DETCOG, Broadband and Health

Can you hear me now? That phrase, made popular by Verizon Wireless in the early 2000s, epitomizes the frustration of rural America over lack of reliable cell phone coverage. To this day – despite what cell phone carriers like AT&T, Sprint, and Verizon advertise – coverage in many areas (including at my house inside the Lufkin, Texas city limits) is suboptimal. AT&T’s answer? Just use WiFi calling! That may work for me; I have adequate internet access. But what about the majority of deep East Texans? More than just being an inconvenience, poor cell phone coverage and inadequate broadband access are harming our health.

Broadband is the infrastructure and information technology network that delivers high speed connectivity to the internet. Think of broadband as a pipeline of information. As with any pipeline, the rate of flow (water, gas, data, etc.) can depend on the number of users, time of day, and reliability of service. But you have to be able to connect to the pipeline.

In the early days, the internet was accessed through slow, often expensive dial-up connections. Today, high speed or broadband internet access is via DSL (or Digital Subscriber Line), fiber-optic, wireless, cable, and satellite services, often bundled with phone and TV subscriptions.

Broadband access is about more than faster access to Facebook and Instagram. Increasingly, reliable and high-speed internet access is important for community health. The Federal Communications Commission (FCC), which is responsible for regulating the radio, television and phone industries, established a Connect2HealthFCC Task Force to raise consumer awareness about the value of broadband in the health and care sectors. You may know about heart-healthy diet and recipe apps and wearable fitness trackers, but did you know that we now have medical devices like pacemakers, defibrillators, glucose monitors, insulin pumps, and neuro-monitoring systems that can utilize wireless technology to control or program a medical device remotely and monitor and transmit patient data from the medical device to the healthcare team? Those without internet access can get delayed and inadequate care.

Maps showing lack of broadband coverage look just like maps of poor, rural America where healthcare is also lacking. In Kentucky, for example, the same areas where higher rates of lung cancer are seen are those with limited broadband access. These county-by-county maps are similar to what we see in deep East Texas with cancer deaths and health outcomes. This does not mean that lack of broadband access causes lung cancer, obviously! But the social determinants of health (such as education level and income) that are associated with smoking, lung cancer, heart disease, obesity, and overall health outcomes, are more pronounced in areas with limited broadband access.

So how could access to broadband increase the health of a community? The FCC believes that “broadband-enabled technology solutions can help us meet the health and care challenges of today and tomorrow by connection people to the people, services and information they need to get well and stay healthy.” Possible solutions that are especially important in deep East Texas include telehealth and telemedicine for improved access to physicians and specialists (including mental health services), health information technology and access, fall detectors, pharmacy connectivity, personal health data upload capability, and connectivity to hospitals and emergency rooms. With a growing and aging population compounded by a shortage of primary care physicians nationwide estimated in the tens of thousands –especially pronounced in rural areas – remote connectivity options for healthcare become even more important.

The Deep East Texas Council of Governments (DETCOG), under the leadership of Executive Director Lonnie Hunt, recently received a report titled Deep East Texas Broadband Growth Strategy, which detailed the potential economic growth (10,300 new jobs and $1.4 billion in GDP growth over 10 years) and growth in median household income associated with near complete broadband access, a loft goal. In IT, education, and telehealth alone, investments have the potential to impact the region with 2,500 jobs and $300 million in GDP over the next ten years.

DETCOG’s goal is to support development of a regional fiber optic-based broadband network throughout its twelve-county region. They hope to do this through creation of a non-profit or other entity that would manage the project, bring the necessary partners together to accomplish the goals, and oversee planning, financing, and implementation of the regional broadband network. Full implementation realistically will cost hundreds of millions of dollars. But it doesn’t have to all come at once.

In February, with support from the TLL Temple Foundation, DETCOG started the process to contract with a major law firm with offices in Washington, DC, to create an entity to manage broadband in East Texas. Funding such an entity and project will not be easy. Other COGs have tapped into grants like the FCC’s Rural Health Care Program, which provides funding to eligible health care providers for telecommunications and broadband services necessary for the provision of health care. Electric and telephone cooperatives, public utilities, internet providers, local, state, and federal entities, and foundations can and should play a role.

