ACO’s Across the Pond: What Some Believe the US and England Can Learn From Each Other

It is amazing how experts in the field of health care are so wedded to ideas that are, with greater scrutiny, the real cause of the dysfunction and failures of providing health care to the citizens of a nation.

Such is the case with an article I found from the Commonwealth Fund, a well-respected organization in health care research, yet doubles down on the root causes of the crisis faced by the health care system in the US.

Late last month, Briggs, Alderwick, Shortell, and Fisher published the article entitled, “What Can the U.S. and England Learn from Each Other’s Health Care Reforms?

The focus of the article was on the idea of Affordable Care Organizations (ACO’s), which in the US were established in 2010 under the ACA. According to the authors, both countries are currently working toward better integrating health services, improving population health, and managing health care costs. They also said that both countries are developing their own versions of ACO’s to achieve these aims.

However, the authors point out, by way of listing previous links to articles they wrote, that results so far have been mixed, patient experience (you mean like having a great time at Disney World, that sort of experience?) and some quality measures have improved.

Yet, financial savings, they report, have been modest and data on outcomes is limited.

On the other hand, across the pond, the English NHS recently created 44 Sustainability and Transformation Partnerships (STPs) [Isn’t that what one puts in a motor car to make it run better?]

These STPs cover the entire country and are “place-based” partnerships of all NHS organizations and local government departments that purchase and provide health and long-term care services for a geographically defined population. They believe that organizations in STPs will work together to improve care and manage local budgets. Some payers are even considering American-style ACO contracting models.

Wait, if we are not having success with ACOs, what makes the Brits think they will do better? Interestingly enough, Himmelstein and Woolhandler, in “Health Care Under the Knife”, chapter 4, page 61, said the following when they were involved with drafting an new proposal for the Physicians for a National Health Program (PNHP):

“Recently, the emergence of huge integrated health systems incorporating multiple hospitals and thousands of physicians (so-called Accountable Care Organizations or ACOs), which dominate the care of entire regions, is causing us to again to talk about NHS models.”

So let me get this straight. We are not having much success with ACOs, yet, the Brits are moving in that direction. And the physician-led advocacy group in this country, the PNHP, that is pushing for single-payer, has been forced to consider models employed by the British NHS.

If that isn’t the definition of insanity, I don’t know what is.

Of course, the move towards ACOs in this country is due to the ACA and to the resurgence of 19th century economic liberalism, also known as neoliberalism, and its impact over the past thirty years on the American health care system. But in the UK, the move away from Labour Party socialism to the Conservative Party’s neoliberalism, is the reason why Britain is exploring the ACO model.

Maybe one day, both Anglo-oriented nations will wake up and stop believing in the fairy tale that the free market works for health care. It does for cars and other consumer goods, but health care is not a consumer good. It is a necessity of life.

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HHS Under Trump: A Revolving Door of Corporate Executives

The following article sheds light on the revolving door at the Department of Health and Human Services (HHS) under the so-called Trump Administration, or should I say criminal regime.

It seems that corporate executives from various health care companies have been appointed to several positions within HHS, only to leave unexpectedly.

Case in point, John Bardis, an executive formerly with MedAssets, became Assistant Secretary of HHS for Administration and resigned under fire. He was the CEO of a health care financial firm, and had experience running other health care related companies; nevertheless, he had no direct experience in health care or public health.

Another example of the revolving door concerns Daniel Best, former Corporate Vice President of Industry Relations at CVS Health, and Pfizer before that, to Senior Adviser to the Secretary of DHHS for Drug Pricing Reform. REALLY!?

Adam Boehler, CEO of Landmark Health, and previous founder of Avalon Healthcare Solutions and Trellis Rx, and Operating Partner of Private Equity company Francisco Partners, was appointed to Director of Center for Medicare and Medicaid Services (CMS) Innovation Center (CMMI).

Dr. William Staley, from McKinsey Consultant to Coordinator of US Government Activities to Combat Malaria. He is a doctor, and his bio on the State Department website lists his prior positions at State.

