 Our guest today is Dr. Anne Neal, now a head in a previous league at the Commonwealth Foundation. I shouldn't be thinking about her in terms of her foundation role, just the way she didn't think of herself as an academic when she was a young faculty member at the Mass General in the 1990s. But rather, the way she thinks of herself is as someone who has devoted her entire career to trying to provide high quality health care and health access to populations. And whether she was doing that through a role in academics or more recently a role in the philanthropy world, it would be more relevant to think in terms of her lifetime goals, which have really focused on providing access to care and eliminating disparities in health care. Dr. Beal's research interests over the years have included social influences on preventable behaviors, minorities, racial disparities in health care, and quality of care for children. Her discipline is pediatrics. She's also well known as the author of a bestselling book called The Black Parenting Book, Caring for Our Children in the First Five Years. Well, it's a delight and a pleasure to welcome Anne Neal. The topic today is Future Directions for Health Equity. Please join me in welcoming Dr. Beal. Great, thank you. Thank you. Have a seat. So as you heard, my goal has been to address and eliminate health disparities and really focus. I'm going to actually move this on underserved populations. Although as a parent, my new goal is to get my children out of my house. So I'm happy to announce that I have one off to college, another one about to go, and the empty nest is a myth. It doesn't exist. So my marriage is better. My house is cleaner. I'm like, so for those of you who have recently left, don't go back home. So because my parents must stick together. So with that said, I wanted to spend some time today talking about Future Directions for Health Equity because I do know that as part of this lecture series, there's been a live discussion about thinking about framing issues of health disparities. And so even at the foundation, we were very deliberate in saying that our program was not going to be about disparities because we're no longer interested in looking at the problem. What we're interested in is looking at solutions. So we don't have centers for poor quality. We have centers for quality. We don't have centers that are looking for the negative. We have centers that are looking for the positive. And so I'm very much trying to have a start to use the language of health equity and health care equity because that is really our paradigm within medicine is that we're trying to get towards high quality. So we have a lot to get through. And I have about half an hour, 45 minutes. How much time do I have? OK. But really wanted to spend some time thinking about this in terms of how do we frame this? How do we develop a common language in terms of thinking about issues of health equity? So even though I think that this is a group which knows that disparities are real, I think it's just worth spending some time to remind people that disparities not only are they real, but they continue to really be in many ways intractable. If you look at the recent AHRQ reports, we've gotten better in some areas, worse in some other areas. But the fact is, is disparities continue to be with us? As you heard, I am a pediatrician. And so one of the areas that we're particularly focused on at the Etna Foundation is around disparities in infant mortality because when you think about it in the last few years, a lot of the work around disparities has focused on what I call the usual suspects of chronic disease, hypertension, cardiovascular disease, cancer. And yet when you think about it historically, particularly from a public health perspective, the longest standing disparity and the best described disparity has been in terms of life expectancy and infant mortality. And while over the years we've been able to actually drive down the overall rates of infant mortality in this country, it's been quite striking when you look at the data, we're driving down the rates and yet maintaining that gap between black and white infant death rates. And so it's important for us to understand that this is not a topic which is about an intellectual exercise, that there are real lives at stake. So let's say we wanted to take diabetes as an example. When you think about it from the perspective of just prevalence of the disease, and these are data from the NHANES, the National Health and Nutrition Examination Survey, essentially when you look at the people who just have a condition, the fact is that minorities and in this case, particularly African-Americans and Mexicans, have a higher rate of prevalence of the disease. And so one might say, well, what is causing that? Is there a genetic predisposition? Is there something about what people eat? Is there something about their communities? There's work which is going on to try to describe that. So from the perspective of just who gets sick before they ever even come in to see us, we know that there are disparities in that area. But then once someone is diagnosed, these are data that are looking at complications resulting from diabetes. And this is actually looking at the relative risk of having an amputation. And what we see here is that, in fact, there are also disparities. So even once then you take the prevalence off the table and then look at then people who are diagnosed with a disease, that we see then a disparity in terms of outcome for people who have diabetes. And then ultimately, and not surprisingly, what we're going to see is that then there's higher rates of mortality associated then with diabetes. And so in terms of prevalence, in terms of quality, and in terms of ultimate outcomes, you see this very consistent and persistent pattern of a disparity in terms of outcomes. And so I chose to do diabetes. I could have looked at infant mortality. I could have looked at hypertension. I could have looked at cancer. I could have looked at any number of conditions. And unfortunately, particularly in the early days of disparities and disparities research, no matter where we looked, we found disparities. And so they're really ubiquitous. And again, in a lot of the early research, I remember it was very surprising for a lot of people to say, well, disparities happened out there, but once patients come into our doors, it doesn't occur. And yet the research definitely demonstrated that it occurred. As you heard, I was at Mass General and my research there was in health disparities. And I remember one of the questions that I looked at is are African-American women as likely to be counseled to breastfeed their babies as our white women? And I found the fact that there was a disparity. And I remember my division chief was like, oh my gosh, the doctors are not counseling women the way that they're supposed to. And one of my colleagues, also a pediatrician, who we also went to medical school together, he's like, so how can we have to spend all these years doing research for what you and I know is the case? We know that there are disparities. And we know that people are not getting the same type of treatment. But I think that there was a sort of trajectory that we had to go through in terms of really making people understand that this was not something which occurred outside of our doors, but this occurs in terms of getting into the doors, getting through the doors once patients come in and then once patients are trying to get out, that at every step of the way we do see a disparity. So given that, and I think that most of the people in this room understand that those are real, we have to ask ourselves, well why is this an important question that we want to deal with? And so I think that we have to have sort of a common language and a common way of talking about these issues in terms of how we make the case for really trying to promote health equity. And I think it's important because I recognize that in this room, I'm really talking to the choir, but the fact is, is not everyone recognizes that disparities exist as a problem. And even if they do, don't necessarily recognize that it's something that for example, medical providers or the healthcare system really should be held accountable for. We know that social determinants are a major driver of these sorts of issues. And so a lot of people might say, well why should I as a nurse or as a physical therapist really be trying to work on these issues? It really, I'm trying to do the best thing that I can and I will take care of all of my patients the same and if there are differences in outcomes, that's a function of what's happened before the patients ever saw me. I think first and foremost, and I know what personally drives me, is that this is an issue on social justice. And I think that fundamentally when we think about how we define ourselves as a nation, and when we talk about the words of the founding fathers, many of whom were slave owners, that all men are created equal, they even if not in practice had a vision that they understood was important in what I think in many ways defines and sets us apart as a nation. And so even in their imperfect way of talking about that despite their personal practices, they understood that all men are created equal and frankly I think it is part of what sets us apart as a nation. That we talk about what is right and what is wrong and that there is a social justice argument that we should not shy away from, that it is about doing the right thing at the right time. And frankly it is a function of what defines us in terms of our humanity. That we care about a sense of fairness for others and I think that this is important. So often when I have these discussions about why we should really make the case for health equity, people say, well, we don't