"Our Region as a Whole Would Benefit": A Conversation about the Social Determinants of Health

8/30/2018

Tom Heintjes:: Welcome to another episode of the Economy Matters podcast. I'm Tom Heintjes, managing editor of Economy Matters, the Atlanta Fed's digital magazine. Today I'm sitting down with Sameera Fazili, a senior adviser in the Atlanta Fed's Community and Economic Development department. We're going to discuss some research Sameera conducted on the social determinants of health—things like safe housing, and access to healthy food—and why those factors deserve greater attention in the ecosystems of health care and community development. Thanks for being here with us today, Sameera.

Sameera Fazili: Thanks for having me.

Brian Bailey, a subject matter expert in the supervision, regulation and credit division at the Atlanta Fed, during the recording of a podcast episode.
Photo: David Fine

Heintjes:: Sameera, just to get us started, could you explain what you mean by "social determinants of health?" I mentioned that they include things like safe housing and having access to quality food, but that must just skim the surface.

Fazili: Yes, "the social determinants of health" refers to all the nongenetic factors or health behavior issues that may drive health outcomes for a person, and so it can include things like: Do you get enough food? Do you get the right types of food? But it can also include: Are you exposed to mold in your house, or rats in the house?—and things like that.

Heintjes:: And clean water—things like that?

Fazili: Yes—clean water, access to clean water, healthy air, like air pollution-type issues. Usually it breaks down into things like: education; employment; income; neighborhood, or physical, built environment; and family and social support.

Heintjes:: Right. Well, that's really interesting, but, tell me: why are you and the Atlanta Fed exploring this topic? What led you to begin looking into it?

Fazili: Health care constitutes about 18 percent of our GDP [gross domestic product] here in the U.S.—a huge, huge part of our economy. At the same time that we spend so much on health care in America, our health outcomes aren't actually that great when you compare us to peer nations: we outspend them, and we don't have better health outcomes. And I was interested in trying to understand: how do we build better efficiencies in the health care system, as well as get better results in that system?

It also links to my work as part of the Community and Economic Development department, where we study local economic development issues and issues affecting low- and moderate-income communities, where health care is a big issue and where community economic development's a big issue, and I started to see that there was a lot of potential here to both improve outcomes in these communities and actually help drive maybe new partnerships between two sectors that should be talking to each other—whose work connected, but they weren't talking to each other and connecting with one another.

Heintjes:: Right. If I'm understanding you correctly, social and economic factors are actually more important, as important to health outcomes, than even health-related behavior or clinical care, and I think that's really fascinating—

Fazili: The number there, for the listeners out there: it's like some 50 percent of health outcomes are driven by social, economic or physical environment, whereas things like clinical care only affect 20 percent of your health outcomes.

Heintjes:: Well, yes, that's really interesting. Do you think that's well understood, generally? Why don't we hear more about this?

Fazili: It's one of those areas where the experts talk about it amongst themselves—the public health folks, and the medical community—they understand it fairly well, but it hasn't really penetrated the general public. I think sometimes experts are good at speaking to each other, but not at putting that information out in a way that the average person on the street can understand.

You know, they even have an adage among themselves in the health care field that ZIP code is a better predictor of health than genetic code, so that's one of the reasons I think we don't hear a lot about it. Sometimes the experts aren't good at communicating it to the general public, but it's precisely what my department at the Federal Reserve Bank seeks to do. We try to develop research and products that help the general public better understand what researchers and experts are talking about, so that that research can actually be activated—it can penetrate, and change practice and behaviors—and more people can learn about it.

Heintjes:: Well, maybe this episode of the podcast will further our understanding of that and advance that dialogue. But I want to delve into your work a little more deeply here: what particular aspects of these social determinants, as we're calling them, are you focusing on? In other words, are there a couple or a few that are especially important?

Fazili: I don't take the work from the perspective of the social determinants, per se. I'm not looking at one social determinant or another. What I have been trying to do is look at where in the Southeast am I seeing collaboration happen, or do I think there's great potential for collaboration between these sectors?

Heintjes:: So you're looking on a regional level?

Fazili: I'm looking somewhat at a regional level, you know—the "Southeast" to me is the states of Florida, Georgia, Alabama, Louisiana, Mississippi and Tennessee. And then within that, there are three areas I'm really bullish on, that I think that I'm seeing a lot of activity on and a lot of interest in our part of the country.

Heintjes:: And those areas?

Fazili: The first is housing. There is a lot of research and evidence in the public health field and in the medical field about how housing impacts health outcomes and health spending and helps decrease overall public spending on health care. At the same time, housing is a huge part of the community development field, so the community development field at the local level often has a lot of expertise in building housing, managing housing, addressing housing issues—especially in the low- and moderate-income populations, where housing can be a big driver of their social determinants of health. So health and housing is one big, big area.

