 All right, next up we have Harold Pollock, who is a Helen Ross professor at the School of Social Administration, Social Service Administration. He's an affiliate professor in the Biological Sciences Collegiate Division and the Department of Public Health Sciences at the University of Chicago and the co-director of the UChicago Crime Lab. I don't think I knew that about you. That's interesting. He's written extensively on the intersection of poverty and policy and public health. Examples of his research include infant mortality prevention and HIV and hepatitis prevention efforts for injection drug users. Welcome, please, Harold Pollock. Thank you. I always wish that my mom were here for those introductions. So this is, I'm going to talk about some work that's really just beginning with many of my colleagues. I'm also the co-director of the University of Chicago Health Lab. I'm trying to accumulate as many titles as I can to achieve total overload. We're trying to help patients with some of the financial issues that they face in their lives. And these are mainly patients that, you heard the wonderful presentation about the CCP intervention. This is folks that are frequent utilizers and who have a lot of life challenges in addition to their medical challenges. And it's been a wonderful experience to get to know that team. I think when we think about ethical responsibilities of clinicians, that there's been an increasing awareness in recent years that the financial well-being of patients is one element of that. And that many of us, not just physicians, I think all of us who are involved in social services and health care services, we don't yet have the toolkit to really deal with a lot of those problems. I was thinking about that actually yesterday night. I landed, I had to be at the University of Pennsylvania yesterday, and I landed, my plane landed, and as soon as I turned my phone on, my mother's on the phone. And she's quite upset. I'm, of course, assuming it's the election. But it turns out that she had, her insurance had changed, and that she may have to pay $60 a month more, and that she's reluctant to fill her medications or go to the doctor until she gets it straightened out. And she called a bunch of, she spent a long time trying to call people, no one, her doctor didn't know how to help her, no one really knew how to help her. She called a bunch of phone numbers where she sort of got the run around. And, you know, she's 85, and she, and it just kind of was too much. And it wasn't an earth-shattering experience, but it's the kind of thing that in the past has led her to delay taking some of her basic hypertension medications, things like that, because she doesn't want to have a surprise bill. And if she's in that situation, many other people are in a more difficult situation. And the fact that all of the people she turned to for help were basically confused about what she was dealing with was very frustrating and disempowering to her. So I should say, by the way, I don't have any disclosures. None of my titles seem to involve any even potential for conflict of interest. I was watching a Noob's thing with Great Envy that I wish some industry would support my work. And this also connects, this work that I'm talking about connects with another interest that I have, which is about financial planning. Some of you, I know many of you in the room and you know that I've written a book on personal finance, and I have a lot of conversations with people about personal finance, and I think that there's an opportunity for helping people here. So I mentioned the C4P program that David talked about as well, where we're trying to help people who are trying to engage patients in the C4P program, and in part engage them both for their medical care and in other ways by offering them educational events and services and resources that will help people enrich their daily lives. And some of those are helping them deal with basic challenges that they have, not just personal finance, but also safety and legal issues, things like that. One of the reasons why patients don't show up at the clinic is they're scared to take the bus home and things like that. We're trying to work on a range of those issues. And we actually think between myself and Dr. Meltzer and Marianne Bertrand and others that there's a set of resources and a set of insights from behavioral economics that can help us help these patients. And they have all the issues that low-income people have, credit and payday loan issues. Some of them have bankruptcy issues or credit, how to maintain their credit rating, how to maintain a household budget. They also have people in their household, sometimes their caregivers, sometimes their children, sometimes others, who have their own financial challenges that weigh on these patients and that these patients are often responsible for. So we've got a range of issues that we're trying to help with. I should note, especially here at the University of Chicago where some of the best work's been done, there is a growing literature on the financial burdens that come directly from chronic illnesses and this notion of financial toxicity, particularly in the context of cancer care, has really spawned an important literature in recent years. And the consequences of financial toxicity are becoming more and more well known. One is, of course, the cost of medication leads to a tremendous amount of non-adherence among patients. Also, the burdens that come from patients, not only for paying for the direct cost of medications and things like that, but also transportation and work time. I actually have done some work with Ronald McDonald House and talked to parents, not just in the United States, but also in Canada, where the parents were being financially drained by very mundane things like the cost of a sandwich