 Hello everybody good evening. I'm Susan Collins the Edward M. Gramlich Collegiate Professor of Public Policy and the former Dean of the Gerald R. Ford School of Public Policy here at the University of Michigan and I am just absolutely delighted to welcome all of you to our very special event this evening. It really is a great pleasure for us to be hosting the inaugural James B. Hudak Professor of Health Policy lecture which is soon to be delivered by Paula Lance who is our very first Hudak Professor of Health Policy. But before we get started I do want to mention that Michael Barr Dean of the Ford School very much wishes he could have been here with us this evening to lead this wonderful celebration and offer both his gratitude and his congratulations. The Hudak Professorship was established in March with the an endowed gift from James B. Hudak who I will say a bit more about in a moment but I have to say up front is an MPP alum of the Ford School a really important claim to fame and his very generous gift supports a faculty member whose research explores health policy issues and aims to address problems in the U.S. health care system. Jim recently retired from a highly successful career in health care where he saw firsthand the need for rigorous research driven evidence in health policy. Most recently he served as CEO and chairman of Paradigm a market leader in managing catastrophic and complex cases for workers compensation. Using data and evidence based approaches Paradigm achieved vastly superior outcomes and also was able to accomplish over 40 percent cost reductions which is really very impressive and the kind of combined work and the implications of that legacy are something that are really something to be very proud of. Jim has also been a very generous and long term supporter and I must say a tireless advocate for the Ford School giving to faculty research as well as student support including we listen which some of you may know about it's a student group that facilitates dialogue again across the political spectrum and he served as the chair of our Ford School committee for over 20 years and I can say first hand how wonderful it was to work with him in furthering the school's mission. His insights his dedication were really just both a pleasure and made such an impact in a variety of different ways. So we thank you Jim for your continued generosity for your vision for supporting health policy research and for ensuring that we are able to continue educating future generations of leaders in health policy. Please join me in thanking Jim. Well tonight we have the pleasure of hearing from Professor Paula Lance. In addition to serving as the Ford School's associate dean for academic affairs she holds a joint appointment as professor of health management and policy in the School of Public Health and now of course she is the James B. Hudak professor of health policy. In recognition of her extremely influential scholarship and policy engagement Paula is an elected member of both the National Academy of Social Insurance and the National Academy of Medicine. She's also an esteemed colleague a fabulous teacher and a great friend. There isn't much happening at the Ford School that Paula hasn't had a positive influence on in a variety of different ways and so it really is an honor for me personally to be introducing her to you here today. Paula's lecture this evening will explore tensions between social policy and health care approaches to reducing inequities in health in the United States population. It's a very important topic and I know that we are in for a real treat so please join me in welcoming Paula Lance to the podium. Thank you all for coming today. Those of you in the room those of you online streaming in with us. I want to start first by also expressing my incredible gratitude to Mr. Hudak for his very generous gift to the Ford School and I feel so privileged and honored to be the first recipient of it. Jim's vision for this gift was to help the Ford School create leaders who will use evidence to bring to some of the issues we have in our health care system and health policy. Are any of you aware that we have some issues with health care in the United States? So Jim's vision is that by bringing this gift to the Ford School it'll help improve the impact that the Ford School might have bringing evidence to health policy and improve health and health care in the United States. And again I'm just really honored to be the first recipient of this gift and I don't want to let you down. I appreciate your trust in me. And it's not only in me I mean some of the gift that Jim has given the school goes to some student support and so I've been able to hire some fabulous students. Wendy Hawkins is in the room and she helped do some research to prepare for this talk. And it's Tori here and another student working with me on a whole other project. So thanks for that. I don't know how many of you have ever had the opportunity to stand in front of a group like this that and I lecture all the time to be groups of people but this is really different. I have family here. Thank you for all your support and patience. And I have some dear, dear friends in the room. People have been friends of mine for well over two decades. You know who you are. And colleagues, mentors, collaborators, Ford School alumni, members of the Ford School committee. There are so many people in here in the room who I really owe a debt of gratitude to and I'm pleased to work with all the time. Special shout outs to a couple of groups. First of all, the Ford School staff who work very hard just to put on an event like this but also it's a privilege to work with them day in and day out on everything we do at the Ford School. I don't think you'll find a better group of staff anywhere. And then also the students, my God, it's a privilege of my life to be hanging around with you and maybe teaching you once in a while but learning from you day in and day out. It's just really a pleasure and an honor to be to have the job. I have a really good job. I'm really happy about it. So I've already lost my clicker. Why didn't it's right here. I'm not that nervous really but okay, have my clicker. Alright, so shall we begin? I do have a lot of slides to get to get through. Alright, so I'm going to be talking about population health and first I just want to define what that is. What do people like me mean when we talk about population health and as we move through the talk, I'll explain to you that there's kind of a new a new version, a new definition for population health and it'll become clear to you very soon that it's irritating to me. But anyway, population health is decades long field of both scientific inquiry and both public health practice and when we talk about population health, what we're really thinking about is within populations, there are health outcomes and distributions of those health outcomes and those distributions are according to things like gender and race and ethnicity and socioeconomic status and where people live. We know that health varies and is distributed unevenly within populations by those things. And so how do we get there? How do we have these distributions within populations? Well, the things that determine health are also patterned by all these things. They have their own sets of distributions. So determinants of health are patterned that leads to distributions and disparities and inequities over here and the reason I've been very drawn to public policy through my whole career is because it's policies and interventions at the individual community and societal levels that first of all, have these things be patterned in the first place, but also that's a way to intervene and maybe try to change those patterned those determinants and how they're they're patterned so we can change the distributions within populations. And just again, little orientation here at the beginning in health. What do I mean by health? I really subscribe to the World Health Organization's definition of health, which is a state of complete physical, mental and social well being. It's