Paula Lantz: Population health disparities - History, tensions, and new policy directions

      Hello everybody. Good evening! I'm Susan Collins, the Edward M. Gramlich collegiate professor of public policy and the former dean of the Gerald R. Ford School of Public Policy here at the University of Michigan. And I am just absolutely delighted to welcome all of you to our very special event this evening. It really is a great pleasure for us to be hosting the inaugural James B. Hudak Professor of Health Policy Lecture, which is soon to be delivered by Paula Lantz who is our very first Hudak Professor of Health Policy. 
      But before we get started, I do want to mention that Michael Barr, dean of the Ford school, very much wishes he could have been here with us this evening to lead this wonderful celebration and offer both his gratitude and his congratulations. The Hudak Professorship was established in March with an endowed gift from James B. Hudak, who I will say a bit more about in a moment but I have to say upfront is an MPP alum of the Ford school, a really important claim to fame. [APPLAUSE] 
      And his very generous gift supports a faculty member whose research explores health policy issues and aims to address problems in the U.S. healthcare system. Jim recently retired from a highly successful career in healthcare where he saw firsthand the need for rigorous research-driven evidence in health policy. Most recently he served as CEO and Chairman of Paradigm, a market leader in managing catastrophic and complex cases for worker's compensation. Using data and evidence-based approaches, Paradigm achieved vastly superior outcomes and also was able to accomplish over40% cost reductions, which is really very impressive and the combined work and the implications of that legacy are something that are really something to be very proud of. 
      Jim has also been a very generous and long-term supporter and I must say a tireless advocate for the Ford School, giving to faculty research, as well as student support, including "We Listen" which some of you may know about. It's a student group that facilities dialogue across the political spectrum. And he served as the chair of our Ford School Committee for over 20 years, and I can say firsthand how wonderful it was to work with him in furthering the school's mission. His insights, his dedication were really just both a pleasure and made such an impact in a variety of different ways. So, we thank you Jim for your continued generosity, for your vision, for supporting health policy research, and for ensuring that we are able to continue educating future generations of leaders in health policy. Please join me in thanking Jim B Hudak. [APPLAUSE]
      Well tonight, we have the pleasure of hearing from Professor Paula Lantz. In addition to serving as the Ford School's associate dean for academic affairs, she holds a joint appointment as Professor of Health Management and Policy in the School of Public Health. And now, of course she is the James B. Hudak Professor of Health Policy. In recognition of her extremely influential scholarship and policy engagement, Paula is an elected member of both the National Academy of Social Insurance, and the National Associate of Medicine. She is also an esteemed colleague, a fabulous teacher, and a great friend. There isn't much happening at Ford School that Paula hasn't had a positive influence on in a variety of different ways. It really is an honor for me personally to be introducing her to you here today. 
      Paula's lecture this evening will explore tensions between social policy and healthcare approaches to reducing inequities in health in the United States population. It's a very important topic, and I know that we are in for a real treat. So, please join me in welcoming Paula Lantz to the podium. [APPLAUSE]
      Paula: Thank you. Thank you so much. Hello. Thank you all for coming today. Those of you in the room, and those of you online streaming in with us. I want to start first by also expressing my incredible gratitude to Mr. Hudak for his very generous gift for the Ford School and I feel privileged and honored to be the first recipient of it. Jim's vision for this gift was to help the Ford School create leaders who will use evidence to bring to some of the issues we have in our healthcare system and healthy policy. Are any of you aware we have issues with healthcare in the United States? [LAUGHTER]
      So Jim's vision is that by bringing this gift to the Ford School, it will help improve the impact that the Ford School might have bringing evidence to health policy, and improve health and healthcare in the United States, and again I'm honored to be the first recipient of the gift, and I don't want to let you down. I appreciate your trust in me. And it's not only in me, some of the gift that Jim has given the school goes to some student support and so I've been able to hire fabulous students. Wendy Hawkins is in the room and she helped do some research to prepare for this talk, and is Tory here? I have another student working with me on a whole other project. So thank you for that. I don't know how many of you have had the opportunity to stand in front of a group like this that -- and I lecture all the time to big groups of people but this is very different, I have family here. [LAUGHTER] 
      Thank you for all your support and patience. And I have some dear dear friends in the room, people that have been friends of mine for well over two decades. You know who you are. And colleagues, mentors, collaborators, Ford School alumni, members of the Ford School Committee, and so many people in the room who I owe a debt of gratitude to and I'm pleased to work with all the time. 
      Special shout-outs to a couple of groups. First of all the Ford School staff who work very hard to put on an event like this. But also it's a privilege to work with them day in and day out on everything we do at the Ford School. I don't think you'll find a better group of staff anywhere. And also the students. It's the privilege of my life to be hanging around with you and maybe teaching you once in awhile, but learning from you day in and day out. It's just really a pleasure and an honor to be -- to have the job -- I have a really good job, I'm really happy about it. So -- I've already lost my clicker. No I didn't, it's right here. I'm not that nervous. Really. I have my clicker. 
      Alright. So shall we begin? I do have a lot of slides to get through. So I'm going to be talking about population health, and first I want to define what that is. What do people like me mean when we talk about population health, and as we move through the talk I'll explain to you that there is a new version, a new definition for population health and it will become clear to you very soon that it's irritating to me. [LAUGHTER]
      Population health is decades long field of both scientific inquiry and both public health practice. And when we talk about population health what we're really thinking about is within populations there are health outcomes and distributions of those health outcomes. And those distributions are according to things like gender, and race, and ethnicity, and socioeconomic status, and where people live. We know health varies and is distributed unevenly in populations with those things. How do we get there? How do we have distributions within population? Well the things that determine health are also patterned by all these things. They have their own sets of distribution. So, determinants of health or pattern, and that leads to distributions and disparities and inequities over here, and the reason 
      I've been very drawn to public policy through my whole career is because it's policies and interventions at the individual community and societal levels that first of all, have these things be patterned in the first place, but also that's a way to intervene and maybe try to change those patterns – those determinants and how they're patterned so we can change the distributions within populations. 
