There is no shortage of strategies to recruit physicians to rural America.
With varying degrees of success, enticements have included student loan debt relief, homey pitches touting country living, membership at the local country club, a house, a car, no ED call, great schools for the kids, a cushy job for the spouse, and for foreign docs, a fast-track to U.S. citizenship.
For all the effort, however, physician recruiting and retention remains one of the most challenging issues in rural healthcare.
One critical access hospital in tiny Ashland, KS (pop. 855) may have found the answer. Rather than attempting to sway physicians with amenities, the 24-bed Ashland Health Center in the southwestern part of the Jayhawk State has instead appealed to physicians' sense of mission.
For the past two years Ashland Health has recruited—and retained—two physicians and three nurses by offering them up to eight weeks of paid time away from the hospital each year.
The clinicians may use that time as they wish. However, Ashland Health makes it clear in the recruiting process that the hospital encourages and supports using that time to provide care for the poor and destitute in the world's most impoverished countries.
Ashland Health CEO Benjamin Anderson believes that the opportunity to make the world a better place is what has brought clinicians on board and kept them there.
"The program was born out of desperation," he says. "Two years ago we had no doctors living in this community. Furthermore, the facility had been through 11 providers in 18 years. The approach that was taken previously wasn't effective, and we knew we had to try something different."
Ashland Health Center needed a recruiting tool that would set it apart from the scores of rural hospitals in small towns in every state that were looking for clinicians.
"There are a thousand communities in America that boast good schools with small classrooms and low crime and people help each other and [there are] beautiful landscapes and a low cost of living. These physicians get four or five mailings a week on opportunities like that," Anderson says.
"Before, this community focused on those things. But what the clinicians really want to see is opportunities to serve," he says. "They want to know that there is an unmet need and that by choosing to come here that unmet need will go away. So we are focusing on the things that a traditional recruiting approach would avoid."
Anderson, who will make his third service trip to Africa later this month, worked in physician recruiting before becoming a hospital administrator. He says there are "four types of providers" in rural healthcare. "The first one is the local kid who grew up there and is coming back to practice. The second one is the problematic doctor who doesn't work well with others. It maybe a character flaw or a personality issue so he can't make with his colleagues and he goes out to a small community where he is the only physician."
"Then you have the J1H1 foreign doctors. I don't want to discount them, but trends show they fulfill their obligation in an underserved area for three to four years and then get to an urban area as quickly as they can, so it is not a long-term fix," he says.
"And the fourth is the missionary doctor. The further away from Starbucks, the better it is for these doctors. They aren't going there for gourmet coffee, or Nordstrom's, or fine dining, or gated communities. They are going there to serve."
Serendipitously, Anderson found that the focus on commitment to a mission also serves as a vetting tool that attracts "people who are motivated by service and who are inclined to work for a cause that is greater than themselves."
At first, the board of directors at Ashland Health Center raised concerns about the cost of providing two months of paid time off, which combines vacation, sick days, and personal days. Anderson says most clinicians would get that much time off as part of a compensation package without the optional international service program. "The alternative is to pay locums to cover you shift by shift," he says. "That isn't good for care or continuity. It's not a good model. It is unsustainable."
There was also concern that the call to missionary work was creating religious requirements for the publicly funded hospital. But Anderson says there are no demands placed upon clinicians' paid leave.
"It can't be faith-based because we are not a faith-based hospital," he says. "We are telling them you can use it however you want. It just so happens we are meeting quite a few people that are faith-focused, and that is OK. If that is what motivates them and the results are excellent, compassionate care, great. Go for it."
Anderson says any rural hospitals can copy the Ashland blueprint if it has a "mission-focused CEO."
"I don't say that lightly. That is often the missing link," he says. "For administrators it isn't as simple as paying somebody for time off. We want to quantify things. What is the cost for me? There is an intrinsic cost and certain intrinsic or intangible benefits. An administrator has to get it and if they don't when they recruit these people they aren't going to stay. Doctors have to know the administration is as committed to the mission and the organization as they are."