want to talk about social justice because nobody's interested in that. I don't agree with that. I think that as a nation, we need to start to have conversations and speak to the better parts of who we are and that is a conversation about social justice. So at the top of my list actually would be that this is a social justice conversation. And so I like to remind people that in fact when people often think about our leaders in terms of social justice, it was actually Dr. King who said of all the forms of inequality and justice and healthcare is the most shocking and inhumane. So most people don't think of Dr. King as someone who targeted and talked about health and healthcare but he recognized that this is key and critical to who we are as a nation and he spoke to the better part of who we are. So I think that the social justice issue is not something that we should shy away from that we should embrace and then really say it is front and center and as I said, it speaks to the better part of who we are. With that said, there's also the argument around population health and so as a nation, in order for us to be competitive in a global market, in order for us to be able to do well, we need to have two things. Have a workforce which is healthy and a workforce which is literate. Unfortunately, we have disparities based upon race and ethnicity in both of those metrics but we're now seeing that people are able to open up plants, are able to do business in a number of different countries around the world and so if you have a choice of having workers who can't read, can't follow directions, don't come to work because they're ill, the cost of healthcare for them costs so much more in one country as compared to another country where your workforce is literate, willing to work, willing to learn and is much healthier, where would you set up shop? So I think that there's a reality in terms of really thinking about this in terms of not only the right thing to do but from an economic perspective in terms of our competitiveness and frankly on a global level. I think the other reason why disparities are important is that when you think about who we are as a nation that by the year 2050 we are going to be a majority minority country and currently when you look at the 25 top or largest metropolitan areas within the United States half of those right now are majority minority and so this is not something which is in the far distant future this is something which is here and now. As you heard I am a pediatrician and so those of us who are dealing with younger populations in clinical settings already know inherently that our patients are black, beige and brown increasingly and so when we just are thinking about our level of performance and how we can function as a nation that if larger and larger swaths of our nation are being left behind in terms of not only health but also in terms of literacy and an ability to compete then it's going to really speak to the demise of ourselves as a nation. And again going back to the example of infant mortality we've all seen the data that looks at infant mortality in the United States as compared to other nations and part of that was kind of the shrug of well you know we don't do as well as others because we're such a heterogeneous population well that should not be acceptable that should not be acceptable. So the fact is given that we are rapidly moving to a majority minority nation we have to think about from a population health perspective as well as from an economic competitiveness perspective that we need to really ensure the health and wellness for a population. In addition we need to think about disparities from the perspective of helping to bend the cost curve. So I don't know if you guys heard federal government might be closing down there was this little issue that happened last week. And front and center in terms of those discussions was really looking very critically at Medicaid and Medicare because the federal government is the major purchaser of healthcare within this country and large parts of both federal as well as state budgets are really dedicated to healthcare if not for their employees than for the beneficiaries who actually make use of these dollars. And so the question of really trying to bend the cost curve is critically important. So when you think about it first of all the rates of healthcare expenditures are rising and we're now currently on a trajectory where it's expected that in 2018 cost of healthcare in this country will be a 4.3 trillion dollars. Does anybody know what the GDP is in the United States? 14, it's 14 trillion dollars. So this is a big chunk of change. This is a big part of what we do. Every tax dollar that we pay, every dollar that we earn, everything that we produce, 20 cents on the dollar is going to go to healthcare. And this is a function of a lot of factors not least of which is the aging of the US population but it's also the increasing reliance on advanced technologies as well as then the inefficiencies which exist in our healthcare system and I would call the health disparities that we see one type of inefficiency that we see. People not getting the right care at the right time. So as I said, the expectation is that about 20% of the GDP is going to be devoted to health. Fundamentally this is going to bankrupt us as a nation. We will not be able to maintain this. And these data actually only talk about to 2018 and I've heard some economists say that given this rate of rise, we're actually looking at a point where healthcare will be 50% of our GDP. And the fact is the economists that I've heard described to say that just can't happen. We will not exist as a nation if we ever get to that point. But the fact is that and you're hearing it in terms of these discussions of the state budgets and they're saying how can we afford some of the proposed federal changes in terms of Medicaid, we can't afford this. You're hearing it in terms of the national discussions that are going on in terms of the budget. We have got to make a fundamental change in Medicaid and Medicare. You're hearing it every time someone goes on strike. So any union that goes on strike, what is front and center in terms of some of those discussions is about pension benefits and really thinking about who's going to pay for healthcare as people age. And it's also about thinking here and now what are some of the health benefits that are available. You're hearing it in terms of when people want to open businesses or start businesses, small business owners who are saying that we can't afford the cost of healthcare. So this is huge. And so the fact is that when you then talk about health disparities, it is an important opportunity for us to really try to bend the cost curve that essentially giving the people the right care at the right time, preventing disease is an amazing way for us to really rain back a lot of these healthcare costs. And again, while we're hearing a lot of the discussions at the federal level, the fact is is the vast majority of people of color in this country are working people who have employer-based coverage. And so this is not just a public sector question. This is not just an issue that is Medicare, Medicaid. This is actually affecting all of us in terms of our healthcare. There's been some work which has been done. And so if you look at the third bullet, this is actually work that was done by Tom Levise at the Joint Center for Political and Economic Studies. And essentially what he did is tried to do an analysis which actually looked at the economic impact of health disparities, looking at African-Americans, Hispanics and Asians and said that over a four-year period that the disparities in health costs us as a nation $230 billion, billion with a B. And so when you think about it, all of the discussions in terms of how we can try to bend the cost curve around health and healthcare, I think that $230 billion might help a little bit in terms of dealing with some of this debt. In addition, when you look at private insurers, because as I said, the vast majority of people of color in this country are employed and have employer-based coverage, for private insurers, just in one year, $5.1 billion is due to be the additional cost that are due to elevated rates of chronic disease among minority populations. And let me be clear, that $5.1 billion is not what it costs to take care of people with chronic diseases, it's just the gap between the prevalence of chronic disease between people of color and whites in this country. And so the issue around healthcare costs and the role that disparities can play in really trying to rein in and help bend the cost curve is, again, not just the social justice issue, but it is an economic issue and it is part of our, I think, our national imperative in terms of surviving. One of the other things that I wanted to point out is when you look at what are the costs of common conditions within the United States, here is a list of common chronic conditions that actually taken together really are about 38% of all healthcare costs in the country. And one of the things that struck me as I looked at this list is that the top three are ones that we know, certainly, are much more prevalent among minority populations. So these are big chunks of our healthcare expenditure and, again, represented by diseases that are much more prevalent among minority populations. And then lastly, these are projections in terms of costs of healthcare and the number of obese people within the country. And it's definitely been demonstrated that even in a 12-month period of time, if you take people with normal BMI, people with elevated BMI, people who are obese, that there is this nice march in terms of healthcare expenditures associated with the prevalence of obesity in different populations. And so, when, again, we