Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

Suicide: More Common Than Ever

A Rice University classmate and friend of mine – a 57 year old woman and mother of two – committed suicide on Easter Sunday. She was going through a divorce, but many of her college friends had been in contact with her one way or another in the weeks (and even the day) before she died. She seemed strong, resilient. Defiant, even. None of us saw it coming. Maybe we should have.

The suicide in 2018 of 55 year old fashion designer Kate Spade captured our collective attention, because here was a wildly successful woman who, by outward appearances, appeared to have everything going for her. Yet according to her husband she suffered from depression and anxiety (others report bipolar disorder) for years. Even so, her death came as a surprise.

Suicide in middle-aged women is on the rise. Kate Spade is not the only celebrity woman to kill herself. Actress Margot Kidder, film producer Jill Messick, model L’Wren Scott, and Mary Richardson Kennedy, estranged wife of Robert F. Kennedy, Jr., have committed suicide in recent years. In fact, the suicide rate among middle age women (age 45-64) has jumped by an astounding sixty percent since 2000. The increase for women is more than double the increase for men. No one knows why.

Mental illness, substance abuse, loneliness and financial and relationship problems have all been linked to rising suicide rates. In a 2018 Wall Street Journal article, psychiatrist Samantha Boardman is quoted, saying “Life satisfaction hits an all-time low in middle age,” and, “Depression and stress are particularly high in this age group. Juggling responsibilities and managing multiple roles takes a toll and can lead to feeling overwhelmed, a loss of control and despair.” But why are people less able to cope today?

Of course, with any one suicide you don’t always know the reason(s). Did the person leave a note? (My friend didn’t, but in retrospect, some of her communications signaled a finality.) Was the suicide planned, or was it an accident? (My friend’s appears intentional.) And as the recent uptick in suicides after the Netflix series 13 Reasons Why is reported to demonstrate, suicide may be suggestible. For the survivors, questions are inevitable and often unanswerable. (Support groups are available for suicide loss survivors and can be of great benefit.)

According to the National Institute of Mental Health (NIMH), there are multiple risk factors for suicide, and interventions and treatment will of necessity vary depending on individual circumstances. Medical therapies are most appropriate when the risk of suicide is related to underlying depression, anxiety or other mental illness. As much as we are a society that likes to medicate our problems away, medication is only a part of the solution for some, but not all, patients at risk for suicide. There is no magic bullet – or pill – for suicide prevention.

Psychiatrist Amy Barnhorst, writing in the New York Times, warned that suicide prevention is often difficult because family members rarely know someone they love is about to attempt suicide. Often that person doesn’t know herself. She advocated “tried-and-true” strategies for working with people at risk of suicide, like limiting access to what she called “lethal tools” (drugs and firearms primarily) and working as a society to improve access to resources like alcohol and drug treatment and individual therapy. “Antidepressants can’t supply employment or affordable housing, repair relationships with family members or bring on sobriety,” she wrote.

Knowing how to gauge how overwhelmed a person is, or the point beyond which there is no return, is hardly a scientific enterprise. And yet we must try, individually, as family, and as a society. Lots of people think about suicide, as it turns out (I did, as a teen). Thankfully, most never act on those thoughts (I didn’t). Common teaching is that if we think someone is depressed, we should talk to them specifically about their emotions, not judgmentally or dismissively, and even ask if they are thinking of hurting or killing themselves. That can open the door to getting professional help.

But data are conflicting about how open people are with their feelings and intentions. One study said nearly eighty percent of suicide victims deny suicidal thoughts before killing themselves. Others say that one-half to two-thirds of people who attempt suicide express thoughts about committing suicide, even if only one-third of those ever make an attempt. How do we identify and screen for those at risk for suicide? We must be willing to have an open conversation on multiple levels. Patricia Todd, a licensed professional counselor and mental health advocate who is herself the mother of a suicide victim, believes that we have a moral obligation to educate the minds and hearts of those around us about all things mental health. Only then can we begin to eradicate the debilitating stigma that is too often attached to suicide.

Our primary care providers (PCPs) are on the front line of mental health care in this country. Reportedly, three-quarters of those who commit suicide have been seen by a primary care provider in the year prior to their suicide. One might conclude that our PCPs would know patients the best and could screen patients for suicide risk. Knowing how busy PCPs are – and how little face time they have with each patient they see – it is unrealistic to expect that mental health screening questions be a routine part of every visit or intake history and physical exam on every patient. Indeed, the US Preventive Services Task Force (USPSTF), an independent panel of experts that makes evidence-based recommendations about clinical preventive services, looked into this and concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. Nonetheless, all physicians should be willing and ready to dig deeper when patients express feelings of depression, despair, and hopelessness.