not merely the absence of disease or infirmity and the World Health Organization states and I wholeheartedly agree with this that attaining a high standard of health is one of the fundamental rights of every human being without distinction race, religion, political belief, economic or social condition. And again, that's why I'm I do the work I do and I'm drawn to public policy. We could I could give a whole talk just talking about differences. There's differences in health in different groups in different populations, and just sort of describe them and try to understand them. But I fundamentally think that they're unjust. I fundamentally think that disparities and inequalities in health are differences that are avoidable unjust and against shared social values. And so all the work that I do is really motivated by this ideal, and no society has ever achieved it, but the ideal of health equity, that we shouldn't have differences in equities disparities in health due to factors that are unavoidable, that are avoidable, unjust or contrary to shared social values. Alright, so we'll do a little history now to get started. So here's a nice chart with going back to 1500. In terms of life expectancy. And, you know, you can see that life expectancy as best as can be measured back many, many centuries ago, sort of bounced around. But really starting in the 1800s, late 1800s into the 20th century really populations on the planet started enjoying longer lifespans, you know, and sort of what's happening here. Famine and pestilence as social epidemiologists and demographers might like me study. So there's a lot of population health science, again, it's been around a long time, engages in activities, like trying to understand what caused this increase in life expectancy that is observed at different points in time for sure, and with different patterns in different populations. And the model that's used to sort of understand and explain this is called the epidemiologic transition, where you have in a population really a period of time with very high mortality and also very high fertility. But things are kind of bouncing up and down in terms of both of those rates. And again, pestilence and famine are really having an effect. But then what usually happens first is the death rate goes down in populations, the birth rate typically going down follows a little bit later. And here, most of the reasons that people die are from infectious disease or starvation. And the epidemiologic transition, so again, first the death rate goes down, then the birth rate goes down. And then what becomes the more leading causes of death are things like chronic disease, injury, other other sorts of things, we would now say human made diseases. And then but both the birth rate and the death rate go down. And in the post transition period, you have low mortality, typically low fertility rates, and then very little but infection can can occur infectious disease deaths can occur but it's sort of bumpy. I'm not going to explain all these graphs. The point here is that the epidemiologic transition has happened in different at different points in time, with different patterns, and many different countries. Why is that? So people have studied that. And one thing that has been long recognized in the epidemiologic transition and really looking at any kind of distribution of health and populations is that it's social factors that are really the driving cause of any sort of distribution you're seeing. Excuse me. You know, we can go back all the way to 1790. And even before that, a famous physician in Germany was writing about the people's misery, the mother of diseases. So understanding that disease is caused by poverty of the people and by the lack of all goods of life are exceedingly numerous. There's actually been some studies that were done. Lots of lots of graduate students were set out to measure the height of gravestones all over the UK. And what else is on gravestones besides their height? Name and length of life. So birth and death. There's an extremely high correlation in these older graveyards in the height of the gravestones and the length of someone's life because the height of the gravestone really represented that person's social status. So a bigger gravestone, more real estate on the gravestone was more of an indicator of social status. So people, I mean, they had this visual within graveyards representation of that more wealth means a longer life, but also could see this in every everywhere in society. It's really with the Industrial Revolution, and in France and England where really population health science really kind of got a foothold and as a science. And it was really through observations of what was happening with the Industrial Revolution. You know, about 1760. And everyone understands what would happen with that lots of people move from the countryside into cities. There were more jobs for people, but the conditions in which people were living were incredible, right? They're polluted water and air and squalid and crowded housing conditions and work conditions themselves were very unsafe for most most people. So there's what we know from studies of health through the Industrial Revolution is that it disrupted notions of health in lots of different ways. First of all, it was sort of where the birth of the science of population health came. And then realizations that, you know, economic development and industrialization were associated with the epidemiologic transition in England and France. It really did fuel decreasing mortality for some people and decreasing fertility, but it also created even larger disparities in health and welfare. There was all kinds of new suffering among the lower class, again moving into the cities and living in these conditions. And also it was the time really kind of the first time in writing where there was this normative realization that if better health, so the health of the upper class got better with the Industrial Revolution and in some ways got worse or just differently, worse for lower classes. But there was this realization that if better health is actually even more achievable for the upper class, then it is and it should be achievable for everyone. Sorry. So that also gave rise over the next several decades through the industrial, this did not happen overnight. Through the 1700s into the 1800s, there was a lot of mobilization, a lot of advocacy, a lot of outcry from people about we use somebody has to make our conditions better. And there were appeals to capitalists to do that, but also more appeals to government to do something in terms of water, sewer, air, food, sanitation. So here's where we really see the beginning of public investments in public health infrastructure. And these are the things that really drove them the full epidemiologic transition. And we know that from looking at many, many other countries, the investments in public health infrastructure, and also housing quality and safety, work quality and safety, environment, transportation, all these things matter greatly for health. And countries are not going to go through this population health transition unless these investments are made. We also know education is very important for population health, especially the education of women. And last point on this very busy slide is that social factors were clearly important to everyone. And this precedes any understanding other than a very rudimentary understanding of germ theory, pathophysiology before antibiotics, right? So back back in the day, I mean, people understood that water in the river in London is pretty nasty. People get sick after they drink it. Maybe we should maybe there's something in it, we shouldn't drink it, but people didn't really understand what cholera was for a while later, but they understood that there was something, something wrong there. Alright, so where, how are we doing now in the US? This is a very busy chart, it may be hard to see of life expectancy in a number of countries. And here's the US. And here's many, many other countries who have longer life expectancy than we do. I can get the numbers right. So in the US right now, the overall life expectancy is 78.6 years. Average life expectancy, it's 81.1 for women. And sorry, guys at 76.5 for men. That gender difference is observed in every country. It's smaller when in countries where there's very high rates of maternal mortality, associated with childbirth and pregnancy and other reproductive issues. But we do not look so great compared to, to other countries. Alright, so also we know life, but life expectancy, again, here's these patterns within the population varies greatly by racial status in the United States. I mean, look at that difference. 