Once that happens, Anderson says, hospitals can recruit staff whose personal mission matches the organizational mission.
"But if you don't understand your own personal mission or vision, or that mission or vision is to stay open another day, that isn't exciting," he says. "Doctors don't run to 'I want to stay open another day.' They want to do it for something bigger than just staying alive."
The program at Ashland Health has been so successful that all of the hospital's 90 or so full-time employees—from doctors to dishwashers—have the opportunity to serve overseas.
"There is a direct parallel. So the more people in our facility that we can get over to see those things before their hearts are changed and the more our local culture is enriched," Anderson says.
Even though Kansas is a world away from Africa, Anderson says all humans share a need for compassionate and accessible care.
"I am fascinated by what serving orphans and widows and people in poverty in Africa does to open our eyes and ears and hearts to needs of orphans and widows and people in poverty here," Anderson says. "It's transforming the culture inside our walls."
The healthcare sector created 32,800 jobs in May—accounting for 47.5% of the 69,000 new jobs in the larger economy for the month, new federal data shows.
Healthcare continues to be one of the few steady bright spots in the latest U.S. Bureau of Labor Statistics monthly job growth report. The reports have otherwise been erratic and lackluster since the economic downturn in 2008 and continuing through the ongoing tepid recovery.
Chris J. Conover, a scholar with the Center for Health Policy & Inequalities Research at Duke University, says the good news about job growth for the healthcare sector is not necessarily good news for everyone else.
"We're all paying for it and it's an indication of where consumption is going," Conover says. "That's been true for a long time and in some senses that statistic is in opposition to this good news story about declining healthcare costs. It is an indicator that healthcare is taking a growing share of the economy."
May job figures from BLS show that ambulatory services, which include physicians' offices, accounted for 22,800 of the new healthcare sector jobs for the month, and hospitals accounted for 4,500 new jobs.
In the first five months of 2012, healthcare created 158,300 jobs, which represent 19.2% of the 823,000 jobs created in the United States. Healthcare created 115,800 jobs in the first five months of 2011, BLS data shows
BLS data from April and May are preliminary and may be revised considerably in the coming months.
In the larger economy, nonfarm payroll employment rose by 69,000 in May. Modest job growth in transportation, warehousing and manufacturing were offset by the loss of 28,000 construction jobs. As a result, the unemployment rate rose slightly to 8.2% for the month. Job growth has declined considerably in the last three months after a hopeful start to 2012 that averaged 252,000 jobs per month in January and February, BLS reports.
Revised BLS figures show that healthcare created 21,900 jobs in April, 31,600 jobs in March, 38,200 jobs in February, and 33,800 jobs in January, continuing a strong trend that saw 296,900 new jobs in 2011. Healthcare accounted for more than 18% of the 1.6 million new jobs in the overall economy in 2011.
More than 14.3 million people worked in the healthcare sector in May, with more than 4.8 million of those jobs at hospitals and more than 6.3 million jobs in ambulatory services, which includes more than 2.4 million jobs in physicians' offices.
In the larger economy, BLS said 12.7 million people were unemployed in May, a slight increase from April. The number of long-term unemployed, defined as those who have been jobless for 27 weeks or longer, grew slightly to 5.4 million people in May, representing 42.8% of the unemployed.
Healthcare spending is forecasted to grow at a historically low rate of 7.5% in 2013, PricewaterhouseCoopers LLC estimates.
PwC's Health Research Institute in a survey and report released Thursday attributes much of the projected slower growth to the tepid economy, the healthcare industry's broad focus on cost containment, higher out-of-pocket costs and, therefore, lower utilization for healthcare consumers, and efforts by employers to keep their health insurance expenses down.
"Cost is at the top of the agenda for everyone in healthcare and you are starting to see the industry move towards reconfiguring itself towards getting costs in check," PwC Principal, Rick Judy, told HealthLeaders Media.