This is what draining the swamp looks like. This is not how government should be run. This is how corporate America gets its grubby hands on the health care system for the profit of a few.

Here is the link to the full article.

Follow-up to My Open Letter to the Medical Travel Industry

Just over four months ago, I published an open letter to the medical travel industry.

To date, I have had no response to my letter of December 14th, nor have I been invited to attend any of the conferences that have been held since, or will be held in the future, and I just learned of one at the end of this month in Washington, DC.

By that time, I will have been writing this blog for five and a half years, and still on a daily basis, my posts get at best, less than fifty views, and on most occasions, not even twenty.

I have posted them to LinkedIn, Twitter, and have re-posted them several times, and yet, each time, I get a few clicks added to the ones previously received.

I am putting my heart and soul in this and not receiving any compensation, although I should. So would it hurt if the industry paid a little more attention to my writing and to me, in lieu of actual remuneration?

As a friend we all know once said to me, “What am I? Chopped Liver?”

I am not doing this to stroke my ego, nor am I doing it because I have nothing better to do. I am doing it because I care. I am in the process of reading a fascinating book on the real reasons health care in the U.S. and elsewhere is undergoing major changes that have affected the delivery of health care, it’s cost, quality, efficiency, and its efficacy.

The least any of you could do is acknowledge my efforts and pay me some courtesy. Is that too much to ask?

I’ve met some of you in the past seven years since I began this journey, but I’d like to meet more of you. And I am sure you would like to meet me. I am funny and am a great person to know.

What say you?

Thank you very much.

Richard

 

The Seven “C’s” of Medical Travel: What Workers’ Compsters Need to Know

If you thought I had abandoned talking about workers’ comp and medical travel, guess again. It was on the back burner waiting for the right time to come forward once again.

This time, it is due to one of my LinkedIn connections, Arlen Meyers, MD, MBA. Dr. Meyers is the President and CEO at the Society of Physician Entrepreneurs.

Dr. Meyers published a medical traveler’s check list which he calls his “7 C’s”. He advises medical travelers to complete the checklist before going abroad for medical care.

For those of you in comp who have been skeptical about the practicality and efficacy of medical travel, this checklist is intended to prove that what medical travel really is, is not some quack form of medicine or third world medicine in some dump of a hospital or clinic.

Here is Dr. Meyers checklist:

  1. Credentials: Check the quality of your surgeon and the facility where they intend to do your surgery. Be sure the hospital or ambulatory surgery center is accredited by a recognized accreditation organization. The table stakes for the surgeon are licensure in the state or country, board certification and a lack of repeated malpractice or disciplinary actions. Harder, if not impossible, to find will be a record of the surgeon’s outcomes for a given procedure, so you will have to rely on referral from a trusted source or recommendations. Online site reviews do not reflect quality of outcomes.
  2. Cost: How and how much will you be expected to pay for your operation? If something goes wrong, who is responsible for paying future care? What will be covered and what won’t? Is there insurance, for example medical evacuation in case of a dire emergency, you can buy to help defer some of the risk? Bundled payment i.e., a fixed price for specifically defined episode of care, is becoming more common.
  3. Continuity of care: In the best case, a doctor at home will help you to find a surgeon away from home and will accept you back as a patient once you return home. However, many surgeons are reluctant to do that so be sure you have a plan for continuity of care when you get home. Find out who will take care of you if, and when your surgeon is not available. If something goes wrong during a procedure in an ambulatory surgery center, where will you be transferred for care? Be sure you understand where you should go for emergency care when you get back home and whether your insurance company, if applicable, will cover the cost.
  4. Care coordination: Leaving home can involve not just medical issues, but travel and hospitality issues as well, e.g., customs and immigration forms, translation services, hotel and flight arrangements, and accommodations for companions or family members.
  5. Companion: Be sure you travel with a trusted, reliable companion or family member who can help and support you during your postoperative recovery. Another option is to hire a trained medical profession, like a nurse, who will accompany you on your trip for a fee.
  6. Continuity of data: Be sure you obtain a copy of your medical records, discharge summary and operative note. Do not rely on the surgeon transmitting the information to your doctor back home. Medical records are not interoperable in the best of circumstances and, most likely, sending reports and forms from a distant place will be a hassle, inefficient and expensive.
  7. Contraindications: Here are some medical conditions that are contraindications to flying.

