Special Issue: Population Health
VOLUME LIX • NO. 8 • 2018
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VOL. LIX • NO. 8 • AUGUST 2018
POPULATION HEALTH
EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD
THE ASSOCIATION President William M. Grantham, MD President-Elect Michael Mansour, MD
MANAGING EDITOR Karen A. Evers
Secretary-Treasurer W. Mark Horne, MD
PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors
Speaker Geri Lee Weiland, MD
Mississippi’s Battle with the Social Determinants of Health: A Review and Commentary Richard D. deShazo, MD; Kyle McCullouch, BBA
334
Population Health Management: The Scope, Training, and Practice – What are the Benefits for Mississippi? Bettina M. Beech, DrPH; Natalie Gaughf, PhD; Sydney Murphy, PhD
344
UProot: Building a Healthier Mississippi from the Ground UP – A New Approach to an Old Problem Mary Currier, MD, MPH; Paul Byers, MD; Thad F. Waites, MD
348
354
Preparing Medical Students to Practice Twenty-First Century Medicine: The Prevention and Population Health Curriculum at the University of Mississippi School of Medicine Joshua R. Mann, MD, MPH;, Leandro Mena, MD, MPH; Alan D. Penman, MD, PhD, MPH
Vice Speaker Jeffrey A. Morris, MD
The Global and National Perspective of the Noncommunicable Disease Epidemic John Gordon Harold, MD
360
Executive Director Charmain Kanosky
Utilizing Technology and Team-Based Care to Improve Cardiovascular Health in Mississippi Donald Clark, III, MD; Daniel W. Jones, MD
366
Comprehensive School Health Education and the Future of Health in America J. Edward Hill, MD
370
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Jill Gordon, MSMA Director of Marketing. Ph. 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2018 Mississippi State Medical Association.
Prevention and Wellness: A Multi-Specialty Clinic Approach Bryan N. Batson, MD; John M. Fitzpatrick, MD
376
Economics of Population Health and Prevention: Is an Ounce Worth a Pound of Cure? Therese L. Hanna, MHS
380
DEPARTMENTS From the Editor – As We Lay Dying Lucius M. Lampton, MD
330
Editorial – Population Health and Prevention: Evolving Science and Potential Salvation Michael Mansour, MD; MSMA President-elect
332
President’s Page – Things a President Learns William M. Grantham, MD
372
Letters
374
In Memoriam
384
Images in Mississippi Medicine – May Farinholt Jones, MD Lucius M. Lampton, MD
386
Poetry and Medicine – Am I Going to Get a Shot? John D. McEachin, MD
387
New Members
388
ABOUT THE COVER
Official Publication
MSMA • Since 1959
Mississippi Civil Rights Leaders Emphasize Social Determinants of Health – In 2008, five of the living black Mississippi physicians who were most active in the American civil rights movement were honored at a gala in Jackson. Continued on page 388 AUGUST • JOURNAL MSMA
Special Edition: Population Health
VOLUME LIX • NO. 8
329
F R O M
T H E
E D I T O R
As We Lay Dying “P
opulation health” is an evolving term frequently used in medicine, but not always understood. The concept is defined as the health outcomes of a defined group of individuals, often geographic populations such as nations or communities. [Kindig D, Stoddart G. “What is population health?” Am J Public Health. 2003, March; 93(3): 380–3.] Delivery of care in our current system is often silo-focused and reactive Lucius M. Lampton, MD rather than proactive and communal. Editor This special issue of the Journal focuses on the importance of population health and prevention efforts as solutions to improve our state’s overall health outcomes. For many in medicine, advocating a population health perspective is simply a return to medicine’s public health roots, emphasizing the principles of epidemiology, preventive medicine, primary care, and health promotion. My title above refers to William Faulkner’s classic novel: As I Lay Dying. Published in 1930, this tour de force is a tale of the death of Addie Bundren and her poor family’s hazardous trek to satisfy her
wish to be buried in her hometown of Jefferson, Mississippi, a town in Faulkner’s fictional Yoknapatawpha County. A physician friend recently joked that any assessment of Mississippi’s current dismal health status should reference the novel and be entitled “As we lay dying,” with apologies to Brother Bill. Faulkner called his home landscape (the setting for most of his writings) “my own little postage stamp of native soil.” Mississippi’s physicians also have their own “postage stamp of native soil” for their difficult medical work: the state of Mississippi. Our postage stamp’s population health can be transformed only by a proactive strategy which impacts citizen behaviors and empowers the medical community. Healthy behaviors can be best achieved by health education in our schools (long championed by Dr. Edward Hill). Empowerment of the medical community is two-fold: 1) The state’s physicians must insist that our political leadership fund appropriately the Department of Health (not just keep the lights on, but actually give it necessary funding to accomplish its core mission). 2) Every physician in Mississippi needs as a second specialty public health, thus integrating public health with the everyday practice of medicine. n Contact me by mail or at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor
JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD
EMERGENCY MEDICINE Philip Levin, MD
MEDICAL STUDENT John F. G. Bobo, M2
ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD
EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH
NEPHROLOGY Jorge Castaneda, MD Harvey A. Gersh, MD
ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD
FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD James J. Withers, MD
OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD
GENERAL SURGERY Andrew C. Mallette, MD
OTOLARYNGOLOGY Bradford J. Dye, III, MD
HEMATOLOGY Vincent E Herrin, MD
PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD
INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD
PEDIATRICS Michael Artigues, MD Owen B. Evans, MD
CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD Nisha S. Withane, MD, Fellow CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD
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ORTHOPEDIC SURGERY Chris E. Wiggins, MD
PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY Shweta Kishore, MD C. Ann Myers, MD UROLOGY W. Lamar Weems, MD
E D I T O R I A L
Population Health and Prevention: Evolving Science and Potential Salvation
T
his issue of the Journal of the Mississippi State Medical Association seeks to promote the importance of population health and prevention efforts in Mississippi, the relevance of these efforts to an evolving healthcare delivery system, and the recognition of the many efforts being advanced and accomplished in our state. In the 1970s and 1980s former State Health Officer Dr. F. E. “Ed” Thompson, who later served as Centers for Disease Control Deputy Director for Public Health, and Dr. J. Edward Hill, past president of Mississippi State Medical and the American Medical Associations, were prescient in their promotion of preventive health by addressing noncommunicable diseases of hypertension, diabetes, and obesity. Dr. John Gordon Harold, World Heart Federation member and past president of the American College of Cardiology, is a leading international advocate promoting the importance of population health for the United States and the global community. His contribution to this issue of the Journal is invaluable for readers to gain the proper perspective of the challenges of noncommunicable diseases. In August 2015, the Mississippi State Medical Association adopted a resolution addressing noncommunicable diseases patterned after the World Heart Federation (WHF) and the World Health Organization (WHO) 25 x 25 Initiatives. The WHF seeks to decrease premature deaths caused by cardiovascular disease 25% by the year 2025, and the WHO goal seeks a 25% relative reduction in overall mortality from cardiovascular disease, cancer, diabetes, or chronic respiratory diseases by 2025. These goals require preventive measures aimed at increased physical activity, reduced sodium intake, reduction in tobacco use, and improved hypertension control along with a halt to the rising incidence of diabetes and obesity.1 This is particularly relevant because it offers the best option to improve health with better outcomes at lower cost. What began for me nearly 20 years ago as a way to address disparities in care through population health and prevention has now become of primary importance as we recognize population health as our best hope for confronting the global epidemic of noncommunicable diseases. This epidemic is particularly apparent in Mississippi. Mississippi has the same high incidence of cardiovascular disease and death as low and middle income countries. As one of the poorest states, Mississippi also has one of the highest incidences of noncommunicable diseases. This places Mississippi at particular risk for negative economic
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MICHAEL MANSOUR, MD MSMA President-elect Guest Editor, JMSMA Special Issue on Population Health
consequences of noncommunicable diseases because of the combined burden of health care cost and lost productivity due to illness and premature deaths. 2 A study commissioned by the World Economic Forum concluded that the world would sustain a cumulative output loss of $47 trillion between 2011 and 2030 because of noncommunicable disease and mental illness with about $30 trillion attributable to cardiovascular diseases, cancers, chronic pulmonary diseases and diabetes.3 Noncommunicable diseases are also a major cause of catastrophic health expenditure among the uninsured.4 In Mississippi this year the Medical Care Advisory Committee, a statutory entity made up of providers, recommended getting rid of caps on office visits and medications to focus on preventive care for Medicaid recipients. To its credit, the Mississippi Legislature passed and Governor Phil Bryant signed the Mississippi Medicaid Bill, removing previously defined limits on the number of medications and the number of office visits allowed per beneficiary, allowing the Division to increase those limits. The health of the population goes far beyond economics. The United States, despite ranking among the 10 richest countries in the world per capita, experiences sizable health disparities among its citizens. These disparities are rooted in social, economic and environmental factors. In the United States, the place of birth is more strongly associated with life expectancy than is race or genetics. On average there is a 15-year difference in life expectancy between the most advantaged and the most disadvantaged citizens. 5 The social determinants of health and disparities in care have been particularly apparent in the Mississippi Delta where the life expectancy of 72.2 years ranks 98th compared to countries around the world. Given
There are bright spots, however. Data from the Mississippi State Department of Health show Mississippi cardiovascular deaths per 100,000 decreased between the years 2004 to 2013 with an overall drop of 19.6% and the greatest drop of 25% occurring in AfricanAmerican women. Preventive medicine and population health will be major determinants for the collective health and wellbeing of Mississippi, and the United States as a whole. As physicians, we are struggling along with our patients through transitions in healthcare that unfortunately may sometimes do more to limit access and increase disparities rather than control the cost of healthcare. If we are to promote the very best care for our patients, we must lead the conversation and efforts to transform healthcare in a way that improves access, decreases cost, but also decreases illness. As a profession, we have done a great job of treating illness and prolonging life. Now we must lead in decreasing the incidence of disease so that limited resources can be appropriately used for all to benefit. The greatest challenge to population health is that it is of necessity a team endeavor. It will take the best efforts of the medical community and policymakers and the cooperation of the general public to accomplish these goals. In fact, this may be the greatest challenge to Medicine in our lifetime. We must move from the science and art of medicine to incorporate the art of engagement, education, and persuasion. It is apparent from the contributors to this issue that we have many great healthcare leaders taking this matter head-on. The University of Mississippi Medical Center is a national leader with its School of Population Health. The authors represent a vanguard of healthcare innovators seeking to raise Mississippi from the worst to the first in health and economic prosperity. The Mississippi State Department of Health’s SHIP (State Health Improvement Plan) program is an example of great leadership and thoughtful planning that focuses on addressing Mississippi’s health care deficiencies. I hope this issue of the Journal will help to advance the cause of better health for our patients and our state. Perhaps our state will serve as a model to address this predominant global public health challenge of the 21st century. This is clearly a challenge that must be undertaken by healthcare
providers and by society as a whole. The current and anticipated change in the healthcare delivery system and payment reform will require physicians and other providers to work more closely as a team to provide the greatest benefits for patients. As healthcare delivery system reform continues to evolve, reducing regulatory burden may be integral to the process of increasing transparency, accountability, and linkage of payment to outcomes. Partnerships among healthcare providers, the spectrum of government policymakers, and community organizations will be critical to efforts designed to implement programs promoting population health in a way that improves health and lowers the cost of healthcare delivery. n
I
“
hope this issue of the Journal will help to advance the cause of better health
for our patients and our state. Perhaps
“
the sophistication of healthcare in the United States, it is also surprising that the United States ranks 33rd in the world in life expectancy with a life expectancy of 79 years. Dr. Richard deShazo has long championed the cause of social determinants of health and racial disparities. The health and wellbeing of African-Americans in the Mississippi Delta are comparable to Americans living in 1974. This 2013 data from the Mississippi Department of Health and the Centers for Disease Control shows Caucasians in this area with health comparable to Americans living in 1997.6,7,8
our state will serve as a model to address this predominant global public health challenge of the 21st century.
References
1. Mansour J, Mansour M. Primordial and primary prevention: Addressing noncommunicable disease in Mississippi. J Miss State Med Assoc. 2017; 58(1):17-18. 2. Hunter DJ, Reddy KS. Noncommunicable diseases. N Engl J Med. 2013;369:1336-43. 3. Bloom DE, Cafiero ET, Jorne’-Llopis E, et al. The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum, 2011. (http://www. weforum.org/reports/global-economic-burden-non-communicable-diseases) 4. Heeley E, Anderson CS, Huang Y, et al. Role of Health Insurance in averting economic hardship in families after acute stroke in China. Stroke 2009;40:2149-56. 5. Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper. Daniel H, Bornstein SS, Kane GC; for the Health and Public Policy Committee of the American College of Physicians. Ann Intern Med. 2018;168:577-578. 6. Mansour M. Health disparities, population health, and preventive medicine. J Miss State Med Assoc. 2014;55(4):128-9. 7. Mansour M, Shor R. Healthcare in transition: Primary prevention and health disparities in focus. J Am Coll Cardiol. 2015;66(16):1837-1838. 8. deShazo RD. Food stamps, public health, politics, a new Mississippi social determinant of health, and the MMPAC budget. J Miss State Med Assoc. 2013; 59(10):296-299.
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P O P U L A T I O N
H E A L T H
Mississippi’s Battle with the Social Determinants of Health: A Review and Commentary RICHARD D. DESHAZO, MD; KYLE MCCULLOUCH, BBA
Abstract The social determinants of health are the social and economic factors in society responsible for health inequities. They have a powerful influence on health and well-being both at the individual and population level. Despite overall health improvements in the United States, disparities in health have persisted in Mississippi to the degree that by 2016 Mississippi had the lowest life expectancy (51st out of 50 states and DC), highest overall death rates (including those in young people 1-20 years old) and was among those states with the lowest number of healthy years of life. Because our health disparities are both historic and intractable, Mississippi has played a central role in the identification, quantitation, and attempts to improve health disparities in the U.S.. Unfortunately, we have yet to benefit from these efforts. Experience shows that improvements in the social determinants of health come from changes in governmental and cultural attitudes, changes driven by strong, intentional and persistent patient advocacy. Although physicians are, by our professional oaths and codes, the most respected, influential, and natural leaders for efforts to improve the determinants, many physician organizations and leaders, especially those in states with high levels of uncompensated health care, have been apt to focus their advocacy more on reimbursement than on governmental health policy. In Mississippi, advocacy for better health has also been muted by our state’s perennial war with the federal government, an oxymoron since that agency provides 40% of funding for our state budget. The toxic mix of poverty, racial discrimination, bad health, libertarian politics, and the timid advocacy of organized medicine to improve the social determinants of health is demonstrated by limited public opposition to the defunding of the Mississippi State Department of Health (MSDH) by the State Legislature. Despite already receiving the lowest per capita state funding in the U.S., the MSDH has traditionally done the heavy lifting to improve the social determinants of health by accessing generous federal support programs to improve them. Now MSDH no longer has an adequate budget to effectively perform its state-mandated disease surveillance and oversight functions, much less compete with other states for federal dollars to improve Mississippi’s health. If Mississippi’s poor rankings in public education, nutrition, housing, urban planning, transportation, and employment are to be addressed, physicians must form a partnership for improvements in these social
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determinants of health with other advocates who understand the association between quality and length of life and decision making in state government. This paper seeks to review the problems at hand, argue that politics is the most important social determinant of health in our state, and offer some thoughts on a way forward for our association. A Learned, Forgotten and Now Rediscovered List Many physicians first heard the term “the social determinants of health” in the surreal environment of the first year of medical school. Most often, the “list” of them was mentioned during several lectures on public health and sandwiched in-between “more important” content on anatomy, physiology, biochemistry, and the like. The list was memorized and forgotten, only to reappear in the faces and lives of our patients. In Mississippi, socioeconomic problems regularly presage poor health and complicate treatment of the chronic diseases that result from them. The health of the poor has always paled in comparison to the health of the rich, and nowhere in the United States (U.S.) has that been more apparent than in Mississippi’s burden of disease.1 In a state with the highest poverty rates in the U.S., more than 75% of citizens 55 years and older suffer from at least one of the five most common chronic diseases. By the time these are diagnosed, often the best physicians can do to address their patient's lengthy problem list is to provide empathy and palliative polypharmacy. Today, the list of social determinants of health has been more precisely defined, extensively studied, and statistically tested. In Mississippi, the list and its extraordinary impact on the quality of life here has changed little over time. Now something radical has happened. For the first time, the life expectancy of all Americans has decreased in each of the last two years and life expectancy in the next generation is predicted to be lower than the present one. Attempts to better understand the complexities around all this has generated a whole new vocabulary (Table 1). Attempts to improve the social and economic factors responsible for health are not new. In 1979, U.S. Surgeon General Julius B. Richmond’s report "Healthy People" laid the foundation for a national disease prevention agenda that included addressing the social determinants of health. Subsequent reports to include "Promoting Health/Preventing
Table 1
Definitions Terms in This Paper Table 1. Definition of Terms inofThis Article Definition The study and promotion of health among individuals Population Health The study and promotion of health among populations of individuals Determinants of Health Factors that contribute to a person’s current state of health. These may be socioeconomic, psychosocial, behavioral or biological Social Determinants of Health The social and economic factors responsible for most health inequities Cultural Competence Behaviors, attitudes and policies that enable effective work in cross-cultural situations Health Literacy A social determinant that identifies an adequate understanding of basic health information to allow wise health decisions Poverty A social determinant that identifies the inability to meet human needs because of the inability to afford solutions to them Socioeconomic Status A social determinant that identifies to social position of an individual, most commonly the sum of income, education and occupation Health Equity The opportunity to attain one’s full health potential Health Inequality Differences in health among groups of people related to suboptimal social determinants of health Health Disparity Differences in health outcomes that are systematic, avoidable and unjust Adapted from, information in the public domain available at Adapted from, information in the public domain available at http://www.cdc.gov/ http://www.cdc.gov/nchstp/socialdeterminants/definitions.html. Accessed nchstp/socialdeterminants/definitions.html. Accessed April 30, 2018. April 30, 2018.
Figure 1. The Determinants of Health. Factors Related to Health and Well Being
Term Public Health
Table 2. Goals of Healthy People 2020
Adapted from, information in the public domain available at https://www. healthypeople.gov/2020/About-Healthy-People. Accessed April 17, 2018.
Disease: Objectives for the Nation" (1980), "Healthy People 2000: National Health Promotion and Disease Prevention Objectives" (1990) and now, “Healthy People 2020” (2010), established national health goals and objectives to form the basis for the development of state and community action plans (Table 2).2 Actionable health initiatives from “Healthy People” were and continue to be most often implemented by state health departments using funds from the Centers for Disease Control, usually obtained through grant applications. Understanding the Social Determinants of Health
Seventy percent of the determinants of health are made up by social determinants, including behavioral, social, environmental factors, and health care variables. Adapted from Schroeder, SA. (2007). We Can Do Better – Improving the Health of the American People. NEJM. 357:1221-8 and available in the public domain at: https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-therole-of-social-determinants-in-promoting-health-and-health-equity/. Accessed April 17, 2018.