as a nation are having challenges in terms of increased obesity and then, when particularly communities of color are having challenges with increased obesity, we know that this is going to have an impact on us in terms of the costs of healthcare. So I hope that I've made the case that there is, obviously, the social justice case. There is the population case. And also, in fact, there is a business case to be made for addressing health disparities. So are there any questions before I go on? I've made the case, no one wants to argue. Okay. So given then that we, hopefully, have a collective understanding of a need to address health disparities, here's what I would say are really the steps towards trying to get us towards health equity. And first is to identify the potential root causes. And so, again, as I said, when we first started to talk about health disparities and identifying, people often said, well, you know, might this be about overuse? That some populations are using healthcare more than others, and that what we're really seeing is minority appropriate use of healthcare services. Well, that's one hypothesis. Are we seeing social determinants? Are we seeing cultural differences? Are we seeing genetic differences? So I've seen discussions where people said, well, you know, African-Americans experience more hypertension because in order to survive the middle passage, they had to really be able to hold on to salt and water in order to be able to survive. So there's a genetic predisposition towards hypertension. If you actually look at all people of African descent in the new world, many of whom came over the Atlantic on the same types of ships, in fact, we know that that is not the case, that it actually is this nice gradient as you move from north to south in terms of prevalence of hypertension. But the fact is that there's a lot of thinking in terms of what might be potential causes of disparities. And what I would argue is that, while we are very smart in this room, we are not the first smart people. And so if there really had been that kind of magic bullet to really give us an answer as to what is driving disparities, some people long ago, smarter than us, would have figured it out. And so I think that it is, frankly, naive to really think that there's going to be that one magic bullet. Or in fact, that disparities among Latinos are the same as disparities among African-Americans. Or that disparities for infant mortality are the same as disparities for cancer. These are very complex issues. And one of the things, and this is my one pet peeve that I will talk about as a funder, is that I often give proposals that really demonstrate no real thinking or nuanced approach to really understanding this, to really just thinking that all we have to do is stratify our analyses and we have a real understanding of what's driving this. But the fact is, is really understanding the root causes. And once you have peeled back all the layers of the onion and understand all the disparities around breast cancer, then you still have to do all the work around hypertension and around heart disease. And the disparities experienced by Latinos versus the experience experienced by Asian populations. This is not one size fits all and it is not going to be a magic bullet. And so I think that we need to be prepared to really be in this area for the long haul to really understand what is driving this. Secondly, once you've identified potential root causes, and I was very deliberate in using that language, is then you have to identify the disparities. And then once you've identified the disparities, then someone has to really say, okay, I'm responsible for this. I'm responsible for this outcome. So again, going back to infant mortality, we've known for years that black babies are more likely to die than white babies. So who's responsible for that outcome? Who's responsible for changing that? And what I would argue is, well, who's responsible for the quality of care within the United States? Who's responsible for infant mortality overall? So I think that there's an emerging opportunity which is occurring within this country in terms of really a sense of accountability for population health. And I think that when you think about the US experience as compared to other countries, one of the things that occurs in other countries is that we don't have this divide between clinical health and public health. What we have is that primary care providers are actually responsible for populations of people and that they have a sense of accountability for the outcomes for those populations. So I think the changes that we're talking about in this country are really gonna be a significant paradigm shift in terms of how we think about who is responsible for these particular outcomes. And then lastly is to talk about testing solutions. So once you know that there's a problem, think that you know the solutions and then have a sense of ownership, then you have to really think through and experiment different ways to address this. So in terms of what causes disparities, I think that if like there's maybe 75 people in this room and I went around the room and I said, so what are some of the causes of disparities? I would probably get like 100 different answers. And so what I've listed here is just some of the different answers that people often give when say what are the factors that are driving disparities? And again what I would argue is that this is actually in many ways a false setup because as I said the disparities in cancer are not gonna be the same as the disparities in diabetes. But in general people will look at issues that range from cultural factors to genetic predisposition to community factors to access to care to the quality of healthcare to patient adherence to economic factors. And I think when you start to think about it in this way can almost become very overwhelming because as a provider or as a researcher, you might say well I don't know where to start, I don't know what it is that I can do to try to address all of these factors which may actually contribute to disparities. And so the way that I like to think about it is for those of you who remember physics, remember the voltage drops and actually this is actually derived from the work that John Eisenberg did in terms of really talking about the voltage drops in terms of quality. But if you think about coming in that this is where people should be in terms of their health outcomes and then the disparity is where people actually are that there are a number of factors that contribute to this. So it can be a combination of genetic predisposition and environmental factors. But it's also going to be a little bit about access to care and the quality of care that people receive when they come in. And then once they do come in it is about the other comorbidities that they may experience. And maybe that there are some physiologic and genetically based differences to reactions to medication. It may be that some people living in some communities may have greater challenges in terms of ease of access to the factors that allow them to engage in improving lifestyle changes. And so for me it helps to think about this that this is not an either or. And I think one of the challenges in terms of for those of us as research is that we're trained to be actually very reductionist in our thinking. We're trained to really think about here's the one factor that we're gonna focus on. And then in our regression modeling we're gonna kind of control for everything else but we're really looking for that magic bullet. And I think actually that that's a false paradigm to have within disparities that it really is a multitude of other factors. So with that said though if I had to put my money on any one or two factors I would say that it's probably related to access to care and the quality of healthcare. I think that as a profession we are significantly challenged to do the right thing at the right time, period. And we know that from Beth McGlynn's work which looked at medical records and found that people only receive appropriate care 54% of the time. And again, this was not stratified by race ethnicity. This is just us as a nation. We can't do the right thing at the right time. So I remember when I was in training and I don't wanna give my age away but for those of you who know when the last major measles outbreak was you can guess how old I am. Pretty old. And I remember working in the emergency room in the Bronx at the time and we had all these children coming in with measles. And I remember one of the senior faculty said, oh, you need to look at this child because measles is something that we have essentially eradicated and you will never see this again. So I remember that first kid that came in and the next thing we know, we had like this major epidemic running through New York City and the Bronx. And the thing about measles is kids died from this disease. Once these kids were sick, there was nothing that we could do, you know, supportive care and just hope that they didn't die. And actually within New York City in that first year of the outbreak, we have 15 children die of measles. And so I remember in the emergency room we were doing a study that was actually many of these kids came in and they were malnourished. And there were some hopes that if we actually gave vitamin A supplementation we might be able to help with their rates of survival. And so, you know, everyone was scrambling around trying to recruit patients and make sure that we got them in on time and all of this to give them this vitamin A supplementation. But I kept scratching my head and saying, but why are we even dealing with this condition in the first place? Here we have a vaccine preventable illness. The efficacious vaccine was developed in the mid-50s. And here we are decades later