A frequently cited statistic in the health equity arena is that 60 percent of health care spending is driven by social factors. During the American Hospital Association Leadership Summit, July 27–29 in San Diego, Rishi Manchanda, M.D., president of HealthBegins, an organization dedicated to achieving health equity, and the former chief medical officer for a large self-insured employer based in California, will deliver a keynote speech depicting a health care system that addresses these social needs using what he calls the “upstream” approach to health care.
Can you give us a taste of what your keynote talk at the Leadership Summit will be about?
MANCHANDA: I’m speaking about the importance of the social determinants of health to health care delivery, which can sound like academic jargon. I describe it instead as the 'upstream approach to health care.' That includes how to improve population health outcomes and how to lower the overall cost of care while also improving the patient experience, commonly referred to as the Triple Aim.
I also include a fourth aim, which is improved professional satisfaction. For those doctors, nurses and others who are part of the health care workforce, the idea of enjoying work is an important aim as well.
Achieving all four is really the holy grail for American health care. That involves a practical and systematic approach to addressing those social determinants or the social needs that often are the main drivers of health outcomes.
How can hospitals address social determinants more effectively?
MANCHANDA: The approach I recommend is the 'Get Ready, Get Set, Go Upstream' approach. The 'Get Ready' element involves hospitals assessing their baseline level of readiness to address patients’ health-related social needs. That starts with a readiness assessment to see how capable the organization is to address health-related social needs.
The second part is to 'Get Set.' That means to review the results, not only internally with key groups, leaders and front-line staff, but also with partners in the community who work on upstream issues. For instance, if one of a hospital's key strategic priorities is to improve outcomes for patients with diabetes, and we know the strong link between food insecurity and diabetes, what if that hospital worked with an upstream partner like a food bank or agency that deals with food insecurity? Hospitals can review their data sources to identify unmet social needs and review existing staffing capabilities that will help them home in on at least one key patient population and one key social determinant like food insecurity, where they and their upstream partners believe they can achieve the greatest impact.
The 'Go Upstream' step allows hospitals to launch an upstream quality improvement project with a partner that goes after a key area of improvement for a specific population and social determinant. By using this three-step approach for specific populations, what ultimately will happen is the practical readiness and capability — the upstream efficacy and effectiveness for the hospital system — starts to improve, as does its ability to achieve the Quadruple Aim and improve health equity.
How would you describe the elements of the upstream approach to health care?
MANCHANDA: The first part of the approach is about making the case for social determinants themselves. The next step is to define how these issues impact health care. Sometimes health care providers will say, 'We understand that where people live and where they work plays a huge role in health, but our role is to take care of people when they're sick. We’re not community organizers, urban planners, workers or transportation specialists.'
Case in point: If you have a patient who routinely comes in and out of the emergency department, often the major driver of that is a nonmedical need. It tends to be linked to something like a lack of housing, food insecurity or social isolation. Those are nonmedical needs, but are vital to health outcomes.
The third element gets to the ‘how’ and speaks to the importance of taking the tools that hospitals already have, including quality improvement measures, to address the upstream drivers of poor health. What I call upstream quality improvement takes existing quality improvement tools and applies them to the root causes of major health care problems.
So, the four elements of a 'Get Ready, Get Set, Go Upstream' approach can help us to select and use upstream quality improvement methods, along with the tools, training and technical assistance, to improve the readiness and capability of hospitals to address upstream issues.
Why did you begin advocating for the upstream approach?
MANCHANDA: It began with my experience as a clinician. I have always been involved in caring for vulnerable populations — whether it's low-income families in South Central Los Angeles, which was my first major clinical job, or taking care of homeless veterans at the VA. I've had health care jobs that have always required me to think about how to provide the best care and the best outcomes for vulnerable populations. That direct experience is what informs my views on the upstream approach. When you’re on the front lines of clinical care, it’s hard not to see the impact of these unmet social needs.
What has the expansion of Medicaid done for the upstream approach and for addressing the social determinants of health?
MANCHANDA: There's no doubt that as more and more people gained access to insurance with the expansion of Medicaid, we saw a large influx of people who formerly were left out of health care. The disproportionate number of folks who were left out, by definition, had unmet social needs — not just lack of insurance, but all the social determinants of health — food insecurity, financial insecurity, housing insecurity, transportation barriers. The influx of these newly insured people into the health care system has started to challenge a lot of providers to begin thinking about the realities of these upstream issues.
What role do other parties have to play in the shift to upstream thinking?
MANCHANDA: There are so many organizations that are invested in improving outcomes for populations in certain communities; for instance, social service agencies like food banks and housing agencies. There are public health departments across the nation that have long been trying to address unmet social needs and public health needs. I think even some businesses and local communities that are invested in keeping their employees as healthy as possible, namely self-insured employers, represent partners as well.
Some hospital leaders say it's important to make a business case for health equity. Any challenges there?
MANCHANDA: Before we start down the path of making a business case for addressing social needs and improving health equity, we have to acknowledge that there is an overall ethical and moral case to be made first. Many of the hospitals that are working on improving health equity haven’t waited for a clear, well-defined business case when they’re in an environment in which they know it’s the right thing to do. Hospitals recognize their role in the community.
Many hospitals that have seen those charitable giving activities as external to core operations are starting to realize that these unmet social needs actually play a vital role to the operations themselves. I often hear, 'How can we afford to do this?' I put the challenge on health care systems to say, 'How can we afford not to do this?' By not screening for and addressing the vital social needs of populations we serve, we actually create more inefficiency and more missed opportunities to provide better care. And if we quantify those missed opportunities, we know that there is a huge cost.
The Manchanda File
Who has influenced you in your career?
Paul Farmer, co-founder of Partners in Health, a nonprofit based in Boston that does work with underserved communities in the U.S. and abroad. The work I did in community health centers as part of the National Health Service Corps was a major influence on me as well. Dr. Jack Geiger, past president of Physicians for Human Rights, continues to be a major role model for me in terms of thinking about how to link the work of health care to the needs of the community.
What do you like to do outside of work?
I spend a lot of time with my family. We travel as much as we can. I have a 9-year-old and a 2-year-old. With a young family, I try to spend quality time together, and that’s what really gives us joy. I also spend a lot of time writing. I wrote a small book a few years ago about ways to deal with health care issues by thinking upstream. I enjoyed writing more than I expected, and now I try to write as much as possible.
Where has been your favorite place to travel?
We just got back from Bali in April for my wife’s 40th birthday, and we had a blast.