Do you hear me now? We must support DETCOG’s vision for a fiber optic network for all of deep East Texas. This will be a long term project requiring many players, both public and private, to accomplish. We need – we must have – high-speed broadband access in our entire region for jobs, for the economy, and for our health.

A True Community Health Needs Assessment

The IRS requires charitable hospital organizations to conduct a community health needs assessment (CHNA) every three years and to adopt an implementation strategy to meet the community health needs identified through the CHNA. CHI St. Luke’s Health Memorial recently completed their 2019 Community Health Needs Assessment and will now begin the process of developing, adopting, and implementing a strategy to address identified needs. Much of this strategy will depend on working together with community stakeholders, many of which participated in the assessment data collection and interview process. Additional data was obtained from sources such as the Texas Department of State Health Services, the US Census Bureau, the Centers for Disease Control and Prevention, the Episcopal Health Foundation, and the Robert Wood Johnson Foundation’s County Health Rankings.

The 2019 CHNA was created by the Center for Community Health Development at Texas A&M University at the request of CHI in collaboration with multiple non-profit community organizations, churches, school districts, and individuals. The entire CHNA is published on the CHI website at www.chistlukeshealthmemorial.org/about/health-needs-assessment/. Because CHI St. Luke’s Health Memorial is a regional health system, the assessment covered not only Lufkin and Angelina County, but a seven-county region that included Polk and San Augustine counties, where CHI facilities also are located.

I have a number of thoughts after reviewing this recent assessment.

1. The health of a community is dependent on far more than just availability of health care. This is well-demonstrated by both the Robert Wood Johnson Foundation’s County Health Rankings (www.countyhealthrankings.org/) and the Episcopal Health Foundation (www.episcopalhealth.org/en/research/county-health-data/). To improve health, we must identify and address everything from education level and health behaviors to racial, ethnic, and socioeconomic factors that affect a community’s health.

2. The 2019 CHNA is community-driven, and solutions to our health needs must include the community as well. So many partners exist, including Burke, the Angelina County & Cities Health District, the Coalition, our many school districts, DETCOG, the Texas Forest Country Partnership, and, of course, our city and county governments. All will need to be engaged in moving the needle to improve the health of our communities.

3. The role of the hospital in the community has changed. In the past, hospitals were primarily a destination to deal with an acute episode, like having surgery or managing a heart attack. Now, hospitals must be part of the chronic care management team for patients with heart disease, diabetes, cancer, mental health issues, and more. Hospitals are being graded – and paid – on how successfully they keep patients out of the hospital, if you can believe it! That requires coordination with community partners to ensure that people get the care they need both before and after they require care in a hospital facility.

4. Risk factors – behaviors – such as smoking, obesity, and exercise must be addressed, as well as substance abuse and mental health needs. We are doing this already, to some extent, across organizations and municipalities. More can be done.

5. Education is widely recognized as one of the primary social determinants of health. The St. Luke’s region has a lower proportion of residents with a college degree (14.2%) than either Texas (28.7%) or the US (30.9%). Within the region, the rate varies from a low of 11.6% in Jasper County to a high of 16.7% in Angelina County, yet both are significantly lower than Texas or the US. Household income and insurance status, which are closely linked to education level, also impact community health. Affecting change in these areas will require a generation of effort.

6. One of the key findings of the CHNA – and one that will require a lot of thought and planning to address – is the inadequacy of local and regional transportation. Lack of transportation impacts access to preventive services and early detection of illness as well as access to treatment and follow up.

As a result of the needs identified in CHI’s 2019 CHNA, with few exceptions, premature death rates in our region are higher than the State in virtually every category. This CHNA must not be an exercise on paper only. Follow up must happen. We have a good idea now of the need. We also have strong communities with excellent resources that can come together to find and implement solutions. Our health depends on it.

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!