dealing with a vaccine preventable illness. So yeah, while it's nice that we may want to, you know, look at the vent settings and all this sort of stuff and vitamin A supplementation for these children, no one was asking the question but why are we dealing with a vaccine preventable illness in the first place? That's why I said I was never gonna be a researcher because it just didn't seem relevant to me. But it was a function of we had not done the right thing at the right time. So I think this issue of one, getting people into healthcare and doing the right thing at the right time is a huge step forward in terms of our ability to address health disparities. And this is not to say that we shouldn't do special interventions and targeted population efforts and things like that, but we need to like stick to the basics. So if you can't look at a population of children and say that they are 100% vaccinated against measles, then any other intervention you do is just trying to put a band-aid on a bad situation. So I would argue that we really need to focus on high quality care as the first step for addressing population health for communities of color. So given then that the focus is on trying to think about quality, one of the best ways to identify disparities is to really monitor quality of healthcare. And it's to think about as I said doing the right thing at the right time. But I would argue that it's not enough to just monitor the quality of care that what you also want to do is monitor the quality of care stratified by race and ethnicity. And so if we don't know what the disparities are, then we won't be able to address it. So for example, looking at breast cancer, we know that African American women are much more likely to die of breast cancer. We know that when African American women are diagnosed, they're usually diagnosed at later stages. So it would make sense that we need to get more African American women screened through mammography. But the fact is that there are no disparities in terms of mammography screening rates between African American and white women. And so we would not know that unless we stratified basic measures of the quality of care by race and ethnicity. So this is a lot of work. This is actually five years of research, all in one slide that I supported when I was at the Commonwealth Fund. And it was a lot of the work that was really done around collecting race and ethnicity data. I have to say for me as a clinician, it's interesting that we required all this research to get people not only interested, but comfortable with asking about race and ethnicity. I remember as a medical student, we had to learn how to ask about sex and sexual orientation and people's practices and what they did. But we never had to do research on that. They just said, okay, students suck it up, you're a professional, you just have to get out there and do it. In terms of race and ethnicity, we had to answer questions, is it legal? Are we able to ask these questions? How should we ask? And a lot of this work actually was done here in Chicago. What category should we use? Who should ask the question? Should it be the provider? Should it be the nurse? Should it be the frontline staff? Should we do it based upon observation? Should we have the person identify themselves? How do people react? What's the best way to respond to the reaction? And so I think this sort of research was important to do. I'm struck with the fact that we actually needed to do it in order to get someone to be able to say comfortably, what is your race and ethnicity? How would you describe yourself? And frankly, I think that that reflects our national discomfort with talking about issues about race and ethnicity. But the fact is that we've done this research. So if there's only one take home point from this particular slide that I would want you all to know is that not only is it legal to collect race and ethnicity data, it is in fact required that you collect race and ethnicity data. So for any institution that collects any sort of dollars from the federal government, and I assume that you all take Medicare here. Okay. That in fact, you need to be able to demonstrate that you do not engage in discriminatory practices. And the only way that you can do that is to collect race and ethnicity data and look at your performance in order to demonstrate that you do not engage in discriminatory practices. So this is a requirement, whether you're in education or criminal justice or in healthcare. But if you take federal dollars, then you need to essentially be able to prove that you do not discriminate. And the only way that you can do that is to have the data stratified by race and ethnicity. So if the question ever comes up, is this legal? Can we ask? The answer is not only is it legal, but it's a requirement. So what I want to show here is the importance and the lessons that can be gleaned from having data. So from a healthcare perspective, one of the first parts of the healthcare system that collected data in large numbers was Medicare. And Medicare wasn't perfect because basically, the way that they collect race and ethnicity data is that you are white, African American, or everybody else. But at least it's something. And so what this is actually is a report that was done by Ash Segal many, many years ago, but I think it's very important in terms of showing the importance of not only quality and quality improvement, but collecting race and ethnicity data. And so what they were engaged in was actually a quality improvement effort to try to improve dosage for hemodialysis for patients. And what you can see here is that at the beginning of the study, and this was an eight year study, there was a gap in terms of performance where whites were much more likely, 10% more likely to receive appropriate dose than were African Americans. And so over the course of the years through guidelines and trainings and outreach to hemodialysis centers, what you see here is that they were very slowly able to increase the overall performance in terms of hemodialysis dosage. In addition, they were able to close the gap between performance for white and African American patients from a 10% gap down to a 3% gap. And so what's important about this study is that, one, this was not a disparities intervention. This was an intervention that was designed, again, to do the right thing at the right time. And they were fortunate in that they were also able to reduce disparities. In addition, they had the data that allowed them to stratify and look at their performance for whites versus African Americans. And so they were able to determine that they, in fact, also were able to reduce disparities. But if they had not been able to stratify their performance quite conceivably, they could have seen a model like this, where in fact, they had an overall improvement in rates, but they maintained the gap. So this slide somewhat looks like the reverse of the infant mortality slide. We're seeing the trends coming down where overall infant mortality is coming down, but the differences in rates between black and white infants is staying exactly the same. It looks just like this. So again, doing the right thing at the right time has the potential to address disparities, but it is not guaranteed. And in fact, what they could have had is an outcome like this, where there was a significant improvement among their white patients and then somewhat improvement among their African American patients, but they could have in fact widened the gap and in fact, worsened disparities. And so, while I think that one of the most important tools is quality and quality improvement to be able to do the right thing at the right time, I think having data to make sure that you inform that you're not having the unintended consequence of actually worsening disparities is important. And I think that's why one needs to have the data that you can't just assume, oh, well, we're doing this work in a minority community and so people will de facto benefit and we will de facto have an impact on disparities. I think in fact, you have to really make sure that you have the data so that you get this effect rather than this effect or this effect. So having the data and then linking it to Evers to improve quality are critically, critically important. And in stage renal disease is an interesting model because economics presumably are even among all participants. Oh yeah, absolutely, absolutely. And particularly in Medicare. So that's why some of the most interesting data in the early days of disparities, it came out of Medicare not only because that's where we had data on whites and African-Americans, but it also kind of took all of the issues around economic disparities off the table. Everyone had the same healthcare coverage and yet we still saw significant disparities. So this is my plug for the home team, for Aetna. One of the things that I wanna talk about is actually we're now in our 10th year of doing work on reducing racial and ethnic disparities in terms of Aetna. And really the take home point is that back in 2001 when we first started this, the very first thing that we did is we collected race and ethnicity data of our patients. And so we currently have data on about 30, 35% of our enrollees. But based upon those data, we've then been able to roll out a number of other types of interventions, whether they're around maternal care, whether they're around hypertension, whether they're around cancer screening, but it all started with the data. And so one of the challenges that I often have is people often think about, okay, so once we have the data, what is the next step? And the fact is that the data then tell you what the next step is. The data tell you where the problems are and then you can decide within your context, whether it's a health plan or a hospital or in your