Why We Can’t Let Health Care Drive Health


Editor’s Note: Cambia Grove is proud to partner with the innovation community to amplify their perspectives on topics applicable to the larger health care ecosystem. This Q+A conversation took place at Cambia Grove’s June 16 event, “Paying for Health: A Community Perspective.” For a recap of that event or other events in the series, click here. Speakers’ comments have been edited for length. The views expressed in this article are solely those of the author and do not necessarily reflect the opinions or positions of Cambia, Cambia Grove, or any other entity or organization. 

The collapse of a federal response for COVID-19, and the handing over of that critical work to state and local governments, has created an urgent new focus on the role of communities in health care. Three experts share their perspectives – with some surprising insights into what “community” and “health” really mean in Washington state, today and for our future.

Nichole Maher is President and CEO of Group Health Foundation. Suzanne Delbanco is Executive Director of Catalyst for Payment Reform, a group of large purchasers of health care. Bob Crittenden, MD, MPH, is emeritus Executive-in-Residence at Cambia Grove, Physician and former Health Policy Advisor. DJ Wilson, CEO of State of Reform, moderated the session, with Maura Little, Executive Director at Cambia Grove, moderating audience Q&A.

1. Has Group Health Foundation discovered any surprises about the health needs of our state?

Nichole Maher 

We’re a start-up foundation, and part of our origin story is our Board of Directors’ explicit focus on health equity and a broad definition of health. The “social determinants of health” is our whole frame of health.

What’s so fascinating is that we found a real difference between what public health experts were saying compared to what communities in all 39 counties in Washington were saying – about the highest health priorities. The four concerns we hear from communities are fear of violence; loneliness and isolation; racism; and a real concern that people from elite backgrounds, who don’t look like the children of Washington, continue to design solutions that don’t work. 

The invitation is to stop referencing that “race” impacts health outcomes. “Racism” impacts health outcomes.
– Nichole Maher

The invitation from communities to health leaders is to stop referencing that “race” impacts health outcomes. “Racism” impacts health outcomes. There’s a false narrative in our state that we’re not diverse, but over 50% of children in public schools are people of color and immigrants. Many counties are majority people-of-color counties and have been since 2006 or earlier.

2. How do we meet the goal of payment reform while meeting the needs of diverse communities?

Suzanne Delbanco

Currently, there’s no such thing as reliable value from the health care system. Payment reform can change the dynamic among the purchaser, payer, provider, and patient. We want to align incentives so that everybody is aiming toward better health in an affordable, efficient way. 

Large purchasers know that how they buy health care sends a signal to the health care system.
– Suzanne Delbanco

I’m working with large purchasers of health care who know that how they buy health care sends a signal to the health care system about what they want it to produce. What purchasers are looking for, of course, is better health for less money.

Traditional fee-for-service, where we pay an amount for every unit of service delivered, encourages more expensive care. If we pay for a bigger chunk – for a whole episode of care or a whole person over time – then we reduce the administrative complexity and increase the ability of providers to think more laterally and broadly about how to produce health. 

3. Why is payment reform so hard?

Bob Crittenden 

Payment reform is absolutely essential. But the issues that drive good health are things like a job, good housing, and being able to afford college. We have to think upstream. We have to think about the whole picture and how we spend our money as a society, not just within health care. Health is influenced by health care, but only marginally so. We can’t let health care drive health.

Health is influenced by health care, but only marginally so.
– Bob Crittenden, MD

Suzanne Delbanco

Too many people make lots of money on the status quo. It’s costly for payers to create new mechanisms to pay for whole episodes of service. It’s costly for providers to figure out how to take a bundled payment, how to distribute it across providers they’re collaborating with, and who’s accountable if something goes wrong.

In 2010, between 1% and 3% of provider payments had a performance incentive attached. Now around 60% of provider payments have a performance incentive attached, but macro-indicators of affordability, efficiency, and safety show that we’re not doing noticeably better. We’ve done a huge amount of work, but most of it feels more intellectual than material. 

Nichole Maher 

You can’t talk about payment reform without tracking a path directly to which institutions have PACS and 501(c)4 capacity, which ensures that their voices are heard. Those who don’t have those mechanisms are not served well. Civic engagement infrastructure is a major challenge as we reimagine our state.

4. Since the hospital “spend” is now 50% to 60% of premiums, do we need a policy to address monopoly pricing and to treat hospitals like public utilities?

