Better Health at Lower Cost: What Can a Community Do?

Doctor Joshua Freeman of the University of Kansas Department of Family Medicine spoke in several places in Oregon this week, giving a presentation on “Better Health at Lower Cost: What Can a Community Do? Social Determinants of Our Health.”

It was a provocative and informative talk. The text of Freeman’s presentation slides and the graphics are below, by kind permission of Dr. Freeman.

   What is social justice?

   What are the social determinants of health?

   How do they impact on health and health care?

   How can communities improve their health by addressing the social determinants of health?

Social Justice
   John Rawls, A Theory of Justice
   All social primary goods – liberty and opportunity, income and wealth, and the bases of self-respect – are to be distributed equally unless an unequal distribution of any or all of these goods is to the advantage of the least favored.” –  Rawls, “A Theory of Justice”, Belknap Press, Cambridge, MA 1971, p 303

Franklin D. Roosevelt:

   Do we have a system of social justice as Rawls or Roosevelt describe in the US?

   NO — We have a system in which the most privileged exert great influence, and (sometimes mostly seem to) use it to increase their privilege.

The 4 core principles are:



•Justice, in health care, can thus be seen as health equity: everyone has the opportunity to access appropriate care.

•A further extension: No one should access inappropriate care.

•Conflict with autonomy?

•Depends in part on how the health system is organized and funded.


Rudolf Virchow “The Father of Social Medicine”

    “The physicians are the natural advocates of the poor, and social problems fall to a large extent within their jurisdiction.

  “Medicine has imperceptibly led us into the social field and placed us in a position of confronting directly the great problems of our time.”  — Virchow: “Report on the Typhus Epidemic in Upper Silesia”, 1848


Dr. Julian Tudor Hart, empirically demonstrated the Inverse Care Law

“The availability of health care services is inversely proportional to the need for them.”

Dr. Julian Tudor Hart, “The inverse care law”, Lancet. 1971 Feb 27;1(7696):405-12

Whitehall Studies

    Michael Marmot and colleagues in England; began in 1960s

    Studied civil servants, people working in the offices at the seat of British government, to minimize the impact of external factors

    Found that health status and mortality are directed related to class

    Whitehall II studies began in 1980s began to elucidate mechanisms

    “Stress” of life with less money and time Components of the “Social Determinants” (among others)






   Treatment / education of women  (The single greatest determinant of the overall society, especially its economic standing, is the education of women.)


Social Determinants of health – the “Cliff analogy” – Camara Jones, MD MPH PhD

How are the Social Determinants of Health Manifested in the Health of Communities?
Jones CP, Jones CY, Perry GS, “Addressing the Social Determinants of Children’s Health: A Cliff Analogy“, Journal of Health Care for the Poor and Underserved, Nov 2008, 20(4):,Supplement, pp. 1-12


Dr. Jones asks: Why are there differences in resources along the cliff face? Why are there differences in who is found at different parts of the cliff?


Why are members of some racial and ethnic groups disproportionately represented in the lower socioeconomic group that has worse social determinants?

How does this play out in the health of people in our communities?


   “We met Tommy Davis in our hospital’s clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient’s privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences. 

   The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening’s end he’d been sent home with a diagnosis of metastatic colon cancer.

   Mr. Davis had had an inkling that something was awry, but he’d been unable to pay for an evaluation… “If we’d found it sooner,” he contended, “it would have made a difference. But now I’m just a dead man walking”.  

Stillman M, Tailor M, “Dead Man Walking”,  NEJM October 23, 2013.
DOI: 10.1056/NEJMp1312793

“I didn’t have the money even to walk in the door of that office…”

Late last month, Donna Atkins, a waitress at a barbecue restaurant, learned from Dr. Guy Petruzzelli, a surgeon here, that she has throat cancer. She does not have insurance and had a sore throat for a year before going to a doctor. She was advised to get a specialized image of her neck, but it would have cost $2,300, more than she makes in a month.I didn’t have the money even to walk in the door of that office,” said Ms. Atkins. (Tavernise, S. Cuts in hospital subsidies threaten safety-net care. New York Times, November 9, 2013)

The gravest of all quality deficits is denial of care”*

   Can we really say that we provide quality care if people do not have access to it?

   Measuring the quality of care given to people you gave care to doesn’t reflect the care received by the whole population.

   The appropriate measure for population health is the quality of care given to everyone who needed it, included those who were unable to access it.

* Schiff GD, Bindman AB, Brennan TA., “A better-quality alternative. Single-payer national health system reform.” Physicians for a National Health Program Quality of Care Working Group. JAMA. 1994 Sep 14;272(10):803-8.

What we can do vs. what we could do

    We have highly advanced technology
    We have tremendously skilled physicians and surgeons
    We have top notch hospitals
    We have incredible imaging procedures
    But not everyone can access these wonders
    Sometimes we apply them too liberally 

    What should Tommy Davis have done?
    What should Donna Atkins do?
    How do we advise them?
    What can we do for them?