clinic, then where's the next step. And so one of the things that you'll often hear in terms of the sort of the universal discussion about what we should do next in terms of health disparities is that it starts with data. But I think then once you have the data, we need to start to think very differently and get very granular in terms of how we address health disparities. I'm gonna skip over this. This is actually just a slide because one of the things that we've developed at Etna is actually we now have an internal dashboard where we look at performance on a number of chronic conditions stratified by race and ethnicity among our enrollees and it helps us to identify where we might want to target interventions. So this is actually looking at diabetes where we looked at the number of our diabetic patients who one have had a hemoglobin A1C within the last year as well as what was the level of performance, whether they were seven and below or nine and above. And not surprisingly, we found a disparity and so this actually was served as the basis for the now different interventions that we're doing. But as I said, once you have the data then it starts to tell you where you need to start to go in terms of interventions. So while data and again, even though I said I didn't wanna be a researcher, I ended up doing health services and disparities research because that I found really interesting as compared to vitamin A in the emergency room. But I think for me, the reason why data are so critically important is that without from either a clinical perspective or a public health perspective, we are then just shooting in the dark if we don't have the data. And so one of the things that we fortunately have is that through the IOM, there is a book that was released in August of 2009. Yeah? Okay. That was basically on standards for collection and reporting of race and ethnicity data. Now the reason why these standards are particularly important now is I'm sure many of you have heard about the Affordable Care Act. Well, buried within the Affordable Care Act to section 4302, which basically talks about the fact, again, that for anyone who is receiving federal dollars that you need to collect and look at your performance stratified by race and ethnicity. And actually they take it beyond race and ethnicity, they also look at gender, primary language and disability status. So they've identified five categories that they're saying are absolutely critical in terms of any performance or self-assessment which is occurring. They also talk about these must be self-reported measures and that they must comply with requirements out of the Office of Management and Budget. And so again, going back to what I was saying before, anyone who takes federal dollars in any way now needs to report their performance stratified by race and ethnicity. So the opportunity to identify disparities in everything is not only going to be for those who are interested just in disparities work and research, this is going to be everybody's job, everybody's responsibility. In addition, it talks about not only in terms of the data collection but then in the analysis and reporting because one of the things that we define is some people collect the data but they don't report the data. So they have just sitting in a data warehouse someplace. But again, that this has to be part of how the data are reported. And then more importantly, there's a lot of work coming out of the Office for the National Coordinator for Health IT on CHIT. And they have now established standards in terms of what should be required as part of the data that goes into the electronic medical record and it includes demographics, which talks about the fact that now every medical record which is now going to be certified as being in compliance needs to be able to have this capacity for us to be able to not only collect but then store these data. So I think this is huge. As we talked earlier, Medicare was the first space where we were able to look at this but now we'll be able to talk about this in terms of Medicare, Medicaid, private insurance, hospital, inpatient. Anyone who touches an electronic medical record that is in federal compliance or takes any federal dollars, so that just, so if you don't do Medicaid or Medicare then you're not part of this, has to be involved and has to be collecting the data. So I think we're actually on the precipice of really having an inundation of data that really are going to be able to tell us where disparities exist as well as where they don't exist. So, okay, we talked about root causes. We talked about identifying the disparities. Now let's talk about creating accountability. So a moment ago I was talking about the Affordable Care Act and within the Affordable Care Act there's a lot of discussions around accountable care organizations. So much so that people are now starting, I hear people making errors in calling the Affordable Care Act the Accountable Care Act but really this whole concept of accountable care organizations is really saying that these enterprises, many of which will be hospitals with affiliated health centers but they're also talking about them being large physician, multi-group specialty practices. There's actually a lot of flexibility in terms of what can be considered an ACO. But I think the thing that is very different about the ACO model as they're talking about and this is actually a question that I presented to Peter Orzak because as he first described it's like, okay, well we'll manage the care and there's gonna be a primary care provider and they will help you to negotiate where you go and things like that. And I was like, so how is this different from HMOs that we were talking about 20, 30 years ago? And Peter's answer is quite simple, that it is that function of accountability, that not only will there be a population which is assigned to these accountable care organizations but providers will then be responsible and help financially at risk for the health outcomes of those populations. So it's no longer acceptable to say, well that patient is out there, they're not part of my practice because I've never seen them. If that patient has been assigned to your practice, whether they come in or not, then yes, you are responsible for them. You're responsible for making sure that when a woman finds out that she's pregnant, she gets in for first trimester care. Or when that person has diabetes, you're responsible for making sure that they get in for the hemoglobin A1C testing. So going back to the question that I asked earlier, when we know that there's a disparity in terms of infant mortality, who's responsible? Well, I think one of the promises that exists within this ACO model is more and more people are going to be moving into it as patients, is that we will increasingly have as providers a sense of accountability and responsibility for the outcomes experienced by our patients. And so I think that this too has a real opportunity for creating a major change and shift in terms of how we approach these health outcomes. Where I think there's a risk, one of the things that we have to be particularly concerned about for communities of color, is that if communities of color, or people from communities of color, are known to have poor health outcomes, and you're basically going to be held liable for those poor health outcomes, you can make two choices. You can either choose to really take those people, work intensively with them in order to get improved outcomes, or you can say, I don't wanna take that risk and choose to not have those patients come to you. So this is something that we're going to have to really watch very carefully as the ACO model starts to evolve exactly how are patients going to then be brought into the system? And what are the criteria that we're going to be used? Is it going to be based on geography? Is it gonna be based upon type of insurance? A lot of those details have yet to be determined. So I think this question of accountability and the creation of the ACOs has the potential to either be a real boon for populations of color and population that risk, or it can also be a real detriment if people decide to essentially cherry pick their patients. And there's evidence historically that that has occurred. But again, within the construct of thinking about the patient accountability, what I wanna talk about is this concept of the patient-centered medical home. And the reality is, and this is why I say here, before there were ACOs, there was the patient-centered medical home. And part of that is because just ACOs are just now starting to emerge and develop. But one of the things that has occurred within the work that's going on in the patient-centered medical home is thinking about this as an enhanced model of primary care. And so there's now a lot of work which is going on, which is really asking the question, does this new model of enhanced primary care really deliver in terms of what the promises are for improved outcomes, improved patient experiences, as well as for reducing cost? So Dr. Chen is working on major projects, which are looking at that, particularly within the safety net. And there's a lot of interest in this model, as well as in thinking about how to sustain and drive this model. So what I want to share is some work that I did when I was at the Commonwealth Fund. We did a national survey that was adults across the United States, and essentially looked at the quality of care that they received. And one of the things that we looked at is we asked them, well, do you have indicators of a patient-centered medical home? Some of the parts of the patient-centered medical home is there has to be access, there has to be an ability for patients to come through quickly, that you have to have good IT in order to really do population-based management. And some