This is not some slick marketing tool created by a medical travel facilitator or promoter. This is a reasoned, carefully constructed checklist written by a medical doctor advising potential patients of foreign medical providers and facilities what to do, what to look for, and what to expect when going abroad for medical care.

Those of you who have criticized my idea in the past, and you know who you are, should be aware that there are real professional people who strive to do the right thing, even if that means that they or their domestic colleagues lose patients to fellow physicians and facilities in other countries. Dr. Meyers did not have to do this for his sake; he did it for the sake of the patient. Which is something you should be doing, instead of doing the same old thing repeatedly and expecting different results.

It is high time workers’ comp opened up and let the sunshine in. The patients will be the better for it.

Tariffs Threaten U.S. Health Care

The petulant man-child occupying the White House is proposing to impose a 25 percent tariff on Chinese products and ingredients, according to a report in the New York Times on Friday.

Some of the products and ingredients are essential to health care in the U.S. such as pacemakers, artificial joints, defibrillators, dental fillings, birth-control pills and vaccines.

In addition, dozens of drugs and medical devices are also among products targeted for the tariff. Some of them are in short supply, and dangerously so. They are epinephrine, which treats allergic reactions, and others like insulin, whose price rising has led to public outrage.

This proposed tariff has unsettled the medical device and supply industries, since a growing number of products and their components are manufactured in China.

The manufacturing of medical equipment has shifted from throwaway surgical gloves to more complicated products like MRI scanners.

An International Trade Commission in January, the Times reported, said the fastest growth in China’s medical device industry has been in sales of orthopedic devices, plates, and screws, made mostly of titanium and used for surgery and sports medicine.

One analyst, the Times continued, estimated that 12 percent of medical devices imported to the US come from China, which amounts to $3 billion a year.

A report this week by RBC Capital Markets, the article mentioned, estimated that if the tariffs took effect, this could cost the medical device industry up to $1.5 billion each year. Some of these higher costs would result in higher prices for those devices, and would affect baby boomers, who are the biggest recipients of hip and knee replacements.

This no doubt would be a boon to the medical travel industry, from the US to countries not imposing tariffs on Chinese products, or not.

Greg Crist, spokesperson for AdvaMed, the device members trade group, said its members were “disappointed because this action threatens to affect the health and well-being of American patients and those around the world, the Times article added.

While it is unclear if the tariffs would be enacted, companies have until May to lobby the administration for changes. But the man-child ratcheted up the pressure by threatening to levy tariffs on an additional $100 billion in imports.

However, analysts said that it was unclear if the tariffs would have an effect on the drug industry, even though China is a leading exporter of raw pharmaceutical ingredients, according to the article.

“We don’t see much impact,” said Umer Raffat, a pharmaceutical industry analyst for Evercore ISI on Tuesday to investors.

This is so because many generic drugs that contain Chinese ingredients are manufactured in places like India and would not be subject to the tariffs.

Yet, one trade group has sounded the alarm, the article indicated. They said that the tariffs could exacerbate the issue of health care costs as the administration is pledging to lower drug prices.

Lastly, there are two drugs on the list of 1,300 Chines exports: epinephrine and lidocaine, which are in short supply in their injectable form.

“Things are so bad right now with the injectables, we don’t need anything else to pile on, to possibly make things worse,” said Erin R. Fox, a drug-shortage expert at the University of Utah.

She also said that the tariffs could exacerbate the shortfalls of generic injectable drugs, the decades-old products that are the mainstay of hospitals and have long been in short supply due to manufacturing problems and disruptions in supply.

