The COVID-19 pandemic exposed long-known inequalities in the United States health care system, leading to low-income communities being disproportionately impacted. Even before the pandemic, these inequalities were part of why life expectancy for some neighborhoods in Baltimore is worse than in North Korea, Syria, and Yemen.
While lack of resources, systemic racism, and racial discrimination are part of the explanation for these differences, the root causes for this problem are much more complex than just access and proper care. Studies have shown differences in how Black patients are assessed and the seriousness with which their pain is treated as compared to white patients, with biases leading some to value a person’s suffering less than another because of their gender and color of their skin.
Addressing the problem involves looking beyond just treating symptoms in a clinical setting to consider how a person interacts with their environment and their comfort within it. The biggest issue that runs through most of those determinants is stress—and how the stress which comes from how we fit within our communities will unravel the human body over time.
Racism, constant worry, and stress cause our bodies to physically break down. A CARDIA study found racial disparities in how hypertension, heart failure, and coronary artery disease develop. Studies have shown links between structural racism and hypertension for African Americans for years. It’s been argued that a “subjective social status,” or how someone walks through life perceiving their value against others, has an effect on one’s health.
The same aspects of human physiology which help us deal with dangerous threats, like the hormones released as part of a fight or flight response, have severe negative consequences when chronic. Worrying for days on end about, say, how the rent is going to be paid is proven to trigger the same hormones as running from a burning building. High levels of cortisol are associated with weight gain, high blood pressure, depression, and sleep problems, all of which are risk factors for cardiovascular disease. In children, stress and abnormal cortisol levels can have neurological effects, induce accelerated aging or stunt one’s growth, and put kids at increased risk for adult diseases which will limit their life expectancy.
If all of this is at the root of poor health and health inequality, how exactly does one go about fixing it, especially from the perspective of health care providers? Some insurance companies are realizing how social determinants affect health, especially in considering that identifying people at risk and preventably addressing these concerns lowers their costs, while also having an overall better result for their customers.
Add into this mix that, earlier this year, the Trump administration on its way out the door approved a special waiver for Tennessee which converted the state’s Medicaid funding to a block grant. The block grant proposal, spearheaded by Tennessee Gov. Bill Lee, a Republican, is supposed to give the state more flexibility in its decisions, save costs, and accentuate the value of health care visits over the volume of people seen. However, in practice, there are concerns that in agreeing to a block grant, while it gives the state greater authority to spend how it wishes, those grants are fleeting. Generally, once the funding has been spent with a block grant, there’s no extra coming. Therefore, there are concerns that a block grant that leads to a cap on Medicaid spending will ultimately lead to a reduction in either the state’s patient eligibility or the services.
Over the last several months a pilot program that takes such social determinants into consideration has been instituted at a pediatric clinic in Memphis, Tennessee. Targeted for Medicaid patients, the challenges of implementing a system to identify social determinants of health within the context of yearly checkups and visits for rashes and coughs makes for an interesting case study of how difficult it can be to effectively help people.
The program attempts to use a visit to the pediatrician in order to screen and identify certain risk factors. Depending on a parent’s answers to a survey, doctors and other medical professionals would provide them with access to food banks, job placement, domestic violence support, housing assistance programs, transportation help, and cash assistance. This is done through a Medicaid plan, BlueCare Tennessee, incentivizing assessments and referrals while providing a large initial payment to medical facilities in order to induce participation. As a person who would be involved with the administration and assessment of these surveys at the clinic, I sat in regular meetings which discussed why this information was important to patient care and the best ways to administer them.
In Tennessee, around 1.5 million people are part of the state Medicaid program TennCare. Almost half the children within the state are covered under the program. Memphis is the second most-populous city in the state, with two-thirds of the residents being Black and over one-quarter of the people in the city living in poverty, making it No. 1 in the nation for overall poverty for a metropolitan area with a population greater than 1 million.
Inside the county where Memphis is located, over 140,000 children, or 57% of the total number of kids in the area, were part of TennCare in 2019. One of the health plans offered by TennCare is called BlueCare, offered through BlueCross BlueShield, and is eligible to low-income children under 21 and pregnant women.
To assess a patient’s situation, BlueCare uses the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) survey developed by the National Association of Community Health Centers (NACHC). It determines an assessment for social determinants of health on a point basis: Accumulate too many points in the survey ,and it triggers referrals. The variables for those points are race (anything other than white gets a point), citizenship status, primary language (anything other than English gets a point), past military experience, housing stability or lack thereof, education level, employment status, income level, the presence of transportation problems, the presence or lack of social contacts, and a person’s own feelings about their stress and safety. For every question, there is a choice of “I choose not to answer” if any question makes them uncomfortable; patients are made aware of the potential benefits but told the survey is optional.