      And just again, an orientation at the beginning. Health, what do I mean by health? I really subscribe in the World Health Organization's definition of health which is which is a state of complete physical, mental, and social well-being. It's not merely the absence of disease or infirmity, and the World Health Organization states, and I wholeheartedly agree with this, that attaining a high standard of health is one of the fundamentally rights of every human being without distinction of race, religion, political belief, economic, or social condition. And again that's why I do the work I to and I'm drawn to public policy. 
      I could give a whole talk talking about differences. There are differenced in health and different groups and different populations, and just sort of describe them and try to understand them. But I fundamentally think they're unjust. I fundamentally think that disparities and inequalities in health are differences that are avoidable, unjust, and against shared social values and so all the work that I do is really motivate by this ideal and no society has ever achieved it, but the ideal of health equity. That we shouldn't have differences inequities, disparities in health due to factors that are avoidable, unjust, or contrary to shared social values. 
      So we'll do a little history to get started. So here's a nice chart going back to 1500's in terms of life expectancy, and you know you can see that life expectancy is best as can be measured back many, many centuries ago, sort of bounced around, but really starting in the 1800s, and into the 20thcentury really populations on the planet started enjoying longer life spans. You know and sort of what happening here: famine, and pestilence. As social epidemiologists and demographers like me study. 
      So, there is a lot of – so population health science, again it's been around a long time, engages in activity like trying to understand what caused this increase in life expectancy that was observed at different points in time for sure and with different patterns and different populations, and the model that is used to understand and explain this is called the epidemiological transition, where you have in a population a period of time with high mortality and very high fertility, but things are kind of bouncing up and down in terms of both of those rates, and again pestilence and famine are really having an affect. But then what usually happens first is the death rate goes down, in populations, and the birth rate typically going down follows a little bit later. And here most of the reasons that people die are from infectious disease or starvation. And the epidemiological transition. So again first the death rate goes down, then the birth rate goes down, and what becomes the more leading causes of death are things like chronic disease, injury, other sorts of things we would now say human-made diseases. And then but both the birth rate and death rate go down and in the post-transition period you have low mortality, typically low fertility rates, and then very little but -- infection can occur, infectious diseases can occur but it's sort of bumpy. Not going to explain all these graphs. The point here is that the epidemmia logic transition has happened in different points in time, with different patterns, and many different countries. Why is that? So people have studied that and one thing that has been long recognized in the epidemiological transition and looking at any kind of distribution of health in populations is that it's social factors that are really the driving cause of any sort of distribution you're seeing. 
      We can go back to 1790, and even before that, a famous physician in Germany was writing about the people’s misery, the mother of diseases. So understanding that diseases caused by poverty of the people and by the lack of all goods of life are exceedingly numerous. There has actually been studies that were done, lots of graduate students were set out to measure the height of gravestones allover the UK, and what else is on gravestones besides their height? Name, and length of life. So birth, and death. There is an extremely high correlation in these older graveyards in the height of the gravestones in the length of someone’s life because the height of the gravestone really represented that person's social status. So a bigger gravestone more real estate on the gravestone was more of an indicator of social status. People had this visual within graveyards representation of that, more wealth means a longer life, but also could see this everywhere in society. 
      Really with the industrial revolution and in France and England where population health science really got a foothold as a science and it was really through observations of what was happening with the industrial revolution, about 1760, and everyone understands what happened with that. Lots of people moved from the countryside into cities. There were more jobs for people, but the conditions in which people were living were incredible. They were polluted water, and air, and squalid, and crowded housing conditions and work conditions themselves were very unsafe for most people. So there was what we know from studies of health through the industrial revolution is that it disrupted notions of health in lots of different ways. 
      First of all it was sort of where the birth of the science of population health came, and then realizations that you know economic development and industrialization were associated with the epidemiological transition in England and France. It fueled decreasing mortality for some people, and decreasing fertility, but it also created even larger disparities in health and welfare, there were all kind of new suffering among the lower class. Moving into the cities and living in these conditions. 
      And also it was the time, really the first time in writing where there was this normative realization that if better help -- so the health of the upper class got better with the industrial revolution, and in some ways got worse or just differently worse for lower classes but there was a realization that if better health is more achievable for the upper class than it is and should be achievable for everyone. So that also gave rise over the next several decades through the -- this did not happen overnight. Throughout 1700s into the 1800s,there was a lot of mobilization, and advocacy outcry from people about somebody has to make our conditions better. And there were appeals to capitalistic to do that, and more appeals to government to do something in terms of water, sewer, air, food, sanitation. 
      So here's where we see the beginning of public investments in public health infrastructure. And these are the things that really drove then the full epidemiological transition and we know that from looking at many other countries. The investments in public health infrastructure and also housing quality and safety, work quality and safety, environment, transportation, all these things mattered greatly for health and countries are not going to go through this population health transition unless these investments are made. 
      We also know education is very important for population health, especially the education of women. And last point on this very busy slide is that social factors were clearly important to everyone, and this proceeds any understanding other than a very rudimentary understanding of germ theory. Path o physiology of antibiotics. Back in the day people understood that water in the river in London is pretty nasty. People get sick after they drink it. Maybe there is something in it we shouldn't drink it. But people didn't understand what cholera was for a while later. But they understood something was wrong there.  