Facebook, after all, is looking. Businessinsider.com reported that Facebook has been monitoring users’ posts since 2017 for warning signs that they might be at risk of suicide, and has even sent emergency responders to users’ houses more than 3,500 times. Who knew? And based on what criteria? My friend who committed suicide was a regular Facebook poster, and Facebook apparently didn’t tag her as being at risk.

Radiologists and researchers in Pittsburgh believe they have found a way to distinguish between individuals with and without suicidal thoughts with a brain imaging technique known as functional MRI (fMRI). Even if this proves to be accurate, this is hardly a practical or cost-efficient method to screen people. It is a provocative idea nonetheless. It makes sense that suicidal brains think differently.

The bottom line is we cannot – yet – rely on computer algorithms or brain scans to identify those at risk of committing suicide. Until we have a better understanding as to why more people are killing themselves – and how to identify those at risk – every one of us must be vigilant.

What can you do? First, know what to look for. NIMH warns that suicidal thoughts or actions are a sign of extreme distress, not a harmless bid for attention, and should not be ignored. The Centers for Disease Control and Prevention (CDC) lists twelve suicide warning signs: feeling like a burden; being isolated; increased anxiety; feeling trapped or in unbearable pain; increased substance use; looking for a way to access lethal means; increased anger or rage; extreme mood swings; expressing hopelessness; sleeping too little or too much; talking or posting about wanting to die; making plans for suicide. The National Alliance on Mental Illness (NAMI) urges that any person exhibiting these behaviors should get care immediately: putting their affairs in order and giving away their possessions; saying goodbye to friends and family; mood shifts from despair to calm; planning, possibly by looking around to buy, steal or borrow the tools they need to complete suicide, such as a firearm or prescription medication.

Communities are starting to put together Crisis Intervention Team (CIT) programs, working with law enforcement, mental health experts and community and religious leaders to respond more effectively to those experiencing a mental health crisis. Communities that don't have this type of formal program should get one started.

If you know someone exhibiting these warning signs, take action. The CDC lists five simple steps to help someone at risk: 1.Ask; 2.Keep them safe; 3.Be there; 4.Help them connect; 5.Follow up. If you or someone you know is in crisis, call the toll-free National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255), 24 hours a day, 7 days a week. Another option is to chat online with someone at www.suicidepreventionlifeline.org. These services are free and confidential.

Dental Health is Community Health

We need to return to adding fluoride to our water supply.

The Centers for Disease Control and Prevention (CDC) states that fluoridation of community water supplies is one of the ten great public health achievements of the 20th century in the United States. It ranks up there with vaccinations and control of infectious diseases. According to the CDC, fluoridation of drinking water, which began in 1945 and now reaches three out of four Americans, is both safe and inexpensive. The benefit? Reductions in tooth decay (40%-70% in children) and of tooth loss in adults (40%-60%).

Fluoridation of the water supply is race-blind and socioeconomic status-blind. It benefits children and adults regardless of access to dental care. According to dental association reports, on an individual basis, the lifetime cost of fluoridation is less than the cost of one dental filling. For communities, every $1 invested in water fluoridation saves $38 in dental treatment costs. This is a straightforward example of the benefit of public health.

The Texas Department of State Health Services runs the Texas Fluoridation Program (TFP) specifically to improve the health of Texans by preventing tooth decay through community water fluoridation. TFP assists public water systems in the engineering design, installation, and maintenance of water fluoridation systems; monitors the adjusted fluoride level in the drinking water; and maintains the US Centers for Disease Control and Prevention (CDC) fluoridation database for the State of Texas. The Texas DSHS notes that community water fluoridation is recommended by nearly all public health, medical, and dental organizations. The US Department of Health and Human Services’ Community Preventive Services Task Force completed its most recent review of community water fluoridation in April 2013; it recommended water fluoridation based on strong evidence of effectiveness in reducing tooth decay across population groups.