For some widely used products, it is unclear, according to the article, how American consumers would be affected. Insulin is one example; however, all three companies that sell insulin in the US, Lilly, Sanofi, and Novo Nordisk said they did not import insulin from China.

Whatever happens with the tariffs, the effect they would have on health care here and around the world is uncertain. However, it would be prudent for those in the health care industry, the medical travel industry, and the workers’ comp industry to be aware and act accordingly to provide their patients with the drugs and devices they need.

What’s Really Wrong With Health Care?

Book Review

Health Care Under the Knife: Moving Beyond Capitalism for Our Health

by Howard Waitzkin and the Working Group on Health Beyond Capitalism

Monthly Review Press
e-book: $18.00
Paperback: $27.00
Hard cover: $45.00

Americans commemorated the assassination of Martin Luther King fifty years ago on Wednesday. Two years earlier, Dr. King, in March 1966, said the following during a press conference in Chicago at the second convention of the Medical Committee for Human Rights (MCHR):

“…Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”

The part of the quote up to the word ‘inhuman’ begins the Introduction of a new book I just began reading called, Health Care Under the Knife: Moving Beyond Capitalism for Our Health by Howard Waitzkin and the Working Group on Health Beyond Capitalism, published by Monthly Review Press, the publishing arm of the Monthly Review, an Independent Socialist magazine.

Those of you who know me, and those of you who have read many of my previous posts, know that my educational background is in the Social Sciences, as my B.A, is in Political Science and History, with Sociology and African-American Studies thrown in, along with some Humanities coursework. My M.A. is in History, with emphasis on American Social History, especially post-Civil War until the mid to late 20th century. In addition, I also have a Master’s degree in Health Administration (MHA).

But what you may not know is that my leanings have been to the far left, and I am still proudly and defiantly so, even if I have tempered my views with age and new insights. I think that is called wisdom.

So, as I set out to read this book, much of the material presented in it will not be new to me, but will be perhaps new to many of you, especially those of you who got their education in business schools, and were fed bourgeois nonsense about marketing, branding, and other capitalist terms that are more apropos for selling automobiles and appliances and such, but not for health care, as this book will prove.

In this book, there will be terms that many of you will either find annoying, depending on your own personal political leanings, or that you are unfamiliar with. Words such as alienation of labor, commodification, imperialism, neoliberalism, and proletarianization may make some of you see red. So be it. Change will not occur until many of you are shaken out of your lethargy and develop your class consciousness.

“Capital is reckless of the health or length of life of the laborer, unless under compulsion from society.” Karl Marx

While the publisher of the book is an independent socialist foundation, it is no means a Marxist or Communist organization. And from my perusal of the names of the contributors to the chapters of the book, I have found that they are all health care professionals or academics, as well as activists.

Two of the contributors of one chapter, David Himmelstein and Steffie Woolhandler, are familiar to many in the health care industry, as they have co-authored many peer reviewed articles in health care journals that I have cited in my previous blog posts.

Be warned. This book may piss you off. Too bad. The future of health care is at stake, as is the health of every man, woman, and child in the U.S. and around the world.

This will probably be true no matter what part of the health care industry you work in. Physicians, insurance company personnel, pharmaceutical company executives, Wall Street investors and money managers, service providers, vendors, consultants and many others will discover inconvenient truths about the businesses that provide their livelihood. As stakeholders in the status quo, you will be resistant to the prescriptions the writers offer for correcting the mistakes of the past, and the recommendations they suggest for the future of health care.

This book will not only be relevant to the health care industry, but also to the workers’ compensation and medical travel industries, as each is a subset of health care.

And if you do get upset or angry at me for what I have to say about health care, then you are part of the problem as to why health care in the U.S. is broken. Those of you around the world will also learn that your own countries are moving in a direction that sooner or later will result in your health care system mirroring our own, as the authors will point out.

This is a book that will shake you to your core. So, sit back, relax, and keep an open mind. It’s about to be blown.

