Ensuring Quality Healthcare for Vulnerable Populations
Healthcare in the United States has undergone unprecedented innovative transformations in the past decade: hospital systems have moved their legacy medical record systems to digital platforms, public and private systems are incorporating sources of “big data” for better predictive uses, and advances in genetic research have fully integrated genetic testing and counseling within the field.[1,2] But one of the most significant changes to healthcare in the past decade has been the increased emphasis on preventative care – steered, in part, by regulations outlined in the 2010 Patient Protection and Affordable Care Act (ACA).[2,3]
Private, public, and nonprofit healthcare providers have all responded to the ACA’s changes with increased funding and programming to address population-level health factors that contribute to pervasive disabilities and diseases – such as genetic predispositions, environmental factors, lifestyle choices, and social determinants of health. As more preventative care resources come available, it is important that these different sectors of the healthcare system make sure their programs reach the populations most in need.
Health disparities persist across Greater Philadelphia, with low-income, nonwhite populations often disproportionately impacted by higher incidences of preventable diseases. As the healthcare industry continues to embrace the preventative care paradigm, private-payers, hospital systems, and community health organizations all need to continually assess how their work is benefitting the region’s most vulnerable populations. They also need to recognize the importance of collaboration with one another and how innovative solutions across the healthcare industry can alleviate local health crises.
In this brief we map measures of local health inequities and highlight innovative cross-collaborations among healthcare organizations pursuing preventative care programming. We then pose questions for members of our 2019 Greater Philadelphia Leadership Exchange cohort to address during their Regional Exploration on public health in Philadelphia presented by Children’s Hospital of Philadelphia and Public Health Management Corporation.
Health Disparities in Greater Philadelphia
Health disparities are intrinsically linked to socioeconomic inequality, and Greater Philadelphia is no exception. Measures of income, employment, race, ethnicity, gender, sexual orientation, and residence correlate to varying health outcomes.[4,5] In the 2018 Health of the City report, Philadelphia’s Department of Public Health devoted an entire section of the report to social and economic determinants of health. In a widely publicized finding, the report noted that life expectancies vary dramatically by the socioeconomic status of the neighborhood – with some low-income neighborhoods seeing a 20-year disparity in life expectancy relative to wealthier neighborhoods.
To illustrate these disparities at a regional-level, we mapped life expectancy estimates from the National Center of Health Statistics' U.S. Small-Area Life Expectancy Estimates Project with median household income estimates from the 2017 five-year estimates of U.S. Census’ American Community Survey. The map below shows the drastic differences in life expectancy for low-income neighborhoods when compared to wealthier neighborhoods across the region.
Life Expectancy and Median Household Income by Neighborhood in Greater Philadelphia
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Life expectancy data comes from the National Center of Health Statistics' U.S. Small-Area Life Expectancy Estimates Project's 2010-2015 estimates while median household income estimates come from the U.S. Census' American Community Survey 2017 five-year estimates.
Poverty and race are key determinants of adverse health. Individuals experiencing poverty have higher rates of unemployment and are less likely to have any form of insurance coverage, therefore their health conditions often go untreated. Since poverty and race are correlated, health inequalities persist across racial and ethnic groups as well. In Philadelphia, Latinx/Hispanic populations exhibit some of the highest rates of chronic diseases like asthma and diabetes when compared with other racial and ethnic groups. These populations are also more likely to be uninsured. The region’s African American population does not fare much better. According to the City’s recent report on the health of black men and boys, non-Hispanic black youth are three times as likely to die before the age of 20 than non-Hispanic white youth, with homicide and heart disease being the most prevalent causes of premature death. These sobering statistics demonstrate the need for more demographically targeted preventative care addressing issues of poverty and other social determinants of health.