The pediatric practice where this program launched in April currently features seven doctors and one nurse practitioner, who see about 200 children and parents/guardians in 15-minute appointment increments every day. As initially envisioned, these survey questions would be asked of every parental figure of a BlueCare-insured child as part of their visit. The clinical assistant responsible for basic intake would be tasked with asking the questions of the adult in the room during the appointment. Once completed, the survey answers would be added to the patient’s record, the doctor or nurse practitioner would review the survey, discuss the answers with the parent, and then make any necessary referrals. Almost from the beginning cracks in the process appeared.
To the clinic staff’s credit, they didn’t just want to get surveys answered in order to receive the financial incentives. There were Zoom meetings with officials from BlueCare, where these assessments were used to stress the importance of the quality of a patient visit, versus worrying about the number of patients that would be seen. I sat in multiple meetings between office managers, administrators, and medical professionals where thought was put into getting honest answers in the least-intrusive way possible.
To that end, initially the plan was for the clinical assistants to ask each question personally, thinking it would be more respectful than just shoving a piece of paper in someone’s face to fill out themselves. But this became problematic; since it was a pediatric clinic, invariably the process would involve asking questions about finances and personal safety in front of children. Also, most of the clinical assistants asking the questions were college students; they had been trained to put paperwork in the computer and check vitals, not to discuss delicate personal matters like finances and housing status with patients.
These issues were compounded by the volume of the clinic’s workload. Slowing things down to do a survey which touches on sensitive topics would be fine if there was time to discuss such things while also doing blood work and other areas of assessment in a pediatric clinic doing well-child checkups. But since the clinic functions around each patient’s visit happening within a 15-minute interval, and seeing as many people as possible, many times the clinical assistants just add a paper copy of the survey to the forms most parents already have to fill out. The problem with this approach, though, was the forms are almost never completed before the medical provider enters the room. Some days there were doctors who had no surveys entered for their patients.
Additionally, the point system of the survey was advisory. Because the referrals were dependent on a given doctor/nurse practitioner looking at the surveys and recommending a referral, a recommendation for a referral could become subjective. What one provider might see as grounds for financial help might not make the cut for another provider seeing another patient.
Since these initial issues cropped up, the situation has improved. Most surveys are given to the parents on paper with a better explanation of the benefits. Response rates have improved, but this experience speaks to the difficulties in just obtaining an assessment on these issues, let alone helping people and moving up a person’s social status.
In the day-to-day practice of medicine, there is a danger of slipping into routine and letting one patient blur into another like fast-food workers moving from one order to the next. A modern medical undertaking advances through a combination of information systems which segment people into appointment slots, documents ailments according to one-size-fits-all templates, diagnoses based on assumed responses to particular suffering, and then files it all with codes for the insurance company and the chart.
Instead of looking at people as people, if one is not careful it can become no different than the way a mechanic works on an automobile, moving his or her way through a procedure at a hospital like it’s a repair in a garage, and sometimes treated just as coldly. If the long-term goal is to improve quality of life, then health care has to be more than just access to the equivalent of an oil change every six months to a year.
The bigger picture of what the word “health” means has to encompass a consideration of the society and living conditions where those decisions between a patient and doctor are made. In a country where we spent almost $4 trillion on health care last year and more per person than any other country, we still trail other areas of the world with socialized medicine in health metrics like life expectancy, infant mortality, and unmanaged diabetes.
It’s too soon to tell how this program at this one pediatric clinic will perform in the long term. There have been referrals made, and some parents and children who’ve been in bad, unsafe situations have been put in contact with support. A case study of PRAPARE’s use at Compass Community Health Center in Portsmouth, Ohio, led to “improvements in clinical quality outcomes, retention rates, and financial outcomes,” with the clinic’s no show rates declining by 13%. Data compiled by NACHC, as well as a clinical study looking at the PRAPARE survey responses, indicated the most common social determinant risks were connected to limited English proficiency, having less than a high-school education, life stressors, and lack of insurance and employment. The ability to target those specific affected segments of the population could lead to improved quality of life in entire communities.
In the end, the process speaks to the imperfect ways we try to help those in a flawed world, who are separated by artificial barriers of class and race.