The book is divided into five parts, with each part containing at most five chapters, as in Part Five, or two chapters, as in Part Two. Parts Three and Four, each contain four chapters. Part One deals with Social Class and Medical Work, and focuses on doctors as workers, the deprofessionalization and emerging social class position of health professionals, the degradation of medical labor and the meaning of quality in health care, and finally, the political economy of health reform.

Throughout the book, they ask questions relating to the topics covered in each chapter, and in Part One, the following questions are asked:

  • How have the social-class positions of health workers, both professional and non-professional, changed along with changes in the capitalist global economy?
  • How has the process of health work transformed as control over the means of production and conditions of the workplace has shifted from professionals to corporations?

These questions are relevant since medicine has become more corporatized, privatized, and financialized. The author of the second chapter, Matt Anderson, analyzes the “sorry state of U.S. primary care” and critically examines such recently misleading innovations such as the “patient-centered medical home”, “pay for performance”, the electronic medical record, quantified metrics to measure quality including patient satisfaction (“we strive for five”), and conflicts of interest as professional associations and medical schools receive increasing financial support from for-profit corporations.

Part One is concludes with Himmelstein and Woolhandler responding to a series of questions put to them by Howard Waitzkin about the changing nature of medical work and how that relates to the struggle for a non-capitalist model of a national health program. Himmelstein and Woolhandler comment on the commodification of health care, the transformation that has occurred during the current stage of capitalism, the changing class position of health professionals, and the impact of computerization and electronic medical records.

Part Two focuses on the medical-industrial complex in the age of financialization. Previous posts of mine this year and last, reference the medical-industrial complex, so my readers will be familiar with its usage here. In this section, the authors tackle the following questions:

  • What are the characteristics of the current “medical industrial complex,” and how have these changed under financialization and deepening monopolization?

Two corollary questions are raised as follows:

  • Are such traditional categories as the private insurance industry and pharmaceutical industry separable from the financial sector?
  • How do the current operations of those industries reflect increasing financialization and investment practices?

Once again, Matt Anderson authors the first chapter in Part Two, this time with Robb Burlage, a political economist and activist. Anderson and Burlage analyze the growing similarities and overlaps between the for-profit and so-called not-for-profit sectors in health care, considering especially the conversion of previously not-for-profit corporations such as Blue Cross and Blue Shield to for-profit.

The second chapter in Part Two is authored by Joel Lexchin, an emergency care physician and health policy researcher in Canada and analyzes monopoly capital and the pharmaceutical industry from an international perspective.

Part Three looks at the relationships between neoliberalism, health care and health. Before I go any further, let me provide the reader with a definition of neoliberalism in case the authors assume that those who read this book understand what it is.

According to Wikipedia, Neoliberalism or neo-liberalism refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism. Those ideas include economic liberalization policies such as privatization, austerity, deregulation, free trade and reductions in government spending in order to increase the role of the private sector in the economy and society. These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.

These neoliberal policies have been associated in the U.S. with the Republican Party and the Conservative movement since the election of Ronald Reagan. In the UK, the rise of Thatcherism ended the long dominance of the Labor Party’s left-wing until Tony Blair’s New Labor took over. Bill Clinton’s election in the U.S. in 1992, diminished some of these policies, and implemented others such as welfare reform, a goal Republicans had wanted to achieve for decades.

Returning to Part Three, the questions asked here are:

  • What is the impact of neoliberalism on health reforms, in the United States and in other countries?
  • What are the ideological assumptions of health reform proposals and how are they transmitted?
  • What are the effects of economic austerity policies on health reform and what are the eventual impacts on health outcomes?

In the next chapter, Howard Waitzkin and Ida Hellander, a leading health policy researcher and activist, trace the history of the Affordable Care Act initially developed by economists in the military during the Vietnam War. International financial institutions, the authors say, especially the World Bank, promoted a boilerplate for neoliberal health care reforms, which focused mainly on privatization of services previously based in the public sector and on shifting trust funds to private for-profit insurance companies.

