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.

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Black History Month and Health Inequity: The Connection between Social Realities and Clinical Norms

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Black History Month is probably one of the most underutilized opportunities to re-ignite the national conversation around social justice in America. As it is typically celebrated, like a random recollection of various contributions by “notable” African-Americans, it feels more like a stale tradition on the verge of irrelevance, than the opportunity to engage issues of racism and social inequality as historical American values that continue to define modern American life.

Last year, I shared why Black History Month remains an essential moment to nationally recognize the lives and works of African-Americans. Right? The original #BlackLivesMatters movement started in 1926.

This year, I want to flesh out examples of how historical American values around race continue to inform national issues and particularly examine how those issues impact health. I’ve talked about mass incarceration, gun violence, and gender inequality a bit in the past.

This month, I’m going to take on the industry of poverty, and child poverty in particular, and how national, state, and local public policy may engineer disadvantage in ways that have profound impacts on health. I also want to talk health systems transformation and consider new models for healthcare delivery that may uniquely serve low-income, communities of color.

And lastly, I want to speak openly and honestly about my dismay with the medical community and our lack of public acknowledgement of the deaths of Oscar Grant, Michael Brown, Tamir Rice, and the other recent victims of police brutality. Lest, we begin to believe that police are the only modern manifestation of our nation’s tragic history with race, I am going to talk about institutional racism and how physician bias directly impacts the health of communities of color, threatening their lives in quantifiable ways.

We are never farther than our willingness to look at where we’ve been allows us to be. In our plight for justice, to move forward, we have to understand where we’ve come from. In February, we are sitting in a powerful moment to look honestly at our nation’s troubled history with race and inequality and find clarity around the pressing issues of our time. Join me this month in discussing how those issues impact our health!

And if there are topics you’d like to talk about, join the conversation and leave a comment below.

Teaching Structural Competency and the Perils of Pretending

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Earlier this year, I started teaching a course to first year pediatric residents at Stanford. In it, I challenge the trainees to identify the structural contexts in which patients and families make choices that may impact their health and well-being. Termed structural competency, the goal is to enable young physicians to understand and confront stigma and inequality as key determinants of health. We talk about educational attainment and health literacy, socioeconomic status and health access, social norms and health practices, institutional discrimination and health disparities, and the built environment and health behaviors. Together, we examine the fragile balance between resources and health, recognizing that local forces that manipulate resources effectively legislate health, by structuring choice and opportunity.

To illustrate these fundamental connections, it is often necessary to convert what otherwise exist as invisible forces in society into accessible, clinically-relevant language. This allows us to conceptualize the structural framework in which patients’ live, work, and play, within a medical model. It shrinks what seems like a diffuse and disconnected system of local policies and institutions into tangible drivers of health and disease that require socially-informed, clinical interventions. It transforms inequality, a sociopolitical phenomenon, into a silent but active participant in the clinical encounter. This makes addressing local infrastructure a central component of any community-centered, health promotion strategy.

But as we expand our purview beyond the exam room and encourage young physicians to adopt a global approach to clinical medicine, we must be very careful not to succumb to, what I will call, “the perils of pretending.” Here, there are 3 common pitfalls that warrant discussion.

1. The Poverty Simulator. In any educational endeavor, experience is perhaps, the greatest teacher. Without experiencing poverty first-hand, it may be difficult for residents to understand the challenges families living in poverty face when seeking medical care or selecting medical treatments.

One such simulator offers “players” a chance to live on a low-income budget. Other programs ask residents to navigate public transit to various appointments. At Stanford, I ask the residents to live on the average food stamp budget for a week. These self-reflective exercises are meant to influence learner attitudes about inequality and build empathy among providers as they realize what it takes to survive under certain conditions.

The problem with poverty simulators is that the process of pretending to be poor unfairly and inaccurately reduces the daily struggle of living in poverty to a series of poor choices, no pun intended. The “game” motif insinuates that some choices are superior to others while completely obscuring the larger network of policies and institutions that concentrate disadvantage and manipulate choice in low-income communities.