of those are the kind of questions that you can only ask providers. And so these were a set of questions that we developed where we could ask the patients themselves. And so we basically asked just four questions. One, just do you have a regular doctor? Not is there a place that you go, but do you have a regular doctor? I wish we could have asked, do you know your doctor's name? Because I've seen that so many times where you're like, well, do you have a doctor? They go, yeah. And you're like, well, what's his or her name? They're like, they don't even know their doctor's name. So it makes me question how much of a relationship they'll have. But in addition to having a regular provider, which frankly is a relatively low bar, then we say, okay, so how easy or difficult is it to contact your provider by phone? If you have questions that you need to get answered, can you provide, not just the provider, or can you contact not just the provider, but the provider's office? Is there just someone at the other end of the phone? And then can you get care or medical advice after hours? If you wake up in the middle of the night with a right lower quadrant pain, is there someone that you can call? Or if you wake up and your baby has a fever of 102, 103, is there someone that you can call at 6 p.m., as compared to 9 a.m.? And so we asked about that. And then we tried to get a sense of if the office just functions well. And so we asked the patients then, I'm sorry, respondents, when you go to see your doctor, are usually the visits organized and running on time? Or does the practice seem chaotic? And basically, if people said, really, if people said yes to all of these questions, then we said, okay, you have indicators that where you receive your healthcare is a medical home. So looking across the bottom, what you'll see is that among whites, 28% said that they had indicators of a medical home. Among African-Americans, 34% said that they had indicators of a medical home. Among Hispanics, 15% said that they had indicators of a medical home. And among Asian-Americans, 26% said that they had indicators of a medical home. When you take it and not stratify by race and ethnicity, approximately one in four people said that they had indicators of a medical home. What's interesting about these results is there are a number of different other types of indices that have been developed to really look at prevalence of having a medical home. And on average, they have come up with about one in four people saying that they have indicators. What you will notice is that in this sample among the African-Americans, they were the group that was most likely to say that they had indicators of a medical home. And so people often ask, well, what does that mean? Where do they have access to federally qualified health centers? I don't know, so don't ask the question. This was actually one of the big conundrums because it was actually an unanticipated result that we received. But it led us to really start to then ask some other questions. Rick and I said, if you drop the running on time, you could double the number. Oh yeah, yeah, yeah. But that's a huge deal for patients. So when people are packing up a sandwich and a stack of books for their kids because they're gonna go and spend the afternoon at the doctor's office, that's like, you shouldn't need a sandwich to get through your doctor's visit. So one of the things that we said is, okay, so there are some people who have access to a medical home and some who do not. But what difference does it make? Does it really make any difference? Well, we asked a number of questions related to access, chronic disease management, prevention, a number of different questions. But this actually proved to be one of the best sort of measures that actually I would love to take credit, but cannot, it actually came from John Watson in his work and he basically asked patients to assess can you get the care you need when you need it? Very basic universal question. So the first thing I wanna point out is that in this particular sample, 55% of patients overall said that they get the care they need when they need it. So do you remember that study that I talked about earlier from Beth McGlynn that was in the New England Journal where they went and looked at medical records to say, do people get the care they need when they need it? The number that they came up with, 54%. So patients are really good reporters of the care that they're getting. In addition, what we saw is that one, the quality of care was pretty low for everybody. So I wanna be clear that when we talk about health disparities, I'm not trying to get minorities up to the same bad level of care that whites are getting. What we're trying to talk about is really improving care for everyone and making sure that minorities are getting improved care. So overall only half of people say that they get the care they need when they need it. And we saw disparities particularly experienced among Hispanics and Asians. But then what we did is stratify people who were in the medical home or we looked at people who said, yes, I have a regular provider, but they don't have all the indicators of a medical home. Or we looked at people who said, and I just don't really even have a regular provider. And so then when we asked people stratified by the presence of a medical home or not, do you get the care you need when you need it? Here's what we found. First of all, so the bars in white are people who have a medical home. And what we found is that the rates of performance doubled, not doubled, went up 50%. Where three quarters of people said, yes, they do get the care they need when they need it if they have a medical home. I also wanna point out that when you look at the total versus white African-American and Hispanic, that there were absolutely no differences by race and ethnicity in terms of people reporting they get the care they need when they need it. When we looked at people who had a regular source of care, but it didn't function as a medical home, again, no differences. That represented the majority of care that was seen. And the level of performance was not as good. And again, when we saw people who had no regular source of care or use the emergency room as their major source of care, we saw that that was the group that was least likely to report that they were able to get the care that they see that they need when they need it. And so what was striking is, so this was looking at that global question. But again, we looked at prevention, chronic disease management. Do you trust your doctor? Does your doctor communicate with you? And for every measure that we saw when we stratified by having a medical home or not, disparities were either eliminated or reduced, and the care overall was much better. So again, going back to doing the right thing at the right time. Now here we didn't control for anything. We didn't control for where people live. We didn't control for their payer source. We didn't control for income. We didn't even control for language or linguistic ability. But what we did is just a simple stratified analysis that showed when patients are in a higher performing primary care setting, they in fact report improvements in care. And so this is a study that was actually released called Closing the Divide, which you can just find online. But you'll see that when we talk about it in terms of prevention, in terms of chronic disease, in terms of all numbers of outcomes that having the patient-centered medical home was a huge step towards eliminating disparities as well as improving care. So lastly, in terms of that four-step process of talking about how do we address disparities. So first is understanding what the root causes are. Secondly is identifying the disparities. And then thirdly is really thinking about the stratification and thinking about it within the sense of quality and having a sense of accountability so that we are responsible for improving the level of performance for certain populations. And then lastly is something that I think we're not that comfortable with, but is that we have to test solutions. And I think where it's easier to talk about testing solutions is within the paradigm of how we think about quality and quality improvement. So one of the paradigms for quality improvement is the PDSA cycle, which is Plan-Do-Study Act. And I always was struck by this, because you say, okay, there's a difference where patients in this clinic complain that they have a longer waiting time. So let's do something about it, let's study it, and then let's try to improve our performance about it. Which is very different from an academic model. Well, let's study it, think about it, then develop an intervention, and then do a before and after analysis. And so the thing with classic quality improvement is that it is very data-driven. But essentially what it is, is through the PDSA cycle, there's let's do something about it, let's study it, and let's continue to try to improve our performance on this. So this is not, well, is sending people reminders the night before a better intervention than sending them a mailing system. It's not really trying to do the randomized controlled trial, it is really trying to say, we are going to continuously try to improve our performance until we get to a level that is acceptable for us. And so one of the things that you'll find as you read the medical literature is there is not a lot that's written around quality and quality improvement. And that is because this is not a framework for the randomized controlled trial. This is not a case in control, this is just keep going at it and use your data in order to determine that you are getting better. And what I would argue is that given that quality, like disparities is a very complicated issue. And that within disparities, we're focusing