When the problem is defects in the structure of "the market", financial incentives won't do much good: Maryland's health enterprise zones

Yesterday's Washington Post has an article, "Prince George's hopes to bring doctors to a Zip code where there are few," about Fairmount Heights in Prince George's County, an impoverished area that is a "health desert" with very few medical professionals and a population with a great many health issues (also see "A growing problem in Prince George's" from the Post which illustrates that Prince George's County has more systemic health problems that aren't necessarily derived from poverty--7 out of 10 people are obese).

Maryland has introduced "health enterprise zones" to attract medical professionals and facilities to underserved areas, by providing some financial inducements.

The real problem is that "the market" in health care and wellness programming isn't a "free market."

The problems with providing health care to underserved populations has to do with people not having money to pay for care.  It's abetted by the fact that the health care system is set up to provide catastrophic care to sick people with insurance, and isn't focused on helping people be healthy, and by doing so, reducing their overall demand for health care, which can be expensive.

From the article:

In a virtual health-care desert, resident Daisy Capers shakes her head as she describes countless preventable predicaments. In medical parlance, a severely underserved community has one physician for every 3,500 residents. In her Prince George’s County Zip code, 20743, there is one for about every 7,000.

At the same time, residents have the county’s highest rates of hospital admissions because of preventable diseases, such as high blood pressure, angina and long-term diabetes. According to county health statistics, a Fairmount Heights resident would be four times more likely to be hospitalized because of diabetes than a resident of Laurel. Life expectancy is 72 years, seven years fewer than the state average. ...

There are many ways to combat poverty, but Maryland is the first state in the nation to try an approach focused solely on health care. Taking a page from tax-incentive programs that have spurred businesses in troubled corridors, the state has designated the Zip code one of five “health enterprise zones” in hopes of luring more medical resources to the community.

The designation entitles the area to $1.1 million in state funding that can be used to help pay off loans for recent medical school grads, purchase discount medical equipment or provide security at clinics. Those perks are intended to be enough to lure five clinics to set up shop over the next three years and recruit 11 full-time primary-care physicians, two dentists and five nurse practitioners to staff them.

So providing a modicum of financial incentives to health care providers to locate in underserved areas, as the Maryland program intends, doesn't do much for people without insurance/money to pay for health care in a system where insurance coverage dictates your access to resources.

In short, I can't see how the Maryland program will have much substantive impact.

There are some interesting examples of ways to change how health care services are provided to the poor, but they require more focused public involvement and funding than what's happening in Maryland--integrating innovation, programming, facilities and financing.

I've written about a couple best practice examples (such as in "Revisiting an example of a real need for regional planning: hospital and wellness services") but there are others.

And while I am criticizing the Maryland initiative, I feel exactly the same about DC's various antics with  the United Medical Center, the only hospital in DC "east of the river" and serving a predominately poor client base.  The hospital has many financial problems and the DC Government is doing various things (not the right ones, in my opinion) in trying to fix the finances.  See "United Medical Center must address 'structural challenges,' consultants say" also from the Post.

I think the solution is to integrate hospitals with community-based clinics and "insurance."

There are some examples of the pieces that can be put together.

1.  The Take Care/Minute Clinic model of the pharmacy industry can be combined with traditional community clinic initiatives of public health departments to deliver basic health care, including the management of some chronic diseases, in disadvantaged areas.  (See "Disruptive Innovation Once Again.)

2.  You could even combine ithese services with a pharmacy/little market, as a kind of public-private partnership.  A key element is to provide service beyond "government hours" of 9am to 5pm Monday through Friday.

3.  DC already has a good system of community clinics.  But while a strength of these clinics, called "medical homes," is their independence, the potential positive impact from knitting these clinics into a network and providing systematic care to people with greater needs is considerable.

... moving more toward how the Bucks County Health Improvement Partnership works.

4.  The piece about planning for health and wellness cites an article about the Denver public hospital and clinic system, ("Denver Health Becomes Profitable After Using Toyota as a Template: Lean manufacturing has made Denver Health a model for public health care") from Governing Magazine. There they have integrated the public hospital with community clinics in the manner that I think we should move towards. From the article:

For Denver Health, the key to eliminating waste turned out to be integration, or restructuring operations at its different facilities to create one mega-system of patient care. The organization treats 170,000 patients annually, more than one-third of the city’s population. Forty percent of the city’s children seek treatment there. Roughly 70 percent of the patients are ethnic minorities, and many of them don’t speak English. Most are poor, and 42 percent of them are uninsured. In addition to a large primary hospital and emergency room, Denver Health comprises eight community health centers, each equipped with its own pharmacy, and another 13 school-based health centers. Denver Health also runs the city’s 911 emergency medical services system, a non-emergency medical hotline, the Rocky Mountain Poison and Drug Center, and the Rocky Mountain Regional Trauma Center.