The term “determinants of health” is defined as the sum total of the effects of genes and biology, health behaviors, health care, and social and environmental factors on health. Those social determinants of health, including health care, individual behaviors, and social and environmental factors, are thought to account for about 2/3 of health and well-being (Figure 1).3 In 2002, the United Nations through its World Health Organization (WHO) created the Commission on Social Determinants of Health to more precisely and scientifically define the social determinants of health, develop international cooperation in their assessment, and to facilitate research on how they may be improved.4 Consensus around the list of determinants and their implications has developed through a series of WHO international consensus conferences.5 As a result, the determinants have been further delineated.6,7 A representative list of the social determinants from these WHO consensus conferences demonstrates visually how they influence health outcomes (Figure 2). Mississippi’s Extraordinary Connections with the Social Determinants of Health Because of its public role in the fight for civil rights and equality in health, Mississippi physicians, like those in the award winning book “The Good Doctors”, have played a central role in the identification of the social determinants of health.8,9 However, two Mississippi physicians, Drs. W.S. Leathers and Felix J. Underwood, played an early national role in
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Figure 2. Representative Social Determinants of Health
Examples of individual or group-level social determinants include gender, race/ethnicity, socio economic status, social class, education, income, occupation, employment status, housing tenure, immigrant status, language use, disability status, and social capital. Social determinants at the population level include socioeconomic deprivation, poverty rate, income inequality, educational opportunity, labor market structure, affordable housing, access to healthy foods/good nutrition, provision of health services, access to essential goods and services, transportation infrastructure, physical and built environments, racial/ethnic population composition, medically underserved or health professional shortage areas, and spending on public safety, social and welfare services. Social determinants at the population level are considered underlying, upstream, or more fundamental determinants of health and disease and are amenable to change through public policy. (Adapted from Wilkinson R, Marmot M, editors. Social Determinants of Health: The Solid Facts. Second Edition. Copenhagen, Denmark: World Health Organization, Regional Office for Europe; 2003. Reproduced from the public domain at https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/. Accessed April 9, 2018.)
the discovery of the social determinants of health (Table 3). The first Mississippi state health officer, Dr. W.S. Leathers, and the first full time state health officer, Dr. F.J. Underwood, were national leaders in the identification of the importance of nutrition, hygiene and sanitation to prevent communicable disease and the necessity to educate health professionals to improve access to healthcare. Dr. Leathers was educated at Harvard and Johns Hopkins Universities and recruited to the Biology Department at the University of Mississippi in Oxford. He was a prolific medical researcher and collaborated with the famous Joseph Goldberger, MD, in experiments at the Rankin County Prison Farm that established nutritional deficiency as the cause of pellagra. He also participated in a national Rockefeller Foundation initiative on hookworm eradication and led that program in Mississippi. Dr. Leathers published studies on parasite and insect-borne infections and influenza, served as the founding dean of the 2-year University of Mississippi School of Medicine in Oxford and as executive director of the Mississippi Department of Health from 1910-1924.10 Dr. Underwood was born in Middleton, Mississippi, in 1882. He attended medical school at the University of Tennessee in Memphis, practiced in his hometown, and served as a president of the Mississippi State Medical Association. He became the Director of the Mississippi (MS) Bureau of Child Hygiene and Welfare at the Board of Health in 1919 and subsequently became the full time executive officer of the Mississippi
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Board of Health in 1924.11 Dr. Underwood identified poverty, rural location, poor sanitation, and access to health care as factors associated with the poor health of Mississippians and attempted to address all of them.12 A vocal advocate for public health in the legislature, he ardently resisted political forces in the legislature and elsewhere against progress to improve health and was known as “a force of nature.” For instance, he managed to convince the legislature during the Jim Crow period to fund a Mississippi State Medical Education Board that granted scholarships to medical school for black and female students as well as white males to improve Mississippi’s doctor shortage. This accomplishment is often confused with a later scholarship program that was implemented by the Southern Governor’s Conference to divert qualified black applicants from southern medical schools to historically black medical schools to preserve segregation in their state universities.13 In 1953, the year the University of Mississippi Medical Center opened, Dr. Underwood published a report on the success of his medical scholarship program in a national journal (Table 4).14 Dr. Underwood also created a Mississippi Hospital Planning and Construction Commission, successfully lobbied for the construction of the 4-year medical school, developed a plan for nursing education, and established a state wide voluntary hospital insurance program. In 2002, then state health officer Dr. Ed Thompson assembled health professionals, politicians, community activists, and academics to analyze Mississippi’s determinants of health resulting in the 45-page long
Table 3
Table 3. MSDH* State Health OfficersState Health Officers MSDH* Name
Dates of Service
Accomplishments
W.S. Leathers, MD, PhD(H)
1910-1924
Hygiene and sanitation (hook worm infestation (with Rockefeller Foundation), influenza, malaria and pellegra (with Joseph Goldberger), organized 2 year medical school at Ole Miss in 1903 and served as dean until 1924.
Flex J. Underwood, MD
1924-1958
Archie Gray, MD Hugh Cottrell, MD
1958-1966 1968-1973
Alton Cobb, MD, MPH
1973-1993
Ed Thompson, MD, MPH
1993-2002 2007-2009
Pre and postgraduate medical education, living conditions, insect born infections (malaria), work environment (industrial hygiene), child health Home health services. Child and maternal health (family planning) Systems of care (districting) disease prevention, immunizations, sexually acquired diseases, infant mortality, information systems Sexually acquired diseases, environmental safety (bioterrorism), emerging pathogens (drug resistant infectious agents), “Mississippi Plan to Eliminate Racial and Ethnic Disparities”
Brian Amy, MD, MPH Mary Currier, MD, MPH
2003-2007 2010-present
Systems of care Quality assurance in public health services (departmental certification), expansion of diagnostic services
*MSDH = Mississippi Department of Health
Table 4. Mississippi Medical Education Board Scholarship Program (1946-1949)
Adapted from reference 14 (Underwood)
“Mississippi Plan to Eliminate Racial and Ethnic Care Disparities.”15 Unfortunately, the Mississippi Legislature had little enthusiasm for funding such programs, and he had little support from outside the MSDH. Drs. Leathers and Underwood served as presidents of the American Public Health Association in its formative years and Dr. Alton Cobb received the association’s highest service award. Dr. Cobb was the state health officer from 1973-1993. After serving as the first director of the state’s first Medicaid program, he worked to improve the determinants of health during his many years of leadership. Influential with legislators, he reorganized MSDH into districts and developed the state’s home health and supplemental nutrition programs
for women, children, and infants.10 Subsequent health officers continue to be active in addressing the social determinants of health as they are able. The rate-limiting step in all of these efforts has been state support for infrastructure, especially in recent years, as federal support for public health initiatives has become increasingly evidence-based and competitive. Another Mississippi connection to the social determinants of health is the story of Tuffs University School of Medicine faculty member and civil libertarian, Jack Geiger, MD, M.Sci. Hyg., ScD, also a member of the Medical Committee for Human Rights (MCHR) and a Freedom Summer volunteer.16 He wrote the federal grant that led to the opening of the first rural Federally Qualified Health Center (FQHC) in Mound Bayou, Mississippi, and the first urban FQHC in Boston, Massachusetts, in 1965. While seeing patients at the Mound Bayou Delta Health Center, he was asked by federal officials why he was writing prescriptions for food for children. His response was, “The last time I looked at the books, they say that food is the treatment for starvation.” Geiger was guided in his Mississippi efforts by physician civil-rights leaders Robert Smith, MD and Aaron Shirley, MD, among others who were also active in support of the state’s first Head Start Program, Children Development Group of Mississippi, to address child hunger, poverty, and access to health care in the Mississippi Delta. The FQHC Program now serves as a national health safety net and includes 21 Mississippi FQHC health centers operating clinics at 50 locations. The FQHC program received 3.8 billion dollars in federal funding in 2018 and will receive 4 billion dollars in 2019.17 A sister hospital-based federal health program that developed out of the FQHC effort, the Rural Health Clinic Program, operates 177 clinics in MS.18 Many researchers, clerics, and politicians have perennially visited Mississippi out of interest in the determinants of health. After an invitation to visit Mississippi from Freedom Summer volunteer, Marian Wright Edelman, ESQ, Senator Robert F. Kennedy discovered food insecurity as a social determinant of health in Mississippi.19 Senator Kennedy and fellow members of an U.S. Senate subcommittee made a historic visit to the Mississippi Delta in 1967. The stark poverty and malnutrition of children Kennedy found triggered a series of investigations, reports and testimony before Congress and resulted in the television documentary, "Hunger in America," hosted by the famous television network commentator, Robert Kurault.20 The social determinants of poverty,
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malnutrition, infant mortality, racism, rural geography, food insecurity, poor sanitation, and lack of access to health care among rural African Americans and poor Appalachian Whites was, for the first time, presented on national television for the American public to see. The public outcry that followed led to modifications in federal health and food programs and the eventual establishment of the National Health and Nutrition Survey (NHANES) in 1971. That survey continues to be the gold standard for assessment of nutrition in the U.S. As a result of these and similar “discoveries,” there is now agreement that, “Social and demographic characteristics… have powerful influences on health and well-being at both the individual and population levels.”6 Out of studies of the social determinants of health came the concept of health disparities. Health disparities are different and undesirable outcomes among specific populations. While the discipline of public health seeks to improve health for individuals or groups, the new discipline of population health focuses on improving the differences in health and social determinants of health among demographic groups and geographic populations. These may seem to be semantic differences, but the different perspectives of the two disciplines open unique and collaborative approaches to improving health. A premier population health effort already mentioned is The Healthy People Initiative introduced by the U.S. Department of Health and Human Services (USHHS) that seeks to decrease present mortality trends by increasing the span of healthy life among Americans and eliminating health disparities.21 Turmoil Created by Studies of the Social Determinants of Health With WHO and other reports on the social determinants of health at the national and international levels, comparisons of results among populations, races, states and nations have created a culture of winners and losers, the losers being those with health disparities. Efforts to use this information to improve health have often been stymied by attempts to assign blame. That blame often ends up on the doorstep of those who experience health disparities, especially those who experience inequalities associated with race, poverty, and geography. Those same individuals are the least likely to have the power and means to defend themselves and prevent their own dehumanization into scapegoats. This scenario is unfortunately very much a part of our history in Mississippi.19 For instance, when a group of distinguished physicians performed a study in the Mississippi Delta that confirmed Senator Robert Kennedy’s observations of starvation among children, Mississippi’s senators termed the report “slanderous” and declared there was “no starvation in Mississippi.” They further suggested that hunger, where present, reflected the laziness of the children’s parents.19 The WHO has identified “knowledge, money, power, prestige, and social connections” as social determinants of health.5 For instance, when there are attempts to address educational or wage disparities, those who fare well are often unlikely to support changes in public policy to improve them, especially if those involve increased taxation on themselves. The
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Figure 3. Origins of Opposition
The authors propose four variables as the primary sources of disagreement around legislation and policy to improve the social determinants of health in Mississippi.
libertarian political philosophy of “boot strapping” is often promoted as a better and just solution.6 In the American South, this philosophy not only helps explain the depth of health disparities but also introduces another quantifiable variable, health inequity. In states like Mississippi where the social determinants of health and a libertarian inclination collide, especially where there is underlying racial bias, even the most well intentioned policy makers can find themselves squeezed to the point that they tolerate the intolerable and support the irrational (Figure 3). One recent example of this “collision phenomenon” is seen in Mississippi’s refusal to participate in Medicaid expansion. After a June 2012 Supreme Court decision struck down a provision of the Affordable Care Act that required Medicaid expansion for states to participate in the Affordable Care Act (ACA), Mississippi political leaders chose not to participate in either the ACA or Medicaid expansion. They offered two explanations. First, they declared that Mississippi could not afford to participate, even though economists reported Medicaid expansion, and the ACA would have been a financial windfall for the state. They based this objection on the possibility that the initial federal funding that covered the costs of ACA startup and Medicaid expansion would not be ongoing and the state would have to pick up that cost. Few pointed out that if such federal cuts appeared and states were unable to bare the costs, states have the power to reduce the scope of ACA and Medicaid benefits. The second reason was that the “government has no business in the business of health care anyway.” This excuse was made despite the state’s long time participation in Medicare and Medicaid, Veteran’s Administration, federal health clinics and critical access hospital programs, and that federal dollars now compose 42.1% of Mississippi’s state budget.22,23 For instance, studies available at the time showed that 40% of adults in Mississippi aged 19-64 had no health insurance and the expansion of Medicaid would immediately provide health insurance for 300,000 Mississippians whose income fell below the federal poverty line. Federal disproportionate share payments (DSH) to hospitals, designed to offset the cost of care for uninsured patients, were phased out by the federal government to help finance the ACA and Medicaid expansion in anticipation of an increase in hospital revenues from newly insured
patients with the ACA (Obamacare) and Medicaid expansion. Since Mississippi did not participate in these programs, financial exigencies now exist in many of Mississippi’s hospitals that lost DSH payments, and a number of rural hospitals have closed. If Mississippi had participated in Medicaid expansion, by 2025 the state would have a 1.04 billion dollar profit margin, created 9,000 new jobs, and expanded health care systems.24 Why did this bad financial and worse health decision occur? One likely explanation is the failure of the medical community to generate enough push-back among voters to stop a decision adverse to their health and driven by politics, not evidence. Support for Medicaid expansion by our MSMA was so timid as to generate headlines like, “Mississippi Doctors Want Medicaid Expansion but Don’t Call It That” in business and health care journals.25 Another example of the disconnect between health, quality of life, and economic prosperity in Mississippi is the defunding of the MSDH mentioned previously. During a period when the legislature offered generous tax cuts and other financial incentives to business in a so far unsuccessful plan to “stir economic development,” the health department budget was cut three budget years in a row. In the 2017-2018 budget
alone, the legislature slashed the MSDH budget 32%. The MSDH will receive only a 4% increase in the 2019 budget, hardly replacing the underfunding it already had before the cuts.26 This defunding of public health has resulted in a host of downstream health problems, including limitations on infectious disease control programs and loss of patient access to a number of health professionals and professional services.27 Two-thirds of the regional offices of the MSDH, like those in Batesville, Greenwood, Starkville, Meridian, McComb, and Hattiesburg, were closed. To no surprise, TB and syphilis rates in the state have spiked, including an attention-getting TB infection on campus at Ole Miss.28 In the process, the health department was told by legislators that the agency “will have to operate more like it did in the 1900’s than it did in the 21st century,” a short-sighted view on both health and economics, to say the least.29 Again, as with Medicaid expansion, there was no successful defense of the MSDH by the medical community or effective attempts to educate the public on the consequences of these actions. In most states, these cuts would have been vehemently opposed by the medical and business communities, municipal leaders, and in some cases by churches. But in Mississippi, politics has been and continues to be the most important social determinant of health and a cruel one at that.30 Mississippi’s Showing on the Social Determinants of Health and Health Disparities
Figure 4. Mississippi’s Health Ranking Among the states in the U.S.
Data on several key social determinants of health to include health literacy, poverty, access to health care, and health disparities help explain Mississippi’s health challenges. They also help explain the prevalence of obesity, heart disease, cancer, and diabetes in our state. Mississippi’s overall health ranking among the states is calculated annually by a respectable source, America’s Health Rankings. Their reports represent a statistical analysis of a comprehensive database to generate a rank order of health status by state. Mississippi has consistently held last place in U.S. health rankings since they have been reported (Figure 4).31 As well, the poor educational status of our population has contributed to our position in the lowest quartile of health literacy, a major factor in the persistence of poor health (Figure 5). The health literacy chasm is explained in part by the deletion of health education from the primary and secondary school curriculum and, in some instances, insertion of scientifically discredited Abstinence Only Programs as health education. Historically, health curricula sought to develop an understanding of the associations between nutrition, human biology, and human health and to encourage healthy living. With the publication of A Nation at Risk in 1983 and the immergence of the “Back to Basics Movement” during the 1980’s, health and physical education in school curricula were first questioned and then regularly deleted from core curricula.32,33 Our country has not recovered from the loss of health and physical education programs and is only now beginning to consider how best to reincorporate health and physical education into elementary and secondary education. The Institute of Medicine published recommendations on how best to proceed in their Mississippi has maintained last place in health for the majority of the last 27 years 1995 report, Defining a Comprehensive School Health Program, but in America’s Health Ranking. Available in the public domain at: https://assets. little progress has been made in their implementation.34 The Mississippi americashealthrankings.org/app/uploads/ahrannual17_complete-121817.pdf. health community has not been an advocate for this program although
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community groups like The Bower Foundation and The Coalition for a Healthy Mississippi, and some state agencies like the Department of Education with their Healthy School Program and Mississippi Public Broadcasting with their Southern Remedy Series have been advocates and leaders in health.
Figure 5. Mississippi Health Literacy Scores
There is a direct correlation between income and good health. “In comparison to other socioeconomic measures, income appears to be a better discriminator of health status than education or occupation.”35 Mississippi’s high poverty rates also place many of our citizens at a disadvantage and contribute to striking racial disparities in health (Figure 6). This is complicated by the lack of access to health care in Mississippi, a major determinant of health which is correlated with the percent of the population with no health insurance (Table 5). Again, disparities exist between black and white Mississippians. Health Disparities Racial and ethnic minorities disadvantaged in the social determinants of health have poorer health outcomes when compared to the rest of the population. These are quantitated as health disparities. Ten leading causes of death in the U.S. account for 74% of all deaths and are unequally distributed among minorities and the poor. These causes are heart disease, cancer, chronic obstructive pulmonary disease, unintentional injuries, stroke, Alzheimer’s disease, diabetes, influenza, pneumonia, and kidney disease.36 Wide racial, ethnic, and gender disparities remain in life expectancy with a gap of life expectancy of more than 17 years between black men (72.3 years) and white women (89.7 years). Life expectancy currently ranges from 74.5 for white men in rural areas to 82.4 years for black women in large metropolitan areas. Black males and females have been left behind when compared to whites (Figure 7).
Mississippi’s health literacy scores by county as calculated by the University of North Carolina. Criteria for ranking were as follows: Adults with Below Basic health literacy skills may be able locate information in simple text (e.g., the time of their next clinic visit from an appointment slip), but would struggle with information in more complex documents. Adults with Basic health literacy skills are able to locate multiple pieces of information in a document, but may have difficulty interpreting or applying this information (e.g., determining whether their body mass index is in a healthy range). Adults with Intermediate health literacy skills can often understand and apply medical information to their specific health context, but may have difficulty navigating multiple complex texts (e.g., consent forms or health insurance documents) or drawing inferences from health materials. Adults with Proficient health literacy skills are able to use a table to calculate an employee’s share of health insurance costs. Available in the public domain at http://healthliteracymap.unc.edu/#. Accessed April 11, 2018.