on community factors, we're focusing on environmental factors, we're focusing on genetic factors that really changing our thinking in terms of the PDSA cycle allows us to work on a number of multiple different interventions to try to address the outcomes. But then what's critically important is that study component, which is having the data to make sure that we're having the desired effect. So you've heard me say that disparities among Latinos is not the same as disparities among African Americans. Well, disparities in New York may not be the same as disparities in Chicago. And what is driving a disparity in one hospital on this side of town may not be the same as driving a disparity on the other side of town. So I think we have to actually get that granular that we're looking at our data and just constantly trying to improve our performance. And not only which we shouldn't be looking to address disparities by saying there's no difference within our institution. What we need to be saying is like I said, we don't want to get minorities up to the same bad level of care that whites are getting. What we want to do is think about what is the standard of care that everyone should be getting regardless of their race and ethnicity. And so really we should be benchmarking our performance against other providers or where we know are some of the best practices that are out there and really engage in this. And this is, it is not scientific and it's not gonna get you published but what it is is definitely data driven to really make sure that you're having the desired impact. And so the way that I think about this is going back them to that voltage drop which got us towards disparity is that it's probably going to take something similar and I can't think of the opposite of a voltage drop, a voltage step up to get us towards the elimination of disparities into absolute equity in healthcare. So again, in order to really get to equity we're going to have to take a multi-pronged approach. We're gonna have to look at genetics and the environment and finances and the community and access and quality and lifestyle. All of those sorts of things but then when we then apply the PDSA cycle to them we're constantly working on all of these different things. And we're not saying to ourselves, okay, well you're only working on access, that's not important because I'm working on quality or you're only working on genetics and what does that have to do because I'm working on the community. The fact is that we all have a role to play in terms of whatever it is that we're focused on in terms of really trying to adopt this model of thinking around continuous improvement but always, always having the data which drives our improvements. And I think the challenge is that disparities is now having as a field is that we were able to do these national studies and I think now in order to really get towards the absolute elimination of disparities is that we're gonna have to get down to the local level. We're gonna have to get down to the individual communities, individual providers, individual practices, individual hospitals and really engage in a continuous quality improvement effort that is again informed by data but to get us towards the level of outcomes that we're looking at. So again, root causes, know them and think about them as part of all of the things that you may want to impact or try to test in terms of a PDSA effort. Identify the disparities, have the data to be able to look at them. Take responsibility that this is not just their problem, this is not just the Department of Health problem but this is our problem that we have patients. And again, I think that the promise which exists within the real push and movement towards accountable care organizations is really going to make us much more accountable and really have a sense of ownership, assuming that we don't engage in cherry picking behavior. And lastly is to test those solutions and it is going to be an imperfect science but I think for those in the room who might be experts in working on quality improvement, we know that it is an imperfect science and I think that we need to get comfortable with that imperfection as people who are in an academic environment but we need to be able to be comfortable with that and really apply that level of comfort with what is kind of a little bit dirty and not the pristine randomized control trial but really be able to apply to health equity. So just very quickly in closing, I just want to spend a little bit of time talking about the Aetna Foundation. So as you heard, I was at the Commonwealth Fund and then essentially my charge was to move to Aetna which is actually a corporate foundation but is to make it a national and strategic foundation which is focused on issues in health and healthcare. So I was actually really pleased and happy to jump at the chance because I often describe it as my chairman gave me a blank slate and a blank check so I could like make this foundation into whatever it is that I want. And so I've now been there for a year and a half and we've been working very hard. One of the first things that we did is really rethought our mission statement. So historically we were doing a lot of work which is what I call traditional philanthropy which is what I call the big check ribbon cutting kind of stuff which makes us feel good and it's charitable giving but what I'm starting to talk to my staff about is no, we're about improving health and healthcare. We are about philanthropy and the difference between philanthropy and charitable giving is that with philanthropy this really is about social investment. And so one of the questions that we ask when we look at grants that come to us is not what is the impact of our grants but what is the impact once our grants go away. Once the funding is gone, what is the sustained impact and outcome which is going to be there because we don't wanna just come in and support a program and then it disappears after our funding goes away. And so I often use the terms and maybe that's cause I'm in a business environment but I think about this as social investment and what is the return on the investment and how are we going to make fundamental changes and improvements in terms of health and healthcare. The other thing is that we narrowed our focus in terms of health issues and so we're focusing specifically on three areas. So one is on obesity for all of the reasons that you saw in the slides before. It is going to bankrupt us as a nation. As a pediatrician I know and I'm sure you all have heard the stats this is the first generation that has a lower life expectancy than the previous generation because of issues of obesity. And where we're very specifically targeted and focused on is root causes and understanding why is it as a nation are we dealing with this problem anyway? And so while simplistically it could be about more calories in than calories out but I know that I grew up eating my fair share of ring dings and watching Gilligan's Island and so I'm not convinced that there's that much more junk food or that there's that much more screen time. That may be the case. But I think the fact is is that in certain communities it is no longer safe for children to go outside. You can no longer buy fresh fruits and vegetables. I think that really thinking about some of the policies which subsidize certain types of foods as compared to others. I think particularly looking at low income communities and what is the price per calorie of say broccoli as compared to price per calorie of other types of food that it makes logical sense particularly for low income people to buy food and be able to fill all the bellies that they're responsible for with a lot fewer dollars. And so I think we need to really think some of our food policies as well as built environment policies that are really driving some of this. And so, and what's quite striking is that the rate of rise of obesity in this country has been so rapid and so profound. So we're very interested in the built environment and as well as in health policies and food policies and what's driving that. In terms of racial and ethnic equity and care, there is a particular focus that we have at the foundation in terms of infant mortality. And I'm actually particularly interested in the role of stress, particularly interested in the stress experienced by African American women. And what role does that play in terms of health outcomes for themselves as well as then for their children. In addition, we're interested in doing some work around breastfeeding promotion because African American women are one of the groups that's least likely to nurse their children. And yet there's been some data actually that came out of Canada that said when you actually take the differences in low birth weight off the table and you can do this through regression modeling that the single biggest sort of easily intervened upon difference in terms of infant mortality is breastfeeding rates. And so if we could get African American women to breastfeed at the same rates or even more so than other groups, we can make a huge, very inexpensive intervention to actually save babies' lives. In addition, in terms of racial and ethnic equity in healthcare, what we're interested in is thinking about doing the right thing at the right time for the right population for communities of color. And so thinking about how do we create clinical excellence for communities of color as basically the first and fundamental first step towards trying to promote equity. And then lastly, in terms of integrated healthcare, this is the one that I often have the biggest problem described because people are like, well, what do you mean and what is it that you're focused on? And just this weekend, Tom DelBanco in JAMA two days ago had a case study of someone who basically