But as far as Denver Health is concerned, all those disparate elements are the same. Every one of those institutions shares the same information system, and every patient who enters the system is assigned a number. So whether someone checks into the emergency room or an outpatient specialty clinic, physicians can access all the relevant data that Denver Health has ever accumulated. It’s been a major shift in the way the system operates, says Thomas Mackenzie, who, as chief quality officer of Denver Health, is charged with implementing and maintaining the lean principles. “It’s not thinking about things in different silos for different components,” Mackenzie says, “but thinking about how you can provide the best care for patients across the whole continuum of care.”

5.  St. Anthony Hospital in Chicago is doing something similar, but not focused on the whole city, but in their greater neighborhood of Lawndale.  From "Chicago safety-net hospitals face uncertain future amid changes to health care system: Area has 20 safety-net hospitals, which are a stop-gap medical system for the poor" in the Chicago Tribune:

When now-CEO Guy Medaglia arrived as a consultant in 2007, the 151-bed hospital was losing millions of dollars annually. Medaglia was tasked by its then owner, Ascension Health, with closing or selling it.

Instead, he emboldened the hospital's board to break away from the chain in 2009 and become independent.  Despite that commercial insurance covers fewer than 1 percent of its patients, St. Anthony has posted operating income nearly every year since.

St. Anthony embarked on its turnaround after assessing the needs of its community and tailoring its services to match. It now functions as a de facto community hub, teaching language classes and hosting courses for people studying to take high-school equivalency tests. It also added health services like dialysis and occupational health and expanded its infusion, pediatric and maternal centers.

"If you're doing what the community needs, you become very valuable to them," Medaglia said. "And to continue to serve them, you really have to think out of the box. You have to think: What can we do that's different, that can service this community at a lower cost and higher quality?"

St. Anthony is pushing forward with plans to build a 1 million-square-foot commercial development at 31st Street and Kedzie Avenue anchored by a 100-bed replacement hospital.

The $430 million Focal Point development is slated to be built on 11 acres acquired from the city for $1 by a nonprofit affiliated with St. Anthony. The complex is set to include two schools, retail stores, a child-care center, an indoor recreation facility and an athletic field.

This concept is not unlike the integrated programming model provided by the Ripley Centers of Houston's Neighborhood Centers Inc., which is one of the case studies in the The Metropolitan Revolution book I reviewed a couple weeks ago.

6.  Mississippi has a similar public health service model for impoverished communities, modeled after a program in Iran.  See "What Can Mississippi's Health Care System Learn From Iran" from the New York Times.

-- HealthConnect, Mississippi State University
-- Delta Health Alliance

7. While I am not sure I am "down with" this idea of health districts/facilities as expressed by the Congress for the New Urbanism, because they are focused on too narrow segments of the health care consumer market, rather than transforming access to health care for the impoverished, I can see how hospitals could anchor improvement initiatives in general revitalization initiatives, in weak real estate markets/poor neighborhoods, if the hospital is focused externally, rather than internally, and works to interconnect with the community as with the St. Anthony Hospital example.

That's counter to the approach that seems to be taken with United Medical Center in DC.

And when doing some commercial district analysis work in a couple neighborhoods in Pittsburgh, that was my experience there too, in Northside, Lawrenceville, and Bloomfield--they have hospitals but the hospitals don't have much revitalization impact.  They could, but it has to be purposive.  Although the hospitals in Northside and Bloomfield did contribute financially and otherwise to community improvement in significant ways, the impact ends up being more indirect. (In Philadelphia, the Frankford Hospital and the University of Pennsylvania Medical Center help to fund business improvement district initiatives in their communities.)

Similarly, Prince George's County has an opportunity to set up a similar kind of system (combining the ideas of St. Anthony and Denver Health) as the University of Maryland Medical System has committed to taking over the hospitals in Prince George's County and building a new facility.

While the smart growthers have agitated for locating a new hospital at a Metro Station (e.g., "Prince George's hospital site starts and stops with Metro" from Greater Greater Washington), no one is really talking about how to systematically provide a different community health care oriented model that addresses the ongoing health problems present in the County.

Typically hospitals are behemoths that are internally focused, so it becomes very difficult to harness their activities in ways that strengthen surrounding neighborhoods, except maybe if the hospital has a program that provides mortgage support programs to employees who choose to live in nearby neighborhoods.

8.  Note that in Travis County/Austin, Texas, there is a health district millage that helps to fund the public hospital system and deliver care, which is an interesting funding model.  It's branded as Central Health.

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When I get around to writing my "Marshall Plan" position paper for eradicating poverty in Wards 7 and 8, the Denver Health/St. Anthony/HealthConnect models will be a key element of the program.  (Not the Maryland concept...)