This is also an equity issue. A dental public health publication concluded that water fluoridation is the most effective and practical method for reducing the gap in decay rates between low-income and upper-income Americans. The Hispanic Dental Association has called fluoridation a valuable tool in the reduction of oral health disparities. Another public health paper noted that school performance is indirectly affected by fluoridation because children with poor dental health are nearly three times more likely to miss school and are four times more likely to earn lower grades.

Most water has some fluoride, but usually not enough to prevent cavities. The City of Lufkin 2017 Annual Water Quality Report – the most recent available online – states the fluoride level at the time was 0.722 ppm. The City of Lufkin website, on their FAQ page, continues to state that they add fluoride “at a constant concentration of 1 part per million gallons” and that it is added “as a deterrent to tooth decay.” But according to the CDC, the City of Lufkin’s water system, which supplies a population of more than 42,000 (not just Lufkin, mind you!), now has a fluoride concentration of 0.3, below what is recommended.

I confirmed with our City Manager, Keith Wright, that the City of Lufkin stopped fluoridating water last year. The rationale was that people get fluoride in many ways now, and it seemed unnecessary. In addition, there was concern about conflicting reports of health effects.

Chronic fluoride toxicity is usually caused by excessive fluoride concentrations in drinking water or the use of fluoride supplements. With controlled, measured fluoridation, there is minimal risk with significant public health benefit. A New England Journal of Medicine Journal Watch commentary noted that there may even be an added benefit for older women by increasing bone mineral density with less risk of hip fracture. As for fluoride from other sources, I love the way the Texas Oral Health Coalition, Inc. puts it: “Community water fluoridation and brushing with fluoride toothpaste complement each other, like seat belts and air bags in automobiles. Both work individually, but together they provide even better protection.”

The US Public Health Service’s recommendation for the optimal level of fluoride in community water systems is a ratio of fluoride to water calibrated at 0.7 parts per million. They reached this number after years of scientifically rigorous analysis of the amount of fluoride people receive from all sources, not just fluoridation of the water supply.

What about cost? The Texas Department of State Health Services Fluoridation Program estimates the cost of fluoride additive at $4011/year to the city, based on Lufkin’s average production rate and current average fluorosilicic acid price at $2.00/gallon. I don’t know exactly how accurate those numbers are, but it is obvious we are not talking a lot of money here.

Bottom line? Lufkin needs to return to fluoridating our water supply. And the Texas legislature should consider requiring municipalities to maintain recommended fluoride levels in municipal water supplies. After all, dental health is part of public and community health.

Continue CPRIT Cancer Research Funding

The Cancer Prevention and Research Institute of Texas (CPRIT) was created in 2007 when Texas voters supported legislation setting aside $3 billion for cancer research and prevention. Since then, results have been measurable and effective. In addition to clinical services that have reached every county in Texas, more than 1,200 grants have been awarded to fund cancer research, product development, and cancer prevention. That amounts to up to $300 million in grant funding annually with 90% dedicated to cancer research. Those dollars have brought world-class research teams and amazing recognition to Texas.

One CPRIT scholar, Jim Allison, PhD, chair of Immunology and executive director of the Immunotherapy Platform at The University of Texas MD Anderson Cancer Center, was awarded the 2018 Nobel Prize in Physiology or Medicine for launching an effective new way to attack cancer by treating the immune system rather than the tumor. Another, Sean Morrison, PhD of The University of Texas Southwestern Medical Center, was elected to the National Academy of Medicine. A CPRIT grantee, Livia Schiavinato Eberlin PhD, an assistant professor of chemistry at The University of Texas at Austin, won a MacArthur Foundation Fellowship, unofficially called a “Genius Grant”.

CPRIT is governed by an appointed nine-member Oversight Committee, who operate under a Code of Conduct and Ethics. CPRIT grants are merit-based and peer reviewed and given to Texas-based entities and institutions for cancer-related research, product development and the delivery of cancer prevention programs.

In my area, the Angelina County & Cities Health District participates with researchers at UT Tyler and with the American Cancer Society to provide colorectal cancer screening and prevention services to indigent and uninsured patients in the East Texas area. This is but one example of how CPRIT funding reaches a local community and an underserved population.

But CPRIT funding is at risk. Legislators are being asked to authorize $600 million in funding for CPRIT over the next two years as well as to pass a bonding authority bill that would ensure sustainability of CPRIT for another 10 years. Programs like CPRIT cannot limp along a year or two at a time; they need sustained funding in order to plan, implement, complete, and report out research and prevention successes and failures.

