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December 3, 2019
State Health Policy Leadership Delivery System Reform Population Health
Christopher F. Koller, President
Back to President’s Blog: The View from Here
Maria was giving shots after church.
She stood up and announced it and then set up a table in the corner of the hall. You could walk up, roll up your sleeve, fill out a form, and she would stick you. And you would have your flu vaccination for the year.
A few folks wandered over holding their post-service coffees. This was the warm-up act. Maria was hanging around all morning, and after the Spanish-language mass, the crowd would probably be larger.
Maria is not a freelancing public health crusader. A nurse case manager and a member of the parish, she had been hired by the local hospital as part of a series of on-site flu immunization clinics. The clinics are a feature of an important statewide public health effort, but they also demonstrate the complex and conflicting roles hospitals play in our health care delivery system.
Rhode Island — Maria’s home state — is pretty good at immunizations. The state buys vaccinations in bulk at discounted rates (assessing insurers for the costs) and distributes them free of charge to providers like Maria’s hospital.
The hospital was sponsoring the clinics — 15 in all over two months — as flu season started up. Although the hospital can bill for Maria’s administration of the vaccine, she was not collecting insurance information since the supplies were paid for. If everything worked exactly right, the documentation from the clinics will make it into the state-administered immunization registry and back to patient’s primary care doctor and into the patient’s medical record.
The clinics are mostly held in lower-income communities, so the hospital was also tracking who was vaccinated to document, for the state department of health and the Internal Revenue Service, the “community benefit” it was providing. To maintain its non-profit status and state licensure, the hospital must conduct a community health needs assessment, implement a plan to respond to those needs, and report on the dollar value of its responses. The clinics check a lot of those boxes.
As a result of the efforts of the state and health care providers, the Centers for Disease Control and Prevention estimated Rhode Island’s adult flu immunization rate for the 2017–2018 season was the fifth highest among the states. But at only 44 percent, there was plenty of room for improvement and Maria’s clinic was aimed at reaching more people.
On the one hand, Maria’s hospital is getting “woke.” An understanding of the effects of a person’s social characteristics — income, education, employment, housing, and relationships — on their health is finally seeping into the US health care delivery system. There is an explosion of literature (and expensive conferences) on these social determinants of health, fueled in part by broader discussions about the societal impact of increasing wealth disparities in the country. Confronted with this research and conversation, health care providers feel compelled to respond.
Seen from this perspective, Maria’s hospital is fulfilling the call to action in the National Academy of Medicine’s (NAM) recent report, Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health. Health care providers, the NAM committee said, should be humble in responding to the social needs of the populations they serve by becoming more aware of what those needs are and adjusting their existing services to accommodate those needs. As they do this in internal work, they can better assist patients in connecting to services in the community, aligning their own services with the community and advocating for public policy changes.
In running community immunization clinics, you could argue that Maria’s hospital is adjusting its services by reducing barriers to needed services.
However, the work of preventing illness and injury is fundamentally different from the work of treating them. In fact, prevention is against most hospitals’ financial interests. A former state director of health and colleague of mine would darkly point out that when hospitals are paid for each service, a “bad flu season” for a hospital may be one where fewer people are infected.
What indeed is the work of a hospital? We think of inpatient care as hospitals’ core business, but outpatient services now comprise more than half of the revenues for most — services that are invariably less expensive individually in freestanding settings.
But there is pressure for hospitals to expand their services. Hospital emergency rooms and awaiting-discharge lists are crowded with people experiencing the consequences of unmet social needs. The hospital is also told it must deliver community benefits to justify its existence. Moreover, other entities in the community know the health care delivery system is where the money is — and they hit up the hospital to finance prevention or social services. Finally, health care systems are also full of do-ers and do-gooders who do not suffer from a lack of self-confidence about their ability to fix things.
Facing demands to do more for more people, the guidance of the NAM report is helpful for hospitals: listen to the community; change your own services; learn to collaborate, not dominate. But expert guidance is no match for political, economic, and cultural pressures that encourage service expansion and organizational consolidation, even if these have not been shown to improve health or lower costs.
So what can counter these pressures? Payment methods that align hospitals’ financial incentives with better heath and lower costs are critical. The NAM report points out that paying for the care of populations rather than individual services, as Vermont and Maryland do, is essential. Also, even if demand for health care services doesn’t follow the rules of well-functioning markets, having some choice of providers keeps costs lower. Organizational governance and leadership that is representative of the community being served, as is required in Oregon’s Coordinated Care Organizations, which must include consumer representatives in their governance, can help, too. Finally, we need public policy that promotes these actions and others — like discouraging hospital consolidation, increasing financial transparency, and investing in a strong, primary care-based delivery system. With this framework, hospitals will be aligned to work with their communities and the services available there.
But change is hard, resistance is great, and patient needs are real. In the meantime, Maria is happy to make a few extra dollars and help out fellow church members who might otherwise get the flu. She will let others figure out what makes for a bad flu season for the hospital.
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