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Commentary: How to solve the health inequity problem in Charleston, and beyond

James H. Suddeth Jr. (copy)

James H. Suddeth Jr.

Health inequity in Charleston is alarming. People living in Charleston County census tract 26.06, west of the Ashley, have an average life expectancy of 81.1 years. People living across the Ashley River in census tract 44 have a life expectancy of 66.6 years, a difference of 14.5 years. Surrounding census tracts on both sides of the river produce similar results.

The problem in Charleston is similar to the situation in many U.S. cities, and it is driven by numerous factors called the social determinants of health. Examples include access to transportation, social support systems, healthy diets, access to primary health care and health education. These directly correlate with income: For instance, the average household income is $28,000 in tract 44 vs. $98,210 in tract 26.06. These factors exacerbate the inability to prevent and manage chronic conditions, such as cardiac and pulmonary diseases, cancer, diabetes and hypertension. The factors also make people more likely to die.

Why does our system allow folks who live just across a river to have such differences in mortality? Because we place more value on sick care than public health and chronic disease prevention and management. According to a 2014 study by the University of Wisconsin, clinical care has a 20% impact on our health status, while 40% is attributable to social determinants, 30% to healthy behaviors and 10% to physical environment. Health care systems should address all of these to promote a healthy population.

The problem is that our health care systems get paid primarily for treating sickness and don't get paid enough to help maintain a healthy population. Broader access to primary care, prenatal care and health education should be directly fostered by health systems. 

Chronic disease prevention and management start with robust primary care. Health care financing places more value on expensive hospital-based procedures — think of cardiac surgery, for instance — than the primary care that could prevent the need for surgery and other hospital-based procedures. Couple this with our dismal attention to public health initiatives, and you begin to understand the why the health of the population is not improving.

Can the free market solve this problem? Not until we make regulatory changes to make institutions in our health care delivery system responsible for both financial and quality outcomes of their patients. Not until we put physicians back in charge of managing patient care.

The solution occurs when health systems such as MUSC, Roper St. Francis, Trident and East Cooper team up with their staff physicians and compete for individual patients in the community. They become the provider and the insurer, accepting the financial risk and accountability for quality. The health system would be paid a monthly per-member fee. Individuals and families could select the best system for their situation with no discrimination or cherry picking allowed by the health systems.

Policies would be established to equitably distribute high-risk members to all health systems. To be price-competitive, systems would need to expand access to primary care in areas such as census tract 44, keeping patients out of their expensive hospitals. Health and nutrition education, home care, chronic disease prevention and management would be provided on a proactive basis.

Administrative expenses would be significantly reduced. The majority of the insurance company and insurance agency middleman costs would be eliminated. Group health insurance along with its administrative burden would be eliminated. There should be complete price and quality transparency provided by consumer reporting operations. Systems would compete for individual, Medicare, Medicaid and Exchange members.

Asset-heavy hospitals deliver expensive care to the sick population and consume the largest percentage of our health care dollars. There is no transparency with quality. Without accountability for both price and quality, the free market cannot operate.

We have enough money sloshing around our current system to accomplish the task of a major overhaul. However, vociferous pushback would occur because there would be dramatic losses in certain sectors, and the fight over dollars would ensue. Until we have a major overhaul of our health care system, folks in census tract 44 will continue to live 14.5 fewer years than those who live just across the Ashley.

James H. Suddeth Jr. is CEO of Suddeth Healthcare Solutions. He is a former board chairman of Palmetto Health Richland.

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