For example, if you live in a food desert, the choice to eat fresh produce is constrained by the proximity of those resources to your home. This “trade-off” requires bargaining between necessities and results in a loss either way. Buying cheaper food in your neighborhood may have adverse health consequences and expending the time and money to obtain healthy food on a fixed income makes other necessities unaffordable. This zero-sum reality profoundly limits choice.

To avoid this pitfall, it is important to be clear about the purpose of the exercise, which is to acknowledge that resource limitations have health consequences. The lesson is that poverty is not a deficiency of ingenuity or the manifestation of good or bad choices. There are no “right” choices when selecting between food and medicine. So if poverty is the result of eroding urban infrastructure and imbalanced resource allocation and is associated with poor health outcomes, then building infrastructure is a health intervention.

2. The Absence of Clinical Models. While the associations between social determinants of health and poor health outcomes are well-documented, we lack comprehensive, evidenced-based clinical models for addressing complex trauma and chronic stress, physiologically significant exposures that are the downstream sequelae of poverty and inequality. Short of co-locating same-day necessities in medical clinics, like food pantries or legal assistance, there are few models to describe how physicians in particular and the medical system at large, should engage the sociopolitical drivers of health through clinical work.

In the absence of these models, some physicians pretend there is nothing that can be done, or worst yet, that these issues are not “medical.”

The problem is that we are complacent in our current clinical practice. Stagnated by the dearth of evidence and overwhelmed by the magnitude of the issue, we simply avoid it. We fail to universally screen patients for social determinants of health because we don’t know where to refer them. We refuse to inquire about these issues because we essentially lack confidence in our ability or aptitude to address them.

The solution here is to do it any way. Just as all politics are local, so too will be the formation and dissemination of novel clinical models that address these issues. So we must encourage our trainees to identify the most pressing needs in their communities and trial socially-savvy interventions in their continuity clinics. This is quality improvement at its best.

3. The Conflation of Race and Risk. When seeking to address the “cultural” influences in a clinical encounter, it can be easy to minimize “culture,” to the readily identifiable traits in the visit. Here, “culture” becomes a monolithic, static archetype we project onto patients based on our unconscious bias about their physical attributes, like ethnicity, nationality, or language.

When we do this, we are pretending that socially-assigned attributes, like race, are a proxy for risk. We track patterns of disease prevalence by these attributes and over time, come to associate the attribute with the disease. This logical fallacy then informs clinical practice and leads clinicians make inaccurate assumptions about certain patient populations, their relationship with disease, and the efficacy of certain medications to address their complaints (remember BiDil?).

The solution is to replace cultural competence with structural competence and educate young providers to interrogate the local context in which patients live, the resources at their disposal, and the networks they rely on to make medical decisions. We must of course, when doing this, not turn a blind eye to the ways in which local policies and historical discrimination produce predictable patterns of disease in certain communities. These patterns may make it seem as if the risk factor is easily recognized in the exam room (race, nationality) as opposed to the real risk factor that lives in our communities – structural inequality.

As medicine advances to address inequality as an important driver of health, we must be thoughtful about the way we educate our trainees to tackle this new frontier in primary care. While there will be pitfalls along way, if we tread carefully and together, we can transform the future of medicine in powerful and meaningful ways.

* Update: To learn more about my course, please check out the syllabus and reference guide I have shared below.

Rhea’s Stanford Course Details

Rhea’s Stanford Course Resources

Who’s Hungry?

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It is no secret that growing income inequality is one of the major issues facing the nation today. Close to 50 million Americans, or 1 in 6, live in poverty and 1 in 3 children are now projected to live in poverty at some point in their lifetime. But did you know, up to 1 in 3 kids in San Francisco may go to bed hungry tonight?

As the price of housing transforms our city into one of the most expensive in the country, the national income gap seems to have landed on our doorstep. And while this topic has garnered robust media attention and local public debate, the focus on poverty remains cursory, at best. Here, the housing crisis is literally changing the face of the city, and yet it is hard to identify who is most affected by the fickle pendulum of the economy and it is easy to make affordable housing the center of the conversation.

But the impact of poverty extends from the most recognizable needs in our community to one of the least – hunger. So let’s talk about it. Who’s hungry in our city?

Meet Lani. Lani’s grandmother originally came to San Francisco from Samoa in the late 1970s and her family has lived and worked in the Bay Area ever since. Like many of us, she dreams of owning a home in the city one day, but like a growing population of San Franciscans, her immediate need is food for her family.