"There is price transparency that is really exerting pressure on providers and allowing patients to shop for their medical care based on value and quality," he says. "Some of the drug patents coming off are moving a lot more patients to generics."
"Another deflator is that medical supply costs are down and that is due to a lot of hospital consolidation and physician alignment," he says. "That is improving the negotiating positions for a lot of providers and there is less tolerance for individual physician preference than there used to be."
Slow growth still outpaces inflation
Medical inflation has been lower than expected for the past three years, and redrawn estimates from PwC show a low range of 7% to 7.5% from 2010 through 2013.
However, that that rate of growth remains more than three times higher than the 2.3% rate of inflation in the overall economy over the past 12 months, as measured by the gross domestic product.
Judy says investments in technology, changing demographics, and a reliance on a volume-based payment system are big drivers of healthcare cost growth above the rate of inflation, but that is a trend that may be changing. Healthcare usually increases as the economy recovers, he noted, but the report identified structural changes that may disrupt that pattern.
A fourth straight year of low healthcare cost growth suggests that the gap between healthcare spending and overall inflation may be narrowing to a more sustainable level.
Judy says the hope is that someday medical inflation will be in line with overall inflation. "We are making great strides to move towards that," he says. "We are starting to see some of the value-based reimbursement models get put into place. We are laying the foundations for different care delivery models that are lower costs, including retail clinics and retail medicine. And getting everybody aligned around an outcomes-based reimbursement model will help to bend the cost curve."
However, PwC also noted factors that could "inflate" healthcare spending growth in 2013. First, as more jobs are added in the economy, those newly hired workers will likely tap into their new healthcare benefits. Second, many patients who've postponed elective surgery over the past few years may feel more confident about spending in 2013 as the economy slowly recovers.
"We have seen lab and elective procedures increasing after a drop off in past years. Some of our studies cite 46% of consumers we surveyed who had delayed care one or more times because of cost," Judy says.
Employers focus on wellness, cost sharing
Employers have embraced a two-pronged approach to reducing healthcare cost growth that relies on an increasing use of workplace wellness programs and foisting more costs onto employees.
"We are seeing huge growth in the high-deductible plans and cost sharing is one of the things that employers and insurance companies are increasingly adopting as they look at benefit design," Judy says. "All indications from the surveys we have done are that they are going to continue to increase. That is making patients more in tune with the way they consume healthcare in this country."
The survey found that:
57% of employers are considering increasing employee contributions to health plans.
Half of employers are considering increasing cost-sharing through plan design, such as higher deductibles. The average emergency room co-pay is now $125 or more.
More than half of employers are considering raising employee prescription drug plan costs.
Average enrollment in high deductible plans coupled with a Health Reimbursement Account has increased to 43.2% in 2012 from 34.2% in 2010.
72% of employers offer wellness programs, and half say they are considering expanding those programs next year.
Such tactics have allowed PwC to project that employers could see healthcare cost growth as low as 5.5%.
"If the plan designs are done appropriately preventative care and wellness-type procedures are going to be the ones that are aligned with the lower costs to encourage patients to seek out those services," Judy says.
"The more elective procedures are the ones that will have higher costs associated with them so patients need to shop around quality and cost and value for those services rather than just consuming healthcare without understanding what those costs are."
Public health policy advocates looking for model primary care programs that are designed to expand coverage, improve care, and lower costs should look to Minnesota.
The state reported this month that the primary care delivery model that was begun in July 2010 has grown to 170 "health care homes," with 1,764 clinicians at the end of 2011.
The "health care home" is Minnesota's version of patient-centered primary care, with the patient always the focus of care decisions. The Minnesota Department of Health certifies these health care homes using a set of criteria with mandates that include 24-hour access to care, patient history tracking, ongoing monitoring of quality metrics, and care coordination and planning with patients.