Figure 6. Poverty Rate Comparison
The disparities in death rates and life expectancy also are likely to reflect the disparities in Mississippi’s health indicators (Figure 8). Rates of overweight and obesity in the U.S. have caught up with Mississippi’s rates to reach an astounding rate of over 50% in all populations. This explains the rising epidemic of diabetes which still affects African American females to a greater degree than American whites. Although cardiovascular mortality rates have declined in the U.S., they remain 28% higher in blacks. So far as child health, Mississippi suffers health disparities in the same health indicators seen at a national level in child health, although the state has the highest rates of infant and child mortality. The mortality rate in the U.S. for black infants is 2.3 times higher than the mortality rate for white infants. The prevalence of asthma, the most common chronic condition among children in the U.S., is two times higher in African Americans than that in non-Hispanic White children. The importance of education as a social determinant of health is
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Mississippi poverty rate, using a system of dated federal guidelines, is among the highest in the US. There is a major disparity in poverty among black residents of the state as compared to rates of black residents in other states. Available in the public domain at https://www.kff.org/other/state-indicator/poverty-rate-by-raceethnici ty/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22 sort%22:%22asc%22%7D. Accessed April 17, 2018 (in the public domain).
Table 5. Percentage of Mississippians with Health Insurance by Race (2015)
Adapted from information in the public domain available at https://msdh.ms.gov/ msdhsite/statis/resources/6414.pdf. Accessed April 30, 2018.
Figure 7. Life Expectancy and Death Rates in Mississippians
represented in data showing men and women with less than a high school education have 42% and 120% respectively more colorectal cancer mortality than those with a college degree. Income levels are directly related to educational status and health literacy. Adults with annual family incomes of less than $35,000 have a 3.6 times higher current smoking rate than those with family income of greater than $100,000.37 Table 6. Recommendations of the WHO for Improving Global Health Equity
Health Equity This figure compares health outcomes among Mississippi white and black and male and female populations as compared to the same populations in the entire United States population. Figure A shows data on life expectancy at birth in Mississippi and US populations and those data are replicated in Figure B as the number of deaths per 100,000 population. Disparities here between whites and blacks in Mississippi are also present in the larger US. Available in the public domain at https://www.kff. org/state-category/health-status/?state. Accessed April 17, 2018.
Figure 8. Mississippi Health Indicators
Health equity is the absence of avoidable differences in health status and outcomes to include disease, disability, and mortality among groups. In 2016, the WHO deemed health inequity ethically unjust since inequities can be remediated by changes in health policy.37,38 The WHO has proposed a number of action items to improve health equity through systematically addressing problems with the social determinants of health. These suggestions were published in the “Commission on Social Determinants of Health – Final Report. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health” (Table 6).4 Their research demonstrates the close association between health and government policies.3 Lessons for Mississippi The data reviewed and referenced above demonstrate that governmental policies are an essential component in addressing Mississippi’s poor social determinants of health. These include promotion of incentives Table 7. Purposes of Healthy People 2020
This figure shows the pattern of overweight and obesity (A), a risk factor for diabetes (B), cancer (C), and heart disease (D) among Mississippi black and white, male and female citizens. The rank order of disparities in overweight and obesity rates are recapitulated in similar rank orders in diabetes, cancer, and heart disease deaths. Available in the public domain at https://www.kff.org/state-category/ health-status/?state. Accessed April 17, 2018.
*Healthy People 2020 is the third 10-year Healthy People Program to improve the health of Americans by establishing bench markers and measuring progress. Adapted from information in the public domain available at https://www. healthypeople.gov/node/5840. Accessed April 30, 2018.
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Table 8. Improving Mississippi's Social Determinants of Health
for healthy living and disincentives for unhealthy living at every opportunity. For instance, Mississippi’s low tax rate on tobacco and no special tax for sugar-rich soft drinks and energy drinks are political decisions, not decisions based on best evidence. It is no secret that the tobacco and soft drink industries are significant contributors to political campaigns in our state and that money clearly influences the decisions of our legislature. Fortunately, MSMA has chosen to publically participate in the tobacco tax debate, a positive sign of increasing advocacy for patients. Conclusion In their essay on the social determinants of health in Mississippi, Azevedo and Chowdhury wrote, “No one can understand the glaring health disparities in Mississippi without considering the state’s sad and convoluted history of race relations.”39 Although factors that promote health and access to healthcare lead to improvements in health, they are “primarily influenced by upstream social determinants such as education, income, social and welfare services, housing, job creation, and transportation of which are quality dependent on the legislated policies of state and federal government.”36,40 However, changes in legislated policies and procedures that address the disparities in health in our state are unlikely to occur until racial reconciliation takes place among our people and the economically privileged come to understand that libertarian ideas of self-sufficiency and boot-strapping do not apply to individuals, regardless of race, who experience glaring disparities in opportunities and upward mobility. It is not possible to boot-strap without boots or straps. The races remain separated in Mississippi and heroes who led the struggle during Mississippi’s civil rights era note that separation is once again increasing, not decreasing.41 Experience shows that racial reconciliation comes after truth telling about the injustices of the past and present and a consensus to work together for change that benefits all of us.42 In the case of physicians, the University of Mississippi Medical Center has proposed a way forward for physicians with their Marston-Smith Symposiums on Race and Medicine, but that effort requires community partnerships to continue. MSMA’s Opportunity To Lead Who will lead to improve our health? The group best prepared and morally positioned by its ethical codes and aspirations is American medicine and in this case Mississippi medicine and the MSMA. It will take a change in our goals and aspirations to assume that leadership. Since politics is presently the most important social determinant of health in our state with race a close second, our patient centered involvement in the political process can be a
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catalyst for positive change. Although there is no consensus on how to move forward, we risk providing some suggestions for changes that may better position MSMA as a much needed leader for change. In the case of Mississippi’s health, timidity is not a virtue (Table 8). n References 1. The U.S. Burden of Disease Collaborators. The State of U.S. Health, 19902016. Burden of Diseases, Injuries, and Risk Factors among U.S. States. JAMA. 2018;319(14):1444–1472. 2. A History of the Healthy People Initiative and Its Relevance. Available at https:// www.researchgate.net/publication/266898374_A_History_of_the_Healthy_ People_initiative_and_its_relevance_to_community_health_planning_and_ policy_development. Accessed April 5, 2018. 3. World Health Organization Classification of Social Determinants of Health. Available at www.cdc.gov/nchhstp/socialdeterminants/faq.html. Accessed April 9, 2018. 4. World Health Organization. Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Available at http://www.who.int/social_determinants/thecommission/ finalreport/en/. Accessed April 18, 2018. 5. World Health Organization. Evidence on Social Determinants of Health. Available at http://www.who.int/social_determinants/themes/en. Accessed April 9, 2018. 6. Singh GK, Daus GP, Allender M, et al. Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016. Int J MCH AIDS. 2017;6(2):139-164. 7. U.S. Department of Health and Human Services. Healthy People 2020. Topics and Objectives. Available at https://www.healthypeople.gov/2020/topics-objectives. Accessed April 9, 2018. 8. Dittmer J. The Good Doctors. The Medical Committee for Human Rights and the Struggle for Social Justice in Health. 2009. Bloomsberry Press, NY, NY:1-8. 9. deShazo RD (ED), The Racial Divide in American Medicine. Black Physicians and Their Struggle in Justice and Health Care. Jackson, MS: University Press of Mississippi. 2018. For release August 2018. 10. Lampton LM. Medicine. In: Owensby T, Wilson CR, Abadie AJ, Thomas JG. D. Jr (eds). The Mississippi Encyclopedia. Jackson, MS: University Press of Mississippi; 2017:805-809. 11. Lampton LM. Mississippi’s medical giant: Felix Underwood (1882-1959). The Man Who Saved a Million Lives. J Miss State Med. Assoc. 1999;40(9):320-326. 12. Evers KA. A tribute to Felix J. Underwood, MD: Alton B. Cobb, MD reflects on Public Health and Medicine in Mississippi. J Miss State Medical Assoc. 1999;40(11): 384-388. 13. deShazo RD, Guinn KK, Riley WJ, Winter WF. A crooked path made straight, The rise and fall for the southern governors’ plan for black physicians. Am J Med. 2013;126(7):572-7. 14. Underwood FJ. Medical education scholarship loans in the Mississippi Integrated Health Program. Pub Health Rep. 1953;68(6):549-553. 15. Thompson E. Mississippi Plan to Eliminate Racial and Ethnic Health Disparities, 2002. Mississippi Department of Health, Office of Minorities, Jackson, MS. 16. Ward TJ. Out in the Rural. A Mississippi Health Center and Its War on Poverty. New York, NY: Oxford University Press. 2017:65-91. 17. Funding for federally qualified health centers. Available at http:// acehealthcaresolutions.com/fqhc-funding-extended-until-2019/. Accessed April 17, 2018. 18. Rural Health Information Hub. Rural health for Mississippi Introduction. Available at http://www.ruralhealthinfo.org/states/mississippi. Accessed April 30, 2018. 19. deShazo RD, Smith R, Minor WF, Skipworth LB. An unwilling partnership with The Great Society Part II: Physicians discover malnutrition, hunger, and the politics of hunger. Am J Med. Sci. 2016;352(1):120-7. 20. Hunger in America. Available at https://www.youtube.com/watch?v=h94bq4Jf MAA. Accessed April 19, 2018. 21. Healthy People 2020: Facts and Questions. Healthpeople.gov Web site. https:// www.healthypeople.gov/2020/About-Healthy-People. Accessed April 17, 2018. 22. Norris L. Mississippi and the ACA’s Medicaid expansion. Available at https://www. healthinsurance.org/mississippi-medicaid/. Accessed April 9, 2018. 23. Pender G. Report: Mississippi remains dependent on federal dollars. The Clarion-
Ledger Web site. Available at https://www.clarionledger.com/story/news/politics/ politicalledger/2017/07/25/mississippi-federal-revenue/509246001/. Accessed April 11, 2018. 24. Center for Mississippi Health Policy. Brief: Medicaid Expansion- An Overview of Potential Impacts in Mississippi, Jackson, MS. November 2012, 1-4. 25. Caffrey M. Mississippi Doctors Want Medicaid Expansion, but Don’t Call it That. American Journal of Managed Care Web site. Available at https://www.ajmc.com/ focus-of-the-week/mississippi-doctors-want-medicaid-expansion-but-dont-call-itthat. Accessed April 16, 2018. 26. Ganucheau A. Lawmakers finalize ‘flat’ FY 2019 state budget, Mississippi Today Web site. March 27, 2018. Available at https://mississippitoday.org/2018/03/27/ lawmakers-finalize-flat-fy-2019-state-budget/. Accessed April 26, 2018. 27. Wolfe A. Health Department Asks Legislature to Reverse Some Budget Cuts. The Clarion-Ledger Web site. December 23, 2017. Available at https://www.clarionledger. com/story/news/local/2017/12/24/health-department-asks-legislature-reversesome-budget-cuts/915066001/. Accessed April 26, 2018. 28. Wolfe A. Tuberculosis case identified on Ole Miss campus, 500 people to be tested, The Clarion-Ledger Web site. April 9, 2018. Available at https://www.clarionledger. com/story/news/2018/04/09/tuberculosis-ole-miss-campus/499479002/. Accessed April 26, 2018. 29. Gates JE, Pender G. Facing major cuts, Health Dept. will have to ‘re-brand’, The Clarion-Ledger Web site. March 15, 2017. Available at https://www.clarionledger. com/story/news/politics/2017/03/15/health-department-budget/99205346/. Accessed April 26, 2018 30. Smith DB. The Politics of Racial Disparities: Desegregating the Hospitals in Jackson, Mississippi. Milbank Q. 2005;83(2):247-269. 31. America’s Health Foundations. United Health Foundation. A call to action for individuals and their communities. Annual Report 2017. Available at https://assets. americashealthrankings.org/app/uploads/ahrannual17_complete-121817.pdf. Accessed April 26, 2018. 32. Evolution of School Health Programs. Schools and Health – NCBI bookshelf. Available at https://www.ncbi.nlm.nih.gov/books/NBK232693/. Accessed April 26, 2018. 33. Goldberg M. Harvey, J. A Nation at Risk: The Report of the National Commission on Excellence in Education. Phi Delta Kappan 65(1): 14-18. 34. Defining a Comprehensive School Health Program: An Interim Statement. Institute of Medicine. (1995) Washington, DC. National Academy Press. 35. Benzeval M., Judge K., Sue Shouls. Understanding the relationship between income and health: How much can be gleaned from cross-sectional data? Soc Sci Med. 2001 May;52(9):1371-90. 36. Singh GK, Siahpush M. Widening socioeconomic inequalities in U.S. life expectancy 1980-2000. Int J Epidemiol. 2006; 35(4):969-979. 37. Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016. Available at https://www.ncbi.nlm. nih.gov/pmc/articles/PMC5777389/. Accessed April 12, 2018. 38. World Health Organization. Health Systems. Equity. Available at http://www.who. int/healthsystems/topics/equity/en/. Accessed April 12, 2018 39. Azedavdo MJ, PhD. The State of Health and Health Care in Mississippi. Jackson, MS: University Press of Mississippi, 2015:18-45. 40. Link BG, Phelan JC. Understanding the socio-demographic differences in health: The role of fundamental social causes. Am J Pub. Health. 1996; 86(4)471-473. 41. Perkins, JM. Dream With Me. Race, Love and the Struggle We Must Win. (2017) Grand Rapids, MI: Baker Books; 2017:33-44. 42. Tutu, D. No Future without Forgiveness. New York: Doubleday; 1999:270.
Author Information Research Associate (McCullouch) Billy S. Guyton Distinguished Professor Emeritus – School of Medicine (deShazo). Departments of Medicine and Pediatrics, University of Mississippi Medical Center, Jackson. Corresponding Author: Richard D. deShazo, MD, MACP; Department of Medicine, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 (rdeshazo@umc.edu). The opinions expressed here are those of the authors and do not necessarily reflect those of the University of Mississippi Medical Center or the Mississippi State Medical Association.
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P O P U L A T I O N
H E A L T H
Population Health Management: The Scope, Training, and Practice
What are the Benefits for Mississippi? BETTINA M. BEECH, DRPH; NATALIE GAUGHF, PHD; SYDNEY MURPHY, PHD
Emergence of Population Health Management The United States (US) has the most advanced healthcare system in the world. Despite this standing on the world stage, the nation’s system is complex, expensive, provides variable quality care and leaves many citizens without coverage.1,2 Individual health care costs may be paid or “covered” by a number of public (Medicare Parts A, B, C, or D, Medicare Advantage; Medigap plans; state Medicaid programs; Veterans Administration, federal employee health benefits, Children’s Health Insurance Plan [CHIP], Women, Infant and Children’s [WIC]) and private (employer or individual plans) sources.3 In 2016, aggregate and per person spending for hospitals, physician, prescriptions and other services provided through this complex and fragmented system cost the nation 17.9% (3.3 trillion dollars) of the gross domestic product (GDP). Healthcare costs are projected to increase to 20% of GDP by 2025.4 Resources devoted to healthcare have not translated to quality care as the US healthcare system has a low rating for quality of care and ranks poorly when compared to the health outcome and process metrics of comparable countries. The United States has improved healthcare quality outcomes in recent years, however, and these advances are due in part to the enactment of the Affordable Care Act (ACA). This landmark legislation is credited with reducing the number of uninsured from 44 million in 2013 to less than 28 million by the end of 2016.5 Other first world countries have also made improvements to their respective healthcare systems during this period. The United States, therefore, continues to lag behind other industrialized nations. In fact, some analysts argue that the healthcare quality outcomes gap between the United States and comparable countries has widened.6 Policymakers, researchers and clinicians have been grappling for decades to develop and implement tangible, feasible, and scalable solutions to address numerous challenges plaguing the US healthcare system. Currently, the ‘Triple Aim’ of health care – improving population health, enhancing the patient experience while simultaneously reducing medical costs – is widely considered to be a compass for healthcare system improvement. This framework has been recently expanded to include a fourth aim (e.g., provider experience, organizational readiness or health equity). However, an intense focus on improving the health of populations remains the central tenant. Population health is a concept that emerged outside of clinical disciplines and has been broadly and simply defined as "a conceptual
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framework for thinking about why some people are healthier than others".7 "Population health management" integrates clinical concerns, and this term represents the application of population health principles in healthcare environments.8 Population health management (PHM) has been defined in multiple ways in the academic literature and within the healthcare industry. However, according to a leading PHM program (Wellcentive), it has been described as “the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record and the actions through which care providers can improve both clinical and financial outcomes.” This approach to the organization and management of the healthcare system is hypothesized to produce better clinical outcomes more safely and cost-effectively, and data to support this contention is growing. PHM is undergirded by the Wagner Chronic Care Model9 and the Population Health Management Model developed by the Population Health Alliance generally begins with the: 1. utilization of electronic tools to identify the clinical population; 2. stratification into high, medium and low-risk groups; 3. implementation of medical and non-medical interventions delivered by providers practicing at the top of their license, and 4. assessment of patient outcomes and associated costs. Given the changing compensation and reimbursement landscape, the practice of population health management is gaining attention from clinicians and hospital administrators. Essentially, implementing PHM requires a significant shift from the traditional business strategy of a volume-driven, fee-for-service model toward a value-based approach which measures health outcomes against the cost of achieving those outcomes. To some extent, this shift still represents a major paradox; however, some major health systems have begun to embrace this change. Mount Sinai Health System released a groundbreaking ad in 2016 that stated, “If our beds are filled, it means we’ve failed”.10 Their overall marketing campaign sought to differentiate Mount Sinai from their competitors through recasting their brand based on a health and wellness framework. Overall, valuebased healthcare delivered via PHM seeks to connect patients with coordinated, accessible and affordable care that works with them to
improve their health and reduce the incidence and effects of chronic diseases. Training the Current and Future Clinical Workforce Physicians of the future will need excellent clinical skills along with PHM-related competences including proficiency in the effective and efficient use of electronic medical records (EMRs), informatics, quality improvement, systems science and the social determinants of health.11 This content is not part of the U. S. medical school curriculum; however, several scientific studies and national reports have called for adding this material, and several schools are heeding this call.1214 Kaiser Permanente, one of the largest healthcare provider systems in the United States, recently announced their intention to establish a new School of Medicine based on an innovative model of medical education. This school will complement instruction in traditional clinical disciplines with focused training in strategic innovation, EMRs, PHM, team-based approach to patient care and patient education.15 In addition to this emerging focus for medical school curriculum, numerous Departments of Population Health have been created within medical schools and academic medical centers (AMCs). Since 2008, four Schools of Population Health within AMCs have been created. The first was established at Thomas Jefferson Medical Center (2008). The other three schools are located at the University of New Mexico Medical Center (2016), The University of California at Irvine (2017) and the University of Mississippi Medical Center. (2016). The John D. Bower School of Population Health (named after nephrologist John Bower, MD, who has been a pioneer in the treatment of chronic kidney disease) was also launched at UMMC. Its mission is to educate and train leaders prepared to transform health care delivery and the health of Mississippians through the development of an innovative academic infrastructure uniquely designed to educate future population health scientists and clinical professionals to conduct pioneering population-based research and provide high quality, valuedriven patient-centered care delivered in an increasingly complex health care delivery system. One of the innovative education programs in the Bower School is a 1-year Executive Masters degree program in Population Health Management that is designed exclusively for practicing clinicians (e.g., physicians, dentists, nurses, psychologists, clinical social workers, physical- and occupational therapists, etc.) with at least 5 years of clinical experience. This program will prepare clinicians to master skills in practice redesign, new incentive payment models, team-based models of care, the use of electronic medical records (EMRs) to improve system care, quality improvement, identifying patient groups, service bundling, working with accountable care organizations, and understanding how to maximize PHM approaches and community assets to improve patient outcomes. Training in PHM is particularly useful to proactively manage a population of patients and acquire a broad knowledge of the new healthcare environment that rewards ‘value’ and penalizes organizations that cannot deliver these outcomes.