Bob Crittenden 

Yes. But the system is so balkanized, and you run into where the money flows. The consolidation of hospitals hasn’t resulted in decreased cost or improved quality; it has increased pricing and been a guarantee of price-setting. We have so much monopoly pricing, even more so in urban areas. Adam Smith [the economist] would be appalled at how our market works now.

5. What about setting aside the challenge of fixing health care and instead focusing on community health?

Nichole Maher 

It’s more complex than that. It’s not: Do you fund either community health or systems change? You can’t have a systems-change, policy-advocacy effort around reform without deep capacity and leadership from communities to be part of that design process. 

We believe that you make long-term grants with maximum flexibility and invest that in communities, so they have the capacity and power – which has always belonged to them – to be an active part of those solutions. 

6. Is lower-cost health care “better” health care, based on data from payment reform compared to fee-for-service models?

Suzanne Delbanco

There’s evidence that 10% to 30% of what we spend on health care is overuse, waste, or inappropriate care. We know we’re overspending in certain ways that aren’t beneficial to people. We also need more research on the myth that health care jobs are good for the economy. For every job you add in health care, you lose about 0.8 of a job in another industry. 

7. Is it time for America to have a conversation about defunding health care, similar to defunding the police?

Bob Crittenden 

There is little overt demand that we get rid of the health care system. Quite the opposite. People don’t know they’re getting lousy care compared to other developed countries. But if communities demand a political voice to redirect where health care dollars go, then we’ll see change. It’s going to be a noisy discussion.

Suzanne Delbanco

In this country, the discussion is always around insurance coverage, but that’s not the same as having access to health care or access to health. We’re not looking at the bigger picture. People are incredibly frustrated and talk about “single payer” or “Medicare for all” as though that’s the solution. That’s just about coverage; it’s not about how we approach the allocation of our dollars. 
Nichole Maher 

We’re in a profound moment of awakening as a country. We’re deciding if we are a country willing to reconcile with our past of chattel slavery and attempted indigenous genocide – and if we’re willing to rebuild systems. When I look at the advocacy for all-out reform for criminal justice and how we police, I’m excited. I hope it’s just the beginning of many things we are willing to reconcile, re-imagine, and redesign, to leave a different legacy.

8. Are purchasers willing to invest in the social determinants of health?

Suzanne Delbanco

It really varies by employer, and whether they have low-wage workers or high-paid engineers. Employers are persuaded by the evidence they’re seeing about how addressing root causes of health can be less expensive than addressing things downstream. They’re focused on the money. There’s more interest, but it’s definitely in the “new” category.

9. Which level of policymaker – in Olympia or at the local level – least represents the children of Washington?

Nichole Maher 

It’s at every level. We live in a country where only about 33% of Americans are white men, but they make up over 70% of our elected roles. Over 90% of our school boards are white. 

It’s easy to talk about gender and race, but it’s really important to talk about income. You have a whole group of folks who have never had to make the choice between buying groceries or buying medicine – and they’re designing whole systems of care targeted at low-income people. It’s not getting us the outcomes that we want. 

10. If you could wave a magic wand, what would you change in health care? 

DJ Wilson
The health care community coming forward with solutions that meaningfully move the dial.

Suzanne Delbanco
A real social support system in this country, so we can focus differently with our resources. 

Bob Crittenden 
Real democracy at the local level to decide whether to spend money on schools or a heart-lung machine.

Nichole Maher 
More reflective, inclusive leadership at every level.

About Rebecca Buffum Taylor

Rebecca Buffum Taylor is the Founder of Prose Arts LLC, specializing in health and medical communications, at ProseArts.com. She researched and ghostwrote The Healthcare Crisis: The Urgent Need for Physician Leadership, a look behind the scenes of our spiraling health care costs and failed attempts at reform. Congressman Adam Smith wrote of the book: “It offers a unique understanding of the factors driving costs in our health care system and is the most objective analysis I have seen on this critical public policy challenge.” Rebecca has held senior editorial leadership roles in publishing, including Editorial Director for the nation’s largest patient education publisher and VP/Executive Editor for an international photojournalism book packager. She was Executive Editor of The Face of Mercy: A Photographic History of Medicine at War, a $1.3 million international photojournalism book project published by Random House. Her clients include the American Academy of Ophthalmology, EvergreenHealth, WebMD, Kaiser-Permanente, Amazon, GeneSage.com, HealthTalk.com, Glamour magazine, Warner Books, Chronicle Books, and Jossey-Bass Publishers.