These state-certified homes provide care more than 2 million of Minnesota's 5.3 million residents. That patient population includes more than 135,000 Medicaid enrollees, or roughly 18% of those in the program who use primary care. In part, that's because chronically ill Medicaid enrollees are incentivized to join health care homes through medical assistance payments of $10 to $60 a month, depending upon the complexity of their health issues.
In addition, Medicare has approved Minnesota as one of eight states that can align with the state program to pay for health care homes. As a result, more than 225,000 Medicare enrollees are expected to be served by health care homes during the three-year project.
A big focus of the Minnesota program is preventive medicine that involves patients and teaches them to better manage chronic diseases such as hypertension and diabetes. In addition, health care home patients are encouraged to adopt health goals that include physical exercise, improved diet, weight loss, and smoking cessation.
The program is new, so state officials concede that it may be difficult right now to gauge or demonstrate its impact on controlling costs and improving quality. There are early indications that they may be on the right path, but reports are mixed.
For example, Medica, the nonprofit health insurance provider that participates in the pilot program, has designed payment models for health care homes that reward improved outcomes.
The insurer reports that at least one large urban provider with a health care home in the Twin Cities has seen per member costs drop by 5% in the past year. However, Medica also reports that a similar large urban health system in the same area saw a 2.6% increase in costs for the same period. Medica did not identify the providers.
As for improved outcomes, the HealthPartners Research Foundation has been studying health care homes and said that preliminary findings indicate that they "have significantly better performance scores for diabetes and cardiovascular disease than non-health care home clinics."
Contrast the progress seen in the Minnesota health care homes pilot with ongoing problems in access to healthcare. For example, a recent survey from the Centers for Medicare and Medicaid Services found that one-in-five ED patients who were sick but did not need an inpatient bed said their primary care doctor told them to go to the ED for care.
Coordinated, wellness- and prevention-oriented services provided at health care homes in Minnesota and in other states won't eliminate needless and expensive trips to the ED. However, it's a good bet that those patients walking into the ED for non-emergent care won't be coming from health care homes.
Physicians' advocates have asked Congress to scrap Medicare's widely reviled sustainable growth rate (SGR) payment scheme and replace it with flexible payment options that reward quality and efficiency.
AMA CEO James L. Madara, MD, in a May 25 letter to the committee said any cost-efficient payment model redesigns should give physicians the resources and flexibility to keep patients healthier, improve care coordination, manage chronic conditions, reduce duplication of services, and prevent avoidable admissions.
"For Medicare's physician payment system to move in this direction, there needs to be a transition period with opportunities for physicians to move into innovative payment and delivery models in ways that enable them to gain skills and experience in taking accountability for improving care and lowering growth in costs," Madara wrote.
"Physicians should have opportunities to help design an array of innovations and choose those that best fit their specialty, practice, patient population, capabilities, market, partners, and resources."
Madara told the committee that a "full menu of innovations" must look beyond shared savings programs and accountable care organizations, and toward initiatives that include performance-based and bundled payments, global- and condition-specific payments, warranties for care, and medical homes.
In addition to flexible payment models, Madara said physicians also need flexible implementation dates "available on an ongoing basis so physicians can plan for the needed changes and join as they become ready."
MGMA President/CEO Susan Turney, MD, in her letter "strongly" urged Congress to repeal SGR as a critical first step in payment reform, and replace it with "stable payments for a period of several years to allow testing of different payment and delivery models, and then allow for a transition to new models."
Turney offered alternative payment models that were largely identical to those suggested by Mardara. The MGMA leader praised the committee for acknowledging that a new payment model cannot be a "'one size fits all' method given the diversity of medical practices. Physicians should have the flexibility to adopt different approaches based on their composition, capabilities and community needs."
MGMA also wants to "break down the silos" that separate payment systems for Medicare Part A and Part B so that different practice models can be accommodated.
"According to the Congressional Budget Office, physician spending only represents 13% of all Medicare spending versus 32% under Part A (hospital inpatient services and SNF)," Turney wrote.