Some have questioned whether or not CPRIT funding, while “unquestionably noble”, is really an essential function of state government. I get it. But, CPRIT is more than cancer research and prevention. It is an investment in our state and our economy. More than 98,000 jobs have been created and $10.9 billion in economic activity has been generated through CPRIT programs. Ray Perryman, president and CEO of the Perryman Group, an economic and financial analysis firm based in Waco, Texas, said that for every dollar taxpayers have invested into CPRIT since 2007, Texas has gained $2 in tax revenue.

Public opinion is behind CPRIT as well. According to a poll conducted by Public Opinion Strategies, 70% of Texans would support reauthorizing the legislature to increase the bond issue for CPRIT by another $3 billion to extend the program for another 10 years. Nine out of ten voters (89%) say it is important for Texas to remain a national leader in cancer research and prevention by providing state funds for CPRIT.

Texas is doing the right thing when it comes to cancer research and prevention. We can all get behind CPRIT: for cancer research, for Texas, and for our future.

We Need Tobacco 21 Legislation Now

Who knew that candy apple, bubble gum, cherry cola, marshmallow, orange soda, s’mores, chocolate, and taffy were literally so addictive? Every one of those flavors – and thousands more! – are available in e-cigarettes today. Tobacco and e-cigarette use – seductively called vaping – are increasingly sucking our youth into a lifetime quicksand of addiction with health and financial costs certain to follow.

A coalition of many partners, including the American Cancer Society Cancer Action Network, American Heart Association, American Lung Association in Texas, Texas Medical Association, Texas Hospital Association, and numerous health systems throughout the state, have come together as Texas 21 to save lives by preventing tobacco use. One simple legislative change that Texas 21 supports can impact hundreds of thousands of lives down the line: raising the age to buy tobacco products to 21.

Almost all smokers start before age 21. In Texas alone, more than 10,000 kids become daily smokers every year. Lest you think raising the age to buy tobacco products to 21 is a radical idea, six states have already done so, as well as hundreds of cities across the country (including San Antonio in 2018). In fact, more than a quarter of the nation is covered by such T21 legislation.

My home county – Angelina County in deep East Texas – has the dubious distinction of ranking dead last in Texas for health behaviors according to the Robert Wood Johnson Foundation (accessible online at www.countyhealthrankings.org). Our higher than average adult smoking rate is a major factor in that determination. If we are to change the health behaviors of an entire county, we must address some factors more globally. Smoking is one of them.

Raising the smoking age to 21 will not have a big economic impact on retailers, as only 2% of US cigarette sales go to those under age 21. But the long-term impact on our taxes, of which too much goes to smoking-caused healthcare, will be significant. In Texas, Medicaid costs caused by smoking amount to almost $2 billion annually. Total annual healthcare costs in Texas directly caused by smoking reach nearly $9 billion. If fewer kids start smoking, we will – over time – see a significant decrease in smoking-related expenditures. Not to mention that our kids will enjoy longer and healthier lives.

Our children are so vulnerable to influence when they are in their early teens. On average, kids in the US try smoking for the first time even before they are 14 years old. They get their first cigarettes from older teens. Most high school seniors can legally buy cigarettes even before they graduate high school, because the legal age to purchase currently is 18. This gives younger teens easy access to nicotine and tobacco though their peers.

States and cities that have enacted T21 legislation have seen a significant drop in youth smoking initiation. The Institute of Medicine (now the Health and Medicine Division of the National Academy of Medicine) notes that raising the tobacco sale age will not only significantly reduce the number of adolescents and young adults who start smoking, it will reduce smoking-caused deaths and immediately improve the health of adolescents, young adults and young mothers who would be deterred from smoking, as well as their children.

It’s not just about cigarette smoking, though. E-cigarettes must be included in any T21 legislation. The tobacco industry, seeing overall declines in US smoking rates, cleverly (and sinisterly) purchased e-cigarette companies and began refining and marketing these nicotine delivery systems to our kids. Vaping became mainstream.

The power of the tobacco industry to addict people to nicotine is evident in the fact that e-cigarette company Juul – in which tobacco giant Altria owns a large stake – has grown quickly to be worth as much as $38 billion by some estimates. Juul’s annual revenue is said to be $2 billion. Addicting teens with flavors like mango, creme brulee, and mint has resulted in more kids using electronic cigarettes than regular cigarettes. In fact, e-cigarette use among youth is now considered to be an epidemic.