87.1 years for Asian Americans. 75.4 for African Americans. That's for men and women together, I guess, yeah. So I mean, that's a huge difference. Actually, if all of cancer and heart disease were wiped out, that would increase life expectancy in the US by less than five years. So that difference is, it's just tremendous. This figure is of infant mortality rates, trends we could go back many, many more decades on that. But the trend over 100 years in the United States is that the African American infant mortality rate has been at least twice that of the white rate. Even if infant mortality rates go down, that disparity has stayed the same. Again, back to life expectancy. It varies within place. Darker colors here represent longer life expectancy. So it varies all over the United States. Even in smaller geographic areas. We see huge differences. But here you see the place in Michigan that has the longest life expectancy is where we are right now, Ann Arbor. The place with the lowest life expectancy is Battle Creek. But one thing I want to point out, so here here's the highest and lowest in the state of Louisiana. But here you see the place that has the highest life expectancy in Louisiana, the New Orleans metro area is pretty close to the lowest in Michigan. And again here, that's a map of New York, you can see the same thing. Importantly, I'm sure many of you know this, life expectancy in the United States has actually gone down in the last two years. That's almost unheard of in a developed Western country. Just to make sure everyone understands what life, do y'all know what life expectancy is? It's an artificial sort of simulated statistic. Life expectancy is what you would expect if a baby was born today and went through its life, experiencing the age specific death rates that we have right now, that's how long that baby would live. So if a baby born today experienced the rate of death we have in every group, that would be the life expectancy. So in the United States, life expectancy has gone down for the past two years. There are three causes of death that have been rising and that are contributing to this. One is Alzheimer's. But that's a small part of it. The biggest part of it is the increasing mortality rate from drug overdose in the United States. I'm sure you're all aware of what's been going on with that. And also suicide has been going up as well. And in both of these cases it's gone up for men more than women. And so the decline in life expectancy in the US is really being driven by a decline in life expectancy among men, not really for women. Could tell a story about breast cancer. I've done a lot of work on racial disparities in breast cancer. So we have interesting trends going on there. Here's a graph with homicide. Everybody knows homicide rates vary by age and also by race and ethnicity in the United States. Smoking prevalence, it's going down in every group, but it's really patterned by education. So the group with less than a high school, so again rates have been going down over the past few years, but this rate is much higher than college grads. So again, patterned by in this case education, but this is also then within it patterned by gender and race and ethnicity. I could show you many more slides. I could just, you know, be dogged with my point that sort of any any health topic we want to talk about any health disease, any disease, any health issue is going to be patterned by social class and by race, ethnicity, gender, place that goes on and on. I have been so fortunate in my career, done a lot of research in the space and early in my career, I was really fortunate to be able to work with Jim House, who's in the back there who took me on as a postdoc when I came to the University of Michigan and let me hang around with him and analyze data from a longitudinal study that he started called the Americans changing lives study. So we've done a lot of research looking at this national population based sample of people followed over time to learn about trajectories in health and also to really better understand how is people's income level and their education level and where they live, how does that influence their health over their life course. So we did a lot of work related to that. One of the things that we did that I that I want to point out here quickly is that so in population health, there's this concept called compression of morbidity. Who's heard of that? Few people. So compression of morbidity is this idea. It's really how we all want to live. We all want to live a long life, right and have any sort of ill health or a decline in our health be compressed into the last little bit of our life. Or actually what we all maybe want to do is like live a long life. And on this axis here, this is the probability of having no physical health limitations. So we want to we want to in this is age 25 up to 95. We want to go along in our life having no physical limitations until one day. I don't know, is that how you want to go? So that's good. Again, that's called the the morbidity that comes with aging is compressed into the last bit of life. That doesn't really happen for anyone. But this this graph shows based on data from the Americans changing life study that you actually can see that it varies greatly by education levels. So this top line here is the trajectory for people in the highest education level and the groups we followed over time. And they're kind of approaching compression of morbidity. People in the highest education group are living, you know, this is age 75 here. They have a level of not having physical functional limitations to their health here that the lowest education group is experiencing really by age 55. That's a 20 year age difference in that measure of health. There's other metrics of health. And so again, we know that this ideal of compression of morbidity, it looks like there there is it's possible to get closer to that. But it depends in this case on your on your education level. And also from a lot of work we've done and many other people have done. There is this notion that's emerged over the last 20 years very strongly of those things that pattern health, the kind of shorthand for that is called the social determinants of health. All the kind of things that matter besides our genetics those matter no one's saying they're not that it doesn't matter. But there's all these social factors that have really complex and intricate and synergistic ways that they impact health. So economic stability, there's many things under that neighborhood and physical environments, education, food, community and social context, and healthcare matters as well. Healthcare is important. But now here's where I start making people not so happy. That doesn't seem to matter in a developed kind of we're past the epidemiologic transition. But even so healthcare doesn't seem to matter as much as these other other things. All right. And when we're thinking about the social determinants of health, we really think about them as on multiple multiple levels. So here we are we're individuals and we're talking about health. So at some point we have to think about how does that get under our skin? Right. How does how do all these social things translate and you know get get into our bodies and create functional limitations, morbidity, mortality, all that. So at some point we do talk about health, obviously at the individual level. But all these things matter at these other levels as well. There's interpersonal