      So how are we doing now in the U.S.? This is a very busy chart, it may be hard to see of life expectancy in a number of countries and here is the U.S. and here is many, many other countries who have longer life expectancy than we do. So in the U.S. right now the overall life expectancy is 78.6years. Average life expectancy is 81.1for women, sorry guys it's 76.5for men. That gender difference is observed in any country. It's smaller in countries where there is very high rates of maternal mortality associated with childbirth and pregnancy and other reproductive issues. But we do not look so great compared to other countries. 
      So also we know -- but life expectancy, again here is the patterns within the population varies greatly by racial status in the United States. Look at that difference. Was that for men and women together? I guess, yeah. So that's a huge difference. Actually if all of cancer and heart disease were wiped out that would increase life expectancy in the U.S. by less than 5 years. So that difference is -- it’s tremendous. This figure is of infant mortality rates, trends, we could go back many many more decades on that. But the trend over 100 years in the United States is at the African American infant mortality rate has been twice that of the white rate. Even if infant mortality rates go down that disparity has stayed the same. 
      Again back to life expectancy, it varies within place. Darker colors here represent longer life expectancy, so it varies all over the United States. Even in smaller geographic areas we see huge differences, but here you see the place in Michigan that has the longest life expectancy is -- where we are right now, Ann Arbor. The place with the lowest life expectancy is Battle Creek. So the thing I want to point out is here's the highest and lowest in the state state of Louisiana. The motor area is close to the lowest in Michigan. And again, that's a map of New York; you can see the same thing. And importantly I'm sure many of you know that life expectancy in the United States has gone down. In the last two years, that’s almost unheard of in a developed western country. 
      Just to make sure everyone understands do you all know what life expectancy is? It’s an artificial simulated statistic. Life expectancy is what you would expect if a baby was born today and went through its life experiencing the age-specific death rates we have right now, that’s how long that baby would live. So if a baby born today experienced the rate of death we have in every group that would be the life expectancy. 
      So in the United States life expectancy has gone down for the past two years, there are three causes of death that have been rising and that are contributing to this. One is Alzheimer’s. But that's a small part of it. The biggest part of it is the increasing mortality rate from drug overdose in the United States. I'm sure you're all aware of what’s been going on with that and suicide has been going up as well. In both cases it's gone up for men more than women. So the decline in life expectancy in the U.S. is being driven by a decline in life expectancy among men not really for women. 
      I could tell a story about breast cancer. I've done a lot of work on racial disparities in breast cancer. So we have interesting trends going on there. Here's a graph with homicide, everybody knows homicide rates vary by age, and also by race and ethnicity in the United States. Smoking prevalence is going down in every group, but it's really patterned by education so the group with less than a high school, so rates have been going down over the past few years, but this rate is much higher than college grads. So patterned by in this case education, but it's also patterned by gender, and race and ethnicity. I could show you more slides, I could just -- be dogged with my point that sort of any health topic we want to talk about. Any disease, any health issue is going to be patterned by social class, and by race, ethnicity, gender, place it goes on and on. 
      I have been -- so fortunately in my career I have done a lot of research in this space. Earlier in my career I was fortunate to work with Jim House who is in the back who took me on as a post-doc to the University of Michigan, and let me hang around with him and let me analyze data from a longitudinal study he started called "Americans changing lives" study, so we've done a lot of research looking at nation population based study over time -- followed over time to learn about trajectories in health and better understand how is people's income level and their education level and where they live, how does that influence their health over their life course. So we did a lot of work related to that. One of the things we did that I want to point out here quickly is that so in population health there is a concept called compression of morbidity. Who has heard of that? A few people. So compression of morbidity is this idea it's really how we all want to live. We all want to live a long life, and have any sort of ill health or a decline in our health be compressed into the last little bit of our life. Or actually maybe what we want to do is live a long life, and on this axis this is the having no physical health limitations, this is 25-95 in age. We want to go along in our life having no physical limitations until one day -- is that how you want to go. [LAUGHTER] 
      So that's good. That's called -- the morbidity that comes with aging is compressed into the last bit of life. That doesn't really happen for anyone, but this graph shows based on data from the American’s changing lives study that you can actually see that it varies greatly by education level. So the top line here is the trajectory for people in the highest education level and the groups who followed over time, and they're kind of an approaching compression of morbidity. People in the highest education group are living -- this is age not having functional limitations to their health here that the lowest education group is experiencing really by age. That's a 20-year age difference in that measure of health. There is other metrics of health. 
      So again, we know that this ideal of compression and morbidity, it looks like there is -- it's possible to get closer to that but it depends in this case on your education level. And also from a lot of work we’ve done and many other people have done there is this notion that’s emerged over the last 20years very strongly of those things that pattern health, the kind of shorthand for that is called the social determinants of health. All the things that matter, besides our Janette bus, those matter, no one is saying it doesn’t matter. All these social factors that have really complex and intricate and synergistic ways they impact health. Economic stability, there are many things under that. Education, food, neighborhood environments, community and social context and healthcare matters as well. Healthcare is important. 
      But now here is where I start making people not so happy. That doesn't seem to matter in a developed -- we're past the epidemiological transition but even so, healthcare doesn't seem to matter as much as these other things. And when we're thinking about the social determinants of health we really think about them on multiple levels.  So here we are, we're individuals and we're talking about health so at some point we have to think how does that get under our skin. How do all these social things translate and get into our bodies and create functional limitations, morbidity, mortality all of that. So at some point we do talk about health at the individual level. But all these things matter at these other levels as well. There is interpersonal interactions with other people, institutional, what happens in our schools churched, worksites that matters as well. Community level factors and then policy is driving all of this. So at the highest level of the model there is policy. There have been a lot of people and still people now trying to figure out well what proportion of this kind of determinant --this kind of determinant what proportion is it in terms of determining health. I think this is a fool’s exercise. 
