'ZIP-Code Risk' in Healthcare Needs Attention, Experts Say

Kerry Dooley Young

June 14, 2019

WASHINGTON — Ditch the phrase "social determinants of healthcare" and start talking about "ZIP-code risk" to speed government efforts to bring needed support to people living in or near poverty, a former Arkansas surgeon general advises.

Joseph W. Thompson, MD, MPH, speaking at a meeting of the Alliance for Health Policy held here on Tuesday, advocated the use of simple language when clinicians seek to persuade policy makers to address economic woes that can affect people's health.

The term "ZIP-code risk" makes it easier for lawmakers to understand how a person's lack of money can undermine even strong commitments by people to lead healthy lifestyles and thus try to avoid disease, Thompson said.

It gives them a way to visualize the message from the growing streams of data about connections between low income and poor health, he said at the meeting, which focused on social determinants in healthcare.

"The ZIP code within which you live should not have as much of an effect on your longevity and the quality of your life as it does today," Thompson, who served as the surgeon general of Arkansas under Republican and Democrat governors, told Medscape Medical News.

The Tuesday meeting featured policy experts who hashed out ideas for approaches for helping people regarding such factors as diet, transportation, and finding childcare to attend medical appointments. The Alliance plans a September briefing for congressional staff on concerns regarding these kinds of social determinants of health.

For many years, policy officials have considered how to retool health programs to address patients' needs outside of clinics and hospitals. The Trump administration, for instance, in April announced a plan for 2020 to allow insurer-run Medicare Advantage plans to offer a broader range of supplemental benefits that, although not directly related to medical care, may help people better manage their chronic illnesses. For example, Medicare Advantage plans may be able to offer help with carpet cleaning to reduce irritants that otherwise would trigger asthma attacks.

The "Root Cause"

It's long been known that people with lower incomes often struggle to pay for basic needs of daily life, as well as the costs of medical care. What's bringing greater interest to this issue now is the increased financial bite that healthcare is having on US spending, said Jamo Rubin, MD, MBA, who is founder and chief executive of TAVHealth, at the Alliance's Tuesday event.

Recent elections have centered on the costs of healthcare for consumers. Medicaid is among the biggest expenses for all state budgets, according to Rubin.

The "root cause" of increased interest in social determinants "is the fact that we are running out of money and we need to do something about it," he said.

On the federal level, Congress has in the past decade sought to peg some Medicare pay to results for patients covered by the program, an approach lawmakers have hoped would restrain the growing cost of healthcare for senior citizens. Readmission penalties, for example, have given hospitals a financial incentive to consider more deeply the challenges patients face when they return home after surgeries and stays for serious conditions.

Often, communities already have a network of organizations that can aid people who would struggle to pay for food, medicine, and other basic needs, Rubin said.

But this information all too often is kept and disseminated in informal ways, in contrast to the more detailed, deliberate approach used to gather medical statistics, he added.

"There is no place in an electronic medical record to put the kinds of things that social workers walk into homes and see. 'She's got nine cats and she's lonely.' Where do I put that? What do I do with that data?" Rubin said.

The response of his firm, TAVHealth, was to develop cloud-based collaboration software that helps coordinate the delivery of social services.

On the company's website, Rubin describes his previous frustration as a physician with the scattershot approach to addressing needs beyond immediate medical care.

In San Antonio, Texas, where he practiced and where TAVHealth is based, there are hundreds of "amazing community organizations to help patients in need. Yet, finding these services for patients required clinicians to make calls and keep tabs of offerings in Excel charts and on sticky notes," he said.

Rubin pressed for a shift toward immediate action to address patients' needs beyond the clinic instead of more abstract research in this field.

"When someone doesn't have money to pay for their medications, that's simple data, and it's actionable," Rubin said. "If we can solve that, we don't need a 2-year retrospective double-blind study to know" why a patient did not comply with a physician's direction to take a certain drug.

"Vulnerable Populations"

Shantanu Agrawal, MD, president and chief executive of the nonprofit organization, the National Quality Forum, observed the frequent disconnect between the people who design policies to address social determinants and those most in need of this help.

"We are not at risk for those things. The folks in this room don't represent the populations that are most vulnerable," Agrawal told the audience at the Alliance's meeting. "Generally, the most vulnerable populations are not part of the discussion."

Agrawal recalled an incident from his medical training that made that lesson clear to him. He was required to ride in an ambulance in Philadelphia, Pennsylvania, with the emergency services team. The ambulance brought him to the home of a patient whom he had encountered as a "frequent flyer" in the emergency department, where she was often seen, owing to her congestive heart failure.

"You knew every time you saw her, she was going to be in decompensated heart failure and was going to be admitted," he said.

The ambulance ride took Agrawal to the patienet's home. It was a hot day, and Agrawal found that the patient lived in a rundown home that did not have air conditioning.

"Every single window was open, and she was sitting in front of a table fan in order to just try to keep cool," he recalled.

That visit made clear to him the value of understanding how patients live, Agrawal said. He came away with great empathy for the challenges this woman faced after seeing how they impeded attempts to manage her heart condition.

"I would not view her the same way when I saw her in the ER again," Agrawal recalled.

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