interactions with other people institutional what happens in our schools, churches, work sites. That matters as well. Community level factors and then policy is driving all of this. Right. So at the highest level of the model there's there's policy. There have been a lot of people and still people trying now to figure out well what proportion of this kind of determinant you know this kind of determinant what proportion is it in terms of determining health. I actually think this is a fool's exercise. It matters what kind of health outcome you're talking about in the first place. And also I don't think it it doesn't matter to me that you know a lot of people think health care has been undervalued in this. I don't know if you can see in these models. Clinical care 10 percent. Health care produces 10 percent of health. This one has 10 percent here. This one brought it up to 20 percent. I mean to me it doesn't matter. It's that all these things all these things are important. And the important thing is that we put way too much emphasis on health care in this country. We think too much that health care is the way to address health problems. I know all of you many of you have seen the slide way too many times per capita spending on health in different countries and life expectancy. Here's a pattern here. Here's the U.S. We spend so much more on health care than any other country way more on health care than any other country. We are such an outlier on it. Would you care if we actually had better population health outcomes. Maybe you wouldn't care so much. But as those two things combine it's like all the slides I just showed you about all the problems we have and sort of where we fit in the rest of the world. So we spend all this on on health care but we don't have any. We don't have high life expectancy. We have higher rates of infant infant mortality kind of any health issue you look at. We don't score well on it. So that's an important finding from population health research and very been a very consistent finding. In 2007 the Institute for Health Care Improvement came forward with this model called the triple aim. Basically it was really a very thoughtful approach saying look we need to do something about this. We can't continue to be this outlier we're spending more and more on health care. We're not getting the results that we want. So the triple aim said well what we need to do is lower cost. We need to lower our health care costs. But we can't do that at the expense of the quality of care that people are doing or are getting and we can't do that at the expense of health in the in the population. So the triple aim is three really hard things. It's lower cost, improved quality, and improved health outcomes, population health outcomes. And that's the phrase that's been used on the triple aim population health improvement. That led with the triple aim coming forward with that and with some policy change to incentivize insurance plans, especially our big public insurance plans, Medicare and Medicaid to really think about this and try to achieve the triple aim. This new field called population health management emerged. Can I just remind you population health has been around for a long time. But now we have this new animal called population health management coming out of the triple aim that again was really focusing on, you know, reducing costs, improving quality, improving outcomes. So in the triple aim notion of population health, the focus here is on patient populations or populations of people who share a health insurer. They're in the same health plan. And again, we're looking at patient populations and their outcomes while attempting to control for cost. And the idea here, too, is something that Jim likes very much. We're going to use data analytics. We use all the information we have about patients. We're going to use data to drive interventions and try again to control costs without reducing quality and getting better outcomes for it. They're also in the population health management movement is a recognition of the social determinants of health. That's there. But that's what we're mostly going to talk about. And also there's a recognition that while population health management probably should have some partnerships with public health and community resources if it wants to try to address some of these social factors that influence health. So in the past, hard to know, I'd say probably in the past seven or eight years, the number, well, right now, we think at least 70 universities have a college, a department or a degree program, population health, management, population health or population medicine, all these words are sort of used. I'd say probably 80% of those are in the past seven or so years. This is a new movement within health systems. Many now have population health management units or activities. There's new journals, there's new professional conferences, there's professional associations, there's executive education, and there's also a lot of money to be made in population health management. There's all kinds of new business products, data analytics and consulting opportunities. Here's just a quick graph of predictions of the population health management market size looking at both software that's being sold to people to manage the data on their patient populations but also services and interventions. This is in the billions of dollars, so this is growing very, very fast. Again, there's all kinds of new companies and business opportunities and software and services in the business of population health. So is this a good thing or a bad thing? And I think in general, I mean, there's some really good things about this movement towards population health within the healthcare system but I have three reasons that I'm really worried about this that I'm going to try to get through pretty quickly. All right. So the first one is what sociologists refer to as medicalization. Who's heard that term before? Right. So medicalization and this has been around for a long time concerns that personal behavioral even social issues are viewed through a biomedical lens which then emphasizes that the problem lies with an individual rather than social pathology and that it's clinicians and healthcare providers who have the authority for the diagnosis and treatment of it. Let me just quickly give you a few examples. So menopause which is something that every woman who has the privilege of living to a certain age will likely go through has been referred to as estrogen deficiency disorder. So that's sort of people say that's a medicalization of like normal aging process and right now it's a much lower rate right now but right now anyone want to guess how many women are on hormone replacement therapy in the United States? What percent? It's 44 percent. It used to be like 70 or 75 right. So anyway it's the medicalization of an aging process. Obesity is that a disease? I'm looking at my public health friend Barbara. It's like no it is not but obesity has become very very medicalized and when it's medicalized then what do many people think is the way to deal with the problem of obesity? It's individual diagnosis, individual level treatment rather than thinking about all the things in our environment that have contributed to this. And quickly this one is really interesting to me. Attention deficit hyperactivity disorder has been going up. The rates have been going up very much. It's going up more in school environments that are very resource constrained. And also a study just came out showing that in school districts with a September 1st cutoff date. So for all of those of you in here who take program evaluation this is a really cool regression discontinuity design. What the researchers did is look at kids who were born right before the September 1st cutoff date for starting school and kids born right after and the ones born right after had to wait a year to go to school. So comparing those kids the rates of ADHD diagnosis are much higher in the younger kids because they get in school and they have behavior. So people are worried that ADHD no one