Juul and other vaping devices are not toys. Evidence continues to build that for young people, using e-cigarettes increases the likelihood of smoking cigarettes. Some of the chemicals in e-cigarettes are harmful as well. And the effects of nicotine on developing brains are not fully known. Especially worrisome is evidence that nicotine can cause impaired brain development, especially of the prefrontal cortex, which affects judgement and impulse control. To flavor a highly addictive chemical and sell it to children is not only sinister and dangerous; it is appallingly profitable for the very tobacco companies who have been driving up our healthcare costs killing us with cancer, heart disease, COPD, and many other illnesses for decades.

What can we do right now? Polls show nearly 70 percent of voters across party lines favor T21 legislation. Over half of voters strongly favor it. Sen. Joan Huffman and physician Rep. John Zerwas have introduced Senate Bill 338 and House Bill 749 — both of which include e-cigarettes — to protect kids from tobacco addiction and save lives by raising the tobacco age in the state to 21. This something we can all agree on. Let’s pass T21 legislation in Texas this session.

The Financial Burden of Cancer Care

As a board-certified radiation oncologist, I’m trained to know all about cancer and its physical effects on people. Similarly, as a board-certified hospice and palliative care physician, I am well-versed about the psychosocial and spiritual trials patients go through, especially at the end of life. But a recent study I read stopped me in my tracks with a disturbing finding: Cancer is bankrupting an astounding number of patients.

Adrienne Gilligan, PhD, publishing her research in the American Journal of Medicine, found that 42% of cancer patients deplete their life savings within 2 years of diagnosis. This “financial toxicity” –  arguably every bit as serious as the emotional and physical toxicity associated with cancer treatment – risks forcing far too many cancer patients to make an agonizing choice between almost certain death and overwhelming debt.

The Advisory Board Company, a Washington, DC-based organization that researches best practices in healthcare and other industries, highlighted from Gilligan’s article that “the direct medical costs from cancer exceed $80 billion in the United States. [The authors] cited previous research finding that up to 85% of cancer patients leave the workforce during their initial treatment, and more than 50% of cancer patients at some point experience bankruptcy, house repossession, loss of independence, and breakdowns in their relationships.”

One observation from this research that should be even more concerning for those of us in deep East Texas is that in more vulnerable populations with lower socioeconomic status and clinical factors such as smoking and poorer health – this describes Angelina County and surrounding counties – the risk of asset depletion is even greater. Even for those with health insurance, the researchers wrote, deductibles and copayments for treatment, supportive care, and nonmedical or indirect costs (for example, travel, caregiver time, and lost productivity) may be financially devastating.

I see this financial burden all the time. Monthly, I get a report from my billing office on the bills that patients are not paying despite multiple contacts. Most of the time, these are deductibles and copays that patients – who live paycheck to paycheck and who have no savings to start with – never are going to be able to pay. Sometimes it is the entire bill, in the case of uninsured and indigent patients. As a physician, I really only have two options: send them to a collection agency to harass them and try to get whatever proverbial blood out of the turnip they can, or write them off. That my patients should suffer not only with a cancer diagnosis and treatment side effects but also possible bankruptcy is absurd. I am rightfully appalled and angered that our federal healthcare reimbursement system and the private insurance complex have achieved “cost savings” by placing more and more of the financial burden onto patients, who simply are unable to pay. The bankruptcy monster is always at the door.

Doctors are familiar with the Latin phrase primum non nocere – first, do no harm. The idea is really that we should balance the risks of treatment with the benefits. I imagine when that phrase was coined the author did not have financial harm in mind. Today, it has become one of the most important “risks” when weighed against the hoped for gains of treatment. Unfortunately, the provision of healthcare has become a commodity and providers are reduced to revenue-producing cogs on the wheel in a system that has replaced the patients’ needs with productivity metrics. The profession of medicine is less and less in charge of the provision of medicine.

In spite of this new reality, healthcare providers – doctors, hospitals, etc. – must recognize that the mission of any healthcare organization is first and foremost health, not profit. When profit alone drives healthcare decisions, the cart is before the horse. And forcing patients into bankruptcy with draconian billing and collection policies profits no one (except maybe collection agencies). Accounts that have little chance of being paid need to be written off quickly and completely.