Colombia’s health reform of 1994, Hillary Clinton’s in that year as well, Mitt Romney’s plan in Massachusetts in 2006, which led to the ACA, are examples cited by the authors. The chapter also clarifies the ideological underpinnings of the neoliberal model and shows that the model has failed to improve access and control costs, according to the authors.

Economic austerity is closely linked to neoliberalism and have led to drastic cutbacks in health services and public health infrastructure in many countries. As I have recently written in my post, Three Strategies for Improving Social Determinants of Health, economic austerity policies have also affected health outcomes through increased unemployment, food insecurity, unreliable water supplies (Flint, MI), and reduced educational opportunities. Recent teacher protests in West Virginia, Oklahoma and other states are examples of this.

In the second chapter in Part Three, Adam Gaffney and Carles Muntaner, focus on social epidemiology, especially the impacts of economic policies on health and mental health outcomes. They also document the devastating effects of austerity in Europe, focusing on Greece, Spain and England. The authors analyze four dimensions of austerity:

1) constriction of the public-sector health system, 2) retreat from universalism, 3) increased cost sharing, and 4) health system privatization.

This trend would seem to have a negative effect on medical travel from Europe and to Europe, as Europe’s health care systems, long touted as a less expensive alternative to medical care in the U.S., begins to suffer.

Part Four examines the connections between health and imperialism historically and as part of the current crises. The question in this part is:

  • What are the connections among health care, public health, and imperialism, and how have these connections changed as resistance to imperialism has grow in the Global South?

The authors are referring to those countries in the Southern hemisphere from Africa, Asia, and Latin America as the Global South. The Global North refers to Europe and North America, and some other industrialized and advanced countries in the Northern hemisphere.

The authors in Part Four focus on the forces and institutions that have imposed a top-down reform of health care in the Global South. Such organizations as the Carnegie, Rockefeller, and Gates foundations, the World Bank and International Monetary Fund, trade agreements such as NAFTA, CAFTA, TPP, TiSA, and health organizations as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) are all termed “philanthrocapitalism” by the authors, and have implemented policies that have weakened public health standards and favored private corporations.

The final part, Part Five focuses on the road ahead, i.e., the contours of change the authors foresee and the concrete actions that can contribute to a progressive transformation of capitalist health care and society.

The authors address these questions:

  • What examples provide inspiration about resistance to neoliberalism and construction of positive alternative models in the Global South?
  • Because improvements in health do not necessarily follow from improvements in health care, how do we achieve change in the social and environmental determinants of health?
  • How does progressive health and mental health reform address the ambiguous role of the state?
  • What is to be done as Obamacare and its successor or lack of successor under Trump fail in the United States?

Howard Waitzkin and Rebeca Jasso-Aguilar analyze a series of popular struggles that focused on the privatization of health services in El Salvador, water in Bolivia, as well as the ongoing struggle to expand public health services in Mexico. These struggles are activities David and Rebeca participated in during the past decade.

These scenarios demonstrate an image of diminishing tolerance among the world’s people for the imperial public health policies of the Global North and a demand for public health systems grounded in solidarity rather than profit.

In the U.S., the road ahead will involve intensified organizing to achieve the single-payer model of a national health program, one that will provide universal access and control costs by eliminating or reducing administrative waste, profiteering, and corporate control.

Gaffney, Himmelstein, and Woolhandler present the most recent revision of the single-payer proposal developed by Physicians for a National Health Program (PNHP). They analyze the three main ways that the interests of capital have encroached on U.S. health care since the original proposal:

1) the rise of for-profit managed care organizations (MCOs); 2) the emergence of high-deductible (“consumer-directed”) health insurance, and 3) the entrenchment of corporate ownership.

The authors offer a critique of Obamacare, explain and demystify innovations as Accountable Care Organizations, the consolidation and integration of health systems, something yours truly has discussed in earlier posts as they relate to workers’ comp, and the increasing share of costs for patients.