Training in Population Health Practice In general, the practice of population health is widely considered to be a team-based approach with the goal of improving the health of either clinically or geographically identified groups. While PHM primarily originates in clinical settings, the practice of ‘population health’ occurs within and among geographic populations and spans a range of settings including medical clinics and community-based environments.16 Transformation of the US healthcare system and substantial improvements in the health of populations will require robust education and training programs to produce clinicians and researchers who can conduct high-impact chronic disease studies, particularly with our increasingly diverse and aging populations. Further, social, behavioral and health outcome researchers are critically needed to bring their substantial skill sets to implement rigorous study designs to population health management programs to evaluate the readiness of these approaches for scaling and dissemination. The masters and doctoral programs in population health science at UMMC will begin to fill this need. Benefit of Employing a Population Health Approach for Mississippi National reports have identified the poor health status and challenges with access and utilization of health care among Mississippians for several decades. Reports such as the County Health Rankings, State of Obesity, Behavioral Risk Factor Surveillance consistently indicate significantly higher rates of type 2 diabetes, hypertension, stroke, many types of cancer, asthma, and obesity in Mississippi, particularly among individuals who reside in low-income and medically underserved communities.17,18 Despite the long-standing ranking as the least healthy state in the nation, many improvements in healthcare and healthcare access have occurred in Mississippi. Groundbreaking surgical and medical treatments have resulted in successful kidney, heart, and liver transplants among both pediatric and adult populations. The growth of telehealth has also increased access to care while retaining quality outcomes among patients. Maintaining and increasing these critically important, individual- and system-level accomplishments to achieve health gains at the population level is the next step logical step to continue to improve the current health trends in the state. Employing population health and population health management approaches hold promise for improving health, health care outcomes, quality of life and eventually achieving health equity where no Mississippian is left behind. n Key Words: Population health, population health management, clinician education References 1. Camillo CA. The US healthcare system: complex and unequal. Glob Soc Welf. 2016;3(3):151-160.
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2. Luft HS. What works and what doesn't work well in the US healthcare system. Pharmacoeconomics. 2006;24 Suppl 2:15-28. 3. Davis K, Stremikis K, Schoen C, Squires D. Mirror, Mirror On The Wall, 2014 Update: How The U.S. Health Care System Compares Internationally. The Commonwealth Fund; 2014. 4. Centers for Medicare and Medicaid Services. National Health Expenditure Projections 2016-2025. 2016. CMS Web site. https://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/proj2016.pdf. Accessed June 23, 2017. 5. Kaiser Family Foundation. Key Factors About the Uninsured Population. Menlo Park, CA: Kaiser Family Foundation; 2017. 6. Sawyer B, Gonzales S. How does the quality of the U. S. healthcare system compare to other countries?. Peterson-Kaiser Health Care System Web site. https:// www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-systemcompare-countries/?_sf_s=How+does+the+quality+of+the+U.+S.+. Accessed June 18, 2018. 7. Young TK. Population Health: Concepts and methods. New York: Oxford University Press; 1998. 8. Kindig D. What are we talking about when we talk about population health. Health Affairs Web site 2015; https://www.healthaffairs.org/do/10.1377/ hblog20150406.046151/full/. Accessed June 16, 2018. 9. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1):75-85. 10. Gooch K. Not your usual hospital ad: “If our beds are filled, it means we’ve failed.” Becker’s Hospital Review 2016 Web site; https://www.beckershospitalreview. com/hospital-management-administration/not-your-usual-hospital-ad-if-ourbeds-are-filled-it-means-we-ve-failed.html. Accessed June 10, 2018. 11. Reuben DB, Sinsky CA. From Transactional Tasks to Personalized Care: A New Vision of Physicians' Roles. Ann Fam Med. 2018;16(2):168-169. 12. Inclusion and integration of population health into undergraduate medical curriculum. 2014; American Association of American Medical Colleges
Web Site. https://www.aamc.org/initiatives/diversity/portfolios/384602/ phintegrationwebinar.html. Accessed June 18, 2018. 13. Duke Community and Family Medicine. Population Health Graduate Milestones: A Report to the Centers for Disease Control and Prevention and the American Association of Medical Colleges. Durham, NC: Duke University; 2015. 14. Maeshiro R. Responding to the challenge: population health education for physicians. Acad Med. 2008;83(4):319-320. 15. Bresnick J. Kaiser Permanente targets population health with new medical school. of December 18, 2015. Healthcare Analytics Web site. https://healthitanalytics. com/news/kaiser-permanente-targets-population-health-with-new-medschool. Accessed June 18, 2018. 16. McGough P, Chaudhari V, El-Attar S, Yung P. A Health System's Journey toward Better Population Health through Empanelment and Panel Management. Healthcare (Basel). 2018;6(2):65-91. 17. County Health Rankings and Roadmaps. Mississippi Rankings Data 2018. County Health Rankings Web site. http://www.countyhealthrankings.org/ rankings/data/MS. Accessed June 20, 2018. 18. Trust for America’s Health. The State of Obesity: Better Policies for a Healthier America. 2017 Health Americans Web site. http://healthyamericans.org/assets/ files/TFAH-2017-ObesityReport-FINAL.pdf. Accessed June 18, 2018. Corresponding Author: Bettina M. Beech, DrPH, MPH Founding Dean and Professor of Population Health Science John D. Bower School of Population Health University of Mississippi Medical Center 2500 North State Street Jackson, Mississippi 39236 bbeech@umc.edu (601) 984-1020 (phone)
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P O P U L A T I O N
H E A L T H
UProot: Building a Healthier Mississippi from the Ground UP A New Approach to an Old Problem MARY CURRIER, MD, MPH; PAUL BYERS, MD; THAD F. WAITES, MD
I
t is well known that Mississippi ranks at or near the bottom among U.S. states for many health indicators. Mississippi’s historically poor performance in health indicators is rooted in difficult social challenges that are a result of geography, history, and culture, the social determinants of health. The World Health Organization defines the social determinants of health as the conditions in which people are born, grow, live, work, and age. This is shaped by the way money, power, and resources are distributed within our population. In our society, these factors are dependent on geography, race, gender, ethnicity, education, and other issues. Over the years, considerable resources and energy have been directed toward improving the health of Mississippians, but progress has been limited. To reconsider how health issues are addressed, over 90 partner organizations, including state agencies, non-profit organizations, businesses, community groups and other stakeholders, joined together in a collaborative effort to conduct a State Health Assessment (SHA) and develop a State Health Improvement Plan (SHIP). These UProot partners have worked together diligently to chart a more effective way of monitoring and responding to the health issues that have the greatest impact on Mississippi. What follows is a summary of the components of the State Health Assessment and the priorities identified within the State Health Improvement Plan. The UProot Summary Report and the full State Health Assessment and Improvement Plan, from which this article was taken in large part, may be accessed at www.uprootms.org. State Health Assessment – Defining the Problem To comprehensively evaluate the health issues facing Mississippi, the UProot partners conducted a state health assessment. This assessment consisted of four components, each looking at health issues that affect Mississippi from a different perspective: • • • •
Health Status; Forces of Change; Community Themes and Strengths; Public Health System.
Health Status The Health Status assessment was conducted through an
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MARY CURRIER, MD, MPH State Health Officer
epidemiological analysis of both Mississippi and U.S. surveillance data and sought to answer the questions: • How healthy are our residents? • What does the health status of our community look like? A review of the demographics of Mississippi reveal that 60% of the state’s population identifies as Caucasian, 37% African American, and 3% identify as another race. About 96% of the population speaks English as a primary language. Mississippi’s population is growing, but at a slower rate than the average growth nationwide. Additionally, most of the growth in Mississippi is occurring in metropolitan areas, while the majority of rural areas is losing population. Disparities among African Americans exist in educational attainment, poverty, access to care, mortality, sexual health, birth outcomes, and chronic disease risk factors. Mississippi lags behind the rest of the U.S. in educational attainment, with fewer residents completing higher education. Additionally, 20% of the population 25 years and older have not completed high school. Lower high school completion rates are seen among African Americans living in rural settings compared to Caucasians and individuals living in metro areas. More Mississippians live in poverty compared to the rest of the U.S. states, with an estimated 20.8% of the population living below the poverty level in 2016. In 2016, the median household income in Mississippi was $40,528, compared to $59,039 nationally. Thirty-six percent of African Americans live in poverty, compared to 14% of Caucasians, again more pronounced in rural vs. urban areas. Access to care is likewise a barrier: from 2011 to 2013, 17.3% of Mississippians lacked health insurance (20% of African American residents and 38% of Latino/Hispanic Mississippians lack health insurance, compared
with 15% of Caucasian Mississippians). In 2016, Mississippi’s ageadjusted mortality rate was 28% higher than the national rate and was the highest of all 50 states (higher among African Americans). Mississippi continues to have rates for STIs that are among the highest in the US. In 2016, Mississippi had the 3rd highest case rate for chlamydia, the highest rate for gonorrhea, the 7th for primary and secondary syphilis, and the 10th highest for HIV (see Table). Individuals aged 15-24 and African Americans are disproportionately affected by STIs. Mississippi also has significantly higher rates of infant mortality, premature birth, low birth weight, and teen births; again African Americans are disproportionately affected by adverse birth outcomes. When considering chronic disease risk factors, Mississippians have very low rates of fruit and vegetable consumption, and low rates of physical activity. In 2016, Mississippi had the 5th highest rate of smoking and the second highest obesity rate, with 40% of children either overweight or obese, and rates of diabetes higher than the national rate (African Americans disproportionately affected). Forces of Change The UProot partners convened to discuss important issues impacting Mississippi, potential implications on the health and quality of life of Mississippians, and the state’s public health system, considering the following questions: • What is occurring or might occur that affects the health of our state or the Mississippi public health system? • What these occurrences generate specific threats or opportunities? By looking at the issues that negatively impact healthcare system infrastructure and access to care, poverty, good health, health literacy and health education, political and financial support for public health, changing demographics, chronic disease, natural and man-made disasters, and urban and rural disparities, a number of opportunities were identified within this component that could change forces for improved health and wellbeing in Mississippi. • Invest in education, child development, vocational training, and workforce planning and development; improve access to healthcare and other basic services; • Invest in walkable communities and parks; improve access to healthcare; create policies that improve living and working conditions, and educate the public on healthy behaviors; • Create readily available, accessible, culturally appropriate health information; disseminate targeted health messages to different communities; • Improve communication with policymakers and the public; articulate the critical role and importance of public health;
Table. 2016 Summary Data for STD/HIV
• Develop service delivery that reflects an understanding of cultural differences; support re-entry efforts for formerly incarcerated individuals to prevent recidivism; create social supports for aging individuals to prevent isolation; • Ensure access to quality preventative care; increase access to healthy foods; support active living by building walkable communities; reduce tobacco use through statewide legislation and community-level smoking bans; • Invest in emergency preparedness infrastructure; promote sustainable agricultural practices and environmental regulations; • Increase recruitment incentives for health care providers who practice in rural communities, such as scholarships and debt forgiveness; • Advocacy at local, state, and federal level for the adoption of Medicaid expansion to improve access to care. Community Themes and Strengths To identify community themes and strengths, the Mississippi State Department of Health conducted a statewide survey of almost 20,000 individuals and facilitated a series of focus groups and community conversations across the state to address the following questions: • What is important to our community? • How is quality of life perceived in our community? • What assets do we have that can be used to improve community health? In rating personal health, 57% of survey respondents rated their personal health as healthy or very healthy, and 8% rated their personal health as unhealthy or very unhealthy. Most respondents perceived their communities as “somewhat healthy,” with only 21% describing their communities as healthy or very healthy. The most important factors for a healthy community identified by the respondents included a good place to raise children, good schools, low crime/safe neighborhoods, good jobs and healthy economy and access to health care. There were differences in individuals' satisfaction with the quality of life in their communities: 58% of Caucasian respondents reported satisfaction or strong satisfaction, compared with 43% of African American respondents; African Americans were almost twice as likely to report that they were unsatisfied or strongly unsatisfied with quality of life in their communities.
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Focus group and community conversation participants identified many community challenges and assets within their communities. Among the challenges identified were lack of affordable housing, community divisiveness and tension, lack of quality employment and community infrastructure, lack of recreational activities, lack of community safety, and lack of trust in the healthcare system. Some assets that reflect the best parts of life in their communities were friendly people and small town atmosphere, natural beauty and community safety. Lastly, the focus groups cited a number of overall barriers to address that impact health in their communities: • Environmental-lack of safe places to exercise • Economic-lack of good paying jobs and high costs to access basic resources • Cultural-traditions centered around food consumption, often including unhealthy traditional foods • Social-lack of social and recreational outlets and unequal opportunities to participate, lack of community unity • Behavioral-lack of healthy habits such as low vegetable consumption and little physical activity • Political-lack of political and public support for public health Public Health System Stakeholders gathered to discuss the collective performance of Mississippi’s public health system, identify strengths and weaknesses and areas of improvement in addressing the 10 Essential Public Health Services (https://www.cdc.gov/stltpublichealth/ publichealthservices/essentialhealthservices.html). To Assess the Public Health System, the following questions were considered: • What are the activities and capacities of our public health system? • How well are we providing the 10 Essential Public Health Services in Mississippi? In looking at the strengths of the public health system, it was recognized that Mississippi has strong disease and health hazard surveillance, nationally recognized emergency preparedness program, robust communication to providers and the public regarding disease awareness and prevention, and successful efforts in tobacco prevention. Weaknesses identified included the prevalence of chronic disease and obesity coupled with inadequate resources to address both surveillance and response to chronic disease. Additionally, low levels of health literacy, low public health funding, lack of public support and diminished workforce capacity were also recognized as weaknesses within the collective public health system.
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As with the Forces of Change component, opportunities can be identified in the face of the strengths and weaknesses within the Public Health System. Not surprisingly, the opportunities include: • Strengthen funding and public support for public health • Advance chronic disease prevention • Foster a culture of health across state • Address the social determinants of health • Increase strategic alignment and coordination of public health efforts throughout the system • Improve workforce development efforts to increase system capacity State Health Improvement Plan – Issue Prioritization Using the results of the State Health Assessment and its four components, the UProot partners met and worked to identify the crosscutting themes and issues that appeared in multiple assessment components. Based on the feedback received and an assessment of available resources, the UProot partners chose to focus on the following four priority areas for the state health improvement plan: • • • •
Create a Culture of Health Improve Infant Health Reduce Rates of Chronic Disease Increase Educational Attainment
Some priority areas, such as chronic diseases and infant health, have been the focus of numerous organizations and efforts for several years. Other priority areas are intended to improve health in a broader sense by focusing on the social determinants of health. Each priority has a team of partners working together to develop and implement actions over the next five years that will advance their achievements. To monitor effectiveness, each team also set corresponding measures that will be reviewed over time. The action plans and outcome measures for each priority can be found at www.UProotms.org. Create a Culture of Health A culture of health starts in communities where healthy choices about what to eat, how much to exercise, or whether to smoke or bicycle or work are easy choices. A culture of health starts where the environments in which we live – our schools, workplaces, and neighborhoods – are health-enhancing. All of the outcome measures for goal #1 are centered on private entities and state government entities. One identified gap in the information we have about worksite wellness programs and health promotion activities within Mississippi is city and county governments. The goal for this priority is to improve the culture of health in Mississippi workplaces and in academic settings. Strategic objectives:
• Increase the number of Mississippi worksites that offer employee wellness programs • Increase the percent of school health councils in full compliance with composition requirements Improve Infant Health Infant death is a measure of the health and well-being of children and the overall health of a community. It reflects the status of maternal health, the accessibility and quality of primary health care, and the availability of supportive services in the community. Infants with low birth weight or preterm delivery have a higher risk of death. The use of alcohol, tobacco, and illegal substances during pregnancy is a major risk factor for low birth weight, infant mortality, and other poor outcomes. Infant mortality rates vary substantially among racial and ethnic groups; the rate continues to be higher for African American infants than for white infants. Mississippi’s infant mortality rate has been consistently higher than the national rate for several years. In 2012, the Mississippi rate dropped below 9.0 (8.8) per 1,000 for the first time in 2012. There have been fluctuations up and down since that time and in 2016 the Mississippi rate was 8.6 (compared to the national rate of 5.6). There are significant racial disparities; the infant mortality rate for African Americans in 2016 was 11.4 while the rate among Caucasians was 6.7. There is evidence that breast fed babies have lower rates of asthma and obesity as they grow. Breastfeeding also protects against Sudden Infant Death Syndrome. Breastfeeding is protective for mothers as well; mothers who breastfeed have lower risks of breast and ovarian cancer, type 2 diabetes and postpartum depression. The American Academy of Pediatrics (AAP) recommends that infants are breastfed for at least 12 months. An important cause of infant mortality in the state is Sudden Infant Death Syndrome and accidents from unsafe sleep environments due to suffocations, entrapments and overlay accidents. Most of these sleep-related infant deaths are preventable, yet every year we lose more than 30 infants in our state to these tragic events. The goal within this priority is to improve infant health in Mississippi through the following strategic objectives: • Increase the number of mothers who are breastfeeding • Increase the number and proportion of families that incorporate safe sleep practices Reduce Rates of Chronic Disease Obesity rates in the state have increased from 19.8% in 1996 to 37.3% by 2016. Obesity is a root cause of most chronic illnesses. The consequences of obesity are Type 2 diabetes, heart disease,
arthritis, stroke, and dementia. Currently in Mississippi, 1.1 million adults and 126,000 children are obese, many of whom already show signs of chronic illnesses. According to the CDC, 75% of total health care expenditures are associated with treating chronic diseases. If Mississippians reduce their BMI rates to lower levels and achieve an improved status of health, the state could save over $13 billion annually in unnecessary health care costs. The goal for this priority is to decrease obesity through the promotion of healthy lifestyles through strategic objectives as follows: • Increase the percent of youth ages 12 and under who engage in 60 minutes of daily physical activity Increase Educational Attainment The U.S. Census Bureau collects educational attainment information annually through the American Community Survey and Current Population Survey. Educational attainment is defined as the highest level of formal education completed (i.e., high school diploma or equivalent, bachelor’s degree, graduate/professional degree). An educated workforce is an important factor for economic development. Completion of formal education is associated with higher paying jobs and access to resources that impact health such as food, housing, transportation, health insurance, recreation, and other basic necessities for physical and mental wellbeing. In Mississippi, 81.5% of adults age 25 and older have at least a high school diploma, this is lower than the national average (86.0%). The goal in the priority is to increase high school graduation rates through the following strategic objectives: • Decrease pregnancy rate in women aged 15-19; • Increase support services for pregnant and parenting teens; • Increase linkages between existing school based health clinics (SBHC), school nurses, and local and state mental health providers and supports. How UProot is Different While this effort builds on the work of multiple organizations in Mississippi for decades, UProot is different in a few key ways: • Collaboration – One purpose of UProot is to rethink ways organizations work together to address health. This includes sharing resources and information more regularly and involving organizations who have not traditionally been part of health improvement efforts. • Root causes – The UProot partners seek to create lasting change in the health of Mississippians by looking for deep rooted issues obstructing our efforts to be healthier. The actions we take will
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focus on individual behaviors as well as the underlying social issues that promote or inhibit good health. • Measurable outcomes – In order to build a healthier Mississippi, we need to determine if we are moving in the right direction. This requires setting and monitoring measurable, attainable outcomes. How to Get Involved One aim is to continue to mobilize new partners and work with community members to consider novel ways to “uproot” the systems and circumstances that contribute to poor health in Mississippi. UProot seeks to bring representatives of Mississippi’s diverse communities together to find ways to improve the health of all of our state’s residents. The UProot website (www.uprootms.org) contains resources to utilize to cultivate health in your area. If you are part of an organization that would like to become part of the UProot partnership, sign up on the website.