      It matters what kind of health outcome you're talking about in the first place, and I don’t think -- it doesn't matter to me that -- a lot of people think healthcare has been undervalues in this. Clinical care 10%; healthcare produces 10% of health. This one has 10% here, this one brought it up to 20%. To me it doesn't matter it’s that all these things are important, and the important thing is that we put way too much emphasis on healthcare in this country. We think too much that healthcare is the way to address health problems. I know all of you, many of you have seen this slide, way too many times, per capita spending on health in different countries and life expectancy, here's the U.S. We spend so much more on healthcare that any other country than any other country, way more than any other country. We is are such an outlier on it. Would you care if we actually had better population health outcomes? Maybe you wouldn't care so much, but it's those two things combined. All the slides I just showed you about the problems we have and where we fit in the rest of the world so we spend all this on healthcare but we don't have any -- we don't have high life expectancy, we have higher rates of infant mortality, and any health issue we look at we don’t score well on it. 
      So, that's an important finding from population health research. And it's been a very consistent finding. In 2007 the institute for healthcare improvement came forward with this model called the triple-aim. Basically it was really a very thoughtful approach, saying look we need to do something about this. We can't be this outlier, we’re spending more and more and not getting the results we want. So the triple-aim says we need to lower our healthcare costs, but we can't do that at the expense of the quality of care that people are doing -- are getting and we can't do that at the expense of health and the population. So the triple-aim is three really hard things. It's lower cost, improved quality and improved health outcomes, population health outcomes and that's the phrase that’s been used on the triple-aim, population health improvement. That led with the triple-aim coming forward with that and policy change to incentivize insurance plans, especially our big public insurance plans, Medicare and Medicaid, to really think about this and try to achieve the triple-aim this new field called population health management emerged. 
      And just -- can I just remind you population health has been around for a long time. But now we have this new animal called population health management coming out of the triple-aim but again was really focusing on you know reducing cost costs, improving quality, and improving outcomes. So, in the triple-aim notion of population health the focus here is on patient populations. Or populations of people who share a health insurer, they’re in the same health plan. We're looking at patient populations and they're outcomes while attempting to control for cost. And the idea here too is something that Jim likes very much. We're knowing to use data analytics. We're going to use all the information we have about patients, and use data to drive interventions and try again to control cost without reducing quality and getting better outcomes for it. They're also in the population health management movement is are cognition of the social determinants of health. That's there. That's what we're mostly going to talk about. 
      And also there is a recognition about well population health management probably should have some partnerships with public health and community resources, if it wants to try to address some of these social factors that influence health. So, in the past -- hard to know, I would say probably in the past seven or eight years, the number -- right now we think at least 70 universities have a college, a department, or a degree program in population health management, population health, or population medicine. All these words are sort of used. I would say probably 80% of those are in the past 7 or so years. This is a new movement. Within health systems, many now have population health management units or activities. There is new journal, new professional conferences, professional Associations, executive education, and there is also a lot of money to be made in population health management. 
      There is all kinds of new business products, data analytics and consulting opportunities, here’s a quick graph of predictions of the population health management market size looking at both software that's being sold to people to manage the data on their patient populations but also services and interventions. This is in the billions of dollars. So this is growing very, very fast. There are all kinds of new companies, and business opportunities and software and services in the business of population health. So is this a good thing or a bad thing? And I think in general, there are some really good things about this movement towards population health within the healthcare system. But I have three reasons that I’m really worried about this that I'm going to try to get through pretty quickly. 
      All right. So the first one is what sociologists refer to as medicalization. Who has heard that term before? Right. So, realization is this has been around for a long time, concerns that personal, behavioral, social issues are viewed through a biomedical lens which emphasizes that the problem lies within individuals rather than social pathology, and that it’s clinicians and healthcare providers who have the authority for the diagnosis and treatment of it. Let me give you a few examples. So menopause, which is something that every woman who has the privilege of living to a certain age will likely go through, has been referred to as estrogen deficiency disorder. 
      So that's sort of -- people say that’s a medicalization of a normal aging process, and right now, it's much lower rate right now. But right now anyone want to guess how many women are on hormone replacement therapy in the United States? What percent? It’s 44%. It used to be like 70-75%. A medicalization of an aging process. Obesity is that a disease? I’m looking at my public health friend Barbara, she's like no, it is not. But obesity has become very medicalized, and when it's medicalized many people think is the way to deal with the problem of obesity, it's individual diagnosis, and individual level treatment rather than thinking about all the things in our environment that have contribute to this. And quickly, this one is really interesting to me. Attention deficit-hyperactivity disorder has been going up. The rates have been going up very much. It's going up more in school environments that are very resource-constrained, and also a study just came out showing that in school districts with a September 1st cut-off date. 
      So for all of those who take program evaluation. This is a cool regression continuity design. What the researchers did was look at kids born right before the September cut off date, and kids born after, and the kids born right after had to wait a year to go to school. So comparing those kids the rates of ADHD diagnosis are higher in the younger kids because they get in school and have behavioral -- people are worried that ADHD, no one is saying it's not a real thing. But ADHD diagnosis is the medicalization of issues dealing with behavioral problems in school settings. All right. So last December I wrote a little essay, a thousand words, on the medicalization of population health who will stay upstream in the millbank quarterly which has been getting me a lot of love, and also some not love. [LAUGHTER]
      I don't want to say hate, that’s too strong. But in this piece I argue that population health which again has been around for quite awhile, and it's my thing, right, it’s my field. Population health is being usurped by something -- as something to be defined and managed by the healthcare system. And it includes the believe that population health a new thing and you can read it all the time, and you probably won't get as irritated as me. But population health this is a relatively new term that has not been precisely defined. The term population health first emerged in 2003 after two doctors defined it. It's a new concept that emerge would a triple-A model. Of course that's not true, but the idea here is that it's a new sort of thing. Yes, it's irritating to me in terms of my field but I’m worried about it for so many other reasons. 