Some hospitals and health care institutions are doing work that focuses on what you can call "high utilizers"—people who use health care too much—and if you manage their housing issues they wouldn't be interfacing with health care, and it's cheaper to address their housing issues than have them keep coming to the ER. And others are sometimes focused on specific patient populations, like kids with asthma, and helping make sure that their house doesn't have environmental triggers that are making them come to the emergency room a lot or have long hospital stays. So housing is one big area.

Another area that I've been focusing on is community development investments, and that usually focuses on these institutions that are called CDFIs: community development financial institutions. They are experts at putting together money that combines private capital with grant dollars with public subsidies to fund community development programs, and so you're seeing partnerships develop where health care is figuring out how it can invest through CDFIs to help pay for these social determinants of health interventions, interventions to improve the social determinants.

And then the last area I'm very focused on is job creation. Jobs and income are a huge driver of the social determinants of health as well. If someone doesn't have enough money to get into quality housing or to have proper food on the table, they can have really bad health and health outcomes as a result. So the health care sector, at 18 percent of GDP at the national level, is in fact a huge source of jobs at the local level as well, and so you'll find in most regions, health care jobs and health care organizations are some of the top employers in that region. Even here in Atlanta, if you look at our top 20 list of employers, I think seven or eight of them are health care institutions.

Heintjes:: So when we hear about rural hospitals failing and closing, that has a huge economic impact on those communities, obviously, and that's of concern to you as a researcher.

Fazili: Exactly, exactly. And when health care tries to address the social determinants of health, I actually think it's a great opportunity to create new jobs in the community that are accessible to low- and moderate-income individuals. They can create quality jobs that people without a four-year college degree can get and can earn a nonpoverty wage. So there's a lot that the health care sector can do to address job and income issues in their local community, but they need some partnership and help to be able to do that.

Heintjes:: Sure. Well, to sum up: we talked about housing, we talked about community development investments, and we talked about job creation. Is there anything about those three areas that are distinct about the Southeast as opposed to the larger U.S. that you've noticed? Or are these generally applicable, you think, to the broader society?

Fazili: I think they're generally applicable across the U.S., not just here in the Southeast—

Heintjes:: Because you hear about these same issues being talked about everywhere.

Fazili: I think they're broadly applicable across the U.S. What is unique about the Southeast is that because we didn't have Medicaid expansion down here, a lot of our hospitals are under a lot of financial strain still, and that has led them to look for new efficiencies that they can achieve in their business operations. And I have noticed that, therefore, jobs has been a really important issue for them—how to reduce HR spend, how to reduce HR turnover. They are feeling the impact of HR turnover even in their middle-skill jobs, people in the medical assistant and medical technician type of categories. I would say the other thing in the Southeast is that the lower educational attainment rates that we often have here means that employers may have to make greater investments in workforce development programming, in programs and efforts to help people get the training and skills that they need to be job ready, that—

Heintjes:: The soft skills we often hear about.

Fazili: Exactly—that folks in other parts of the country may not face where you have a more educated population.

Heintjes:: A job-ready work force.

Fazili: Exactly.

Heintjes:: Well, it sounds like one of the keys here is fostering collaboration among organizations that might not traditionally have worked together. As you discuss your findings with people in health care and community development across the Southeast, what kind of reactions are you seeing? Are they curious? Enthused? Skeptical?

Fazili: Honestly, I will say I'm surprised how few people are skeptical. They are usually curious and enthusiastic, and they ask for more follow-up information on, "How can I do this? How do we do this?" There is a strong sense among both the community development professionals and the health care professionals that their industries are experiencing rapid change, and that business models need to change in both sectors, and people aren't quite sure what they need to move towards, so they are excited about the idea of helping bring in and spur new innovation to their sector through collaboration and partnership.

Heintjes:: What would you describe as the biggest hurdles to achieving this sort of greater collaboration among the various stakeholders? We all know how hard it is to break down those dreaded silos.

Fazili: [laughs] It's very hard to break down silos, and "collaboration" is a really big buzzword out there I think in almost every field, so there may be some fatigue with that word, but some of the biggest hurdles to greater collaboration are things like, first and foremost, language—they just don't know each other. They never sit in the same room, they never have had to talk to each other. So they don't know each other's systems, they don't know the language the other person speaks—everyone has their own, inside baseball terms that they use.

Heintjes:: Right, jargon.