There are easy things health care providers can do that promote health in their own surroundings. Implement changes in your own organization’s environment to make it easier for your co-workers and employees to be healthy (such as changing vending machine contents, assuring healthy foods at pot luck lunches, making sure employees know the importance of not smoking, and have knowledge of the free tobacco quit line) – creating your own culture of health. Be an advocate for chronic disease prevention through your own actions, becoming an example in your work, home and faith communities. Assure that your medical practice includes information for patients regarding healthy foods and exercise. Please contribute examples of your activities on the Uproot website. We didn’t get to where we are now overnight, and we cannot expect all of our problems to go away quickly either. Mississippi needs drastic and innovative efforts to grow communities fostering health in all residents. We all need to think about how our systems affect health and UProot what isn’t working so that we can build a healthier Mississippi from the ground up. n
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P O P U L A T I O N
H E A L T H
Preparing Medical Students to Practice 21st Century Medicine:
The Prevention and Population Health Curriculum at the University of Mississippi School of Medicine JOSHUA R. MANN, MD, MPH; LEANDRO MENA, MD, MPH; ALAN D. PENMAN, MD, PHD, MPH
Introduction Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”1 “Population health management, sometimes called population medicine (to differentiate it from Public Health), has been defined as “the design, delivery, coordination, and payment of high-quality health care services to manage the Triple Aim for a population using the best resources we have available to us within the health care system.”2 The Triple Aim, in this context, consists of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare. Population health approaches assume a biopsychosocial model of health, in contrast to the older biomedical model, and typically include a significant emphasis on prevention and wellness, and reducing health inequities among different populations groups by addressing the social determinants of health. To achieve these goals, it is important to identify at-risk populations and manage those populations proactively, in collaboration with community partners such as public health agencies, payers, and not-for-profit organizations.2
strong foundation that will enable them to provide prevention- and population-focused care effectively. In this article, we describe the curricular content provided to medical students at the University of Mississippi Medical Center, Mississippi’s only academic health center with the state’s only allopathic school of medicine. Prevention and Population Health Instruction at the University of Mississippi School of Medicine The University of Mississippi Medical Center (UMMC) was founded in 1955 and, until William Carey University opened its osteopathic medical school in 2010, was the state’s only medical school. UMMC remains the state’s only academic medical center, and just under 50% of the state’s currently practicing physicians graduated from medical school at UMMC (Mitchell, John. Director of the Office of Mississippi Physician Work Force, UMMC. Personal communication.). The current class size for the UMMC School of Medicine is over 150 per year and is expected to continue growing in the future. Therefore, UMMC is in an excellent position to impact the way medicine is practiced in Mississippi in the future.
There is a growing emphasis on such approaches in medical practice, being driven by the recognition that many factors not addressed in traditional medical practice are major drivers of health outcomes. Also, major changes in our healthcare reimbursement model that traditionally focus on volume have begun shifting to emphasize and incentivize positive outcomes for patient populations.3 In the context of these developments in health care, national organizations such as the Association for Prevention Teaching and Research and the American Association of Medical Colleges are encouraging medical schools to incorporate population health concepts in the medical school curriculum.4, 5
From the time of its founding until 2008, UMMC housed a Department of Preventive Medicine within the School of Medicine. The areas of emphasis for this department varied over the years but included a range of topics including tropical medicine, genetics, epidemiology and biostatistics. The department became dormant in 2008 because of a desire to re-envision what the department should have as its focus, given the changing landscape of health care. Faculty from the department who remained at UMMC were placed in other departments across the Medical Center but continued their involvement in teaching public health concepts to medical students.
Population health and prevention-focused approaches are particularly salient for Mississippi which exhibits high levels of preventable morbidity and mortality and significant disparities in health outcomes by race, geography, and socioeconomic status.6, 7, 8, 9 Therefore, it is important to ensure that physicians practicing in Mississippi have a
In 2014, UMMC hired an Associate Vice Chancellor of Population Health, and in 2015 the Department of Preventive Medicine was reopened with a renewed emphasis on reducing preventable morbidity and mortality in Mississippi. Subsequently, the John D. Bower School of Population Health was formed in 2017, third of its kind in the United
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States, as evidence of our institutional commitment to improve the health of all Mississippians. The school currently has three departments: Population Health Science, Data Science, and Preventive Medicine (which also retained its presence as a department in the School of Medicine). In late 2017, the Accreditation Council on Graduate Medical Education (ACGME) granted accreditation for the first residency program in Public Health and General Preventive Medicine in the state. The program is set to matriculate its first residents in July 2018. The departments of Data Science and Population Health Science currently have academic programs that have as a priority to support the development of our state’s population health workforce. Recent Developments in Prevention and Population Health Instruction When the Department of Preventive Medicine re-opened in 2015, one of its primary goals was to expand the teaching to medical students, retaining the epidemiology, biostatistics and public health content sustained after the Department was suspended, but incorporating additional content related to the following key areas: • Social, economic, and other non-biomedical factors that influence health (frequently termed the social determinants of health) • Health disparities • Population health management • Healthy nutrition/dietary counseling • Health behaviors and behavior change • Clinical prevention • Health policy Our philosophy has been to foster enthusiasm for this content by incorporating experiential activities as much as possible, and while assuring the instruction of core preventive medicine and population health elements, maintaining some flexibility for students as to content areas they would like to emphasize to reinforce interests or address gaps in their knowledge. We also wanted to integrate prevention and population health activities into the “clinical” (third and fourth) years of education, whereas it had typically been constrained largely to the “non-clinical” (first and second) years. A Population Health Curriculum Sub-Committee of the School of Medicine’s Curriculum Committee had been created in 2014 and included faculty members from a variety of specialty areas and backgrounds. This sub-committee, currently chaired by the Chair of the Department of Preventive Medicine, has as its charge to: “design, implement, oversee and evaluate a longitudinal curriculum for Population Health and Epidemiology that is integrated both vertically and horizontally (across disciplines, both preclinical and clinical), through participation by faculty, students, administration and external partners.” It has been instrumental in helping to shape the new curriculum components.
To date, we have been successful in implementing many of the desired curricular components. The tables below summarize the current status of preventive medicine and population health teaching for medical students at UMMC. We believe this curriculum provides a good balance of the skills and knowledge relevant to disease prevention, health promotion and population health. We are continuing to develop new educational experiences and expect that the curriculum will continually evolve as we learn in the process, identify gaps, and recognize emerging changes to our healthcare system. We feel that the current curricular components provide students with a strong foundation in prevention and population health that they can apply to their future practice, whatever specialty they pursue. In the tables, components that were present before the re-opening of the Department of Preventive Medicine are highlighted in gray while those that have been implemented since July of 2015 are not highlighted. Facilitating Factors Some factors have created great opportunity in accelerating the progress made in expanding our curriculum in prevention and population health in a fairly short period. These include the institutional changes outlined above (re-opened Department of Preventive Medicine, the hiring of an Associate Vice Chancellor of Population Health and the formation of new School of Population Health, etc.). Additionally, leaders recognized, across the School of Medicine and other schools and units in the Medical Center, the increasing importance of chronic disease prevention and effective population health approaches in the new realities of medical practice. Another major facilitating factor is the institutional support provided by the University of Mississippi Medical Center which includes in its vision statement: “training committed health care professionals who work together to improve health outcomes and eliminate health care disparities.” This focus on improving health outcomes and eliminating health care disparities provides a strong rationale for educating medical students on effective approaches for prevention and population health management. Challenges There are also important challenges to enhancing the prevention and population health aspects of medical student education. First is the sheer volume of content that medical students must learn during their four years of medical school. Increasing the amount of time spent in one topic area inevitably requires that time allocated to other content areas must be reduced. Concurrent with the efforts to enhance prevention and population health teaching, the School of Medicine has also participated in other aspects of the curricular redesign which have included identification and elimination of unintended redundancies in content across the curriculum. This has helped free up additional time needed for prevention and population health topics. A second challenge is the interdisciplinary nature of prevention and population health. Ideally, much of the learning in these areas would
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Table 1. Required M1-M2 Prevention and Population Health Curriculum Elements
Table 1. Required M-1 and M-1 Prevention and Population Health Curriculum Elements Content Area
Objectives
M1-M2 Core Curriculum Public Health Definition of health; social determinants of health; health disparities; health status and health policy of Mississippi, the United States, and other nations Health Care Healthcare accreditation, certification, and licensure; legal issues for health care Administration providers; HIPAA rules and compliance; models for financing and reimbursement for and Finance health care; effects of health care cost and quality on reimbursement; impact of electronic health record systems, financial information systems, and practice management systems on health care delivery; trends in telemedicine, personal health records, and mobile health technologies. Clinical Primary, secondary, and tertiary prevention; adult and pediatric immunization Prevention recommendations; Vaccine Adverse Event Reporting System; Organization and goals of the United States Preventive Services Task Force (USPSTF); USPSTF review and recommendation process; current USPSTF recommendations for clinical preventive services in adults; evaluation of screening tests Basic science behind immunizations; indications, contraindications, and precautions for immunizations; recommended preventive services for children and adolescents; recommended preventive services for pregnant women Health Behavior Identify and describe the levels of the social ecological model; illustrate how each Change level of the social ecological model has the potential to influence health behaviors across all levels of disease prevention; identify and describe one social and behavioral sciences theory of health behavior change at the intrapersonal and interpersonal levels; appraise the application of social and behavioral sciences health behavior theory to an intervention study Community Effective approaches to community level health improvement; introduction to the Prevention Community Guide to Preventive Services Participate in community-based health screenings focused on obesity, diabetes, and hypertension Epidemiology, Principles of study design; use of commonly used statistical methods for hypothesis Biostatistics, and testing; relative risk and odds ratio; interpretation of statistical analyses in scientific Evidence-Based articles; calculation of sensitivity, specificity, positive and negative predictive value, Medicine and likelihood ratio Nutrition (In Fundamentals of healthy nutrition; approaches to healthy cooking; effective Development) nutritional counseling; nutrition in diabetes and hypertension management; bariatric surgery and weight loss medications Environmental Importance of environmental medicine for health and medical practice Medicine M1-M2 Selective Experiences (Must choose one of the following) Basics of Clinical Research Climate Change and Health Communication in Practice Evolution in Health and Disease Health Department Observership Health Care Disparities Public Health in Film and Literature The Healer’s Art (values and professionalism curriculum available through the Institute for the Study of Health and Illness) Nutrition/Culinary Medicine
Activity
Contact Hours
Lecture; Self Study
5
Lecture; Self Study
8
Lecture
5
Lecture
2
Lecture
3
Lecture
2
Community service
3
Lecture; Small Group Discussions
10
TBD
TBD
Lecture
1
Group discussions; Assigned reading; Other applied activities
11
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Table 2. Required Activities for M3 and M4 Students
Table 2. Required Activities for M-3 and M-4 Students Content Area Objectives Clinical Provide clinical preventive services such as Pap testing, blood lipid Activities During screening and management, immunizations, and others in the Rotations context of clinical rotations Environmental Medicine in Medical Practice Chronic Disease Prevention and Management (Internal Medicine Clerkship) Clinical Prevention in Family Medicine (Family Medicine Clerkship) Hospital Discharge Planning
Health Behavior Change (added to Family Medicine Clerkship) Effective Health Communication
Preventable Hospitalizations (in development for required M-4 Medicine rotation) Population Health Management (in development)
Interpretation of environmental factors impacting health; effectively take patients’ exposure histories; use available information and clinical resources to assess and modify environmental health risks Understand principles of screening for and management of hypertension, diabetes, and dyslipidemia
Activity Clinical activities; Faculty discussions Lecture
Contact Hours NA
Small group discussion
2
Understand and apply national guidelines on clinical preventive services, adult health maintenance, well-child and adolescent care, promoting quality of life in chronically ill and older people, nutrition and weight management, and pregnancy prevention and contraception; understand the use of motivational interviewing to promote health behavior change Identify non-medical factors that impact successful or unsuccessful transition after hospital discharge; understand the roles of nurses, social workers, case managers and other in performing discharge planning; describe the role of the physician in working with nurses, social workers, case managers and others in discharge planning.
1
Group project; Assigned readings; Lecture; Standardized patient Patient interviews; Discussion with social worker; Write summary paper Understand factors that motivate patients to adopt healthy lifestyle Patient changes; understand factors that motivate patients to adopt healthy interview; lifestyle changes; understand challenges faced by patients in Write implementing and sustaining healthy lifestyle changes; develop a reflection strategy for applying knowledge about behavior change to the paper; Group practice of medicine discussion Understand barriers to effective communication between physicians Patient and patients; Understand factors that facilitate effective interview; communication between providers and patients; apply the Write knowledge gained to develop strategies for effective reflection communication with patients in the future paper; Group discussion Identify clinical and non-clinical causes of preventable hospital Chart review; admission; develop feasible recommendations at multiple levels Patient (health care provider, health care system public health department, interview; and public policy) for reducing preventable hospital admissions Reflection paper
5
Utilize health system data to identify high priority (patient populations and health outcomes) for population health management interventions; develop specific goals for addressing population health needs; identify health system and community resources to assist in accomplishing identified goals; develop a plan for assessing impact
Participation; Completion of assignments
Participation; Completion of assignments
Approx 3
Approx 3
Approx 3
TBD
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Table 3. M3 and M4 Elective Experiences Table 3. M-3 and M-4 Elective Experiences Content Area Objectives
Activity
Public Health Observership
Gain an understanding of the role and activities of a district public health department
Health Policy Elective (M-4; Approved for 2019)
Understand the process by which bills become laws; demonstrate knowledge of current issues related to public health and health policy; recognize potential opportunities for physicians to influence health policy positively
Lifestyle Medicine Elective (M-4; In development)
Understand the role of lifestyle changes for preventing and improving management of chronic diseases; understand effective approaches for promoting healthy lifestyle changes in a clinical setting; effectively apply health promoting interventions for individuals
occur with students in a variety of fields (medicine, nursing, pharmacy, etc.). While we are working on interdisciplinary learning opportunities in prevention and population health, this can be difficult because of the complex and differing schedules of students in the different health professions programs. A third challenge has to do with the traditional models of healthcare and medical education in Mississippi and the University of Mississippi Medical Center, respectively. Unlike some other states where managed care participation is very high and population health approaches are emphasized, Mississippi’s health care landscape is dominated by the traditional fee-for-service model. This affects the practice models at UMMC and means there are fewer practice-based learning opportunities in population health than might be available in settings where managed care approaches and accountable care organizations are more prominent. Opportunities We will continue to develop additional learning opportunities in prevention and population health for medical students. Given limits in the available time for mandatory courses and experiences, most of our new learning opportunities are likely to be elective experiences. For example, we are developing elective courses/rotations in clinical prevention/lifestyle medicine and environmental health, and we expect that we will continue to identify additional elective opportunities for interested students. Another opportunity is the availability of master and doctoral degree programs in Population Health Science and Data Science in the School of Population Health which will provide opportunities for students to
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Observe activities of the public health department Attend meetings related to health policy; Research and create policy brief Patient care; Prevention programs; Disease management programs; Culinary medicine
Contact Hours Approx 80 Approx 160
Approx 160
pursue dual degrees (e.g., Medicine and Population Health Science) at the Medical Center. The School of Population Health admitted its first students into its Biostatistics and Data Science program in 2017. Degree programs in Population Health Science are beginning in 2018, and we anticipate that there will be interest in these degree programs on the part of some medical students. We also anticipate that students in other health professions programs will be interested in joint degree programs in population health. Finally, as pay for performance and managed/accountable care approaches become more prominent in Mississippi as they have in other regions of the United States, we anticipate that additional practice-based opportunities for learning will become available. This development will also likely drive continued interest from students in both elective opportunities and joint degree programs. We anticipate that these developments will also drive interest in UMMC’s newly accredited residency program in Public Health and General Preventive Medicine. Summary In conclusion, there has been dramatic growth in both required educational experiences and elective opportunities in prevention and population health for students at the University of Mississippi School of Medicine. The curricular changes being made should provide Mississippi with a physician workforce that is well equipped to address the chronic disease prevention needs of the state and to adapt to ongoing changes in healthcare reimbursement that emphasize 13 health outcomes for assigned patient populations. UMMC is committed to continue enhancing the curriculum for medical students and thereby improve the health of our state’s population. n
Key Words: Medical students, curriculum, preventive medicine, population health References 1. Kindig, DA, Stoddart G. (2003). What is population health? Am J Pub Health, 93:366-369. 2. Lewis N. Institute for Healthcare Improvement. (2014). Populations, Population Health, and the Evolution of Population Management: Making Sense of the Terminology in US Health Care Today. Available at http://www. ihi.org/communities/blogs/_layouts/15/ihi/community/blog/itemview. aspx?List=81ca4a47-4ccd-4e9e-89d9-14d88ec59e8d&ID=50). 3. The Quality Payment Program. Modernizing Medicare to Provide Better Care and Smarter Spending for a Healthier America. Available at https://qpp.cms. gov/ 4. Prevention and Population Health Teaching Modules - Association for Prevention Teaching and Research (APTR). Prevention and Population Health Teaching Modules. (n.d.). Available at www.aptrweb.org/?page=pophealthmodules. 5. Inclusion and Integration of Population Health into Undergraduate Medical Curriculum. (June 26, 2014). Association of American Medical Colleges. Available at https://www.aamc.org/initiatives/diversity/portfolios/384602/ phintegrationwebinar.html. 6. Mississippi State Department of Health. Office of Health Disparity Elimination Office of Health Data & Research (2015, October). Annual Mississippi Health Disparities and Inequalities Report. Available at https://msdh.ms.gov/
msdhsite/_static/resources/6414.pdf. 7. (2017, October 12) Improving Health in the Mississippi Delta through Powerful Engagement. (n.d.). Available at https://www.pcori.org/research-inaction/improving-health-mississippi-delta-through-powerful-engagement. 8. Mayfield-Johnson, S., Fastring, D., Fortune, M., & White-Johnson, F. (2015). Addressing Breast Cancer Health Disparities in the Mississippi Delta through an Innovative Partnership for Education, Detection, and Screening. J Community Health, 41(3):494-501. doi:10.1007/s10900-015-0121-2 . 9. Short, Vanessa L., Ivory-Walls, Tameka, Smith Larry, Loustalot, Fleetwood. (2014, Jan. 1) The Mississippi Delta Cardiovascular Health Examination Survey: Study Design and Methods. Epidemiology Research International, 2014, 1-9. doi:10.1155/2014/861461 .