Many low-income groups are unable to address health needs due to barriers in accessing the healthcare system. Lack of insurance coverage, fear of costs, language and cultural differences, and historical biases in the healthcare field often prevent low-income, nonwhite populations from seeking regular care. This often pushes them to seek only emergency medical care or to substitute emergency departments as sources of non-emergent care. Emergency room visits are often used as a proxy measure for determining inadequate healthcare access. Using combined 2015 and 2018 estimates from the Public Health Management Corporation’s Southeastern Pennsylvania Household Health Survey, we mapped the prevalence of frequent emergency room visits by combined ZIP code areas. The data detail a representative sample of respondents, 18 years or older, who visited an emergency room for a medical need one or more times in the previous twelve months. In low-income areas like Upper North Philadelphia and Southwest Philadelphia, there is a far higher prevalence of emergency room visits than in wealthier areas like the Main Line municipalities in Southeast Montgomery and Northeast Chester Counties - as well as North Montgomery County.
Southeastern Pennsylvania Population's High Frequency of Emergency Room Visits
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Data were obtained from combined estimates of the 2015 and 2018 waves of Public Health Management Corporation’s Southeastern Pennsylvania Household Health Survey
According to the Pennsylvania Healthcare Cost Containment Council, approximately $1.2 billion was spent in hospital payments for “potentially preventable” hospitalizations in Pennsylvania in 2017. “Potentially preventable” hospitalizations are inpatient stays for select conditions that might have been avoided with effective primary or preventative care. Thus, preventative care has both medical and economic benefits.
Closing the Gap with Innovative Preventative Care Strategies
Greater Philadelphia is served by a vast array of private health entities, numerous hospital and medical research systems, a robust coalition of public health organizations, and a myriad of community health groups and nonprofits. Each of these entities serve a unique role within the healthcare ecosystem. Yet, with the shift of focus to preventative care, each of these entities also needs to play a role in providing quality care to the region’s most at-risk populations.
Nonprofit and community health organizations have a long history of working directly with vulnerable populations. They are on the frontlines of local health issues and have the most face-to-face interactions with the community; they can speak to the needs of vulnerable populations and keep tabs on developing health crises. Prevention Point Philadelphia is one such organization utilizing a preventative care approach, particularly with respect to the ongoing opioid crisis centered in the city’s Kensington section. Originally founded as a needle exchange program in the early 1990s, Prevention Point has become an integral resource to the area. Its clout with the communities surrounding Kensington and its ability to address prevailing social determinants behind substance abuse by providing counseling, housing, legal aid, education, and overdose-reversal training uniquely positions it as a leader. Prevention Point is often asked to share its successful strategies with cross-county gatherings of local governments, community health organizations, and private care providers.
Public health providers and hospital systems are the largest sources of primary, secondary, and tertiary care for the region. They are also the primary educators of new generations of health practitioners and the general public. Many of these entities have been using preventative care strategies for decades, and many have programs that directly work with at-risk populations. While they may have less interaction with vulnerable populations than local community health organizations, many of these entities are deploying substantial research and funding to address the social determinants of health. Examples of such initiatives in Greater Philadelphia include the Children’s Hospital of Philadelphia’s Healthier Together initiative and Jefferson Health’s Philadelphia Collaborative for Health Equity. These programs bring significant resources to bear on direct health interventions within disadvantaged local communities.
Private payers in the region have perhaps the greatest resources to address health inequalities. While many are for-profit businesses, private insurers act as the intermediaries for Medicaid coverage on behalf of state governments. This means many private payers are already providing coverage for low-income populations. Like public health providers and hospital systems, private insurers can directly address the social determinants of health. UnitedHealthcare has invested large sums in affordable housing across the U.S. because homelessness and inadequate access to shelter make preventative care nearly impossible for individuals.