saying it's not a real thing but ADHD diagnosis is really the medicalization of issues dealing with behavioral problems in school settings. All right. So last last December I wrote a little essay a thousand words on the medicalization of population health who will stay upstream in the Millbank Quarterly which has been getting me a lot of love and also some not love. I don't want to say hate that's too strong but anyway so in this piece I argue that population health which again has been around for quite a while and it's my thing right it's my field population health is being usurped by something as something to be defined and managed by the health care system and it includes the belief that population health is actually a new thing and you can you can read it all the time and you probably won't get as irritated as me but population health this is a relatively new term that has not been precisely defined or the term population health first emerged in 2003 after two doctors defined it. It's a new concept that emerged with the triple aim model. I mean of course that's not true but the idea here is that it's a new sort of thing. Yes it's irritating to me in terms of my field but I'm worried about it for so many other reasons. So first of all I think it's just really ignoring what is a good and rich history of over 200 years of research and policy regarding the social determinants of health and health disparities. I also worry about it for what I refer to as denominator shrinkage. The population health when I think about it and do research on it the population is everybody in a social political geographic sort of space. Population health management the denominator the population is people who are simply sharing a health plan or a health care institution probably for a pretty short period of time. So for to me it's a much more narrow group of people we're caring about and people are going to be going in and out of those populations. And also it's part of a long history of conflation and to do the medicalization of thinking about health in this country. We can't we have a hard time thinking about health without thinking about health care but they're not the same thing. And health disparities are not the same thing as health care access quality outcome disparities. Health equity isn't the same as health care equity. Also and let's get ready for all the debates going on they're going on right now but what are we going to do sometimes it's raised what are we what are we going to do about health in the United States or what are we going to do about health care. What is all anyone's talking about health insurance right so health insurance is not health care and it's certainly not health policy. So this is a bigger pattern so now here we go population health has now become medicalized and completed with population health management and the social determinants of health are being conflated with patient social needs. What the health care system is calling the social determinants of health is actually really individual level needs within patients. And I worry about that for a lot of a lot of reasons. We can talk more about that in the Q&A if you want but I think it misdirects policy and investment of resources in so many really important ways. All right so I'm also worried about this because the efforts that the health care system is engaging in right now in the space of social determinants of health and population health management are very much what we call downstream. They're really aimed at the individual level. And so what's happening primarily in this space is that patients with identified social issues they're being identified and then they're being referred to community partners who are already so underfunded and exhausted and their safety net is fall but the health care system now going to identify more of these needs and then you live this day to day Alfrida, right, pushes them out to the community. There is a report that just came out last month from the National Academy of Science, Engineering and Medicine called integrating social care into the delivery of health care moving upstream to improve our nation's health. The premise here is that integrating social care into health care delivery holds the potential to achieve better outcomes for the nation and address major challenges facing the US health care system. That sounds great. It's not going to work. All the research and evidence we have suggests that this promise is it's an over promise. It's not going to work. Let's take a moment and talk a bit about this phenomenon that's happening. So the best estimates right now are that 25% of health care delivery systems in the United States are screening their patients for social determinants of health and maybe some of you have had this experience as well. I saw a tweet about a year ago from a physician that said I screen my patients because some of them have social determinants of health and it's like... Okay, we all do. We all have social determinants of health. You know, really what is going on is screening patients for social needs. Sam, you're here, right, Samantha? Yes. The great fortune of working with Samantha Ivan for several years and we're working on this and it's okay, I'm telling them that this is your... Sam went to the doctor and started filling out this and she's like, hey, I mean, screen for social determinants of health. And so this is Sam's... Maybe we're violating HIPAA rules now. I don't know. Okay, anyway, it's things like, you know, things that you can see on here. In the past year, have you had a hard time paying your utility company bills? Yes or no? And Sam nicely just, you know, doesn't have that problem. So she says no. But so from the time I started worrying about this and looking at it, maybe four or five years ago, at that time there were three screening tools out there and now there are dozens and dozens and they all say they're validated, which all that means is that they actually are measuring people's social needs. So that's okay, but what are some of the things being looked at? Here's the domains that are being promoted in this area of screening patients for social determinants of health. So food insecurity, utility needs, transportation, employment, social isolation and support, housing instability, financial resource strain, et cetera, et cetera. Not all clinicians don't like this. It's taken their time. They're not sure what to do with that information. They're usually not the one to have to deal with the information. Now some physicians like it because they say it better aids me in understanding the social context of my patient and I might do a better job with you thinking about why aren't you taking your meds? Well, what are the other things going on in your life? Et cetera, et cetera. So this kind of information could help a clinician in clinical care, but that's not why the data's being collected generally. It's being collected because the healthcare system then thinks it's gonna do something about it. So there's lots of pros and cons with this and again on the pro side, clinicians understanding the social situations and context of their patients is good, but also on the con side, there are a lot of things to be worried about, a long list here, I'll unpack a couple of them in just a second, but I do worry too that busy untrained clinicians, people filling out this form, and then what's gonna happen? You fill out this thing, you turn it in, and then usually nothing's going to happen. That's just gonna exacerbate mistrust, frustration, and that's not good. We have these issues, especially with communities of color, trusting healthcare providers and systems. It's also, it's medicalizing social factors. Again, it's conflating social determinants of health with social needs. So I actually get out of here once in a while, so I go around and I talk to people about this, and I know there are several health systems in the University of Michigan. Michigan Medicine is one that has started screening some patients in primary care settings for social determinants of health, but this is being used more for data