in the hospital cafeteria and the cost of parking. And not to mention bewildering insurance issues such as my mom had, only more complex. And we know that these distort patients' care choices in lots of ways. I thought one of the most disturbing findings in the financial toxicity literature is how people, the nature of the care that people choose is sometimes really distorted. And you see patients who end up in the ICU rather than being at home because their insurance actually deals with the ICU care in a more comprehensive way than the care that they might need at home. And of course, medical bankruptcy and in the Oregon health insurance experiment, randomized trial was done where individuals were given access to Medicaid benefits. And the largest benefit that's been seen so far in health outcome is in mental health. And it's really in reduction in anxiety. And a lot of that, when they dug into it, was reduced medical debt and reduced fear of medical bills that they couldn't pay. I've heard a lot of people say Medicaid doesn't improve people's health, well, except their mental health. And that's sort of a strange way to think about the well-being of patients. It only improves their mental well-being. So we have some early data. And Andrea Tenton prepared the slide I'm about to show you. Where it was quite involving. And I want to thank her for sharing with me the work that she's done on the team. We have a survey where we're just asking patients, do you have a lot or some, a little or no unmet need in these different domains? Food, housing, money for basic needs. And we go down the list, health insurance. And when we look at the patients, there's several different groups of patients. This is the slide that's very hard to read. Everyone has to have at least one in their presentation. I actually have more than one because I excel in all these different roles. But what you see is that the leftmost column is the C4P group that's going to ultimately get some of the services that we're talking about. We see a third of people report that they have a high unmet need in financial need. 50% have a significant insurance issue, 25% a legal issue, 42% in the area of transportation, 33% in budgeting. And it goes down the line. Very high rates of challenges that we need to help them with. And if we look at, 20 patients identified that they would be interested in having some sort of help. And not surprisingly, they had higher rates of need. So 42% of them reported that they had difficulty affording food for themselves or they had missed meals because they couldn't afford it. But they had significant money problems, 68% reported insurance problems. I'm going to come back to the insurance one in a minute. 58% legal issues, 42% helped with budgeting. So just down the line, we see very high rates of basic needs. But one of the things that I'm struggling to get my head around is a lot of their financial problems, of course, relate to bills that they have from the University of Chicago Medical Center. And so we'll have to think about how to manage all the complexities of that aspect. And we also asked more particular questions in the last 12 minutes. Did you ever feel that you ate less than you felt that you should because you didn't have enough money? Did a utility shut off your electricity or gas? Are you worried about stable housing and so on? Did you ever skip medications to save money or go without medical care for the same reasons? There are, oops, sorry. And we see 50% of the people reported that they had basically missed out on food. 25% of them reported problems with their utilities. And 35% concern about unstable housing and just down the line. So these are the patients. If you have a clinical population in the south side of Chicago, these are the patients that you are seeing. These are probably more acute because these are patients with frequent utilizing patients. But you're seeing patients who have all of these problems. Whether they're talking to you about that or not is another question. 25% of them reported that they actually had an urgent need. For example, I don't have food tonight. I don't have a place to sleep tonight, something like that. That's 25%. So now we get to my own strange career as a financial guru. And some of the services that we might offer. Are we OK so far? It's a little late in the day. It's a little dark. So stay woke. That was my product placement, by the way, given the election. So I did this thing several years ago. I wrote this index card. And I posted it on the internet. And some of you may have seen this. I got 400,000 hits on this. It was basically advice for people. And the claim was that anything you need to know about personal financial planning could fit on an index card. And so I said that once in a conversation on the web. And I got an email saying, where's the index card? And so I just scribbled out in two minutes this index card and took a picture with my iPhone and posted it. And it was one of those insane experiences that is the craziest thing that I've known of until a week ago. So it basically was one of the best new financial, one of the best new ideas of the year in Money Magazine, which I think is hilarious. If you look at it, it's like pay off your credit card at the end of the month. Like that's really, that's a great idea. It's really not a new idea. Sort of like trying to think of a medical equivalent, the germ theory or something. But this thing got a response. And people seem to really relate to it because it made an intimidating set of tasks into something that people could digest. And I've been trying to think about how we could do this for low income people. Because the card's useful, but it's a decidedly middle class thing. Talking to this C4P patients about their 401k accounts is a little bit ridiculous. So I made a card for