Fazili: Exactly. The second is the level of evidence—that's going to sound very research-y, I realize, but—

Heintjes:: Yes, I was just going to ask you—[laughs]

Fazili: "What does evidence mean?"—right? But that's actually precisely the question. Every field has its own way that it measures evidence and effectiveness, and what data and results that they track. And these sectors all track outcomes in really different ways and have to learn what is going to be sufficient for me to take your evidence. In the health care field especially, they want randomized, controlled trials that have gone on for 10-plus years, you know, or 20-plus years, and that's a really long timeline for evidence to have built up. So the two communities have been talking to one another about: Okay, so what are the different tiers of evidence and types of evidence you can use to build out different kinds of programming?

And then a third barrier can sometimes be timeline, related to evidence. If you're working with a health insurance company, they might want to see results within three years because that's kind of average turnover they have for one of their patients. But for a housing developer, they're looking for 15 years out, because that's how long their public subsidy lasts. So trying to align timelines between all the actors.

And the last big barrier ends up often being data sharing and privacy rules. It's so different in every sector. I'm sure all of us have gone to those doctor's offices and signed away on those HIPAA forms that we don't read and don't understand, but there's really different data sharing rules in different sectors and industries, so trying to figure out what data each can collect and share with one another has proven to be a challenge in some of the cases.

Heintjes:: Sure, it does sound challenging. Well, Sameera, I guess it's fair to say that this sort of health and community development partnership is still in its infancy, at least in our region—but they are becoming more common across the Southeast, and also across the nation, aren't they?

Fazili: They are totally becoming more common, exactly. I think that for health care, they're really being pushed to change their business model to really show better bang for their buck, that there are quality improvements being made, there are efforts to pay the health care industry based on quality outcomes and quality indicators, not just for every single procedure they perform. And on the community development side, their business models are changing and have been for years, because of decreases in government spending, and so they are hungry to find new partners and new funders who they might be able to work with to achieve their goals to improve job quality, improve income, improve quality of life outcomes for low- and moderate-income communities.

Heintjes:: Can you give an example of one or two such partnerships regionally in the Southeast?

Fazili: I'm going to try to give you three. [laughs]

Heintjes:: Okay, I'll take more! [laughter]

Fazili: I'm going to try to give you three, and hopefully they all will be interesting to our listeners. The first is Florida Hospital in Orlando—

Heintjes:: Which, I should add, is the nation's second-largest hospital in terms of beds. I recently discovered this fact.

Fazili: And what they did was they started to realize that homeless people were coming in and out of their ER in an inefficient manner. They were using the ER a ton, getting hospitalized a lot, and they wanted to improve the quality of care that this population was receiving, and so they entered into a partnership with the local homelessness coalition, and first joined it to say, "We're just going to learn from you guys. What are you trying to do? How do we more effectively work with this population?" And then they took $6 million of grant dollars that they had, and set it aside to invest in homelessness programming—because nonprofit hospitals have an obligation under the tax laws to do grant making in their community, so Florida Hospital used $6 million to invest in homelessness strategies, and they used their civic leadership to get other large corporates, like JPMorgan and Walt Disney in the Orlando area, to also contribute to this pool of funding. And the money has allowed Orlando to become one of those places that moved to a more innovative homelessness system, which is called "Housing First," where they were able to build new housing for the homeless people and create new data systems that allowed people to track and manage these families as well—and a lot of it is because of the leadership of Florida Hospital.

The second example I would give is in my "jobs" category. It's Ochsner Hospital, which is based in New Orleans and is one of the largest employers in both the city of New Orleans and the whole state of Louisiana, actually.

Heintjes:: Wow!

Fazili: Yes, and they recognized that their medical assistant position was having higher-than-average turnover rates, and that that was negatively affecting their reputation in the community—because these are the frontline folks doing customer service, or a customer service kind of relationship—and they partnered with the local Community Foundation and the City of New Orleans to develop a lot of really innovative workforce development programming to help low income folks in New Orleans be able to access training programs, to become credentialed in the medical assistant field—for free, so they don't have to pay any tuition for it—and they would automatically get hired by Ochsner at the end of this training program, because they designed such a strong training program. And Ochsner saw that it had lower turnover rates and improved manager satisfaction scores from designing this program, which involved a partnership between the Community Foundation, the city, and actually a local community-based organization that helped them find good candidates for the job as well.

The third partnership that I find exciting is one in south Florida, in the Miami area, between Baptist Health and Catalyst Miami. Catalyst is a community-based organization that does a lot of financial counseling and helps low-income people and low-wealth people better manage their finances and navigate benefits. And they entered into a partnership with Baptist—also funded by Baptist's community benefit dollars—to, onsite at Baptist, do a combined financial counseling and health counseling session, and those sessions helped Baptist see improved quality of care indicators for their patient population in this really low-income area called Homestead, in the Homestead Hospital that Baptist runs down there.

Heintjes:: Wow, those are tremendous examples.