"To truly address costs, incentives must be aligned to encourage physicians to reduce spending in the highest cost areas of the Medicare program. Many of the new emerging models will only succeed if the silos are broken down, allowing physicians and hospitals to work together to prevent hospitalizations and provide cost effective care."
Fairview Health Services CEO Mark Eustis will retire this summer amid allegations that the Minneapolis-based health system he led for five years used strong-armed and possibly illegal debt collection tactics against patients.
Eustis, 59, joined Fairview in 2007 and his contract was due to expire on July 31. Fairview's board of directors met in a special session Wednesday and voted not to renew it.
"Mark committed to five years as Fairview's CEO," Board Chair Chuck Mooty said in prepared remarks. "During that time, he established a clear, compelling vision for the future of healthcare delivery at Fairview."
Mooty will serve as interim CEO at the seven-hospital system, effective August 1, until a successor is named.
Attempts by HealthLeaders Media to contact Eustis on Thursday were not successful. The health system said it would have no comment beyond the media release announcing Eustis's departure.
The Star Tribune newspaper reported that Eustis announced his departure in a memo to employees on Thursday morning, saying in part: "I believe deeply in Fairview and the vision we have set in motion. I can retire knowing that what we have worked so hard to establish will carry forward."
Fairview had come under the scrutiny of the Minnesota Attorney General Lori Swanson, who issued a scathing multivolume report detailing strong-armed bill collection tactics that allegedly were recommended by Accretive Health Inc., a Chicago-based consulting firm that Eustis had hired.
Fairview severed its contract with Accretive in April.
After the board ended its ties with Eustis this week, they had only kind words for him and no mention of Accretive or the AG's investigation. In the media release announcing his departure, Eustis was credited with "spearheading transformation of Fairview's care delivery and core business model to improve clinical outcomes, enhance the patient experience and reduce total cost of care. Under Eustis' leadership, Fairview created a new care model focused on improving the health of defined patient populations, developed and implemented one of the first shared-savings contracts in the country, and became one of only 32 Medicare Pioneer Accountable Care Organizations in the country."
The Pioneer Pressreported this month that inspectors from the Minnesota Department of Health visited the hospital to conduct an on-site inspection and the Centers for Medicare & Medicaid Services has launched an investigation to determine if Fairview's billing tactics violated the federal Emergency Medical Treatment and Active Labor Act (EMTALA). The law requires hospitals that take Medicare money to provide appropriate care for emergency room patients regardless of their ability to pay.
Accretive has denied any wrongdoing but told the Chicago Tribune this month that it is considering ending its debt-collections services, which represent about 5% of total revenues.
Mooty said the search for Eustis's successor will begin immediately.
"We will be looking for a dynamic, proven executive to lead Fairview's highly skilled and committed leadership team and its mission-driven employees and providers, and to continue to elevate Fairview's leadership position in the national health care community," Mooty said.
The nation's leading urology associations are fuming over a federal panel's report this week that discredits the widely used prostate-specific antigen screening test for prostate cancer.
The U.S. Preventive Services Task Force said in a report that the PSA test is too inaccurate, creates needless anxiety for patients, and can lead to costly and potentially harmful follow-up procedures.
"The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harm," the report stated.
Major urology associations knew in advance about the USPSTF recommendation and urologists launched a counterattack when the report was made public this week.
"It's an absurd recommendation. It is ill-researched and ill-conceived," Sanford J. Siegel, MD, a board member with the Large Urology Group Practice Association, told HealthLeaders Media. "This will only do damage to all the great work that has been done for prostate cancer awareness and to control the deaths from prostate cancer."
American Urological Association President Sushil S. Lacy, MD, said in prepared remarks that he was "outraged" by the report. "It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations such as African-American men," Lacy said. "Men who are in good health and have more than 10-15 years life expectancy should have the choice to be tested and not discouraged from doing so."