got lost in the sauce, someone had a renal mass and radiology knew about it, but they didn't send the notice back to their primary care provider and then the surgeon picked it up because he happened to be looking at him for a back problem. And so this is a patient who had a renal mass, fortunately, that was benign, but that went undetected for six months because although the radiologists knew about it, there was not good care coordination among the providers. And so we're particularly focused on this issue of care coordination, thinking about standards for care coordination as well as creating measures for care coordination and identifying models. And so just in a little bit more detail, in terms of thinking about integrated healthcare, one of the things that we're working on at the foundation is really developing the same type of language that we all should use. And so integrated care is not just about administrative integration, it's also about clinical integration. It's also about financial integration. And so really thinking about it systematically, so when we see integrated care, which I think is part of the discussion, which is now emerging around accountable care organizations, how do you really see, is it just about IT or is it about the doctors know each other? Is it about everyone has essentially some skin in the game financially? And so we're working to identify and talk about that. And then a big part of also that our work in terms of care coordination is that from our perspective, it starts with a high performing primary care provider. And that at the center of all of the work that we're doing around care coordination, one leg of that coordinated care has to be with primary care. And so the way that I think about it is the primary care provider ideally should be at the center of all this going on for a patient, whether it's imaging studies or pharmacy or laboratory or whatever, but it really is the primary care provider. And so this has been very helpful to us because we sometimes will get studies that are looking to say physician to nurse sign off within the hospital or inpatient to long-term care facilities. And I think one of the reasons why people are doing those kind of studies, particularly in hospitals, because that's where the patients are, that's where the researchers are, but I think from the perspective of what's really going to help reduce waste in terms of health and healthcare is around this coordination, which occurs around the primary care provider. So we're looking for work around really, what are some of the best models that are out there to coordinate care. And then what I hope is evident is that we have these three program areas of obesity, equity, and integrated care. And what we're particularly interested in is not having programs that are, one is over here, the other's over here, but is that we're really looking at the intersection of the three of them. So it's quite obvious that there is an intersection between obesity and health equity. And what we're also interested in is then the intersection between health equity and integrated care. Thinking about integrated care has one ability to provide high quality healthcare, particularly to communities of color. And so this is really the model that we think about and talk about in terms of our different projects that we have these three programs, but we're particularly interested in and we're particularly interested in the overlap across the three. So I'm going to actually skip over this because this is just some examples of the types of projects that we're interested in within the context of health equity, but basically you can get this off of our webpage, which is listed there as etnafoundation.org. And with that, I'll thank you for your time and attention and I'll open it up for questions. The floor is open for a number of questions. I noticed in your reasons for disparities, the two that you focused on were access and quality, but your interest in obesity and infant mortality goes beyond the healthcare arena, which kind of brings home to my concern in heart failure that patients' priorities are different from my priorities. And the disconnect has a lot more to do with the disparities in education, economics, social safety. So I wondered if you'd care to comment on that. I don't remember if you talked about this, but early in my career, one of the first jobs I had was actually I was doing homeless health in New York City. And I worked with this program where we went out on mobile medical units to different shelters around the city. At the time, there was major crack epidemic going on in the city and so there were huge disruptions to families that were really making people become homeless. And I have to say to me, that was a real humbling experience when I wanted to talk to these young mothers who were in the shelter system about, say, developmental issues or reading to their kids or even being able to give medicine for an ear infection. And the mother was like, well, if you give me a Moxacillin, I can't refrigerate it, because I don't have a refrigerator. And as part of one of the advantages of having the mobile units is that we actually took this truck and pulled up in front of the shelter and there were 11 shelters that we service across the city. And we often did room visits for babies who were particularly sick. And to see where those people were living and to see the conditions under which they were living, just really brought home to me how low on their list of priorities health and health care can be. I would imagine that if a kid had otitis media but didn't cry all night that we would see even fewer mothers coming in because they had so many other things that they were trying to figure out and deal with within the shelter system. So now obviously that's a real extreme in terms of what can impact people's lives. But I know that even for myself, I don't define myself as a patient. I just don't until I absolutely have to. And I think the vast majority of us don't define ourselves as patients until we absolutely have to. And I think that the people in this room, we have other things that allow us to focus on health and wellness because we're not worried about keeping the lights on. We're not worried about the strife in our family. We're not worried about domestic violence in our household. And so I have to say, while it can be very frustrating with patients, I'm actually very humbled when I think about what drives people in terms of their thinking and impacts their lives and what can, in fact, where health does this fall on that. So I would say to really try to think through what might be some of the other factors that are going on because I think it does, it really gets it into perspective that we become a lot less frustrated. And sometimes, again, after doing site visits to my patients, I was actually impressed that the parents were trying to do what they could do given everything else that was going on. Hi, I'm Arshaa Vaig. Thank you so much for coming today. I'm a community-based researcher and a general internist, so I do primary care as well. And I guess my question is probably broader. When you talk about the PDSA cycle, and you're saying in quality improvement, we try to do things. Well, I guess my question is a little, what do you think the role is of academia then? Because I guess me being community-based researcher, I work in Mexican neighborhoods here in Chicago regarding diabetes at that granular level. So how can people in this community use their resources to improve their diabetes? Because there are Latino people who have great diabetes care in the same community. So I'm bringing those people together to understand, but at the same time, then there's this pressure of academia to put up papers and research. So I guess, how as a foundation do you see academia addressing health disparities, or what's their role? Yeah, that was actually the conversation that we had over lunch. I think that academia needs to have essentially a conversation with itself that asks about its relevance. And I think that part of this dialogue which needs to occur is starting to occur in some places where people are changing some of the criteria by which we determine who's going to be promoted, who becomes assistant associate, full professor. And I think increasingly, particularly as we get into this era of accountability, that in many ways, academic centers are ideally situated to become ACOs because they have the infrastructure that's there. It would have the data to be able to look at their performance, but they haven't had that accountability in terms of patient outcomes. And so I think, let's assume that academic places are filled with smart people. Once they figure out that, okay, we are responsible for a certain population, a certain catchment area, then it's not gonna be a huge leap to then say, okay, in terms of our performance, because they're real dollars on the table from the feds in particular, that are helping to really help us to drive towards improved outcomes for patients. So I think that academic institutions will be able to engage in that process. I think then the next question is, is then what role could academic institutions play in terms of leading that process? And I do think that that actually has to be an internal conversation. And in fact, would be a question that I would pose. Like you can be one of the pack or you can differentiate yourselves and how are you gonna do that? So I think that has yet to be determined. I wanna thank Dr. Gila enormously for taking the time to come visit us here in Chicago and for the remarkable work that you've started to do in the last year and a half at the Etna Foundation. It's really a delight to meet you and to host you here for this short session. Thank you very much. Thank you for having me. Thanks for having me.