Fazili: So in that one, the community-based organization counsels people on both their financial issues and gives them culturally sensitive health care coaching. And it's funded through grants. The staff is paid for by Baptist through grants.

Heintjes:: Right, well, those are great examples, Sameera, thank you. You know, it's no secret that many parts of the Southeast rank poorly in terms of measures of public health, so I would think there are ample opportunities for improvement—is that right? I mean, are you bringing the results of our work to certain parts of the region that would really benefit from it?

Fazili: I think our region as a whole would benefit from it, which is why I've picked this topic to study and to work on, because we hope that our research is actually responsive to the needs of our district—something we actively look for, picking up topics that we think will be a benefit to our region. But I would say there are certain sectors I'm looking to target the work towards—especially the health care industry, because I have found that they have been hungry for this information but don't know where to get information from a neutral source that doesn't have a dog in this fight. I'm not looking to get a grant from them, so I'm a kind of third party, a disinterested party, who can give them some neutral, unbiased information on this topic.

In the health care industry, you can think of that as both the health care providers, like the hospitals. It's the health insurers as well, like the people who actually pay for the health care, health care foundations, there's a lot of health care philanthropy in our district, and then the public health sector, too—there's a lot of government agencies, too, looking for good information.

The other part of our district I'm really eager to bring this work to is rural areas, because they have high health care need and health care is often a really large part of their economy—if they're lucky enough to have a hospital in their area. It's often a huge driver of the local economy. Or, if they don't have one, that's actually a big part of their economic development strategy: How do we help get a hospital, or improve access to health care? So I think rural communities in our district could really benefit from trying to better understand and develop these models that integrate community development with health care.

Heintjes:: Right. It's obvious that there are some really interesting wheels in motion now, so I want to ask you: what's next for you in this area, Sameera? Do you have next steps in mind to follow up as a researcher?

Fazili: I have one paper out already, which provides a great—I think a great—a decent enough introduction to the field of health care and community development—

Heintjes:: Which we will link to on the website, by the way.

Fazili: Thank you. That will help people understand the basics of what we're talking about, provide some case studies. And I think if you're a novice to community development, you can read the paper. If you're a novice to health care, you can read the paper and understand it.

Heintjes:: So this is written for a lay person, or a nonspecialist?

Fazili: Exactly. It's written for a nonspecialist audience to start to understand this space. I'm hoping my research can be a conversation starter, then, so people can more quickly parse through that denser research that's done by the academics out there, and that practitioners and policy makers here in the Southeast can leverage the paper to help build their partnerships and their strategies in this area.

We are always available to come speak at events in local areas, and so I'm always looking for good opportunities to come speak in places that are looking to try to deploy these ideas in one way or another. I will keep doing research in this space as well. I hope to have a second paper out sometime next year that goes a little bit more granular on the economic case on all this, that really lays out some of the economic pressures the health care industry is facing and how new business models need to or can be, and are starting to be, developed to drive these partnerships.

Heintjes:: Right. Well, Sameera, let's close our conversation with a little bit of blue sky-ing here. Ultimately, what would you like to see happen, or what would you hope will happen, as a result of your research and this work?

Fazili: So I'm going to be very "blue sky" here and—

Heintjes:: Sure, the bluer the better.

Fazili: I'm going to be super-optimistic here, and just pretend that I can dream really big—I'm dreaming big here—but one, I do hope to see more partnership and experimentation in the Southeast. It can be scary to be a first mover, but it can be fun to be a first mover, because there's going to be failure but people are going to learn from you, and I hope to help folks in the Southeast—both inspire them and encourage them to try, even if it means they may fail. We all need to learn in this area.

The second big, big dream of mine—which I know will take some time—is…you know, health care is a $3 trillion industry here in the U.S. I would like to see more of that $3 trillion being spent towards community economic development activities, towards addressing the social determinants of health. Most of it right now is spent on health care, not actually addressing what's making people unhealthy.

So that's my other "pie in the sky" dream there, I would say: helping drive more investments from the health care system towards community economic development activities to address the social determinants.

Heintjes:: Well, let's hope the skies remain very blue. I want to thank you for your time, Sameera—this has been a great conversation. I've really learned a lot from sitting down with you today.

Fazili: Thank you.

Heintjes:: And thank you for listening to another episode of the Economy Matters podcast. I'm Tom Heintjes, managing editor of Economy Matters, and on our website, frbatlanta.org, we'll have a link to the paper we've been discussing, and I encourage you to look at it. It's a very interesting and readable take on what we've been talking about today. That's all for this episode, and I hope you'll join us next month when I'll sit down with David Lott of our Retail Payments Risk Forum, when we'll discuss the security risk posed by smart appliances and what we call the "Internet of Things." Thanks for your time today, and come back next month.