A similar statement was issued this week by the American Association of Clinical Urologists, which called the USPSTF recommendations "misleading and harmful." The major urological associations say the USPSTF ignored new studies supporting the value of PSA tests, and that the panel refused to address concerns they raised about the conclusions during the comment period. In addition, the urologists complain that there were no urologists or oncologists on the panel.
Siegel, who is also the president and CEO of Maryland-based Chesapeake Urology Associates, says urologists have long understood that the PSA test can lead to a high percentage of false positives, but he said that doesn't mean the test should be discounted.
"It is just a screening test, one of several things we look at when we decide whether a man needs a biopsy or not," he says.
Siegel concedes that PSA testing could lead to needless and costly procedures performed out of fear or caution.
"There is no question that men get prostate biopsies that obviously in hindsight shouldn't happen. But we are looking at improving PSA testing and other testing to help us find out which men will progress with more advanced prostate cancer," he said.
The problem, he says, is that no one has yet come up with an alternative to determine which patients will develop advanced prostate cancer.
"Yes, it is true that many men can live with this disease their whole life. That is why active surveillance has become a treatment option," he says. "If we knew in advance who would and who wouldn't advance in the cancer, that'd be great!"
USPSTF said it could find no evidence to support claims that PSA tests are responsible for "reduction in all-cause mortality."
"In contrast, the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death," the report said. "Many more men in a screened population will experience the harms of screening and treatment of screen-detected disease than will experience the benefit."
The report said that over-diagnosis and overtreatment becomes an "inevitability" with PSA testing, which "means that many men will experience the adverse effects of diagnosis and treatment of a disease that would have remained asymptomatic throughout their lives. Assessing the balance of benefits and harms requires weighing a moderate to high probability of early and persistent harm from treatment against the very low probability of preventing a death from prostate cancer in the long term," the report said.
Siegel said the report ignores or fails to explain the dramatic decrease in deaths from prostate cancer over the last several decades.
"About 250,000 men are diagnosed with prostate cancer each year. That has stayed pretty stable. It is the death rates that have come down significantly," he says.
"In the last 30 years the deaths have dropped from 48,000 to 28,000 a year. The surgery is better. The radiation is somewhat better. But there haven't been significant advances except in some of the surgical techniques to explain this, other than screening."
Siegel says he is concerned about "the greatest damage" the report will have on prostate screenings for African-American men, who are disproportionately affected by prostate cancer.
"I have been a urologist for almost 30 years. When I started training, 40% of African-American men at that time presented with metastatic disease. Now that number is miniscule," Siegel says. "Tell me how that happens without early screening? How do death rates go down from 48,000 when I trained to 28,000 now? How do you explain that without screening? You can't! It's impossible!"
Even though the test is being discouraged by the task force, Siegel says he believes many men and their physicians will want to keep the option on the table.
"If I am with a patient, I'm going to tell them 'we have a blood test to help diagnose prostate cancer. Yes, there are false positives. But if you have prostate cancer, do you want to know or do you want to play Russian roulette?'" he says. "Of course, I wouldn't say it like that. But that is the question. Who's going to say no?"
We compartmentalize population health issues in this country. Perhaps it is because the challenges are vast and daunting and there are usually exceptions to any consensus. Therefore, using reams of data to carve national healthcare issues into smaller bits based on region, race, gender, or socioeconomic class makes issues seemingly more digestible and solvable.
However, one of the unfortunate ironies of population health in the United States is that the people who live in the most remote sections of the country often face the same health and healthcare access issues that plague people in large cities.
Robert L. Ludke, PhD, a co-editor of the compilation and a professor of family and community medicine at the University of Cincinnati, told HealthLeaders Media that the "common denominators" for the poor health status of many people in Appalachian hollows and inner-city slums are "poor environment, low socioeconomic status, and lifestyles behaviors."
Ludke says Appalachian inhabitants from coal-producing regions, for example, would feel the ill effects of living in a contaminated environment, just as any urban inhabitant might suffer from living near an industrial complex, or from moldy and substandard housing.