The next two chapters concern overcoming pathological normalcy and confronting the social and environmental determinants of health, respectively. Carl Ratner argues, that mental health under capitalism entails “pathological normalcy.” Day-to-day economic insecurities, violence, and lack of social solidarity generates a kind of false consciousness in which disoriented mental processes become a necessary facet of survival, and emotional health becomes a deviant and marginalized condition.

Such conditions of life as a polluted natural environment, a corrupt political system, an unequal hierarchy of social stratification, an unjust criminal justice system, violent living conditions due to access of guns, dangerous working conditions, and so forth, Ratner dissects as the well-known crises of our age in terms of the pathologies that have become seen as normal conditions of life.

Next, Muntaner and evolutionary biologist Rob Wallace show how social and environmental conditions have become more important determinants of health than access to care. They emphasize struggles that confront social determinants through changes in broad societal polices, analyze some key environmental determinants of health including unsafe water (Flint again), capitalist agribusiness practices, and deforestation in addition to climate change. And they refer to the impact these have on emergent and re-emergent infectious diseases such as Ebola, Zika and yellow fever.

Lastly, Waitzkin and Gaffney try to tackle the question of “what is to be done.” They outline four main priorities for action in the U.S. and other countries affected by the neoliberal, corporatized, and commodified model of health care during the age of Trump:

  • a sustained, broad-based movement for a single-payer national health program that assures universal access to care and drastically reduces the role of corporations and private profit, 2) an activated labor movement that this time includes a well-organized sub-movement of health professionals such as physicians, whose deteriorated social-class position and proletarianized conditions of medical practice have made them ripe for activism and change, 3) more emphasis on local and regional organizing at the level of communal organizations…and attempted in multiple countries as a central component in the revolutionary process of moving “beyond capital”, and 4) carefully confronting the role of political parties while recognizing the importance of labor or otherwise leftist parties in every country that has constructed a national health program, and understanding that the importance of party building goes far beyond electoral campaigns to more fundamental social transformation.

In their book, the authors try to answer key and previously unresolved questions and to offer some guidance on strategy and political action in the years ahead. They aim to inform future struggles for the transformation of capitalist societies, as well as the progressive reconstruction of health services and public health systems in the post-capitalist world.

Throughout this review, I have attempted to highlight the strengths of the book by touching upon some of the key points in each chapter.

If there is a weakness to the book, it is that despite the impressive credentials of the authors, they like many other authors of left-of-center books, cling to an economic determinism as part of their analysis, which is based on theories that are more than one hundred years old.

As I stated in the beginning of this review, my views have been tempered by examining and incorporating other theories into my consciousness. One theory that is missing here is Spiral Dynamics.

Spiral Dynamics is a bio-psycho-social model of human and social development. It was developed by bringing together the field of developmental psychology with evolutionary psychology and combines them with biology and sociology.

In Spiral Dynamics, biology is concerned with the development of the pathways of the brain as the adult human moves from lower order thinking to higher order thinking. The social aspect is concerned with the organizational structure formed at each stage along the spiral. For example, when an individual or a society is at the Beige vMeme, or Archaic level, their organization structure is survival bands, as seen in the figure below.

At the Purple vMeme, or Mythic level, the organizational structure is tribal, and so on. There is, among the authors of the book, an evolutionary biologist, but it is not clear if he is familiar with this theory and what it can bring into the discussion at hand.

It would not only benefit the authors, but also the readers to acquaint themselves of this valuable theory which would present an even more cogent argument for better health care. As the book concludes with a look at the future of health care after capitalism, knowing the vMemes or levels beyond current levels will enhance the struggle.

As I continue reading the book, I hope to gain greater insight into the problems with privatized, corporatized, free-market capitalist health care. My writings to date in my blog has given me some understanding of the issues, but I hope that the authors will further my understanding.