collection. We wanna be able to better describe our patient population. And to that I will say, okay, but do patients know that? Do they know what's gonna be done with the data? And again, are you creating unfulfilled expectations, exacerbating this mistrust and frustration? But in lots and lots of places, these screening tools are being used to then think about interventions. I have a master's degree in preventive medicine and epidemiology, and I had to take lots of classes on screening. And screening 101 tells you don't screen people for something unless, Dr. Freed. Right, so don't screen, there's no point in screening anyone for anything unless then you think you can do some kind of intervention for it. So again, what's being done? I'm gonna move ahead here. So there is fundamentally, again, when the screening happens, it's identifying this lowest level, and it's important, but at the individual level, a patient need. It's not addressing the cascade in that social ecological model of things that are driving those needs within people, but within neighborhoods and communities, et cetera, et cetera. And improving education access and reducing student debt is, that's a social determinant of health, trying to address that, versus interventions that focus on patients' health literacy. Screening patients for trouble, paying for their prescriptions and utility bills. Again, that might be important if you can do something about it, but that is not addressing the social determinant of health, which is it's poverty and income insecurity that's driving those problems in the first place. And then that leads me to be worried about, well, what's happening out there in terms of interventions? And I'm worried about a lot of them going on. So let me tell you about some work that we did recently. Population health management, a really common thing that's happening is the data are being used to identify the superutilizers or the highest users of healthcare. And then from there, those highest users, and that could be defined, we did a study looking at interventions addressing the superutilizers of emergency departments. That's really expensive for people to show up there. So who are those highest users defined sometimes as people who have 40 or more trips to the emergency department in one year, or maybe it's 20 or it's the people on the top 5% of the distribution, whatever. So Samantha, who's here, led our team doing a systematic lit review of 44 published studies of interventions, trying to identify first of all those superutilizers and then intervening with them. And the most common model of intervention was a case management model where the idea was, well, these people have complex medical needs that need to be managed, but they also have some social needs and we'll connect them with social services within the community. What do you think we found? There's a lot of buzz about these interventions. They work. I have been, I can't tell you how many meetings I've been to where a health system has done this kind of work and not published it and said we looked at our superutilizers, we gave them an intervention and the next year their rates were way down. It works. Well, in our systematic lit review, we found that the studies, this again for those of you, this is why we make you take program evaluation for school students. The studies that actually had a comparison group or a control group found the same level of decline. So it turns out if you take the people at the tail end of a distribution, you take the highest users of healthcare, then next year they're gonna look better. Just because, it's a regression to the mean. It's a regression to the mean problem. So that was disappointing, right? It's disappointing to all the people out there who are doing these kinds of interventions. So now, I've made you all sad. What works? I'm Debbie Downer. There's so much sadness going on. Can you tell me like dogs? I don't have a dog. I want a dog. Okay, so what's going on out in the world? There are lots of positive sorts of interventions going on and I wanna get to some Q and A, so I'm gonna have to go through this pretty quickly, but something called the Medical Legal Partnership is interesting and Alfred is here. I don't have time. I'll free to talk about what Michigan Medicine, oh, Brea's here too. Oh my God, I've had the privilege of working with some people at Michigan Medicine about a really innovative way to use community benefit dollars. So all non-profit hospitals have to show the IRS in order to have their tax exempt status that they're investing in things that are to the benefit of the community and the University of Michigan is doing some really innovative work in that regard and actually pushing money out to the community, letting the community define what they want to do, explicitly addressing the social determinants of health. They're applying for money, for intervention work to address the social determinants of health and it's very exciting. And actually there are some health systems that are investing in housing, both housing first interventions which is a model providing housing for the chronically homeless or people at risk for it, but actually there are some health systems that are investing in just building up the number of affordable housing units within their communities. There's a really big project going on in Baltimore right now and also UnitedHealthcare is investing in 80 different communities across the country to provide more affordable housing for the community whether or not those people get their healthcare from them. All right, so at this point in the talk and usually recently I've been invited to talk to a lot of people within healthcare systems. I gave a keynote at the Cleveland Clinic a couple of months ago and there were a lot of people in white coats sitting in the audience and you know what that means, right? And so by this point in my talk and I gave kind of a different talk there but they were like this. And so here's the point where I say to my healthcare provider friends, to my healthcare system friends, don't get defensive about this because there's so many challenges for the healthcare system to go upstream, right? It's not a criticism to say this is gonna be challenging. It's not the primary mission or responsibility of the healthcare system. There's a lack of expertise. And also fundamentally this is about public policy. It is policy that is driving the things that create health advantages over our life course. It is policy that is driving the things that create health disadvantages over our life course. And also who's gonna pay for all the stuff that needs to be done? So again and everyone says community benefit money, well that only goes so far, right? It's a place to start. So there are conversations with the Medicaid for actually paying for some non-medical interventions. Right now Medicaid is very, very constrained to pay for anything other than medical care. But what if Medicaid could pay for housing? Those kinds of things. And also there's some interest in public-private partnerships and again I've been doing some work in the space with Samantha and some other people looking at the possibility of social impact bonds or what's also referred to as a pay for success model for doing this kind of intervention. So here's my picture of Sedona. Maybe it's more for me to like center. I'm gonna wrap up and we have a little time for questions. So good news, I think here is that population management and other healthcare system efforts have brought some new attention and action on the social determinants of health on patient social needs and health equity. I'm delighted that these conversations are going on within the healthcare system. That is the good news. However, I'm really worried that because that's what our healthcare lens does that this has medicalized the notion of social determinants of health and narrowed and steered population health efforts towards this downstream path that is gonna be probably good at identifying patient social needs but it's not heading anywhere in the direction of the mezzo macro, these