      First of all, I think it’s ignoring what is a good and rich history of over 200 years of research and policy regarding the social determinants of health and health disparities. I also worry about it for what I refer to as denominator shrinkage, population health when I think about it, and do research on it. The population is everybody in asocial, political, geographic sort of space. Population health management the denominator, the population is people who are simply sharing a health plan or a healthcare institution probably for a pretty short period of time. So to me, it's a much more narrow group of people we’re caring about. And people are going to be going in and out of those populations. And also it's a part of a long history of conflation and it’s due to the medicalization of thinking about health in this country. 
      We can't -- we have a hard time thinking about health without thinking about healthcare. But they're not the same thing. And health disparities are not the same thing as healthcare access quality outcome disparities. Health equity isn't the same as healthcare equity. Also, and lets get ready for all the debates going on. They're going on right now, but what are we going to do --sometimes the phrase what are we going to do about health in the United States, or what are we going to do about healthcare. What is all anyone's talking about? Health insurance. So health insurance is not healthcare, and it's certainly not health policy. So this is a bigger pattern. So, now, here we go. Population health has now become medicalized and conflated with population health management and the social determinants of health are being conflated with patient social needs. What the healthcare is calling the social determinants of health is actually really individual level needs with inpatients. And I worry about that for a lot of reasons and we can talk more about that in the Q & A if you want. I think if Mr. -- resources in so many important ways. So I'm also worried about this because the efforts that the healthcare system is engaging in right now in the space of social determinants of health and population health management are very much what we call downstream, they're really aimed at the individual level. 
      And so what's happening primarily in the space is that patients with identified social issues are -- they're being identified and being referred to community partners who are already so underfunded and exhausted and their safety net is full but the healthcare system is now going to identify more of these needs and you live this day-to-day. Right? Pushes them out to the community. There is a report that just came out last month from the national academy of science, engineering, and medicine called "integrating social care into the delivery of healthcare moving up upstream to improve our nation's health.” The to achieve better outcomes for the nation and address major challenges facing the U.S. healthcare system:  That sounds great; it's not going to work. All the research and evidence we have suggests that this -- this promise is an overpromise. It's not going to work. 
      Let's take a moment and talk a bit about this phenomenon that’s happening, so the best estimate are that 25% of healthcare delivery systems in the United States are screening their patients for social determinants of health. And maybe some of you have had this experience as well. I saw a tweet about a year ago from a physician that said, "I screen my patients because some of them have social determinants of health." L.A. [LAUGHTER], and it's like we all do, we all have social determinants of health. What is really going on is screening patients for social needs. 
      Sam, you're here, right? Samantha? The great fortunate of working with Samantha Ivan for several years and we're working on this and it's okay, I'm telling them, Sam started -- went to the doctor and started filling this out, and she's like I'm being screened for social determinants of health, and so this is Sam’s maybe we're violating HIPPA rules now, I don't know. Anyway, it's things like --things that you can see on here. In the past year have you had a hard time paying your utility company bills, yes or no, and Sam nicely just doesn't have that problem so she says no. So, from the time I started worrying about this and looking at it, maybe four or five years ago, at that time there were three screening tools out there, and now there are dozens and dozens and they all say they’re validated which all that means is they're measuring people’s social needs. 
      So, that's okay but what are some of the things being looked at? Here are the domains that are being promoted in this area of screening patients for social determinants of health. Food and security, utility needs, transportation, employment, social isolation and support, housing instability, financial resource strain, etc., etc. Not all -- not all clinicians don’t like this. It's taking their time. They're not sure what to do with that information. They're usually not the one to have to deal with the information. Now some physicians like it because they say -- better aids me in understanding the social context of my patient and I might do a better job thinking about why aren't you taking your medicine, well what are the other things going on in your life, etc., so this information could help a clinician in clinical care, but that's not why the data is being collect, generally. 
      It's being collected because the healthcare system thinks it’s going to do something about it. So there are lots of pros and cons with this. And again on the pro-side, clinicians understanding the social situations and contexts of their patients is good. But on the con side there are a lot of things to be worried about. A long list here -- I'll unpack a couple of them in a second. I do worry too that busy untrained clinicians, people filling out this form, and then what’s going to happen? You fill out this thing, you turn it in, and then usually nothing is going to happen. That's just going to exacerbate mistrust, frustration, and you know that is not go.  Good. We have issues especially with communities of color trusting healthcare providers and systems. 
      It's also -- medicalizing social factors, again conflating social determinants of health with social needs. So, I actually get out of here once in a while so I go around and talk to people about this, and I know there are several health systems in the University of Michigan. Primary care settings have screened for social determinants of health, but this is being used for more data collection. We want to better describe our patient population and to that I will say okay, but do patients know that? Do they know what going to be done with the data, and are you creating unfulfilled expectations, and exacerbate the mistrust frustration. In a lot of places these screening tools are being used to then think about interventions. I have a master's degree in preventative medicine and epidemiology and I had to take a lot of classes on screening. And screening 101 tells you don’t screen people for something unless Dr. Free, d. So don't screen -- there is no point in screening anyone for anything unless then you think you can do some kind of intervention for it. So, again, what is being done? I’m going to move ahead here. 