In hospital systems, some critical services – for example, social work, patient navigation, discharge planning – may have no direct link to the bottom line in terms of a reimbursable, codable procedure or office visit, but nonetheless have a profound impact on preventing financial losses by impacting readmission rates and avoidable costs associated with inability to comply with prescribed courses of treatment. In addition, finding sources of payment for patients can bring dollars in that otherwise would not be seen. These services must not only continue, but be expanded.

Ultimately, legislators need to change the way healthcare services are valued and reimbursed so that the increasingly unmanageable financial burden that falls on everyone – even the insured, hardworking folk – doesn’t bankrupt us all. This isn’t about patient responsibility; it is about preventing personal financial catastrophe. And now it’s January with high deductibles and never-ending copays to meet. I’m afraid we are in for a bumpy ride. Happy New Year!

County Health: Where Do We Begin?

First, let me say that the title implies that we are not doing anything for community health, which is certainly not true. The Angelina County & Cities Health District does amazing work, day in and day out, to provide primary care, immunizations, preventive services, and much more. Our two hospitals – and the physicians, nurses, and other personnel who staff them – are monumental institutions of care, providing both emergency and specialty services (like heart surgery, neurosurgery, neonatal care, and cancer treatment) that many towns our size could only dream of. Our city and county governments help in their own way, with everything from parks, sidewalks and public transportation to smoking ordinances that, together, form a net of support for any broad public health initiative.

But now what? Last month, I wrote of our poor county health ranking (as determined by the Robert Wood Johnson Foundation) and the fact that Angelina County is dead last in Health Behaviors, which includes adult smoking, adult obesity, physical inactivity and access to exercise opportunities, excessive drinking and alcohol-impaired driving deaths, sexually transmitted infections, teen births, and food environment index. Collectively, we’ve got to do more to improve the health of the residents of Angelina County.

As President and CEO of the Episcopal Health Foundation Elena Marks loves to say, health is not healthcare. We cannot spend our way to health by doing more medical procedures writing more prescriptions for illnesses. Once people reach the healthcare system (emergency room or hospital, for example), so much of what determines true health has already been ignored.

What are the determinants of health? Dr. Paul McGaha, formerly with the Texas Department of State Health Services and now Chair of the Department of Community Health in the School of Community and Rural Health at UT Health Science Center in Tyler, describes four broad categories that determine a community’s health. First are social and economic factors, which are 40% of health determinants. These factors include education level, employment, income, family and social support, and community safety. Health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, accounts for 30% of a community’s health. Our physical environment, such as air and water quality and housing and transit availability, are responsible for 10% of our health. That leaves only 20% for what most people think is actually responsible for a community’s health, and that is actual access to and quality of healthcare. Unfortunately, healthcare expenditures nationwide are so unbalanced that 97.5% of spending – a staggering $3.3 trillion – is for that clinical care which only accounts for 20% of health. In other words, only 2.5% of healthcare spending goes to 80% of what determines our health as a community.

The facts are that US healthcare spending – dollars spent on actual care – far exceed other countries, and US spending on “social services” – including education, parks, public safety, transit, public health, etc. – is significantly less than other countries. What do we get for all that healthcare spending? Worse outcomes and lower life expectancy. Yet spending on healthcare continues to rise.

If we are to improve our county health rankings, we must attack determinants of health on all fronts. Much of that attack must come from outside the healthcare community, though those of us in healthcare need to both inform and encourage that discussion. We must consider the community health needs and ramifications in everything we do. How do we affect overall community health by curriculum choices in the schools, choice of grocery store displays (not to mention availability of fresh, healthy groceries), availability of parks and sidewalks, public safety, welfare, public health spending?

To that end, DETCOG has an opportunity to work with the Episcopal Health Foundation to access county by county data on healthcare and social services spending (analyzed by health economist J. Mac McCullough, PhD, MPH) so that we can learn how spending decisions impact the health and well-being of our residents. From that, we can explore opportunities to impact the health of our entire community by allocating our precious city and county funds for the biggest bang for the buck. Along with possible school-based initiatives mentioned last month, we must continue to look outside the box of traditional healthcare spending for ways to actually improve community health. As they say, it isn’t brain surgery. And that’s the point.

We can’t afford to pay for all the healthcare we are currently providing and projected to need in the future. The beautiful thing is, by wisely directing our resources now, we will be healthier and less of a burden to care for in the long run. That, my friends, is a win-win!