low income people who are not sick after talking with people who work with social work folk about what is it that low income people should be thinking about. And it's a different set. It's things like manager and income tax credit, save consistently, know and manage your credit score, things like that. It's a simpler set of things that seem to be valuable for people. And I've been talking to various people who work with low income people about how to do this well. I've also been trying to look at where people could go to get good advice with their financial problems. For example, I need help budgeting. There's a for-profit industry to help people. And there's really two problems with it. One is that the best advice is basically available for free on the index card. So if you're paying someone for advice, they're probably giving you bad advice. And the second is there are apps and things like that. The people that are in this intervention, they're older people. They're not exactly the kind of people who have 500 apps on their smartphone. And a lot of the things that are good for younger people to help with some of this aren't really appropriate. And so there's a nonprofit sector that actually is very good at helping people. And we all should know about who to send people to when they have financial issues. But that nonprofit sector doesn't know anything about health challenges and doesn't know anything about health insurance and the issues that are clinically important that these people are experiencing for their bills. So all of the issues that I mentioned before about sort of financial toxicity and so on, the people who are good at helping low-income people with their money issues don't know about this stuff. They really don't know how to help people pick their insurance plan or manage their deductibles or anything like that. And so we have a responsibility to make sure that someone with that expertise is touching that person when they need it. So I'll mention just a few of the things that are available. So here's the financial coaches. I think everyone who's in primary care should know about financial coaches. They provide very basic help. They're typically nonprofit. The United Way does a lot of work. They're the working family success now. Has anybody here ever sent a patient to a financial coach or financial counseling? So I don't see any hands up. So that kind of illustrates. I think that we need to- I am. Did you? Sorry, I was marginalizing you. And the good thing about these financial coaches is they also know how to help people with some of the other needs they have, like hooking them up with food stamps and things like that. So that's a very valuable role. And there's actually been a really nice RCT that the Urban Institute did. And what they found was that you could help people do- the financial coaches are really good at helping people do the basic things a little bit better. Like reducing late fees on their credit cards, improving their credit score and dealing with delinquencies. They weren't that great at helping someone stay in their home if their fundamental problem was I don't have enough money. But they could help people with the easy things that people often let slip. But also the financial coaches, it's not a highly professionalized role and it's certainly not one that has any specialized training that relates to health and illness. There's also some specialized financial counselors that are available in other realms. For example, there's a very nice- there are very nice services available to help first-time homeowners who actually have a lot of expertise on the mortgage market. And in some ways might be a good analogy for what we need for health insurance. I'm not gonna talk about it now, but there's some pretty good results with that sort of counseling. And I'll just mention that if people went through a pretty simple program, they had a 5.8 percentage point lower likelihood of defaulting on a mortgage, which is an awful lot for having people come to several coaching sessions. That's a big program impact in people's lives. Now, so what is it that clinical professionals can do? I think one of the first things is to assume that every patient or client at least potentially has a personal financial challenge that's intertwined with whatever brings them to your office. And that those are gonna really affect the kinds of care that that person needs and the way they're going to use the care that you try to provide them. And so you have to know, as a professional, what are the impacts on their medical bills and their co-pays and things like that from the costly therapies that I might recommend? And I'll leave it there for the moment, but I think it's very important to understand this is just part of the landscape of most patients. Also, it's something that people, we need to talk about this with people in a normalized way. When we do a wellness assessment, this is kind of a nightmare for a lot of primary care doctors because after I do the domestic violence screen and the car seat screen and the alcohol screen, now you're telling me to do the personal financial screen pretty much. But we have to normalize financial stresses and learn how to talk about them with people and know about, particularly for low income people, the kinds of issues that they're likely to face. Many, many patients are gonna have difficulty with issues related to the Affordable Care Act, especially right now due to all the uncertainty after the election. You don't have to know all those things, but you have to be a click away from someone who knows those things so that they can get the help that they need. And there's some specific populations that you need to know about too. For example, a lot of unauthorized immigrants and we don't have such a huge population at UCMC of that, but many of the