upper levels of change that are needed. And I put this here just to say I'm not the only person saying this. There's a big report that just came up. What are some of the responses to the arguments that I and other people are making? And I've heard these all and I've heard all of these in the last few weeks, by the way. But Paula, it's better than nothing. I'm actually not sure about that. Paula, don't let perfect be enemy of the good. At least the healthcare system is trying to address social factors. The one I hear the most is like, you are going to anger the beast that has all the money. The healthcare system has all the money and you're gonna make them mad and they are gonna say, we finally, we care about social determinants of health and now you're complaining about that. We will just go walk away. But also people ask me, are you telling clinicians to stay in their lane? And to that I wanna say emphatically, I'm not. I'm not telling my very good friends and colleagues and collaborators who care about healthcare policy and work within the healthcare system to stay in your lane. What I am saying, however, is like, let's get in the right lane. And to me, the right lane is not downstream or now I'm gonna make, how many of you like to hike? My family here is like, I'm crazy about, I like dogs and I love hiking. So downstream population health management activities are doing a nice job of grooming easy trails. But they're not leading up to, I didn't take this picture hiking, this is not the kind of hiking I do. But anyway, they're not leading up that mountain, they're not leading up to the hard places where we need to do the hard stuff and that's where public policy comes in. Social policy reform is the only thing that's going to help us address the social determinants of health and achieve health equity in this country. And number one, if we don't do anything about systemic racism and institutional discrimination in the United States, we will never have racial health equity ever. That is the underlying history and still current driving force behind that. We need investments in all of these things. And now I will just say, I have loved being in and working in schools of public health for the majority of my career. I'm now here at the Ford School and the reason I'm at the Ford School is because I feel like I needed to learn more about all these kinds of social policy from some of the best experts in the world. They're here at the Ford School on education policy, on poverty, prevention, poverty. Did I see Luke in here? He was here. He's busy preventing poverty. Okay. Criminal justice reform, et cetera, et cetera. So health equity requires a very broad policy approach. Social welfare policy is health policy. All these kinds of policy are health policy. And yes, healthcare policy is health policy as well but it's downstream and if we don't do anything about all this, we're still, it's still putting a bandaid on it and we're gonna have all this investment in population health and have no better population health outcomes. That's my worry, that's my passion and that's what I do. Thank you so much for coming today. We do have time, we have some time for questions. Yes, and I should have said at the beginning. First of all, thank you so much. Thank you. Please, because we're being live streamed, please wait for a microphone before you ask your question and we would appreciate it if you would identify yourself first. So again, we would love a couple of questions. So Paula, one of the things, by the way, great lecture and great way to look at the healthcare system, or the health policy system. Let's put it that way. You mentioned health insurance companies having worked at one time for UnitedHealth Care. I kind of know that. What you didn't mention at all was the pharmaceutical companies and when you take the medicalization of a condition, then there's a pill for it. How much do you think the pharmaceutical companies in their lobbying are driving some of this medicalization and why didn't you mention them as well as health insurance, just curious. Well, I think it's really easy to pick on the pharmaceutical companies because I think that is driving a lot of the medicalization. But let me give you a quick example where I actually think medicalization can be good sometimes too. So actually it was the medicalization of nicotine addiction, actually calling it nicotine addiction syndrome and giving it a code that gave pharmaceutical companies the notion that well, then if it's a diagnosis, then it made them invest in nicotine replacement therapy basically. So what we know now about the best ways for people who are addicted to nicotine to quit smoking is with nicotine replacement therapy and companies were reluctant to invest in that unless they knew that insurance companies would pay for it and that they could recoup. It costs a lot of money to develop a drug, et cetera. So the medicalization of nicotine addiction syndrome is thought to have set out a whole course that helps create these products and has led to a lot of smoking cessation. So it's not always bad. But yeah, that's all I wanna say about the pharmaceutical companies till we chat later. Okay, yeah. Hi, I'm Christopher Soianowski. Hi. She used to be, well, she is my mentor, long-term mentor now. I think, my question is kinda living around, I think we all agree that this is true, this lovely little slide up here, but how do we start to move the needle in that direction? And I don't mean just conversations, but now we have a majority of Americans, for example, who feel that the Democratic Party is too left leaning. Right. I mean, if we're gonna address all these things, let's, we need to be radical and not radical in an extreme sense, but we need new ideas. But how do we create a culture where everyone buys into this and that our goal as a society is this? And this is something I struggle with in my work as well. Yes, well, you know, I do as well. I don't know, that is the million-dollar question. I don't know. I don't know how to make everyone else care about the same things I do in the same way. But again, one of the reasons I'm really, I'm worried about the healthcare system getting so much in this game is because I think all the attention and resources is going to be down here and then it's gonna, and then a lot of people, we've seen this time and time again, it absolves policy from doing other stuff. The healthcare system is taking care of social needs and health, so we don't really need all this stuff. We'll just sort of punt it to them. I don't know, I have, again, I give a lot of talks and I give a lot of talks or I go to a lot of conferences where there's a lot of clinicians there and every talk I have seen recently has started with a photo of a patient and sort of a story of an individual patient. Meet my patient, Mrs. So-and-So, I just saw this in Cleveland a few weeks ago. She is housing insecure, she has mental health issues, she is socially isolated, her family lives away from her, just lists social determinant of health after social need, after social need, making the case for why we should care about Mrs. X. And we all know our communications friends tell us, our media friends tell us, you gotta have stories, right? You gotta have the anecdotes. That's what's gonna make policy makers care. I don't think, I don't think they care. And actually, so, and I know I'm not like everyone else, but I just always wonder, like why don't statistics move people, right? So, but I'm serious, my son's going mom. Okay. Here's some statistics. Okay. One out of five children in this country lives in poverty. Right now, over 40% of African-American children in this country are living in poverty. All right. State, I got a bunch because I like statistics. Couple more. The state of Oklahoma, over 100 school districts have moved to four-day school weeks because Medicaid has taken over so much of the state budget they can't fund their public education system anymore. They cannot afford to run buses five days a week so they have gone to four-day school weeks. This is happening in Colorado, Idaho, Montana. Should