This is a problem we face daily

   Just a few real people that I saw in one week on our family medicine inpatient service (names and non-relevant details changed):

Get a job!

    AG has diabetes and high blood pressure.

    He had lost his job, and while unemployed and without health insurance he hadn’t been going to the doctor. Luckily, his chronic diseases weren’t bothering him much, except for a small sore on the bottom of his foot.

    He finally found a job, a reasonably good job with the promise of health insurance after a while. Unfortunately, it involved walking almost 20 miles per day, not a good thing for his foot.

     The foot developed a severe infection, requiring expensive hospitalization for intravenous antibiotics, and might still need to be amputated.

Get a place to live!

    PS also has diabetes and, in late middle age, presents with a very serious infection, requiring not only intravenous antibiotics, but surgery to clean out the pus, resulting in an open wound.

    A machine attached to his leg to drain out the residual infection and keep it clean will need to be regularly replaced for many weeks as he continues the intravenous antibiotics.

    Fortunately (should you ever be in a similar situation), home health can be arranged to provide these services. . . . Provided, that is, you have health insurance coverage. Oh yes, and a home. PS has neither. This makes follow-up care a little more difficult.

Health Disparities [vs. inequities]

   The social determinants of health manifest as disparities in health status

   Inequities are disparities that could be addressed

   Some places have done a better job than others

   For example, maybe the situation for my patients would have been better if they lived in Oregon, which has expanded Medicaid, than it was in Kansas.


From UCSF Center for Health disparities

White mortality rates rising

    Case and Deaton (economists) study, Proceedings of the National Academies

    White mortality rates in US rising – all other groups and developed nations decreasing

    Not evenly distributed across class: in low-income, lower-educated (HS or less)

    Not new: Virginia Commonwealth University study reported early 2014

    Causes of increased death rates are substance abuse, suicide

    Loss of “American dream”

    African-American mortality rates still higher


Perspective in Absolute Risk: Life expectancy as a consequence of personal wealth. Brookings Institution: U. of Michigan Health and Retirement Study as reported by Sabrina Tavernise New York Times 2016_02_12

Note: The [life expectancy] gap is large and increasing.

Note for women, the life expectancy for the bottom 30% is DECREASING.

For context, median household income is $53K, and in the 40s for individuals; an individual making $100K is in the top decile.


The Woolf “Thought Experiment” Short blue bars – deaths we could avert by medical advances; Tall maroon bars – deaths we could advert by eliminating education-associated excess mortality Woolf et al, AJPH 2007, 97:679-83

The Woolf Thought Experiment:

Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances
Woolf et al, AJPH 2007, 97:679-83

Woolf demonstrates that even if we attribute all reduction in mortality over to medical advances (nowhere near true; most are due to the types of societal change generally characterized as “public health”, such as clean water, sanitation, and cleaner air), eliminating the disparities that exist on the basis of educational level would dwarf that change, as shown in this table.


•Allows comparisons between states and counties.

•Ranks State vs. State or County vs. County by Education (% of people with at least some college) and Income (% of people over 200% of poverty)

•Has a very cool slider that allow you to see what would happen to health indicators if Education or Income went UP or DOWN. You can select a state or county and see which are the best and worse states or counties within a state. The “slider” allows you to change those percentages and it reveals how many lives would be saved.


    In Education, near the top with 63% of people earning at least 2x the poverty rate (low WV 41%, top CO 66%, national average 56%)

    In Income also high, at 67% of people having earning twice the poverty level (range 56% in MS to 80% in NH, average 68%)

    There are 12,900 deaths/year, 197,000 people with Diabetes, and  $999 million spent on caring for diabetes

    In Oregon, if
  5% more people attended some college, and
  4% more had an income higher than twice the federal poverty level,
we could expect to save 1,300 lives, prevent 11,300 cases of diabetes, and eliminate $54.7 Million in diabetes costs every year.

    Best: Clackamas County, 77% >200% poverty
    Worst: Wheeler County, 50%

    Best: Benton County, 77% w/ at least some college
    Worst: Jefferson County, 44%

   Others: Inc/Educ    Multnomah: 67% / 68%; Lane: 63% / 64%Marion: 61% / 55%; Benton: 64% / 77%; Linn: 67%/53%


From Clackamas to Wheeler County, there is just one (Wasco) in between; same for Benton to Jefferson County.

In Kansas, the richest and healthiest county (Johnson) and poorest and least healthy (Wyandotte) are right next to each other.

What can WE, providers and communities, do?

“To improve health the US must spend more on social services”

    Bradley and Taylor, “To Fix Health Care, Help the Poor”, challenge the idea that the US spends more per capita on health [than other nations].

    Amounts are closer if all social service spending factored in

    US is exception in that almost all of this money [social service spending] is spent on medical care.