Author Information Preventive medicine physician, professor and chair, Department of Preventive Medicine, School of Medicine and the John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson (Mann). Infectious disease physician, professor and chair in the Department of Population Health Sciences, John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson (Mena). Physician, public health researcher, and biostatistician, professor, Department of Preventive Medicine, University of Mississippi Medical Center, Jackson (Penman). Corresponding Author: Joshua Mann (jmann4@umc.edu).
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P O P U L A T I O N
H E A L T H
The Global and National Perspective of the Noncommunicable Disease Epidemic
C
ardiovascular disease (CVD) is the leading cause of death globally and in the United States. Regional variation is significant, and Mississippi ranks as one of the most obese states in the nation and has some of the highest rates of diabetes, hypertension, heart disease, and strokes. Based on data from the Global Burden of Cardiovascular Diseases Collaboration, total cardiovascular disease burden increased for both men and women from 2010 to 2016 in Mississippi and was associated with the highest cardiovascular disease disability-adjusted life-years (DALYs) in the United States.1 The rate of cardiovascular DALYs in Mississippi among women was the highest in the nation. Most of the cardiovascular disease burden can be attributed to known modifiable risk factors such as obesity, hypertension and smoking. How to implement changes in these risk factors at the population level remains a challenge for Mississippi and global public health. This special issue of the Journal of the Mississippi State Medical Association focuses on Population Health and the goal of conquering the epidemic of noncommunicable disease and to bend the cost curve of healthcare in the state of Mississippi. According to the Center for Disease Control (CDC), 75% of total health care expenditures are associated with treating chronic diseases. This topic could not be timelier given the alignment with the 150th Annual Session of the Mississippi State Medical Association (MSMA) House of Delegates, the inauguration of Dr. Michael Mansour as the 151st MSMA President and his focus on promoting a healthier Mississippi and sustaining health throughout a lifetime. Global health is about social justice and human rights in the context of health. It aspires to health equity for all. Health, illness and disability are socially patterned and are not bounded by borders and best addressed by cooperative action and collaborative innovation among relevant stakeholders. CVD is the number one cause of death worldwide, affecting all populations irrespective of demographic or socioeconomic differences. A bold new global agenda to end poverty by 2030, focus on health equity and pursue a sustainable future was adopted in September 2015 by the 193 Member States of the United Nations (UN) at the start of the three-day Summit in New York City on Sustainable Development.2 I had the privilege of representing the American College of Cardiology (ACC) at the Summit, which included participation by more than 150 world leaders and Pope Francis as part of the 70th Session of the UN General Assembly. I participated in various plenary and satellite sessions with leaders of the NCD Alliance, the American Heart Association and the World Heart Federation (WHF), which
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JOHN GORDON HAROLD, MD Past President, American College of Cardiology Professor of Medicine Cedars-Sinai Smidt Heart Institute
focused on the adoption of the Sustainable Development Agenda. The Sustainable Development Goals (SDGs) were approved unanimously by the UN General Assembly and made the prevention and treatment of noncommunicable diseases (NCDs) – including cardiovascular disease – a top sustainable development priority including the target of reducing premature mortality from NCDs by one third by the year 2030. I was honored to serve as the chair of the World Heart Federation (WHF) Partners Council in 2016 on behalf of the ACC. The vision of the WHF is to work with the cardiovascular health community to hasten the day when cardiovascular health is no longer a privilege – but a right, and when cardiovascular disease is transformed from a life-threatening disease to one that can be prevented and managed in all populations. The WHF serves as a global facilitator, convener, trusted adviser and representative of cardiovascular disease stakeholders to the World Health Organization (WHO), driving the global cardiovascular health agenda by converting policy into action, through its members and a broader network of partners. The widespread impact of cardiovascular disease is a prime example of a global epidemic that needs to be targeted in a collaborative fashion. The ACC has joined the global fight against cardiovascular disease including heart disease and stroke in collaboration with the WHF and is a member of the WHF Global Coalition for Circulatory Health. The ACC supports the achievement of the global target of a 25% reduction by 2025 in premature mortality from heart disease and stroke and a key milestone to achieve the UN Sustainable Development Goal 3.4 of a one-third reduction in premature NCD deaths by 2030.3 The MSMA recognized the importance of NCD’s and the House of Delegates adopted the following at their 2015 summer meeting: “WHEREAS, Mississippi closely reflects the high incidence and death from cardiovascular disease and death as seen in low- and middle-income
Dr. John G. Harold (right) with Dr. Thomas Gaziano (left) at the World Health Assembly in Geneva 2017.
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countries and is correlated to raised blood pressure, increased blood glucose, elevated blood lipids, and obesity; and •WHEREAS, the Mississippi Delta has the highest incidence of cardiovascular disease and death in Mississippi; therefore, be it •RESOLVED, that MSMA promote the adoption of the international goals set by the World Health Organization, and endorsed by the American College of Cardiology and the American Heart Association, by all Mississippi physicians to achieve a 25% reduction in premature mortality from NCDs by 2025 (the 25x25 target) by achieving the following goals: 1. Reduce tobacco use by 30% with decreased second-hand smoke, 2. Reduce physical inactivity by 10%, 3. Reduce harmful use of alcohol by 10%, 4. Reduce salt/sodium intake by 30%, 5. Reduce raised blood pressure by 25%, 6. No further increase in diabetes and obesity, 7. Ensure 50% of eligible people receive drug therapy and counseling to prevent heart attack and stroke, 8. Ensure 80% availability of essential medicines and basic technologies to treat CVD and other NCDs. The 2016 Mississippi Public Health Report Card featured the 25x25 initiative and was the highlight of an MSMA news conference at the State Capitol in Jackson. Both the Public Health Report Card and an additional article on the 25x25 target were published in the January 2016 issue of the Journal MSMA. World Heart Day is celebrated on September 29th each year and unites the CVD community in the fight against heart disease and stroke. This global initiative was created by the World Heart Federation to highlight CVD prevalence and impact on global health. Ischemic heart disease and stroke have remained the leading causes of death globally in the last 15 years claiming 17.5 million lives each year. Eighty percent of these preventable deaths occur in low- and middle-income countries with similar disparities occurring in areas of the United States such as the Mississippi Delta. The focus of World Heart Day is to educate the global healthcare community regarding the scope of the problem, the potential for making an impact and a pathway to accomplish these goals by highlighting actions that individuals can take to prevent and control CVD. The focus is on modifiable risk factors such as tobacco use, unhealthy diet and physical inactivity so that most of premature deaths from heart disease and stroke could be avoided. The World Health Assembly (WHA) is the forum through which World Health Organization (WHO) is governed by its 194-member states. The WHA held on an annual basis in Geneva is the decisionmaking body of WHO and is attended by delegations from all WHO Member States. The WHA meets in the assembly hall of the Palace of Nations (Palais des Nations) which is the European home of the UN in Geneva, Switzerland. The Palace was built between 1929 and 1938 to serve as the headquarters of the League of Nations. It has served as
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the home of the United Nations Office at Geneva (UNOG) since 1946. The 2018 WHA was the seventy-first meeting of the WHA and took place on May 21-26, 2018. The ACC has sent delegations to the WHA for the past several years. I had the pleasure of participating at the 2017 meeting in Geneva. As global advocates of cardiovascular health, we have a responsibility to further our collective mission of preventing cardiovascular disease morbidity and mortality and improving heart health. Meetings like the annual WHA remind us just what is at stake if we don’t work together to address NCDs. These meetings also provide a place to gain perspective and renewed energy to solve a problem that can at times feel insurmountable. I had the additional privilege of addressing the United Nations General Assembly hearings on noncommunicable diseases in 2014. The WHO became the successor to the League of Nations' Health Organization (LNHO) which was inspired by the ideal that the equitable provision of health and welfare could reduce internal social conflicts and help prevent war. The WHO’s constitution was endorsed on April 7, 1948, in New York City. World Health Day is celebrated on an annual basis on April 7th and this year’s celebration was dedicated to one of the WHO’s founding principles: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” WHO currently has representation from 194 Member States across six global regions and WHO staff aspire to achieve better health for everyone, everywhere and to achieve the UN Sustainable Development Goal of ensuring “healthy lives and promote wellbeing for all at all ages.” Over the past 7 decades WHO has led global efforts on public health and in recent years has focused on the epidemic of noncommunicable diseases (NCDs) including the impact of risk factors on cardiovascular health. These modifiable risk factors translate into cardiovascular events such as devastating heart attacks and strokes. There is a pressing need to meet the challenge of noncommunicable diseases which constitute the highest global burden of diseases. NCDs such as cancer, diabetes and heart disease account for 70% of all deaths. Every year approximately 40 million people die from NCDs of which two thirds are related to modifiable risk factors. By 2025, there will be 7.8 million premature deaths annually from cardiovascular disease if trends for hypertension, tobacco smoking, diabetes and obesity continue. The WHO has focused on modifiable risk factors and the promotion of healthy eating, physical exercise and regular health assessments. The WHO has run global health campaigns on the prevention of diabetes, high blood pressure and negotiated the WHO Framework Convention on Tobacco Control to help reduce disease and death caused by tobacco. Tobacco use is an important global risk factor for the development of heart disease, stroke, and peripheral vascular disease. Dr. Valentin Fuster in his 2017 JACC article on the Future Role of the United States in Global Health – Emphasis on Cardiovascular Disease highlighted the report published by the National Academies of Sciences, Engineering, and Medicine (NASEM). The report examined the changing landscape of global health and provided recommendations to
Dr. John G. Harold at World Health Assembly, Geneva Switzerland, Geneva 2016.
the U.S. government, as well as non-governmental organizations and the private sector to improve responsiveness, coordination and efficiency in dealing with global health issues at home and abroad.4 The report focused on 14 recommendations that require ongoing commitments to eradication of infectious disease and increase the emphasis on chronic diseases including cardiovascular disease. The report cited improving early detection and treatment, mitigating disease risk factors, shifting global health infrastructure to include management of cardiovascular disease, developing global partners and private-public ventures to meet infrastructure and funding challenges, streamlining medical product development and supply, increasing research and development capacity, and addressing gaps in global political and institutional leadership to meet challenges and opportunities in global health. This document provides a road map for states such as Mississippi to follow and focus on the epidemic of noncommunicable diseases at home. The United Nations General Assembly is convening the third High-level meeting on the prevention and control of noncommunicable diseases in September 2018 and will undertake a comprehensive review of the global and national progress to date and will bring together Heads of State and Government, civil society, people living with NCDs, academia and the private sector to address this global epidemic. The national and global burden of noncommunicable diseases (NCDs) represent a major public health challenge that undermines the social and economic development in countries with limited resources and has implications for states such as Mississippi where large disparities in the
total burden of cardiovascular disease persist. These disparities present challenges and opportunities for physician members of MSMA to make an impact in population health and prevention as a transformational approach to healthcare disparities. I know that Dr. Mansour will harness the power and diversity of MSMA members to advance patient care, spur innovation, and improve health equity among individual patients and populations. We should encourage continued advocacy for heart healthy choices, promote affordable quality care, and advocate for cardiovascular health in Mississippi and across the world. n References 1. Roth, Gregory. Global Burden of Cardiovascular Diseases Collaboration. The burden of cardiovascular diseases among US States, 1990-2016. JAMA Cardiol. 2018;3(5):375-389. doi:10.1001/jamacardio.2018.0385. 2. Zoghbi WA, Duncan T, Antman E, et al. Sustainable development goals and the future of cardiovascular health. J Am Coll Cardiol. 2014;64:1385-1387. 3. O’Gara PT, Harold JG, Zoghbi WA. Thinking globally to transform cardiovascular care. Lancet 2014;384 (9941):379-380. DOI: 10.1016/S0140-6736(14)61141-7. 4. Fuster, V, Frazer J, Snair M, Vedanthan R, Dzau V. The future role of the United States in global health: Emphasis on cardiovascular disease J Am Coll Cardiol. 2017 Dec 26;70(25):3140-3156. PMID: 29198877, DOI: 10.1016/j.jacc.2017.11.009. Epub 2017 Nov 30.
Author Information John Gordon Harold, MD, MACC, MACP, FESC, FRCPI, FRCP, FCSI, FCCP, FAHA Scientific Policy & Advocacy Committee, World Heart Federation. Past President, American College of Cardiology. Clinical Professor of Medicine, Cedars-Sinai Smidt Heart Institute, and David Geffen School of Medicine at UCLA.
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P O P U L A T I O N
H E A L T H
Utilizing Technology and Team-Based Care to Improve Cardiovascular Health in Mississippi DONALD CLARK, III, MD; DANIEL W. JONES, MD
Introduction Reducing the burden of cardiovascular disease (CVD) in Mississippi remains a major public health priority. The impact of CVD in Mississippi is enormous – CVD is the leading cause of mortality, the highest rate in the nation, accounting for over one-third of all deaths in the state.1 Substantial CVD-related disability and medical costs plague patients and families while draining societal resources.2 Upward trends of obesity, diabetes, and hypertension stand to threaten 3 decades of progress reducing statewide CVD mortality.3 Broad CVD prevention strategies, such as tobacco regulation and food supply salt reduction, are necessary to shift the distribution of risk at a population-level.4 Additionally, effective behavior modification and medical treatment of CVD risk factors are essential to improve cardiovascular health for individuals. A well-established longitudinal physician-patient relationship is essential for effective management of chronic disease. The goal of this article is to highlight the supplementary role of technology and team-based care for chronic disease management among individuals at risk for CVD. Key Words: Prevention, cardiovascular disease Team-Based Care Ideal health behavior and evidence-based medical therapies to control CVD risk factors including hypertension, diabetes, and high cholesterol are foundational to improve cardiovascular health and reduce CVD events. It is important to recognize that cardiovascular health is often one of many competing priorities clinicians must juggle. In the increasingly complex healthcare system, a busy primary care practice must consider hundreds of quality indicators for a broad range of conditions such as asthma, low back pain, headache, depression, and preventive screening. As such, it is estimated that only approximately half of recommended healthcare interventions are delivered during the course of normal care.5 Recognizing these challenges, team-based care models have emerged as an effective approach for chronic disease management. Team-based care is patient-centered and includes the patient’s primary care physician and some combination or other professionals including nurses, pharmacists, physician assistants, dietitians, social workers, and
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community health workers. Chronic conditions such as hypertension, diabetes, and dyslipidemia are well-suited for team-based care because management is often routine and algorithmic. Team members can provide process support and share responsibilities which are clearly delineated and appropriate for their knowledge and skill set. For example, after the initial diagnosis and evaluation of uncomplicated hypertension, ongoing management includes lifestyle education, medication titration, blood pressure and laboratory monitoring. These tasks can be protocolled and assigned to team members including nurses, nutritionists, and pharmacists.6 Delegation of routine matters to team members allows the primary physician time to focus on more complex and acute issues. These principles align with comprehensive delivery models, such as The Chronic Care Model or The Patient Centered Medical Home, designed to improve continuity, access, and coordination of care.7,8 There is strong evidence, including randomized controlled trials and meta-analyses, supporting the use of structured, protocolled, team-based interventions for chronic disease management. Among hypertensive patients, utilizing team-based care to support medication management, active patient follow-up, adherence and self-monitoring results in substantially improved blood pressure control as compared to usual care.6,9-11 These findings are consistent across a range of care settings and population groups in the United States, and similar results have been demonstrated with diabetes.12 Based on these data, current guidelines from the American Heart Association/American College of Cardiology and American Diabetes Association strongly recommend team-based care for the management of hypertension and diabetes.13,14 Technology Chronic conditions, such as hypertension and diabetes, are subject to variability over time in response to environmental and behavioral influences.15 Traditional intermittent office-based visits provide a “snap-shot” of a patient’s condition and are better suited for the reactive care of acute illness. Chronic conditions require regular monitoring of patient-level data to provide appropriate real-time intervention.15 This issue is exemplified by the well-established discrepancies between clinic-based blood pressure and ambulatory blood pressure monitoring.16 Furthermore, frequent clinic visits for chronic disease
management constitute considerable costs to the patient and society. On average, a 20-minute clinic evaluation takes over 2 hours when accounting for travel, wait time, and ancillary tasks – representing $52 billion in annual opportunity costs that disproportionately affect racial/ethnic minorities.17,18 The advent of home-based technologies for remote monitoring of patient health data allows the opportunity to improve chronic disease management by enhancing self-monitoring and patient engagement. For hypertension, randomized trials have demonstrated substantially improved blood pressure control and higher patient satisfaction using remote-self monitoring and protocolled medication titration as compared to usual care.19,20 However, robust clinical research evaluating long-term health outcomes and cost-effectiveness remain relatively limited. The evidence gap grows with the expanding, yet unproven, market of applications, sensors, and devices to monitor patient-generated data.21 Wearable technology manufacturers and software developers are often entirely consumer-directed, often without focusing on established medical guidelines.22 Successful implementation of telemonitoring warrants two key considerations: 1) active versus passive monitoring and 2) integration into the patient’s care delivery system. Based on available evidence, durable improvement appears to require monitoring coupled with prespecified interventions, emphasizing the need for these innovations to integrate into the electronic medical record and practice workflow fully. Conclusion The physician-patient relationship has been and will remain the cornerstone of medical care and is essential to effective long-term management of chronic disease. However, to improve cardiovascular health in Mississippi and address the chronic disease epidemic, we must restructure the way care is organized. Evidence strongly supports the use of protocolled team-based care models for routine chronic disease management. Additionally, technologies for remote patient monitoring will play an integral role in the future of chronic disease management, and much work remains to implement and test these treatment strategies. Despite challenges, Mississippi is well-positioned to gain significant benefit by utilizing these tools to improve cardiovascular health. n References 1. Heart Disease Mortality by State: 2016 published by the Centers for Disease Control and Prevention National Center for Health Statistics. CDC Web site. https://www.cdc.gov/nchs/pressroom/sosmap/heart_disease_mortality/ heart_disease.htm. Accessed April 2018. 2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation. 2017;135(10):e146-e603. 3. Mendy VL, Vargas R, El-Sadek L. Trends in Heart Disease Mortality among Mississippi Adults over Three Decades, 1980-2013. PLoS One. 2016;11(8):e0161194.
4. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4):586-613. 5. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645. 6. Proia KK, Thota AB, Njie GJ, et al. Team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med. 2014;47(1):86-99. 7. Long T. Patient-centered medical home: the future of healthcare delivery? Postgrad Med J. 2014;90(1067):486-487. 8. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78. 9. Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of teambased care interventions for hypertension: a meta-analysis. Arch Intern Med. 2009;169(19):1748-1755. 10. Clark CE, Smith LF, Taylor RS, Campbell JL. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ. 2010;341:c3995. 11. Santschi V, Chiolero A, Colosimo AL, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3(2):e000718. 12. Piatt GA, Anderson RM, Brooks MM, et al. 3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial. Diabetes Educ. 2010;36(2):301-309. 13. W helton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017. 14. The American Diabetes Association (ADA). Improving care and promoting health in populations. Diabetes Care. 2018;41(Suppl 1):S7-S12. 15. Milani RV, Bober RM, Lavie CJ. The role of technology in chronic disease care. Prog Cardiovasc Dis. 2016;58(6):579-583. 16. Schwartz JE, Burg MM, Shimbo D, et al. Clinic Blood pressure underestimates ambulatory blood pressure in an untreated employer-based US Population: Results from the masked hypertension study. Circulation. 2016;134(23):17941807. 17. R ay KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Opportunity costs of ambulatory medical care in the United States. Am J Manag Care. 2015;21(8):567574. 18. Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Disparities in time spent seeking medical care in the United States. JAMA Intern Med. 2015;175(12):19831986. 19. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013;310(1):46-56. 20. McManus RJ, Mant J, Franssen M, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomized controlled trial. Lancet. 2018;391(10124):949-959. 21. Rudin RS, Bates DW, MacRae C. Accelerating innovation in health IT. N Engl J Med. 2016;375(9):815-817. 22. Franklin NC, Pratt M. Let's face it: Consumer-focused technology is the future of cardiovascular disease prevention and treatment. Prog Cardiovasc Dis. 2016;58(6):577-578.
Author Information Department of Medicine, Division of Cardiology, University of Mississippi Medical Center (Clark). Department of Medicine and Physiology, University of Mississippi Medical Center (Jones). Corresponding Author: Donald Clark III, MD; Assistant Professor of Medicine, Department of Medicine, Division of Cardiology, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216. Ph: (601) 984-5640 (dclark2@umc.edu).
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J. EDWARD HILL, MD Chairman of the Board, World Medical Association, 2006-2010; Past President, American Medical Association, 2005-2006; Past President, Mississippi State Medical Association.
[The remarks on the opposite page are taken from a talk Dr. J Edward Hill gave to national political leaders when he was President of the American Medical Association, 2005-2006. Dr. Hill has graciously agreed to allow excerpts of his speech to be used here to illustrate the long- standing advocacy of members of the medical community to promote population health and prevention. A notable result of Dr. Hill’s leadership included the Mississippi Healthy Students Act of 2007 (MHSA). The act mandated physical education K-8 and health education beginning in K-8 and continuing grades 9-12. This act also required the Mississippi State Board of Education to establish regulations for child nutrition and also defined duties of School Health Councils to oversee these efforts. The data generated from these efforts helped to elucidate the importance of social determinants of health. These social and environmental factors (race, gender, education, housing, environment, jobs, and violence) influence health and outcomes. Partnering with community organizations and institutions such as schools help to address these issues in a way that may produce lasting results and change the culture contributing to the disparities in health outcomes.] – Michael Mansour, MD, guest editor
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P O P U L A T I O N
H E A L T H
Comprehensive School Health Education and the Future of Health in America
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here is a definitive revolutionary change badly needed in this country relative to population lifestyle changes in health.
Here is the list of estimates of the societal costs not just of healthcare but also including lost wages, lost taxes, and lost investments of eight unhealthy lifestyle choices, all of which are preventable. Medical and societal costs include the following: Violence and abuse: $300 billion Alcohol and other drug abuse: $290 billion Work-related injuries: $156 billion Accidents and injuries: $170 billion Tobacco-related illness: $182 billion Obesity-related illness: $110 billion These numbers are from various sources and obtained by various methods. They are not exact numbers but rather clearly indicate the magnitude of the problem is unmistakable and equally unmistakable is the fact that proper choices by individuals can dramatically reduce these societal costs. In the year that these estimates were collected, 2006, total health care cost for the United States was $2.7 trillion. The estimated total cost of these six scourges at that same time was $1.2 trillion, almost half of our total healthcare expenditures. Good health habits don’t originate in a physicians office. Good health habits begin in childhood and the two places where children spend the biggest part of their formative years, at home and school. We believe we have an answer to this problem. It is called Comprehensive Sequential School Health Education (CSHE) for Pre-K through 12. This program is designed to be taught by trained health educators that work alongside school health nurses and hopefully trained counselors and social workers. The return on investment for these programs would far outweigh the costs. Our bad health habits cost us hundreds of billions of dollars every year. If you multiply these behaviors by 10, 20, or 50 years, the result is an unimaginable cost to our states and nation. In addition to monetary costs, we cannot lose sight of the hundreds of millions of lives lost or impaired. We must recognize that it’s easier to create good health habits early in life rather than to fix bad habits later and treat the diseases and conditions resulting from these bad habits. Ten minutes in a doctors office isn’t going to cure lung cancer or even stop a person from smoking. But 50 hours of comprehensive
sequential coordinated health education offered every year of grade school and high school including segments on tobacco control will prevent tobacco use for many children. This will make a significant impact on the incidence of cancer, heart disease, and lung disease. Health education works. Students need at least 50+ hours of health education every year to develop good health habits and put them into action. Students who get comprehensive health education at school are less likely to smoke, take drugs, or even ride with the driver who’s been drinking. In one, Centers for Disease Control report only 5% of elementary school students and 13% of middle and high school students receive 60 hours or more of classroom time dedicated to health. Some people believe there’s not enough time in the school curriculum for 50 hours of health education every year. According to one report from the New York City Board of Education, the reading and math scores of third and fourth graders who receive the comprehensive sequential health education are significantly higher than children who did not receive this curriculum. The American Medical Association has more than 20 official policies that advocate teaching comprehensive sequential health education to promote healthy lifestyles. A 1993 Gallup survey found that 9 out of 10 adolescents feel health information and health skills are either more important or as important as other subjects taught in school. Four out of five parents agree on the importance of this education. The Centers for Disease Control has developed a proven ageappropriate comprehensive school health curriculum that both the federal government and the schools can adopt and use for free. Complete implementation of the program would require full funding for health education teachers, counselors, health nurses, and collaborating physicians. This program might be funded in the same way that federal matching funds are appropriated to states for infrastructure improvements. These matching funds would build educational programs based on health promotion and prevention. I am convinced that this model would be appealing to all political leaders if they understood the economic implication of reducing the eight preventable behaviors that drive almost half of our nation’s health care cost every year. If a 10%, 20%, 30%, or even 50% reduction in these preventable behaviors could be accomplished, it would make a substantial impact on the cost of healthcare and the health of our children. And nothing unites Americans more than protecting the future of our children. – J. Edward Hill, MD, Oxford
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P R E S I D E N T ’ S
P A G E
Things a President Learns
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lot of education can be packed into a year as President of the Mississippi State Medical Association. Here are some of the things I learned this year (in no particular order).
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Politics and policy making are year-round endeavors, and there’s not enough time in a year to accomplish everything you want to see done. Thus, a boiled egg is hard to scramble. Ronald Reagan was right on point when he summed up the government’s view of the economy like this: “If it moves, tax it. If it keeps moving, regulate it. And, if it stops moving, subsidize it.” It’s quite possible to travel to all four corners of the state in a year while continuing to practice medicine; but, it’s darn hard. The Natchez Trace ends at Highway 61. It just stops. Na-da, no more road. It’s a good thing at least one of the staff has been to the Indy driving school. Speaking of travels, I still wonder why gas stations lock the restroom door. Are they afraid someone will clean it? And another thing, how do they get the deer to cross the Trace at that yellow sign? The anti-vax lobby and legislators have one thing in common: some of them will never be confused by facts. Science schmeyeence. One of the Moms-for-Measles actually said, “What’s science have to do with it?” You can never underestimate the power of uninformed people in large groups.
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William M. Grantham, MD
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GoogleIsNotMedicalSchool may be the best hashtag of all time. MSMA’s social media post saying “Vaccines cause adults” was shared/posted more than 67,000 times!
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Traveling to local medical societies proved there are more Fed Ex trucks and UPS drivers than people in most of the towns I was visiting. I’ve decided that if those two companies merge the new company could be called Fed Up.
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The only thing that could possibly be better than a medical degree is a parking place close to the hospital door on a cold, rainy day. Yet, some people think a nursing degree and a medical degree are the same things. Who knew you can see patients and travel to three events in three different parts of the state all in one day, but it’s a darn long day. In a related note, a bank is a place that will lend you money if you can prove you don’t need it.
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It’s lonely at the top, but you eat better. At the local medical society meeting in Oxford, you order the steak with chimichurri. On the Gulf Coast, you get the redfish. (The salad fork is the smaller of the two.) If you’re Doctor of the Day at the Capitol and it’s a deadline day for considering bills, you might get a sitdown with the Lieutenant Governor.
Far too many physicians across this state are close to burning out from the never-ending roster of tasks invented by insurers and regulators. We need more exercise and more time to relax. Me, I am fascinated by golf. It’s taken me forty years to discover I can’t play it. The medical school students I have met in our state give me great hope for the future of medicine. They also remind me that my own time in medical school happened sometime during the last century. When organized medicine speaks with one voice, decision makers listen. Likewise, a verbal promise may not be worth the paper on which it’s written. But, the best lesson I learned is that whatever hits the fan during your year as president definitely will not be evenly distributed! Seriously, in MSMA we truly do have the oldest, largest and best medical association in the state and it’s been my greatest honor to serve as your president.
Write me at President@MSMAonline.com. n
MSMA President 2017-2018
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J M S M A
Letters Retiring UMMC cardiothoracic surgeon Dr. Giorgio Aru reflects on his 41 years of medical practice Dear JMSMA Editor, I am retiring after 41 years in the medical profession of which 23 were at the University of Mississippi Medical Center. In these years, I have been able to positively impact the lives of thousands of Mississippians, while at the same time developing a fantastic working relationship with the cardiologists and other colleagues of the Medical Center, many of whom have become personal friends. I have been truly honored for many years to be their go-to-surgeon, and in my retirement, these colleagues will be a part of the Medical Center that I will dearly miss. Other equally important people that I will deeply miss are the residents and the medical students, the nurses and the ancillary personnel. Without their hard work, it would have been impossible to achieve the results reported for many years in the STS database. But what I will miss the most are the patients that I took care of and who gave a special sense to my life day after day. During these years, I also enjoyed being the service responsible for the general thoracic surgery at the GV “Sonny” Montgomery VAMC, taking care of our veterans. Our Jackson VAMC has always offered all the necessary support to achieve better than national average risk-adjusted mortality in lung and esophageal surgery according to NSQUIP. I have a few tips for the students, residents and future colleagues. 1. First of all, love your patients. They need you, and they put their trust in you. 2. Dedicate to your patients all the time necessary for their care without short-cuts. 3. Give priority to your patients over your family and yourself. They are sick, scared and needy. Your family will see you tomorrow. 4. Take care of your family. Your family is your biggest investment for a happy old age. An unhappy family will spell trouble later on. 5. Take care of yourself. You have needs too, beyond satisfaction on the job. Take care of your body and your spirit. Understand what burn-out is, learn to recognize it and find help if needed. Nobody will monitor you as long as you are productive; you have to monitor yourself. Nobody will ever ask you to work less! Have a balanced life. This includes getting enough sleep. Lack of sleep pre-disposes to burn out, sometimes taking years to heal. 6. Don't expect recognition or glory for what you do. At the most expect a fair salary. Always remember that you are a physician because you wanted to take care of people. In fact, your biggest payback is the unbelievable satisfaction that you derive from making a positive impact on your patients’ lives using the skills that you have acquired. Again, don’t expect anything other than your personal satisfaction and you won’t be disappointed. 7. If, after graduation and completion of your training, you choose an academic career, remember that you work in a University because you
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enjoy interacting with medical students and residents and you make a commitment to educate and train them. Do not use them just to do your work. Otherwise, do not work in an academic center! 8. Educate your patients about their condition in clear terms so they understand it and can actively participate in their own healing. Often their disease comes from ignoring the deleterious effects of their lifestyle. 9. Do not perform on them any procedure that in the same situation you would not like to be performed on yourself or your family! RVU’s should be something that you consider only at the end of the year, not when you make decisions for the patients. At the end of the day, look at the person in the mirror and be at peace with that person. 10. Remember that death is not the worst thing that can happen to us. We are all going to die! Prolonging an agony without having a reasonable hope of making the patient better and functional deserves an honest discussion with the patient and the family. Do not forget to involve in these difficult decisions the Ethics Committee and other physicians who do not participate in your patient’s care. When in doubt, act in the patient’s best interest according to modern evidence-based medicine; nobody will fault you for that – not the lawyer, not the Judge nor God. 11. Choose your Institution and your partners with care. Once you have made your choice, make your commitment to support your partner(s) and the Institution like you would support your family. If you support your Institution, the Institution will support you. Remember to respect the people that have been there before you came. They have “guarded the fort” for many years and know the Institution very well. No matter how confident you are, they can mentor you through your first steps. If you see a partner in distress, do not take advantage of your partner but offer help as you would do with your best friend. Remember that you have made mistakes too. 12. Remember two rules to be successful: a) 3A’s – “Be available, affable and able” – when your colleague calls you Saturday night at dinner time, go to help with a smile and competence. (S)he will not forget you! b) “Fly in formation” – At the beginning of your career, stay in the back of the flock and don’t try to pass ahead of the group too early or be too eager to be successful, because you may be the first to be shot over the pond. Your time in front of the pack will eventually arrive, and your wings will be stronger. 13. At the beginning of your career SAVE MONEY as much as you can and invest it wisely. Use a trusted financial advisor. Read this nice article about “One house, one spouse, one job.” http://www.mdmag.com/physiciansmoney-digest/personal-finance/one-house-one-spouse-one-jobavoiding-the-true-pitfalls-in-personal-finance – Giorgio Aru, MD, Jackson
Department of Basic Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, MS 39762 E-mail: stokes@cvm.msstate.edu.
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3 Lyme disease agent not detected in deer ticksDepartment from Mississippi Mississippi of Health, 570 East Woodrow Wilson Drive, Jackson, MS 39215, USA.
Dear JMSMA Editor, The presence or absence of Lyme disease (LD) in southern U.S. states is a controversial issue, with strong opinions on both sides.1-4 The vast majority of LD cases occur in the northeastern U.S., the upper Midwest, and California.5 While cases with positive laboratory findings are reported to the Mississippi Department of Health each year without any history of travel to Lyme disease endemic areas, they are rarely confirmed (Mississippi Department of Health unpublished data). Confounding the issue, erythema migranslike lesions, often indicative of LD, do occur in southern states (including Mississippi) but are likely hypersensitivity reactions to tick saliva and not due to an infectious agent.6,7 In 2015, the Mississippi Department of Health funded a small survey of the state for deer ticks, Ixodes scapularis, the primary vector of the agent of LD in the eastern U.S. Ticks were collected by drag cloth in ten counties around the state from September 1, 2015, through April 30, 2016, (Table). Also, a few specimens were removed from dogs or cats. Ticks were placed in 70% ethanol, identified to species, and shipped to the Centers for Disease Control in Ft. Collins, CO for analysis. At the CDC, ticks were again identified and tested by PCR for the presence of DNA of the following disease agents — Borrelia burgdorferi (agent of Lyme disease), Anaplasma phagocytophilum (agent of granulocytic anaplasmosis), and Babesia microti (agent of human babesiosis) according to a protocol described previously.8 Seventy-four specimens were collected from vegetation in the ten counties; four specimens were removed from dogs/cats. All specimens tested negative for the three disease agents listed above; however, two of them were considered inconclusive, as no pathogens were detected in them, but the overall “tick DNA” test on these samples was too low to make the test results valid for them. These results confirm earlier studies that the prevalence of the LD agent, B. burgdorferi, is at or near zero in Mississippi. A LD survey, conducted by the U.S. Army at Camp Shelby near Hattiesburg, MS in 1989, found no ticks or small animals positive for B. burgdorferi.9 And, a study we conducted in 1999–2000 examined 53 adult I. scapularis for B. burgdorferi and found none positive.10 We have unpublished data (20072009) of 81 I. scapularis from Copiah, Franklin, Madison, Marshall, Oktibbeha, and Simpson Counties which were all negative by PCR for B.
Table. Location of 2015-2106 tick collection sites in Mississippi and numbers of specimens collected
Table 1. Location of 2015-2106 tick collection sites in Mississippi and numbers of specimens collected. Region County Number of Deer Ticks North Noxubee 5 Oktibbeha 37 Panola 8 Tallahatchie 3 Central Hinds 5 Rankin 5 Simpson 1 South Claiborne 5 Pearl River 4 Pike 5
burgdorferi. A much larger (published) study during 2010-2011 yielded 244 adult I. scapularis from Mississippi and found none of them positive for B. burgdorferi.11 While it might be argued that the sample size (n= 74) in our current (2015) study is too low to be meaningful, when added to the previous I. scapularis tested from the state (almost 400 ticks), we can infer that the agent of Lyme disease in Mississippi ticks is at most, rare, if not absent. It seems paradoxical that cases of LD continue References to be diagnosed in the state without confirmation of the causative agent in field-collected ticks. 1. Barbour A. Does Lyme disease occur theanalyzed south? for A survey of emerging tick-borne Acknowledgements: Ticks in this 2015-2016 studyinwere disease agents by Christine Graham in infections in the region. Am J Med Sci. 1996;311:34-40. the lab of Dr. Rebecca Eisen, Centers for Disease Control, Ft. Collins, CO. Ticks in the 1999–2000 study were 2. CDC. Southern Rash Illness. Centers for Disease Control Prevention, analyzed by personnel in theTick-associated Viral and Rickettsial Zoonoses Branch, Centers for Disease Control,and Atlanta, GA. http://www.cdc.gov/ncidod/dvbid/stari/index.htm; 2011. Sheryl Hand, RN, at the Mississippi Department of Health provided Lyme disease case data for Mississippi. Goddard J, Varela-Stokes A, Finley RW. Lyme-disease-like illnesses in the South. J Miss State Med Assoc. 2012;53(3):68-72. Jerome Andrea TinaJrM. Nations, SantosL.Portugal, 4. Rudenko N, Goddard, Golovchenko M, Varela-Stokes, Clark KL, Oliver JH, Grubhoffer Detection of Aaronstricto Walker, and Wendy C.americanum Varnado ticks in the southeastern Borrelia burgdorferi sensu in Amblyomma United States: the case for selective compatibility. Emerg Microbes Infect. 2016;5:e48, doi:10.1038/emi.2016.1045. Department of Biochemistry, Molecular Biology, Entomology, and Plant Pathology, 100 Twelve Lane, Clay Lyle 5. CDC. Surveillance for LymeMississippi disease- United MMWR Entomology, Mississippi State University, State, MSStates, 397622008-2015. (Goddard, CDC, Portugal) Surveillance Summaries. 66:1-13;2017. Contact: Jerome Goddard, PhD. E-mail: jgoddard@entomology.msstate.edu. 6. Blanton L, Keith B, Brzezinski W. Southern tick-associated rash illness: erythema Department of Basic Sciences, College of Veterinary Medicine, Mississippi State University (Varela-Stokes) migrans is not always Lyme disease. South Med J. 2008;10:759-760. 3.