Lani is a 35-year-old working mother of 2 and the only employed adult in her household. Her husband was a construction worker who, because of poor health, is physically unable to work. And after losing her mother in 2008, she and her husband became legal guardians to her younger siblings. That means, it’s all up to Lani to make ends meet.

As a high school graduate, she’s worked in food and cleaning services, but with the downturn in the economy, consistent work has been hard to find. In 2012, she became a certified nursing assistant and found a part-time position that offered $14 an hour but no benefits. She took it.

All 6 members of her household live in a government subsidized apartment in Hunter’s Point and yet because of her new income they recently found out they no longer qualify for food stamps or CalWorks. Struggling to get by without any additional aid, they rely on food from her church to make it to the end of the week. Sometimes, that is only a bag of rice and a can of vegetables. Her kids, aged 6 and 7, are just starting primary school. Without the free breakfast and lunch they receive there, she says she “probably wouldn’t be able to find something nutritious for them to eat at home.”

Hunger is a problem. But the issue here is more complex than the physical sensations of inadequate caloric intake. The more insidious challenge facing family’s like Lani’s is food insecurity, or limited or uncertain access to the resources to buy, store, and prepare the nutritious and culturally appropriate food necessary to support a healthy lifestyle.

According to the 2013 San Francisco Food Security Task Force’s annual report, 1 in 4 San Francisco residents live at or below 200% of the federal poverty level. For a family of 4, that’s about an income $47,100 per year. These low-income families make up a quarter of the city’s residents are the most likely to be food insecure. But the population we seldom recognize, despite having similarly high rates of food insecurity, is our city’s children.

For these communities, food insecurity is literally changing their lives. There is mounting scientific evidence showing that food insecurity is related to poor health outcomes like increased risk of adult chronic disease including diabetes and heart disease, and in children, increased risk of obesity and learning and behavior problems. And recent data from San Francisco General Hospital’s Community to Clinic Linkage Program, indicates almost half of the patients seeking urgent care at our county hospital are food insecure.

This is a public health problem and it sits at the intersection of income inequality and poverty in every city in America, including our own. In December 2013, the San Francisco Board of Supervisors issued a charge to local legislators and community organizations, to eliminate food insecurity in San Francisco by 2020. In collaboration with the San Francisco Food Security Task Force, help address this important issue!

Here are some things you can do today:

  • Support your local food bank by making a monetary donation, hosting a food drive, or donating food. The most needed items are: tuna, canned meat, peanut butter, soup, chili, beans, cereal, canned fruit and vegetables, and granola bars. Visit the SF-Marin Food Bank website to learn more.
  • Of all the students in the San Francisco Unified School District (SFUSD), 60% qualify for free or reduced priced meals, but less than half of those who are eligible are enrolled to receive this benefit. If you know of a child who may qualify, go the SFUSD website to apply now!
  • As summer approaches, even fewer low-come students have access to nutritious food. Know of a child who may need food over the summer? Go to the Department of Children, Youth, and Families website to find out how to enroll them in the After School Snack and Summer Meal Programs.
  • If you are a medical provider, start universally screening all of your patients for food insecurity. Here is a quick, validated tool you can use. If they screen positive, call 211 to connect them to food services!
  • Contact your state representative to support AB-2385. This bill would create the Market Match Program to provide additional income to recipients of programs like food stamps, to purchase food at farmer’s markets. A similar measure is being considered for San Francisco. Want to learn more? Visit the California Legislature website.
  • Join your local pediatricians and the American Academy of Pediatrics at Supervisor John Avalos’ Office in City Hall Room 244 to view a free photo exhibit entitled “Who’s Hungry? You Can’t Tell by Looking!” This exhibit captures the faces of local children to raise awareness of this often invisible need.

National rates of poverty are the highest they have been in decades and they impact our city in unique ways. But when you ask Lani what she wants for her kids, she doesn’t talk about eliminating financial stress or putting food on the table. She simply says, “I want them to become someone.” Healthy food and snacks are the building blocks to “become someone.” If recognizing the problem starts with asking the right questions, perhaps it is time we all asked, “Who’s Hungry?”