     To fix health care, help the poor”, NY Times, 12/8/11

    Bradley E et al, “Health and social services expenditures: associations with health outcomes.” BMJ Quality and Safety 2011 Oct 20(10):826-31.


•Not discriminate

•Provide Justice/Equity: the same options for care available to everyone

•Not “make assumptions”

•Provide new and expanded services based upon the need in the community, not profit or competition

•However, providers will respond to financial incentives.

•Who bears the cost?


•Address the social determinants of health

•Support government and private programs that benefit the “least advantaged”

•Provide equity in philanthropy


Harm reduction model: anything that decreases harm, or ill health is good: Homes first … harm reduction


   States (Colorado) and cities (New Orleans, Houston) have nearly eliminated homelessness

   Rather than requiring people to clean up all the rest of their act (drugs, jobs, etc.) to get housing, these cities recognize that having a place to live  makes it possible for people to focus on the other things they need to do. Otherwise there is a usually insurmountable wall.Housing in Oregon

   “Formerly Homeless People Had Lower Overall Health Care Expenditures After Moving Into Supportive Housing.”

   Housing for the homeless saves $8700 in health care spending the first year
    Wright, et al. Health Aff January 2016 35:20-27;


    Kansas City Kansas community: collaboration with community researchers
    Community: OK, we need sidewalks
         Us: Oh, we do health
    Community: Food desert: Transportation
         Us: Got a grocery to come in!
    Community: How do I walk there? No sidewalks…
    How do I exercise?
    “I can’t walk; I don’t have a car!”
    Communities collaborating on . . . sidewalks.


   Dr. Michael Marmot, leader of the “Whitehall Studies”
(showed that social class is linearly connected to health status)

   Recently President of the British Medical Association (2011)

   Development of white paper – and action“Social determinants of health: what doctors can do,” an effort by the British Medical Association to identify:
     •   principles of addressing social determinants of health
   Evidence for effectiveness of interventions
     •   Direct and indirect impacts

     •   Best practices being implemented.

     •   But really: What doctors and communities in collaboration can do!

Camden model: “The Hotspotters”

    New Yorker article by Dr. Atul Gawande:

    Jeff Brenner and others in Camden: Camden Coaltion of Healthcare Providers

    Collaborations with other cities and with faith-based organizations:
Kansas City’s Communities Creating Opportunities (CCO)


     •   Coordinated Care Organizations: Type of ACO
     •   Local control: Fifteen community boards
     •   Flexibility in what to spend money on
     •   Plan to reduce spending [rate of] increase by 2% per year (5.4% to 3.4%),
save $8.6B in 10 years

     •   Pretty successful;
    Cost saving (but increase in primary care = good!)
          •    Improvements in quality with bonus payments

          •    Improvements in “screening, brief intervention, and referral to treatment for alcohol and substance use (0.1% to 7.3%)
    Less consistent improvement in quality measures not tied to bonus

(McConnell, KJ, “Oregon’s medicaid coordinated care organizations”,
JAMA 1 Mar 2016; 315(9):869-70.)


Gov. John Kitzhaber, MD [asked]:

Which will most benefit a 92-year old who lives alone during a heat wave?
(a) Ambulance ride to ED, treatment and probable admission, risk to life, at cost of many $Thousands once she is found with heat stroke and dehydration?


(b) $200 air conditioner?

   “One thing unique about the C.C.O. process is the degree to which it focuses on all the elements of an Oregon Health Plan recipient’s life.”
(i.e., Social Determinants of Health)


    Questions to ask in philanthropy:

    Will the project I am donating to improve the health of all people or the most vulnerable?

    Or will it just create more options for those who already have access?
(The non-underserved)

    Does a community benefit from private fund raising for duplicative services?

    Example: If I donate to create or expand a cancer center at hospital X when there is already one at hospital Y, will it serve different people and expand care, or will it just try to “steal” hospital Y’s?

    Community benefit vs. institutional benefit

    Equitable distribution of health resources
     •    Social determinants of health
    Recognizing systemic injustice
     •    Advocating for positive change in the health care system and society
    Content about eliminating structural violence
     •    Specific understanding about how social issues lead to poor health

“Health in all” policies

     •   Require work in the community
     •   Transportation
   Land use
   Built environment
     •   Taxes

     •   Housing
   Environmental justice

    Social conditions are the biggest determinant of health status

    Social inequities (lack of social justice) results in health disparities

    Addressing inequities decreases disparities and the burden of ill health

    Communities – if possible, in collaboration with physicians and other health care providers — can and should be involved in efforts to address disparities and advocate for social justice in order to improve their health

Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary.”  –   Martin Luther King, Jr

“Charity isn’t a good substitute for justice”  –  Jonathan Kozol.

 “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”  –   Martin Luther King, Jr
Joshua Freeman, MD, Department of Family Medicine, KUMC
3901 Rainbow Blvd., MS 4010
, Kansas City, KS 66160        


Copernicus Healthcare. 2015. Hardcopy or Kindle