financial issues that unauthorized immigrants have, there are some very simple fixes that are very helpful to people. A lot of people don't realize that they can actually open up a regular checking account even if they don't have a social security number, for example. And understand that people will be ambivalent about it. A lot of financial issues are like other risk behaviors that people have, and so you have to use the tools that you have to deal with any other risk behavior and methods like motivational interviewing can be quite helpful in talking to people about some of their financial challenges if that's where you need to go with that. And so the social work staff can really be very helpful in that way. I think linking people up to outside services is really important, and I mentioned some here. The Center for Economic Progress is very good here in Chicago. You can't really turf that off though and ignore it because the person that you send them to will not know anything about their financial problems related to their medical expenses. So you really have to stay in contact with them. So with that, I'm going to stop and thanks very much. Are there questions? No, I have a question. Uh-oh. Do you think that these financial coaches can help patients navigate through the, right now, people's insurance is changing very frequently. Sometimes they'll be dropped from one program and put onto another one and especially Medicaid patients. Do you think that these financial coaches can help them navigate through what this means for their benefits or is there anybody that you would recommend that might be able to help them understand exactly what benefits they have? Can they help me understand what benefits they have? They do not have the expertise that enrollment assistors would have are navigators, the alphabet soup of people that, and unfortunately, we do not have enough of the people who are, so the people that I mentioned in these, they definitely do not have that expertise. I think I would go to the enrollment navigators for that. I think, unfortunately, I mean, as of Tuesday, I don't know what the future is. And it's not even so much what President-elect Trump will do is really what Governor Rauner will do to support the infrastructure. These are all, the enrollment assistance is state government and there's not enough of that. I do think that it's really important to see in-house to do some social networking and say, okay, who in the hospital here actually has a good handle on that? And I would appreciate anyone sharing with me their connections because I must say when I get a lot of calls from people and I really struggle to help people myself and I'm supposed to be an expert on that? Yeah, I don't think anybody really understands. This literally, thank you for the great talk. This literally comes up every single week in my clinic and at least once a month I consider or don't bill a patient because I'm worried that they'll get a bill for something that they can't afford, that they were here not of their own accord, but were given a follow-up out of network or whatnot and I really wish we could be better at it but it seems to change so fast no one can. So thank you, this is great. Tell our patients. Can I ask a, sorry, can I ask a question? I'm sorry. I have a question and we're ahead of schedule and this, like I said, happens to me all the time so go ahead. Hi, in some work I do outside of medicine, actually I deal with financial literacy issues in low income women. Do you separate, because we talk quite a bit about financial literacy leading to worse outcomes for low income people. Is financial counseling, are you considering that a separate kind of activity from some of the financial education type of programs? Well, I think that there needs to be, I think the problem with, if we think of this as behavior change, then we realize, all of the ways that we know that telling someone they should quit smoking is not a particularly effective intervention for smoking cessation. That is exactly what people are dealing with when they are having difficulty with their home budgeting and so there needs to be relationship engagement and all of the tools that we would have if we were trying to deal with a chronic challenge that a person has and so I think that the term financial literacy is a somewhat misframing of it because it, because you need to really, both there needs to be more of an interpersonal dimension and there's a granularity to the issue. I can tell you in 30 seconds that the best investment is invest in a low cost Vanguard index fund and pay off your credit card at the end of the month. I've just given you basically most of what's true that is communicated in a lot of financial literacy and that's actually total, everything, that's totally important to say, boy that's getting you not even to square one with a lot of the issues that people are facing and it almost always is the case with people in complicated circumstances that their money problems are interrelated with so many other things that are going on and when you really start to talk to someone, I can't tell you when I published my book which is available for sale, I can't tell you how many people would, my students would say things like, I've been living with my boyfriend for two months, we both know what each other did last summer, we have each other's Facebook passwords but I've never shown him my visa bill because that's kinda too personal and money is very intimate to our humanity and whenever it's going on in the household, I have a son who's got some, whose behaviors are creating a financial problem for me, all those kinds of stuff are often in the mix so I'm sort of cynical about this sort of quick fix thing although I'm all in favor of the quick fix thing but you need to have someone else with it. Thank you.