Mississippi Department of Health (Nations, Walker, Varnado) References
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1. Barbour A. Does Lyme disease occur in the south? A survey of emerging tick-borne infections in the region. Am J Med Sci. 1996;311:34-40. 2. CDC. Southern Tick-associated Rash Illness. Centers for Disease Control and Prevention, http://www.cdc. gov/ncidod/dvbid/stari/index.htm; 2011. 3. Goddard J, Varela-Stokes A, Finley RW. Lyme-disease-like illnesses in the South. J Miss State Med Assoc. 2012;53(3):68-72. 4. Rudenko N, Golovchenko M, Clark KL, Oliver Jr JH, Grubhoffer L. Detection of Borrelia burgdorferi sensu stricto in Amblyomma americanum ticks in the southeastern United States: the case for selective compatibility. Emerg Microbes Infect. 2016;5:e48, doi:10.1038/emi.2016.1045. 5. CDC. Surveillance for Lyme disease- United States, 2008-2015. CDC, MMWR Surveillance Summaries. 66:113;2017. 6. Blanton L, Keith B, Brzezinski W. Southern tick-associated rash illness: erythema migrans is not always Lyme disease. South Med J. 2008;10:759-760. 7. Goddard J. Not all erythema migrans lesions are Lyme disease. Am J Med. 2016; Epub ahead of print, doi: 10.1016/j.amjmed. doi: 10.1016/j.amjmed. 8. Hojgaard A, Lukacik G, Piesman J. Detection of Borrelia burgdorferi, Anaplasma phagocytophilum, and Babesia microti, with two different multiplex PCR assays. Ticks Tick Borne Dis. 2014;5:349-351. 9. Korch GW, Jr. Pest Management Consultation, Camp Shelby, Mississippi. U.S. Army Environmental Hygiene Agency, Aberdeen Proving Ground, MD, Consultation No. 16-44-0519-91; 1991. 10. Goddard J, Sumner JW, Nicholson WL, Paddock CD, Shen J, Piesman J. Survey of ticks collected in Mississippi for Rickettsia, Ehrlichia, and Borrelia species. J Vector Ecol. 2003;28:184-189. 11. Goltz L, Varela-Stokes A, Goddard J. Survey of adult Ixodes scapularis for disease agents in Mississippi. J Vect Ecol. 2013;38:401-403.
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P O P U L A T I O N
H E A L T H
Prevention and Wellness: A Multi-Specialty Clinic Approach BRYAN N. BATSON, MD; JOHN M. FITZPATRICK, MD “An ounce of prevention is worth a pound of cure.” – Benjamin Franklin, 1735 While this United States founding father may have been referring to fire safety in Philadelphia and not the country’s health crisis, the axiom could not be any truer today when approaching the challenges of population health. Hattiesburg Clinic began our population health initiatives as part of a bigger journey toward value-based care delivery. From the outset, we believed that for a population health strategy to be truly effective, it must be rooted in preventative care. Background Hattiesburg Clinic’s Physician Quality Reporting System (PQRS) data from 2011 revealed that our organization was below the national 50th percentile on items such as influenza and pneumococcal vaccinations, breast and colon cancer screening, and depression and fall risk assessments. Most of these measures are largely felt best handled in the primary care setting. The predicament, however, was that our primary care physicians, like most in our state, were already overwhelmed by their volume of patients with acute needs and chronic disease management. To add dedicated time to focus on these important preventative care measures and screenings was felt to be a daunting task for these extremely busy physicians. The Hattiesburg Clinic was not unique in this challenge as many practices across the country struggled with trying to balance these different needs of patients in the face of physician shortage and decreasing reimbursement. The Centers for Medicare & Medicaid Services (CMS) acknowledged this challenge and sought to facilitate a path for primary care providers across the country to have dedicated, compensated time to focus on these preventative care metrics. In 2011, through the Affordable Care Act, CMS established the Annual Wellness Visit (AWV) as separate E&M codes with no patient copay – reimbursable at that time at $154.88 for the initial exam and $103.21 for subsequent yearly assessments – as a way to incentivize providers to devote time and effort toward improvement of wellness and preventative care. However, in 2014 only 15.6% of Medicare beneficiaries received an AWV.1 Data at Hattiesburg Clinic was even worse, with fewer than 5% of eligible patients receiving this service in 2014. The visit is quite prescriptive, requiring a clinician to complete a lengthy set of elements including vital signs, vision check, dementia
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and depression screenings, pain level and health risk assessment, and documenting activities of daily living as well as end-of-life care preferences. The majority of Hattiesburg Clinic physicians who attempted to implement this service into their practices cited that it was too cumbersome and time-consuming to perform correctly, and the enthusiasm for doing them waned quickly. A Change in Approach In building a population health strategy to address the deficiencies identified in the PQRS scores, we recognized that Annual Wellness Visits in the Medicare population addressed many of the quality measures including vaccinations, screenings, and preventative care. As just the first step in a much broader swath of quality improvement efforts through a newly-formed Quality Management Department in 2014, we built upon the successes of other organizations in the American Medical Group Association who were early adopters of nurse-administered AWV programs. We approached the project with a very deliberate expansion of the primary care provider’s care team with designated AWV Registered Nurses. The implementation of the program across 42 primary locations spanning 18 counties hinged upon several keys steps: 1. A full understanding of a complete, compliant AWV per CMS guidelines (source material was primarily from the Medicare Learning Network) 2. Adequate training of the staff who were going to be performing the visits 3. Education and buy-in of primary care providers rendering these services 4. Patient education and marketing efforts 5. EMR tools that helped standardize and streamline the documentation 6. An administrative structure to coordinate scheduling of patients and nurses and ongoing management and tracking of performance, compliance, and quality outcomes In regards to physician buy-in, this crucial piece was facilitated by regular meetings with them and providing data on the urgent need for quality improvement in the preventative care realm and the proposed plan for closing those gaps. As the program launched, real-time
The data above was convincing evidence that the wellness visits performed by a Quality Management experience and feedback were ingrained while providing the services an extension of themselves through the expansion of the care team Department nurse were far moreAWVs successful in addressing preventative in their offices. Furthermore, the nurse-performed were sent to surrounding them. care and wellness items. the supervising physician for review upon completion. This approach Simultaneously, the physicians were freed up to provide care to patients in need of more medicallyhad two important benefits: first, it ensured compliance with ‘incident Results to’ services, and secondly, it reminded the physicians the level of detail required tointense performservices. these visits correctly. As initial data regarding To date, the Annual Wellness nurses are still trained and managed the number of care gaps closed with these visits became available, centrally and deployed locally to the primary care locations where the physician endorsement for the service improved further. The they see patients five days a week. What began with two nurses physicians were further motivated by sharing in the profitability of charged with rotating throughout the satellite facilities has grown into performing these AWVs. a team of 13 dedicated Annual Wellness visits nurses. Primary care offices with three or more providers typically have enough patient Patient buy-in was also essential. Outreach marketing materials with volume to support a full time dedicated AWV nurse while other sites mailers and videos were prepared (naturally a needed piece), and have nurses rotating through their facilities. Initially, some physicians scripting for receptionists, billing staff and managers was productive. were reluctant to turn over this work to a nurse. However, as we began But by far the most significant element was ultimately physician to perform these visits under the Quality Management Department endorsement and explanation to their patients of the reasoning we provided regular feedback to the providers about the results of behind the was ‘extra’ visitevidence and the preventative care. We the visits, specifically when compared to patients who had either no The data above convincing that importance the wellness visitsof performed by a Quality Management undoubtedly had success with fliers and phone calls, but it was a rare Annual Wellness Visit performed on had it performed by a physician Department nurse were far more successful in addressing preventative care and wellness items. occurrence for a patient to decline the nurse-performed AWV when or nurse practitioner within Hattiesburg Clinic. Simultaneously, the physicians were freed up to provide care to patients in need of more medicallyit was encouraged by their primary care provider and explained as intense services. The data above was convincing evidence that the wellness visits As shown in the table, there was a greater than 10-fold increase AnnualManagement Wellness visits performed in were far performed by ainQuality Department nurse more successful in addressing preventative care and wellness items. 2015 compared to the prior 2 years. More import than the volumethe of visit increase theupcontinued Simultaneously, physicians werewas freed to provide care to patients in need of more medically-intense services. improvements in the closure of care gaps for wellness and preventative care across the Medicare As shown in the table, there was a greater than 10-fold increase in Annual Wellness visits performed in 2015 compared to the 5 prior As shown in the table, there was a greater than 10-fold increase in Annual Wellness visits performed in 2015 compared to the prior 2 years. More import than the volume of visit increase was the continued improvements in the closure of care gaps for wellness and preventative care across the Medicare
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two years. More important than the volume of visit increase were the continued improvements in the closure of care gaps for wellness and preventative care across the Medicare population. In a subset of this Medicare population, Hattiesburg Clinic has just over 20,000 patients in our Medicare Accountable Care Organization (ACO); in 2017 Hattiesburg Clinic’s team of nurses performed AWVs on over 58% of those ACO patients, totaling over 11,000 Annual Wellness Visits. This model has proven financially sustainable, and the downstream effects have made a significant impact in preventative care quality measures, moving us from below the 50th percentile to above the 90th percentile nationally in most categories. The improvements in the overall health of this population of patients cannot be overstated. From increases in early breast and colon cancer detection to discovery of abdominal aortic aneurysms to identification of depression and significant improvement in vaccination rates, there will be lasting results for years to come. This Medicare Annual Wellness Visit “pilot” project under the Quality Management Department was just Hattiesburg Clinic’s first step in our population health journey when it began in 2015 with two AWV nurses. It has spawned further expansion of the care team supporting our primary care providers in areas beyond wellness and prevention. The department is now also home to 13 Chronic Care Management (CCM) nurses charged with protocol-driven chronic disease management, two Transitional Care Management (TCM) nurses charged with reducing 30-day readmission rates, a social worker, and most recently nurse practitioners hired to help better manage nursing
home and home-bound patients. Furthermore, predictive analytics software allows us to identify “high cost, high need” patients and route these individuals to a more comprehensive care clinic to manage these patients more effectively. AWVs are just the entry point to a system-wide approach to addressing patients’ needs across the continuum of care. Ultimately, we cannot lay the entirety of patient care on the shoulders of physicians alone – we must expand the support system to ensure patients are getting the right care at the right place and time with the right provider, with everyone on the team operating at the top of their license. n Hattiesburg Clinic was founded by in 1963 by 10 physicians as a multi-specialty clinic, and it has grown to nearly 300 physicians and over 2,000 employees in 42 specialties and 68 locations. With a service area of 18 counties and a market area of over 525,000 patients and over 1 million outpatient visits per year, Hattiesburg Clinic’s mission as a group practice is to provide quality health care in an efficient and cost-effective manner, with emphasis on excellence and service to the patient.
Reference 1. McWilliams JM, Souza J, Ganguli I, Mehrotra A. Trends in use of the US Medicare Annual Wellness Visit, 2011-2014. JAMA. 2017; 317(21):2233-223. Author Information: Practicing Nephrologist and President of the Board of Directors. Hattiesburg Clinic (Fitzpatrick). Director of the Hypertension Center, Chief Medical Information Officer, and Medical Director over Quality Management and the organization’s Accountable Care Organizations (Batson). Corresponding Author: Bryan N. Batson, MD, Hattiesburg Clinic – Hypertension Center, 7 Medical Blvd., Hattiesburg, MS 39401.
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P O P U L A T I O N
H E A L T H
Economics of Population Health and Prevention: Is an Ounce Worth a Pound of Cure? THERESE L. HANNA, MHS
Introduction Much has been written in health literature about the relative position of the United States among the world’s industrialized countries from the standpoint of health care expenditures and health outcomes. Although spending almost twice as much as other countries on medical care, the United States ranks poorly on such population health outcomes as infant mortality, injury-related deaths, and life expectancy.1 While much of the difference in spending can be attributed to higher prices in the U.S., researchers note that a key contributing factor is disease prevalence.2 The United States, for example, has higher rates of obesity and concomitantly high prevalence of diabetes and other chronic illnesses. Within the United States, Mississippi stands out as having particularly elevated prevalence rates of obesity and chronic disease and high mortality due to unintentional injuries. Not surprisingly, Mississippi also ranks at the bottom for many of the behavioral risk factors contributing to poor health, such as low levels of physical activity and consumption of fruit and vegetables, and high rates of tobacco use.3 Economic Impact Disability associated with injuries and long-term chronic disease enacts a heavy toll in the form of high public cost for medical care and disability insurance payments, as well as for lost productivity and lower workforce participation. Examining both the expense of treatment and the indirect costs, the Milken Institute estimated the economic burden to the United States of five major chronic diseases (cancer, diabetes, heart disease, hypertension, and stroke) at $1.5 trillion for the period 2008-2010.4 The estimated economic burden in terms of medical costs and work loss related to injuries has been estimated at approximately $6.4 billion (in 2015 dollars).5 Chronic disease and injury cost employers as well through workers’ compensation claims, health insurance premiums, and lost productivity. One study attributed 22% of employer and employee medical expenditures to ten modifiable risk factors.6 Population-Based Interventions While direct medical care is needed to treat individuals for chronic
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disease and injury, behavioral risk factors must be addressed through public health and population-based interventions if widespread improvements are to be realized. Most of the gains in life expectancy achieved in the twentieth century have been attributed to public health interventions such as vaccinations, motor vehicle safety, infectious disease control, and food and water safety.7 Researchers examining more recent data on mortality trends for the years between 1969 and 2013 in the United States note that the overall drop in death rates for unintentional injuries is largely due to reductions in motor vehicle-related mortality and acknowledge the impact that smoking prevalence reductions have had on improved rates of deaths due to heart disease, stroke, and cancer.8 Evidence-Based Interventions A wide range of population-based interventions can be implemented to address any particular health issue. To ensure the investment in the intervention produces the desired economic benefit, it is best to replicate a strategy shown by evaluative research to be effective. One key resource is The Guide to Community Preventive Services of the Community Preventive Services Task Force (CPSTF). This Task Force was established by the United States Department of Health and Human Services to determine the effectiveness of communitybased health promotion and disease prevention programs. The CPSTF conducts systematic reviews of the evidence related to the level of effectiveness and economic impact of interventions and issues findings in the Community Guide, rating interventions as either Recommended, Insufficient Evidence, or Recommended Against. Interventions reviewed include those that can be implemented by health care providers, as well as those more commonly conducted by public health agencies. Where there is evidence on the economic impact, Task Force findings will include a section on the Summary of Economic Evidence, which provides guidance on how economic benefits can be maximized. For example, in reviewing school-based dental sealant programs, the Task Force notes that “Economic evidence indicates the benefits of school sealant programs exceed their costs when implemented in schools that have a large number of students at high risk for cavities.”9 Table 1 shows examples of ratings for interventions in the category of reducing excessive alcohol use.10
Table 1. Community Preventive Services Task Force Findings Regarding Interventions to Reduce Excessive Alcohol Use10
Tobacco As An Example The Community Guide recommends the implementation of smoke-free policies to reduce tobacco use and secondhand smoke exposure based on strong evidence of effectiveness and cites 11 studies supporting a positive economic impact from these policies.11 In Mississippi, researchers at Mississippi State University have documented reductions in hospital admissions for acute myocardial infarction (AMI) following enactment of local comprehensive smokefree ordinances. The controlled observational studies documented a 27.7% reduction for Starkville residents and a 13.4% reduction for Hattiesburg residents.12 These Mississippi findings are consistent with similar research worldwide documented in meta-analyses.13,14,15 Table 2 summarizes the reductions in AMI admissions found in studies from a variety of locations. Research also points to an association between smoke-free laws and reductions in preterm births and hospital admissions for asthma.16 The cost savings associated with lower AMI admissions for Starkville and Hattiesburg, Mississippi for the 2-3-year study periods were estimated to be approximately $288,270 and $2,367,909 respectively. Other studies involving larger populations have calculated savings as much as $6.9 million from the decrease in AMI admissions during the first year following implementation of a smoke-free law.17 Return On Investment Since interventions targeting behavioral risk factors such as smoking, poor nutrition, and low levels of physical activity can impact multiple chronic conditions, the return on investment can be substantial. One study projected that reducing the prevalence of diabetes and hypertension by 5% would save $9 billion nationally in the first two
Table 2. Reductions in Rates of Acute Myocardial Infarction Hospital Admissions Following Smoke-Free Laws by Study Location14
years, growing to $24.7 billion annually in 5 years. Under state-level estimates, Mississippi was estimated to save $92.3 million in the shortterm and $274.8 million in the longer term, with most of the savings accruing to private payers and Medicare.18 A positive return on investment can be measured not just in dollars saved because of reductions in expensive medical care but also in terms of positive impacts on economic growth due to a healthier population. Economists have estimated that a one-year improvement in life expectancy for a population can equate to a 4% increase in economic output, a result of not just increased labor productivity, but also the accumulation of capital.19 Mississippi’s State Economist
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has testified before the Joint Legislative Budget Committee that Mississippi’s lagging economy can be attributed to a “lack of human capital” resulting from low education levels and poor health.20 Several studies have documented an association between spending on public health and improvements in health outcomes, particularly at the local level. A study conducted at the University of Arkansas for Medical Sciences examined local public health spending over a thirteen-year period and found that mortality rates fell between 1.1 % and 6.9% for every 10% increase in local public health spending. Researchers noted that the strongest association between public health spending and mortality rates was found for infant mortality, cardiovascular disease, diabetes, and cancer. They estimated that a 10% increase in local public health spending could be expected to result in a 3.2% decrease in cardiovascular mortality.21 Another study found that an increase in local health department spending was significantly associated with a decrease in infectious disease morbidity, and an increase in local health department staffing per capita was significantly associated with a decrease in cardiovascular disease mortality.22 Research in North Carolina found reductions in infant mortality associated with increases in local health department staffing and prenatal services.23 Reluctance To Invest Despite a growing body of research documenting the benefits of investing in public health, only about 3% of the nation’s healthcare spending is directed to population-based interventions.24 This level of contribution is only a fraction of an ounce for every pound of cure. If investments in population-based strategies are so advantageous economically, why the reluctance by federal, state, and local policymakers to fund these services or by health care providers to adopt a more population-focused approach? Policymakers and health care executives are met with competing priorities when deciding how to spend their dollars, and so much of the savings to be found from investments in population health are long-term and rather nebulous. Researchers have also suggested that states with higher disease prevalence must spend more on direct medical care and, therefore, have less to spend on public health and social services to address the social determinants of health.25 Other researchers point out that the manner of implementation matters: resources must be targeted to interventions that have been proven effective and applied to the appropriate populations at risk. If communities are not effectively and efficiently directing their resources, they will not see the improved outcomes desired.26 Policymakers must have sufficient assurances that programs will be implemented in a way that will bring about a positive return on investment. As one economist noted, “Political will and institutional efficiency are more important than GDP in determining health.”27
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Conclusion High rates of chronic disease and disability have a strong negative economic impact on the United States – and Mississippi in particular. Evidence-based population health interventions provide cost effective methods to reduce disease prevalence, lessen the burden of expensive tertiary care, and improve the health of the population when appropriately targeted and implemented. Adoption of population health strategies has been slow, however, in large part due to reluctance to invest in longer-term solutions when immediate needs also require funding. Some population health strategies, such as clean air policies, require little funding to implement, but do require political will and capital for enactment. Vision and leadership are necessary to direct at least an ounce of resources toward evidence-based population health strategies that could produce economic and health status improvements for Mississippi. n References 1. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024–1039. doi:10.1001/ jama.2018.1150 2. Dieleman JL, Squires E, