Hillary Clinton. Thank you. I see you. You are the cornerstone of this democracy. You who labor and serve and nurture and endure, who have given from the depths of your womb and through the pain of your wounds. Thank you. You who stood in line without hearing a candidate utter the intersections of your lives, elevate your contributions to community, or value your consistent, historic presence at the polls as both patriot and rebel – ever challenging your nation to rise to its values. Thank you. This nation owes you great thanks.

And to all of us. We do this work for the children and youth who must live under the fruits or failures of our efforts. We do it so we can say and show what already made America great.

Now is the time for organizing.

The fight is not yet won.

The night is the time for organizing.

The fight begins at dawn.

Until dawn, will you do the work?

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Is Scalability Overrated?

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Scalability is the end goal of nearly every tech start-up, systems innovation, and teenager you-tubing their cat – it’s going viral, business-style. And traditionally, it’s been seen as a marker of relevance and success. Growth is good, right?

But in healthcare systems transformation, do we lose something meaningful when we measure the value of our work by its national impact?

Take Iora Health, a new healthcare venture out of Massachusetts that contracts with large companies and insurance plans to provide care for employees or insured patients. Iora clinics have a for-profit model and are seeking to capitalize on saving money. They charge companies and insurance plans monthly fees and in turn endeavor to keep their patients out of hospitals and emergency rooms, the most expensive places to receive care. If they successfully prevent costly services, and save their company or insurance plan money, they take a percentage of those savings as profit.

The Iora model is essentially beefed up the primary care services offered in the comfort of a patient’s community, sometimes even as convenient as a local shopping center. They argue that by providing health coaches, lower doctor-to-patient ratios, around-the-clock availability, excellent customer service, and unlimited visits per patients, they can effectively manage most chronic illness before it progresses and requires hospitalization or emergency services. Now, nothing they are offering is particularly new, as primary care practices across the country are considering or implementing similar strategies. But what is intriguing, is their plan for growth.

As The New York Times recently wrote, Iora’s “ultimate goal is hundreds of practices across the country, a kind of Starbucks for healthcare.” And as their CEO Dr. Rushika Fernandopulle stated, “Building one good practice is mildly interesting, because a few people have done that. But how do you scale that across the country? That’s much harder.”

Hard, yes. But meaningful, I’m not so sure.

See, Iora’s foundation is venture capital and their business model aims to create a revenue stream providing services most clinics cannot afford; because most financial incentives in healthcare favor hospital and emergency visits. On the surface, it’s a win for doctors because many physicians want to provide comprehensive care, and it’s a win for patients, because Iora is paying to provide a care experience consumers want. But what about low-income populations? They lose here.

To maintain the for-profit status that supports their model, Iora Health purposefully doesn’t take patients off the street, the uninsured, or the unemployed for that matter, I guess unless some unemployed individuals are buying insurance with a plan they contract with. And yet, Iora says their model is going to “transform healthcare” and scale across the US.

When 5.5% of the population is unemployed and more than 1 in 7 live below the poverty line, how is this model “transforming” the system for everyone? The truth is, it’s not.

So I return to my initial question, do we lose something meaningful when we measure the value of our work by its national impact?

In Iora’s case, as with many clever and highly specialized health systems innovations, I think we do. Iora’s business model is what drives their innovation, but it is also what makes their services irrelevant in populations that don’t qualify or need their comprehensive care. It doesn’t make what they are doing any less valuable, but it does mean they may not find significance with every population. In addition, since their model excludes populations already under-served by the healthcare system, their national dissemination may actually threaten access to care for low-income families.

Healthcare is a complicated enterprise where the needs of the consumer are variable and evolve overtime. That diversity of need and resource distribution defines the challenge in our current system. And in the end, that variability may be too complex for a one-size-fits-all, Starbucks model.

Perhaps healthcare doesn’t need cookie cutter solutions imposed on populations with distinct assets and needs. Perhaps just like politics, all healthcare transformation is local and finds meaning in its local application, not its national prominence.

We all know ideas with traction and those that find their way to a national stage are exciting. But I think there is something to be said for offering a unique service to a distinct population, and doing that well for the long-term. So instead of looking for the next big thing, the actual big thing is made up of small things that are changing the way each of us experience our healthcare.

Sick Care: Is There Any Healing Left in Health?

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Incentive structures in healthcare have to change. Right now, we pay for services, or have a so-called, “fee for service” system. The idea is that the more patients doctors see, the more expensive tests doctors order, and the more patients doctors hospitalize, the more money clinics and hospitals make. This incentive structure has transformed our health care into sick care.

The reality is, in America, we are adept at caring for complicated medical problems that require multiple tests, specialists, long hospitalizations, and frequent clinic visits. We focus a lot of resources and attention on this part of medicine because it is what we are paid to do. And to further our efficiency in providing this model of care, many medical systems have adopted business practices, like Toyota’s Lean Strategy, to run our hospitals and clinics more like factories. We essentially increase the number of cogs, or patients in this case, on our conveyor belt, to increase profit margins.

Now, it is only fair to acknowledge that “Lean” and other strategies to improve healthcare efficiency also have real hopes of lowering healthcare costs. In fact, there may be evidence of that. And streamlining health services so that every patient gets a standard quality of care, will likely create equity in the system and reduce costly medical errors, preventing patients from receiving disparate care based on race, gender, or cultural affiliation.

But as we extol the benefits of these patterns of practice, we must also be critical of their overall impact. Is the way we are paying for medicine coming at the expense of delving deeper into the heart of our field? As care becomes more standardized and protocolized, with each patient treated with machine-like accuracy and precision, we do improve “quality” and efficiency in the system. But where is the healing? Where is the prevention? Where is the practice of medicine caring for the human condition and working to keep us well?

Being well isn’t simply having your diabetes under control, it is preventing you from getting diabetes in the first place. If we continue to commoditize patients, valuing their ailments over their wellness, we miss the opportunity to provide the very care we claim to offer, health.

So how do we re-organize the way we pay for care to build a health care system instead of perpetuating a sick care system?

First, if we recognize that social needs have profound and costly health impacts, then as we transform our payment structures under the Affordable Care Act (ACA), we have to support innovative models that address social inequity. That means, using healthcare dollars that are typically spent on clinic visits and hospitalizations to also pay for education, food, housing, and job creation in low-income communities of color. That also means that in the spaces where we provide medical care, we should also be equipped to address patients associated needs. There are models for this.

Second, we have to change the narrative about what it means to provide care. We need to think about the overlap between natural life processes, like birth and death and medicine, and learn the limitations or boundaries of the medicines we wield. When there are no quick fixes or magic pills, how will we care for the human condition? In the spaces where listening is better than treating and healing doesn’t come at the end of a needle, we need to foster the relationships in our communities that provide healing and build resilience.

Third, it is time to transform the physician-patient relationship, a dynamic historically limited to a clinics and hospitals, to team-based care. In team-based models, physicians use their trusted relationship with patients to lead a team of community health advocates to address patients’ health needs in the places where they arise. Sometimes those places are hospitals and clinics but more often they are in homes and neighborhoods. The future of care, if we are smart, will deploy complex networks of healers that extend the reach of the system into people’s lives, supporting their wellness as we address their disease. This will require thinking across sectors, partnering with unconventional liaisons in the social service and for-profit sector, to have a coordinated approach for health.

Right now, The Department of Health and Human Services (HHS) is doing historic work to re-design how we will pay for healthcare. With the guidance of the ACA, HHS is laying out a plan for a population-based payment structure that incentives providers to be efficient with precious medical resources. Doing less for more means we will have to learn how to keep people well. These new changes have the opportunity to shift the focus of our system, towards health. Looking down the pike, let’s be actively engaged in ensuring quality, efficiency, and equity guide how care and healing are provided.

This piece was co-authored by my friend and colleague, Dr. Jessica Schumer. Follow her on twitter @schumerj.

Fighting for Failing Care: How Hospital Closures May Impact the Safety Net

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In the post-Affordable Care Act healthcare landscape, sweeping hospital closures have created new barriers to access in a system already criticized for its fragmentation and saturation. Looking back over the past 20 years, urban hospitals, and urban trauma centers in particular, bore the brunt of this impact, closing at the highest rates in the country. Now, evidence suggests the impact of urban hospital closures may disproportionately affect those living in poverty, racial and ethnic minorities, and the uninsured.

This concerning trend begs an important question:

If urban hospitals are a trusted point of access for low-income communities of color, does their closure undermine the national safety net OR does it create opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations?

To answer this question, let’s look at the contentious 2007 closure of Martin Luther King Jr. Harbor Hospital in Los Angeles.

As a bit of background, MLK-Harbor opened in the wake of the 1965 Watts riots and general unrest regarding the lack of sufficient public investment in communities of color in South Central (now termed South LA). The hospital was to provide healthcare in one of the poorest and most violent neighborhoods in LA. At the time of its closure, it remained the only public hospital to serve a large part of South LA, treating more trauma patients than almost all other hospitals in the region. Its closure was prompted by a series of egregious medical errors that eventually threatened the hospital’s accreditation.

Mounting quality concerns aside, what was most notable about its closure, was the staunch community protest. In the face of unquestionably dangerous medical practices, the community rallied to protect their safety net; even garnering the support of Congresswoman Maxine Waters, who rose to the cause’s defense in 2004. Despite their efforts, the trauma center was shut down in 2004 and the general acute care hospital closed thereafter in 2007.

So why would a community fight for the failing care of their discredited hospital? Is the safety net worth protecting when it is offering poor care or is the community’s advocacy tacit admission that poor care is better than no care at all? And ultimately, does “no care” threaten the safety net or does it provide an opportunity for something better?

Let’s dissect these questions piece by piece.

First, it is a basic human instinct to protect what you perceive as yours. Even if what you have is broken. Now superimpose on that instinct, a history of having no say in what is taken from you; a history of abandonment by public institutions charged with investing in your community infrastructure; and a history of displacement driven largely by resource scarcity and discrimination. When viewed in this structural context, the motivations to fight to protect resources become obvious.

Second, let’s explore the idea of fighting for “failing” or “poor” care. Here, the assumption is that low-income communities of color either don’t understand or don’t want, quality. Why else would they protest the closure of a bad hospital, right? In this case, I think we’ve got the assumption wrong. Americans love a deal. We want more for less. Whether it’s super-sizing our french fries or buying into the housing market at the right time, we want quality and we want it at a bargain price. In this way, quality is an American value that translates across the economic spectrum. But sometimes, “the deal” trumps quality. So the real question is, what is the “deal”?

In the case of MLK-Harbor, if there is not another medical facility near your home and public transportation is unreliable, or if you are uninsured and you cannot afford a second opinion, or if the medical specialty you need is only available at your local provider; then the deal is access, the deal is cost-savings, the deal is specialization. This is why low-income populations are vulnerable. Because their lack of resources offers them a bad deal, around which there is little leverage.

So it is not that poor care is better than no care. It is that no care should no longer be an option, but for many, that is the deal they are left with. So as engineers of the system, we have to create something better.

And herein lies the answer to our initial question. It does both.

Because urban hospitals are a trusted point of access for low-income communities of color, their closure undermines the national safety net AND creates opportunities to deploy lower-cost, higher-quality delivery models for vulnerable populations.

In attempting to forge a better healthcare system in the midst of our broken one, every failure is an opportunity for improvement.* As the Affordable Care Act re-organizes the medical landscape into regionalized, micro-systems that are accountable for local populations, it provides the opportunity to consider our past failures and the global impact of shifting costs and shifting care on the vulnerable.

The tension between eliminating inefficiency, maintaining quality, and controlling cost while elevating the voice of the community and prioritizing the needs of the under-served, remains. These are the challenges that loom at the forefront of a healthcare system that seeks to cut costs and maximize quality for all. But this is a cause worth fighting for and I’m all in. Are you with me?

* To see how MLK-Harbor (now MLK Community) is improving their system to re-open in 2015, click the link.