There are lifestyle behaviors, particularly around high-fat diets and high incidences of tobacco use in Appalachia and among lower-income Americans regardless of their neighborhoods that contribute to health problems.
There is a high incidence of mental illness and substance abuse. Finally, there is the poverty—the grinding, stubborn and notorious pockets of blight that can be found in the shadows of mountains and sky scrapers.
"When you put together the environment, the lifestyle behaviors, the socio-economic status, and couple that with this overlay of the healthcare system and the difficulty to access services because of where they are located, they all contribute to the greater disparities," Ludke says.
He was talking specifically about Appalachia, but the words could apply to the health issues that are seen every day at urban safety net hospitals.
Of course, not everyone who lives in an inner-city neighborhood or a backwoods tract is poor, uneducated, or unhealthy. And before we can gain a better understanding of the healthcare challenges that face many inhabitants of Appalachia, Ludke says, we must first get past the hillbilly stereotypes that have plagued the region for decades.
"The Appalachian culture in many respects is no different from other cultures. These aren't people that follow those stereotypes. They are people like you and me in many respects," he says. "What we try to do in the book is to raise the questions about what is underpinning the health of the people living within the Appalachian region as well as those individuals who have migrated to the region to urban areas such as Cincinnati, Detroit, Chicago, Pittsburgh, Cleveland, and Indianapolis."
For example, when it comes to access to care, Ludke says, the challenges in Appalachia as a region are about the same as anywhere else in the country, and that is not necessarily a good thing.
"When you look at it more carefully, you see that about half of the Appalachian region is rural and what you see which is comparable to other rural areas in the country is that those are the areas where there are limited healthcare services," he says.
"Just like the country as a whole, it's not necessarily where we have shortages of healthcare professionals or facilities. What we have is a maldistribution issue where they are concentrated in the major population areas. Therefore, people who live away from those areas have a much more difficult time to try to get care."
One disturbing commonality between the urban and rural poor is the effect of stress on their health. "It's not just thinking about stress as 'what kind of a day do you have?'" Ludke says. "There is clearly a body of literature out there that says that early in life, even before we are born, we are exposed to stress and it builds up over time to the point where it leads to the onset of disease."
Are people poor because they are stressed, or are they stressed because they are poor? It's a chicken-or-egg question. Regardless, Ludke says there is a link.
"People living in lower socioeconomic conditions are living in environments where there is a higher degree of negative environmental exposure," he says. "They are living under higher stress than people not living in those environments to the point where they would be more susceptible to disease."
Bottom line: No matter where you live, poverty isn't easy.
Four former healthcare vendors have been sentenced to prison terms of up to three and a half years for their roles in a bribery scheme that directed cash, goods and services to South Florida hospital executives in exchange for contracts worth $15 million, federal prosecutors said.
The four vendors are among the nine people, including three hospital executives, arrested last June in the bribery probe at two hospitals in Fort Lauderdale-based Memorial Healthcare System.
Sentenced for federal bribery convictions this month in U.S. District Court were: Thomas Kennedy, 44, of Davie, FL, to three and a half years in prison and three years of supervised released; Richard Cohen, 45, of Wellington, and Paul Chaiet, 48, a CPA, of Dania, to 18 months in prison and three years of supervised release each; and Thomas Pacchioli, 52, of Weston, to three years probation with 180 days home confinement. The four former vendors were ordered to pay restitution.
Court documents and trial testimony showed that co-defendant Adil Osman, 64, the former director of facilities management at Memorial West in Pembroke Pines, accepted kickbacks from the vendors for thousands of dollars in home improvements, including new gutters, a swimming pool, fencing, and an electric generator.
In exchange, Osman awarded inflated contracts to the vendors that concealed the value of the services they provided for him, federal prosecutors said.
Prosecutors described a "nearly identical kickback scheme" that involved former "team leaders" Elliot Gordon and Anthony Merola at Memorial Regional Hospital in Hollywood, FL. Both men pleaded guilty last year and are now serving prison sentences. Osman is scheduled to be sentenced on June 1, along with former vendor Robert Andrei, 70, of Davie.