I believe that anyone who truly wants to see the U.S. follow other Western nations who have created a national health program, whether they are politicians like Bernie Sanders, his supporters, progressives, liberals, and yes, even some conservatives who in light of the numerous attempts to repeal and replace the ACA, have recognized that the only option left is single-payer. Even some business leaders have come out and said so.

I recommend this book to all health care professionals, business persons, labor leaders, politicians, and voters interested in moving beyond capital and realizing truly universal health care and lower costs.

 

Three Strategies for Improving Social Determinants of Health

A shoutout to Irving Stackpole for bringing this to our attention today on LinkedIn. This is an important topic that can address the serious issue of poverty in our inner cities.

The topic of food deserts first gained national attention thanks to the efforts of former First Lady, Michelle Obama, who not only created a vegetable garden on the White House grounds, but championed the creation of other gardens in inner city elementary schools.

One in particular was created at a Washington, DC school, and Mrs. Obama invited Chef Robert Irvine of Restaurant: Impossible to cook for inner city school children at Horton’s Kids, a local community center that provides after-school meals for kids.

So an article last week in Managed Care magazine, discussed the three strategies health care systems and payer organizations are trying to address patients’ social needs.

The first strategy, Tackle a neighborhood, focuses on the work ProMedica, a 13-hospital not-for-profit system in Toledo, Ohio is undertaking.

In the UpTown neighborhood of Toledo, the average median household income is less than $21,000 a year, and more than a quarter of all adults have not completed high school. Few residents have homes or vehicles, and healthy food options are hard to come by.

One way they are dealing with the food deficit in the neighborhood is by opening a grocery store called Market on the Green, and is a joint project of ProMedica and the Ebeid Institute.

They also initiated a job-training program, a financial opportunity center, and personal-finance advice and programs.

Last year, ProMedica doubled down and announced a 10-year plan to invest $50 million to create a national model for neighborhood revitalization. In March, they announced a partnership with a New York City-based nonprofit to invest additional capital to spur further economic growth.

Lastly, they expanded their screened 4,000 Medicaid patients who use the food clinic, and found that emergency department utilization decreased by 3%, and 30-day readmission by 53%, with a modest increase in utilization of primary care.

They also expanded screening  to include housing, transportation, and other social needs.

The second strategy is Tackle the top problems.

Here, Humana has been working on its Bold Goal, a population health strategy to improve the health of the communities it serves by 20%.

Humana wants to increase the number of “healthy days” in seven markets: Louisville, KY; Knoxville, TN; San Antonio, TX; Broward County, Fl; Baton Rouge, La; New Orleans; and Tampa Bay.

In the first year, the San Antonio market showed a 9% increase in healthy days, which was attributed to several initiatives, namely a telepsychiatry pilot to increase access to behavioral health services, food insecurity screening at primary are offices, and a collaboration with other organizations to improve diabetes management,

Finally, the third strategy is Develop a social determinants workforce.

Trinity Heatlh, a 93-hospital health care system in Michigan, and one of the largest Catholic systems in the country, has been addressing their patients’ social needs through a series of small experiments.

Trinity’s strategy is to develop a cadre of community health workers who will use pathways, regimented, evidence-based multistep protocols to help individuals address their specific needs.

Trinity found that by focusing on patients covered by Medicare, Medicaid, or both, and assisted by community health workers, they reduced their emergency department and hospital utilization considerably.

Trinity also hired AmeriCorps workers to serve as community health workers in nine markets. They focused on the social determinants of health of a narrow group of patients: high-utilizing eligibles in an ACO or other at-risk contract.

The strategies these organizations are undertaking are bold initiatives that show some promise of success, but time will tell just how successful they will be.

Yet, in an era of huge tax cuts going to the wealthy, and budget cuts  eliminating many government programs or severely limiting them, these companies are taking decisive action to reverse decades of neglect and despair in our inner cities.

But they won’t be effective unless there is greater cooperation from the communities they wish to serve, and from the rest of the health care community, and those in other institutions.

There is an accompanying story here: Social Determinants of Health: Stretching Health Care’s Job Description.