I go on? Right. So, again, I don't know why people, this isn't a big red flag. Oh, here, I'm gonna give you one more. There is no community in the United States in which someone making minimum wage can afford a two-bedroom apartment. There is no community in the United States where a single mom working minimum wage could afford an apartment without some help with more than one bedroom. These are crisis statistics to me and so the fact, I don't know, I don't know. Okay, we're gonna have to get together for a drink again at the last word, but yeah. Yes. Do you have a microphone for? Could you say more about social impact bonds and how you ideally would organize them at a local level to make them work, to deal with some of these upstream issues? Yeah, oh, we have so many papers on this. So, I didn't have time to talk about it, but... So yeah, my colleagues, Samantha and I, really do believe that this is not a magic bullet, but so social impact bonds are when a private investor puts up the money for an intervention and if it provides some value to the public sector, the government, they will pay back the private investor, but they'll only pay back the private investor if a set of outcomes that's been predetermined have actually been achieved. So it's actually, this is the really sexy topic of performance-based contracting in which private, again, a private investor would put up money, public sector finds it a value and then will pay back the private investor. Most of the private investors doing this are non-profits, so they're really not out to make money about it. So yeah, we think there's a lot of promise in this area and where we've seen the best results are in supportive housing interventions, some really interesting projects going on in the US. Using this model to support early childhood education and pre-kindergarten education is another area and then also we have a paper on, we did a simulation model in Detroit where if we use this model to have the private investor money improve the housing stock and reduce asthma triggers and if you combine that with good medical case management because that's important, that could reduce hospitalizations and emergency departments and that actually would pay for itself but there's all kinds of legal and regulatory constraints on that so I'm happy to follow up with you but we see with a new federal law that was passed last year, CIPRA, funding we see the door opening for Medicaid to get into the social impact bond space. I'm Mitch Vernick, I'm on the Ford School Committee and I'm also an alum of the Ford School. Great talk Paula, thanks. So, assuming we wanted to move in the direction that you suggest, which makes great sense and we were looking for funds and you talk about statistics, we hear a lot about end of life costs and the massive disproportion. How does culture, religion, the medical system, all those things, I'd love to hear your thoughts on that since it appears to be a large amount of money with statistically minimal payoff. Yeah, so one of the differences in the United States versus other countries is a culture around healthcare and it's kind of weird because we pay for it in a really different way than other places that have universal health insurance sort of system. But in the US, people have done some studies suggesting that a lot of people in the US feel that when care is denied, and it's not so much to themselves, but it's to their loved ones, especially at end of life care, if you're going to tell, I have a 90 year old mother, I have a 90 year old mother, we actually talk about this a lot too, just like I don't want a lot of stuff at the end of my life. Write this down because it's hard for people who love other people to say, don't withhold the care, don't do everything you can. We know that compression of morbidity, slide I put up there before, we know in the US that except for the last few years where life expectancy went down, people are living longer, we have an aging population, we also know people are living a longer period of their life with chronic conditions and lots of healthcare needs, but our culture is not one where we want to, I don't know how many of you want to deprive yourself of medical care, so I don't know, there's been lots of interventions that have been tried around that and none of them have worked really well and I have no magic bullet in myself, but yeah, if we can't crack that nut, it's gonna be hard, but I don't mean to sound naive when I say this, but again, I'm really focused on, if we can get people to those later stages of life in better health, that would be good. It may or may not save healthcare costs, I don't know, but it potentially could. Okay, or not. I'm only doing this since no one else came in. I'm David Forrey with the Ford School Committee and I really have two things, I'll just do the first one first, but because of the story, but the second one I have a question about Medicaid, Medicare and Oklahoma, Colorado, et cetera. I'm both public administration graduate of the program as well as social work and some of the things you're talking about in terms of social needs and meeting social needs hit me, oh yeah, that's what helped form social work as a profession in the early part of the century. Number of the leaders said somebody has to get out and drain the ditch if we have cholera or whatever. You can't, it can't just be the patient and in my own hometown of Richmond, Virginia, current hometown, the visiting nurses or community nurses who spun off from the medical college of Virginia around the turn of the century, 1900, 1920, weren't well accepted in the medical field and going outside the hospital, but when they got into the homes, social needs and they couldn't do their medical practice of which they have a fair amount of leeway when they left the hospital and went into the homes and I think it helped preserve the development of community nursing and the visiting nurses association for a good long time. They began to draw in people who had an interest in doing social work type things related to the family and the community if it meant housing or draining the ditch or whatever and in fact a number of the nurses moved into doing the social work part because they found that more rewarding than the medical part and then they ended up sharing settlement homes and so was interesting history, wonderful and social work benefited from that, it's wonderful. But what I really wanted to ask you about because I've seen this in action in Virginia a good number of years ago with the legislature and I'm not sure I understood you and which program you're referring to in terms of the state budget eating up being a Medicaid, that's what I thought and that always sets me off, quite honestly I haven't watched it. It is such an easy excuse for legislators to say well we can't because of federal mandates or demand and you all in your districts we know you want these services and be paid for, et cetera. And then we add on today those states that are now more and more turning to funding when they didn't go along first time in terms of increasing Medicaid, et cetera, payors. And it's a frustrating thing, but when I heard you say that I said well gee, yes but do we let them get away with that? How do we do that? Yes we do but how do we not do that? So I'll leave that as a question, thank you. I don't know, voted, I don't know, it's hard. I mean I will say that Medicaid now takes up probably at least 40% of every state budget and that's high. That's really, it does crowd out other things. I mean nobody, even I think the most left leaning Democrat wants to keep raising taxes and taxes and taxes to pay for this. So Medicaid is a problem in public administration and public finance and trying to find ways to do other things. I agree in Oklahoma if they wanted to fund public schools they probably would find a way to do it but that's the excuse that's being made. Medicaid has crowded out so much of our budget we can't give local school districts any more money than we are. I'm sorry, we're out of time. Thank you so much for coming today. Thank you.