      So there is fundamentally again, when the screening happens it’s identifying this lowest level, and it's important but at the individual level of patient need. It's not addressing the cascade and social ecological model of things that are driving those needs within people, but within neighborhoods and communities, etc. And you know, improving education, access and reducing student debt is -- that's asocial determinant of health, trying to address that, versus interventions that focus on patients’ health literacy. Screening patients for trouble, pain for their prescriptions and utility bills, again that might be important if you can do something about it, but that is not addressing the social determinant of health, which is - it's poverty and income security that's driving those problems in the first place. And that leads me to be worried about well what is happening out there in terms of interventions? And I am worried about a lot of them going on. 
      So let me tell you about some work we did recently. Population health management, a really common thing that’s happening is the data are being used to identify the super utilizers or the highest users of healthcare. And then from there, those highest users, and that could be defined -- we did a study looking at interventions, frustrating the super utilizers of emergency departments. That's really expensive for people to show up there. So who are the highest users defined, sometimes as people who have 40 or more trips to the emergency department in one year. Or maybe it's 20 or it's the people in the top 5% of the distribution, whatever. So Samantha, who is here, led our team doing a systematic review of 44 published studies of interventions, trying to identify first of all, the super utilizers, and then intervening with them. And the most common model was intervention was a case management model where these people have complex medical needs that need to be managed but they also have social needs and we'll connect them with social services within the community. What do you think we found? 
      There is a lot of buzz about these interventions. They work. I have been -- I can't tell you to how many meetings I've been to where a health system has done this kind of work and not published it. They say we looked at our super utilizers; we gave them an intervention and the next year their rate were way down. It works. Well, in our systematic lit review we found the studies, this again for those of you, this is why we make you take program evaluation. The studies that actually had a comparison group or a controlled group found the same level of decline. So it turns out if you take the people at the tail -- the end of a distribution if you take the highest users of healthcare, the next year they're going to look better just -- it's regression to the mean. It's a regression to the mean problem. So that was disappointing. It's disappointing to all the people out there who are doing these kinds of interventions. So now -- I made you all sad. What works -- I'm Debbie downer, there is so much sadness going on. Can you tell I like dogs? I don't have a dog. I want a dog. [LAUGHTER] 
      Okay. So, what's going on out in the world. There are lots of positive sorts of interventions going on, and I want to get to some Q and A so I’m going to have to go through this pretty quickly, but something called the medical legal partnership is interesting. And al Freda is here; I don’t have time to talk about Michigan medicine, and -- is here too. I have had the privilege of working with people in Michigan medicine and really in an innovative way to use community benefit dollars. So all non-profit hospitals have to show the IRS in order to have their tax exempt status that they’re investing in things that are to the benefit of the community, and is the University of Michigan is doing innovate work in that regard and pushing money out to the community letting the community define what they want to do, explicitly addressing the social determinants of health. They're applying for money for intervention work to address the social determinants of health, and it's very exciting. And actually there are some health systems that are investing in housing. Both housing first interventions, which are -- which is a model of providing housing for the chronically homeless or people at risk for it. 
      But actually there are some health systems that are investing in just building up the number of affordable housing units within their communities. There is a really big project going on in Baltimore, and also United healthcare, is investing in 80 different communities across the country to provide more affordable housing for the community whether or not those people get their healthcare from them. So at this point in the talk recently I've been invited to talk to a lot of people within healthcare systems. I gave a keynote at the Cleveland clinic a couple of months ago, and there were a lot of people in white coats sitting in the audience. And you know what that means. So by this point in my talk I gave a different talk there, but they were like this --[LAUGHTER] 
      And so, here's the point where I say to my healthcare provider friends, to my healthcare system friends don't get defensive about this. Because there is so many challenges for the healthcare system to be upstream. It's not a Congressman --criticism to say this is going to be challenging. It's not the primary manipulation or responsibility of the healthcare system. There's a lack of expertise, and fundamentally this is ability public policy it is policy that is driving the things that create health advantages over our life course. It is policy that is driving the things that create health disadvantages over our life course. And also who is going to pay for all this stuff that needs to be done? 
      So again, everyone says community benefit money. Well, that only goes so far. It's a place to start. So, there are conversations within Medicaid for actually paying for some non-medical interventions. Right now Medicaid is very constrained to pay for anything other than Medicare. But what is Medicaid could pay for housing? Those kinds of things. And also, there are some interesting private partnerships and again I've been doing work in the space with Samantha looking at the possible of social impact bonds or what’s also referred to as a "pay for success" model for doing this kind of intervention. 
      So here's my picture of Sedona. Maybe it's more for me to center. I'm going to wrap up and we have a little time for questions. So good news, I think here is that population management and other healthcare system efforts have brought some new attention and action on the social determinants of health on patients social needs and health equity. I am delighted that these conversations are going on within the healthcare system. That is the good news. However, I am really worried that because it's what our healthcare lens does that this has medicalized the notion of social determinants of health and narrowed and stored population health efforts towards this downstream path that is going to be probably good at identifying patient’s social needs but it's not heading anywhere in the direction of the upper levels of change that are needed, and I put this here -- I'm not the only person saying this there is a big report that just came out.
       What are some of the responses to the arguments that I and other people are making, I’ve heard these all, and all of these in the last few weeks. But it's better than nothing. I'm actually not sure about that. Paula, don't let perfect be enemy of the good. At least the healthcare system is trying to address social factors. The one I hear the most is like -- you are going to anger the beast that has all the money. The healthcare system has all the money, and you are going to make them mad, and they are going to say we care about social determinants of health and now you're complaining about that? We will just go walk away. But also people ask me are you telling clinicians to stay in their lane? And to that I want to say emphatically, I am not. I am not telling my very good friends and colleagues and collaborators who care about healthcare policy and work within the healthcare system to stay in your lane. What I am saying however is let's get in the right lane, and to me the right lane is not downstream or now I'm going to make. 