There is a dawning recognition that collaborations and partnerships across the discrete elements of the healthcare ecosystem can lead to better outcomes in terms of reaching vulnerable populations and addressing health disparities. During this regional exploration on public health, we ask our leadership cohort to think about the roles each of these healthcare entities play in addressing the needs of populations most at-risk for preventable diseases by asking the following questions: How do these healthcare entities identify at-risk populations? How can these entities build collaborations that amplify their reach to vulnerable populations while addressing weaknesses in their individual approaches? What more can these entities do to address prevailing healthcare crises in the region? Participants in the 2019 Greater Philadelphia Leadership Exchange will have the opportunity to explore these questions with leaders rom Prevention Point, UnitedHealthcare, Public Health Management Corporation, Puentes de Salud, and Jefferson Health, among others.
 West, Steve. 2017. “How Healthcare Analytics Has Changed in 10 Years.” Streamline Health. Retrieved from: https://www.streamlinehealth.net/HIM-blog/healthcare-analytics-changed-10-years/.
 Vogenberg, Randy F. and John Santilli. 2018. “Healthcare Trends for 2018.” American Health & Drug Benefits, 11(1): 48-54. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5902765/.
 Wagner, Robert F. 2018. “Promoting Prevention Under the Affordable Care Act.” Annual Review of Public Health, 39: 507-524. Retrieved from: https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-040617-013534.
 Office of Disease Prevention and Health Promotion (ODPHP). 2014. “Disparities.” HealthyPeople.gov. Retrieved from: https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities.
 Artiga, Samantha and Elizabeth Hinton. 2018. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Issue Brief: May. Washington D.C: Henry J. Kaiser Family Foundation. Retrieved from: file:///C:/Users/MichaelShields/Downloads/2018-05%20INSIGHT%20KFF%20Brief.pdf.
 Department of Public Health, City of Philadelphia. 2018. Philadelphia’s Community Health Assessment: Health of the City 2018. Philadelphia, PA: City of Philadelphia. Retrieved from: https://www.phila.gov/documents/health-of-the-city/.
 Dafilou,Caleb. 2019. The North Philadelphia Latino Community Health Needs Assessment. Philadelphia, PA: The Philadelphia Collaborative for Health Equity. Retrieved from: https://p-che.org/news-resources/rfp-to-address-needs-in-eastern-north-philadelphias-latino-community/.
 Department of Public Health, City of Philadelphia. 2019. Brotherly Love: Health of Black Men and Boys in Philadelphia. Philadelphia, PA: City of Philadelphia. Retrieved from: https://www.phila.gov/documents/brotherly-love-health-of-black-men-and-boys-in-philadelphia/.
 Mathison, David J., James M. Chamberlain, Nuala M. Cowan, Ryan N. Engstrom, Linda Y. Fu, Anthony Shoo, Stephen J. Teach. 2013. “Primary Care Spatial Density and Nonurgent Emergency Department Utilization: A New Methodology for Evaluating Access to Care.” Academic Pediatrics, 13(3): 278-285. Retrieved from: https://www.sciencedirect.com/science/article/pii/S1876285913000387.
 Pennsylvania Health Care Cost Containment Council (PHC4). 2019. Potentially Preventable Hospitalizations in Pennsylvania, April (revised in May). Harrisburg, PA: Pennsylvania Health Care Cost Containment Council. Retrieved from: http://www.phc4.org/reports/researchbriefs/hospitaladmissions/17/.
 UnitedHealth Group. 2019. “UnitedHealthcare’s Investments in Affordable Housing to Help People Achieve Better Health Surpass $400 Million.” UnitedHealth Group. Retrieved from: https://www.unitedhealthgroup.com/newsroom/2019/2019-03-26-uhc-affordable-housing-path-metro-villas.html.
FURTHER READINGS ON THIS TOPIC:
Race, Gentrification and Health in Philadelphia - Brookings 2017
How will Hahnemann’s closure affect Philly’s opioid crisis? - Inquirer 2019
Staying Healthy: Access to Primary Care in Philadelphia - Department of Public Health 2018
Philly’s injection site just picked up a ton of national support - BillyPenn 2019