Relatively modest investments in social determinants of health for children have demonstrated impressive results.
Healthcare policymakers and industry players alike should devote more attention and resources to meeting kids' health needs, says R. Lawrence "Larry" Moss, MD, FACS, FAAP, president and CEO of Nemours Children's Health System, based in Jacksonville, Florida.
The undertaking is an important long-term strategy to boost outcomes and strengthen the U.S. economy overall, Moss said during a presentation to fellow executives at a recent HealthLeaders CEO Exchange gathering.
"The biggest lever that we have as a society to influence health—and ultimately to influence our economic vitality as a nation—is to invest in the health of children," he said.
Moss, a pediatric surgeon, just completed his first year as the top executive at Nemours, which operates two major medical centers, one in Orlando, Florida, and the other in Wilmington, Delaware. He took his current job after seven years as surgeon-in-chief for Nationwide Children's Hospital in Columbus, Ohio.
While the U.S. healthcare system generally does an excellent job of treating complex medical conditions, it does a relatively poor job of addressing the general population's basic health needs, Moss said.
"If you have a premature newborn with esophageal atresia and congenital heart disease, this is the best country in the world hands down to receive care," he said. "But if you're a kid with asthma living in the inner city or you're [among] the 99% of kids in this country without complex medical problems, you're arguably in the worst country in the developed world to receive healthcare, and your health outcomes are worse than most other developed countries on the planet especially when you look at the amount we spend trying to achieve those outcomes."
Moss used his presentation to explain the problem, as he sees it, and to outline the ways in which he aims to orient Nemours toward sustainable solutions.
He listed three big goals that guide his work:
1. To tout the power of investments in children's health.
As evidence that relatively small investments in health during childhood can return big benefits decades later during adulthood, Moss pointed to The Abecedarian Project, which began in 1972 at the UNC Frank Porter Graham Child Development Center.
Researchers on the project provided a full-time educational environment for 111 at-risk children, from their infancy through age 5, with individualized attention and activities around social, emotional, and cognitive development, with an emphasis on language skills. Participating children also received free on-site healthcare and nutritious meals.
In the years since, researchers have determined that participants in the project perform better academically, earn higher incomes, and have better health outcomes as adults. They determined, for example, that those who participated in the project have significantly lower prevalence of risk factors in their mid-30s for cardiovascular and metabolic diseases, according to a 2014 study.
The total cost of the five-year project was about $67,000 per child, when adjusted for inflation in 2002 dollars, according to the study.
"This is less than treating one adult with severe heart disease or lung cancer," Moss said. "Obviously, the return on that investment is outside the typical budget cycle of a hospital, and it's certainly outside of the election cycle for a politician, but it's very real."
While the short-term cost-reduction benefits of strategic investments in children's health may be modest, the longer-term possibilities are bigger and could lead to healthier generations of American workers, leading to greater economic stability and growth, Moss said.
2. To expand the nation's definition of 'health' in children.
Medical care represents only a fraction of what we should consider when we think about health, Moss said. The rest includes things like social determinants of health, in their various forms, including education, literacy, housing, safety, freedom from adverse childhood experiences, and other social factors.
That idea was foundational to the way Nemours approached a three-year $3.7 million grant it received in 2012 from the Center for Medicare & Medicaid Innovation (CMMI) to improve the health of children with asthma, rather than simply treat their asthma-related medical complications.
Nemours took patient-level actions, such as adding air conditioning units in the homes of kids with asthma, and community-level actions, such as facilitating asthma education efforts and striking a variety of partnerships to identify problems and solutions, Moss said.
"One of the nurses noticed that the metered-dose inhalers in our pharmacy didn't have any readers on them, so you couldn't tell when the thing was empty," Moss said. "There were many hospital admissions because the inhalers were empty and families didn't know that."
Nemours worked with the state agencies to change the formulary. That impacted more than 11,800 children, Moss said.
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Nemours found out that school buses were idling outside the schools while waiting for kids, causing significant downstream health impacts and resulting in a number of hospital admissions and ER visits. The health system worked with schools to change that practice, impacting more than 14,000 children, Moss said.
"Simply turning the key and turning off the engines had an enormous impact," he said. "We wouldn't have learned that if we had focused on what happened to these kids after they were in the hospital."
Nemours also backed a smoke-free ordinance in the city of Wilmington, Delaware. That impacted more than 19,200 children, Moss said.
Altogether, the efforts contributed to some impressive results, he said:
- 60% reduction in asthma-related ER visits;
- 44% reduction in asthma-related hospital admissions; and
- $2,100 reduction in annual medical costs per child.
These results are population-based data from the state of Delaware, Moss said. The details are outlined in a report published by the University of Delaware.
"We essentially changed the complexion of what it meant to have asthma in the region," he said.
"No new drug was introduced, no new genetic discovery was made, no major biological or physiologic change in the way that we treated these kids was made," he added. "We just implemented the social interventions that I talked about. This transformed what it meant to have asthma."
Partnerships are critically important in this process, Moss noted. Nemours is an expert on delivering medical care but not an expert in social services, so the health system sought to partner with agencies who are experts in addressing social needs and worked with them to help these children, he said.
3. To take on full risk for Nemours pediatric patients.
Regardless of what healthcare providers say about where they stand on value-based care or where they want to be, the reality is that health systems are generally still operating in a fee-for-service environment, Moss said.
"That's the world we live in right now," he said.
The irony of the current system is that improving health on the front end reduces demand for revenue-generating healthcare services down the line.
"Until you transform the economic incentives, you can't really transform the health system," Moss said. "We are currently incentivized to create the opposite of what we want, which is health. We're not incentivized for health. We're paid for volume of care and complexity of care, and that's what we're getting."
Even so, Moss said Nemours is committed to invest as heavily as it can afford to invest in its Value-Based Services Office (VBSO), which focuses on four prongs: medical management, data analytics and IT, population health management, and primary care. The goal is to move to full capitated risk for the patients Nemours serves.
Ultimately, the goal is to improve health for everyone.
"I've never met a single adult in my life who didn't use to be a kid," Moss said. "If we can transform a generation of kids, that's the next generation of us."
The HealthLeaders CEO Exchange annually gathers leading hospital and health system CEOs for a custom dialogue on only the critical issues facing the future of their organizations. The 2019 event was held September 25–27 in Park City, Utah. For more information on this and future events, please email email@example.com.
“The biggest lever that we have as a society to influence health—and ultimately to influence our economic vitality as a nation—is to invest in the health of children.”
Nemours CEO Larry Moss
Steven Porter is an associate content manager and Strategy editor for HealthLeaders, a Simplify Compliance brand.
Photo credit: Nemours Children's Health System President and CEO R. Lawrence "Larry" Moss, MD, delivers a presentation during a HealthLeaders CEO Exchange gathering in Park City, Utah. (HealthLeaders/Dana Hartig)
Our current system is better equipped to provide complex healthcare services than to meet basic health needs, the top executive at Nemours Children's Health System says.
Boosting children's health is a way to build a stronger and more productive future economy, he says.