      How many of you like to hike? I'm crazy about -- I like dogs and I love hiking. So, downstream population health management activities are doing a nice job of grooming easy trails. But they're not leading up to --I didn't take this picture hiking. This is not the kind of hiking I do. But they're not leading up that mountain. They're not leading up to the hard places where we need to do the hard stuff, and that's where public policy comes in. Social policy reform is the only thing that's going to help us address the social determinants of health and achieve health equity in this country, and number one, if we don't do anything about systemic racism, and institutional discrimination we will never have racial health equity ever. That is the underlying history and still current driving force behind that. We need investments in all of these things. 
      Now I will just say -- I have loved being in and working in schools of public health for the majority of my career, I'm nowhere at the Ford school, and the reason I'm at the Ford school is because I feel like I needed to learn more about all these kinds of social policy from some of the best experts in the world. They're here at the Ford school on education policy, on poverty prevention; did I see Luke in here? He was here? He's busy preventing poverty. Criminal justice reform, so health equity razor a very broad policy approach. Social welfare policy is health policy all these kinds of policy are health policy, and yes, healthcare policy is health policy as well, but it’s downstream, and if we don't do anything about all this we’re still -- it's still putting a Band-Aid on it, and we'll have all this investment in population health and have no better population health outcomes. That's my worry. That's my passion, and that’s what I do. Thank you so much for coming today. [APPLAUSE]
      We do have some time for questions. Yes and I should have said at the beginning, first of all thank you so much. Please because we're being live streamed, please wait for a microphone before you ask your question, and we would appreciate it if you would identify yourself first. So again we would love a couple of questions. 
      So Paula, one other things. By the way, great lecture and great way to look at the healthcare system or the health policy system, let's put it that way. You mentioned health insurance companies having worked at onetime for United health, you didn’t mention was the pharmaceutical companies and when you take the medicalization of a condition, then there is a pill for it. How much do you think the pharmaceutical companies and their lobbying are driving some of this medicalization and --and/or why didn't you mention them as well as health insurance, just curious. 
      Paula: I think it's easy to pick on the pharmaceutical companies because I think that’s is driving the medicalization. But let me give you a quick example where -- I actually think medicalization can be good sometimes too. So actually it was the medicalization of nicotine addiction. Actually calling it nick o teen addiction syndrome and giving it a code that gave pharmaceutical companies the notion that well, then if it's a diagnosis, then it made them invest in nicotine replacement therapy. So what we know now about the best ways for people who are addicted to nicotine to quit smoking is with nicotine replacement therapy, and companies were reluctant to invest in that unless they knew that insurance companies would pay for it, and that they could recoup -- it costs a lot of money to develop a drug, etc. So the medicalization of nicotine addiction syndrome is thought to have set out a whole course that helps create these products and has led to a lot of smoking cessation, so it's not always bad. But that's all I want to say about the pharmaceutical companies until we chat later. [LAUGHTER]
      Hi. I'm Chris. She used to be my mentor. My long-term mentor now. My question is kind of living around -- I think we all agree that this is true. This lovely little slide up here. But how do we start to move the needle in that direction and I don’t mean just conversations, but now we have majority of Americans for example that feel that the Democratic party is too left-leaning. Which -- if we're going to address all these things we need to be radical, and not radical in an extreme sense but we need new ideas. But how do we create a culture where everyone buys into this and that our goal as a society is this:  And this is something I struggle with in my work as well. 
      Paula: You know I do as well. That is the million-dollar question. I don't know how to make everyone else care about the same some things I do in the same way. But again one of the reasons I'm worried about the healthcare system getting so much in this game is because I think all the attention and resources is going to be down here, and then it's going to --a lot of people -- we've seen this time and time again it absolves policy from doing other stuff. The healthcare system is taking care of social needs and health. So we don't really need all this stuff, we'll just sort of punt it to them. I don't know. I have -- again I give a lot of talks and I give a lot of talks or go to a lot of conferences where there is a lot of clinicians there, and every talk I have seen recently has started with a photo of a patient and sort of a story of an individual patient. Meet my patient, Mrs. So and so, I just saw this in Cleveland a few weeks ago. She is housing insecure, she has mental health issues, she is socially isolated her family lives away from her, just list social determinant -- social need after social need making the case for why we should care about Mrs. X. And we all know our community --our communication friends or media friends tell us you have to have stories or the anecdote that’s what is going to make policy-makers care. I don't think they care. And actually -- and I know I’m not like everyone else but I always wonder why don’t statistics move people? [LAUGHTER] 
      So -- but I'm serious. My son is going mom -- here are some statistics. One out of five children in this country live in poverty. Right now, over 40% of African American children are living in persuasive -- poverty. I have a bunch. The state of Oklahoma, over 1manschool districts have moved to four day school weeks because Medicaid has taken over so much the state budget they can't fund their public education system anymore. They can't afford to run buses five days a week so they've gone to four-day school weeks. This is happening in Colorado, Idaho, Montana, should I go on? So again I don't know why people this isn't a big red flag. Here, I'm going to give you one more. There is no community in the United States in which someone making minimum wage can afford a two-bedroom apartment. There is no community in the United States where a single mom working minimum wage could afford an apartment without some help with more than one bedroom. These are crisis statistics tome, and so the fact -- I don’t know -- Christopher -- we’re going to have to get together for a drink again at the last word -- but yeah. 