Kerting Baldwin, a spokeswoman for Memorial Healthcare System, said the provider fully cooperated with the investigation. "The United States Attorney's Office has commended our management and security personnel for their assistance in this investigation," Baldwin said. "Ever since we discovered irregularities in the Plant Engineering Department and turned over the case to the proper authorities, we have been proactive with all of the investigating agencies to bring this case to conclusion."
For those who embrace the wellness movement, two federal departments have just issued two separate reports that hearten and frustrate for the same reason.
First, the Department of Agriculture issued a report on Wednesday that found that healthful foods such as fresh vegetables cost no more "per calorie" than processed foods and junk foods. That bit of economic analysis eliminates a lame excuse that many of us have used while waiting in the $1 menu line at McDonald's.
One day after this report was released, however, the Treasury Department issued a report that found that 24.8 million Americans live in areas with limited supermarket access, what the feds call LSA, a problem significant enough to warrant its own acronym.
The Treasury report, Searching for Markets "identifies 1,519 communities where supermarkets do not exist, and where the unmet demand within the community is large enough to support a full-service grocery store." Treasury says LSA communities are 2.28 times more likely to be low-income and have larger minority populations.
These reports underscore a stubborn hurdle that faces well-meaning wellness advocates. While it is heartening to know that fresh foods are just as affordable as junk food, that information is teasingly useless for 25 million generally poorer Americans who could greatly benefit from healthier diets but have limited access.
And these two reports should give pause to advocates of "skin-in-the game" punitive financial measures such as higher health insurance premiums for overweight or obese people. It's not that simple.
Let's be clear: Lack of access to fresh produce does not give anyone license to simply forfeit responsibility to maintain his or her health. It is imperative that we find the incentives that make people adopt healthier lifestyles. However, it is also unfair to hold everyone to the same weight measure or dietary standard when it is not so readily available to all.
It is legitimate to say that if a person doesn't take the initiative for his own health, nobody else will. Action is needed, but it shouldn't be a one-size-fits-all strategy that penalizes the people who can least afford it.
Businesses establishing a wellness program should take the time to tour neighborhoods where their lower-wage employees live to better understand the advantages and challenges they may face in their home environments.
It's not just about access to healthy food. We can advocate fitness measures and exercise programs, but does that take into account neighborhoods with no sidewalks or parks, or inadequate street lighting, or higher crime rates? Does the supervisor who devises an exercise plan while sitting at a desk all day understand that some workers might be standing on their feet for eight hours a day or longer and are therefore less enthusiastic about that after-work Zumba class?
For safety net healthcare providers that see firsthand the debilitating effects of the overweight and obesity epidemic, the problem is even larger than an employee wellness plan. How can we hope to improve health outcomes if patients who live in LSAs are sent home with a simple admonishment to eat more greens?
It is not enough to restate to people the obvious fact that they need to eat healthier diets. Even armed with that knowledge, no person can follow that directive if they can't regularly and easily access the healthier food.
In April I spoke with Chip Johnson, the mayor of Hernando, MS, a city that was recently identified as one of the healthiest in the Magnolia State. Johnson is one of those innovative types who understands that a problem as big as the obesity epidemic can't be solved with one sweeping mandate.
Instead, Hernando has taken a long-term incremental approach towards improving the health of its residents with simple steps that include building more sidewalks and bike lanes, and improving access to healthier food. The city situated its farmers' market within walking distance of its poorest neighborhoods.
"We can't expect people to eat healthier and be healthier if they don't have access to those foods. So a farmers' market is one way to do that," Johnson told me. "And you have to make sure your farmers' market is in places that are within reach of your poorest communities, your underserved communities."
This is a good first step for healthcare organizations and community wellness advocates who find that they may have an LSA in their service area.
It is time to promote not just eating healthier food but access to healthier food.