      Do you have a microphone? Could you say more about social impact bonds and how you ideally would organize them at a local level to make them work to deal with some of these upstream issues? 
      Paula: We have so many papers on this. I didn't have time to talk about it, but so yeah, my colleague Samantha and I really do believe. This is not a magic bullet, so social impact bonds are when a private investor puts up the money for an intervention and if it provides some value to the public sector, the government, they will pay back the private investor. But they'll only pay back the private investor if a set of outcomes that's been predetermined have been achieved. So it's actually this is -- you know the really second topic of performance-based contracting in which private, again a private investor would put up money public-sector finds it a value and then will pay back the private investor. Most of the private investor doing this is non-profit so they’re really not out to make money. So we think there is a lot of promise in this area, and where we’ve seen the best results are in supportive housing interventions, really interesting projects going on in the U.S. Using this model to support early childhood education and pre-kindergarten education is another area. And then, also we have a paper on -- we did a simulation model in destroy where if we use this model to have the private investor money improve the housing stock and reduce as many triggers, and if you combine that can medical case management, because that's important. That could reduce hospitalizations in emergency departments and that would pay for it. But there are all kinds of legal and regulatory constraints on that. So I'm happy to follow-up with you. But we see with new federal law that was passed last year, supra funding we see the door opening for Medicaid to get into the social impact bonds space. 
      Hi I'm Mitch. I'm on the school committee, and an alum of the Ford school. Great talk Paula, thank you. Assuming we wanted to move in the direction that you suggest, which makes great sense, and we were looking for funds and you talk about statistics we hear a lot about end of life costs and the massive disproportion. How does culture, religion, the medical system all those things -- I love to hear your thoughts on that since it appears to be a large amount of money with statistically minimal pay-off. 
      Paula: So one of the differences in the United States versus other countries is a culture around healthcare. And it's -- it's kind of weird because we pay for it in really different ways than other places that have universal health insurance systems, but in the U.S. we tend to -- people have done studies suggesting that a lot of people in the U.S. feel that when care is denied, and it's not so much to themselves but to their loved ones, especially at end-of-life care, if you're going to tell – I have a 90-year-old mother. We talk about this a lot-she’s like I don't want a lot of stuff at the end of my life. 
      It's like write this down because -- you know it's hard for people who love other people to say don't -- you know withhold the care, don't do everything you can. We know that compression of morbidity slide I put up there before. We know in the U.S. that except for the last few years where life expectancy went down, people are living longer. We have an aging population, and we know people are living a longer period of their life with chronic conditions and lots of healthcare needs. But our culture is not one where we want to -- I don't know how many of you want to deprive yourself of Medicare? So I don't know there has been lots of interventions that’s been tried around that, and none of them have worked really well. And I have no magic bullet myself. But if we can't crack that nut, it's going to be hard. But, I know -- and I don't mean to sound naive when I say this, but, again, I am really focused on -- if we can get people to the later stages of life in better health that would be good. It may or may not save healthcare costs, I don't know. But it potentially could. 
      So unfortunately this is the last question. I'm only doing this since no one else came in. I'm David Forey with the Ford School committee. And I really have two things; I’ll just do the first one first. Because there is a story but the second one I have a question about Medicaid, and Medicare, and Oklahoma, and Colorado. I'm both public administration graduate of the program as well as social work and some of the things you're talking about inters of social needs and meeting social needs hit me, oh, yeah, that's what helped form social work as a profession in the early part of the century. Number of the leaders said somebody has to get out and drain the ditch. If we have cholera, it can’t just be the patient, and in my own hometown of Richmond, Virginia, current hometown, the visiting nurses or community nurses have spun off from the medical college of Virginia around the turn of the century, Well except in the medical field and going outside the hospital. But when they got into the homes social needs and they couldn’t do their medical practice of which they had are a fair amount of leeway when they left the hospital and went into the homes. I think it helped preserve the development of community nursing and the visiting nurse’s Association for a good longtime. They began to draw in people who had an interest in doing social work type things, related to the family and the community. If it meant housing or draining the ditch, and a number of the nurses moved into doing the social work part because they found that more rewarding than the medical part. Then they ended up sharing settlement homes, interesting history. Wonderful. And social work benefited from that. It's wonderful. But what I really wanted to ask you about because I've seen this in action in Virginia a good number of years ago with the legislature, and I'm not sure I understood you and which program you were referring to in terms of the state budget eating up --Medicaid that's what I thought. 
      Paula: Medicate. That always sets me off, honestly, it is such an easy excuse for legislators to say well we can't because the federal mandates or demand, and you all in your districts we know you want these services, and be paid for, etc., and then we add on today those states that are now more and more turning to funding when they didn't go along the first time in terms of increasing Medicaid etc., and it's a frustrating thing. But when I heard you say that I said well, yes, but do we let them get away with it. Yes, we do, but how do we not do that, so I'll leave that as a question. Thank you. Paula: I don't know. It's hard. I will say that Medicaid now takes up probably at least 40% of every state budget, and that’s high. That's really -- it does crowd out other things. Nobody, even I think the most left-leaning Democrat wants to keep raising taxes and taxes to pay for this. So, Medicaid is a problem in public administration and public finance and trying to find ways to do other things. I agree in Oklahoma if they wanted to fund public schools they probably would find a way to do it. But that's the excuse being made. Medicaid has crowded out so much of our budget we can't give local school districts any more money than we are. I'm sorry, we're out of time, thank you so much for coming today. Thank you. [APPLAUSE]
      Thank you all for coming and joining us and I hope you will join us for refreshments out in the hall.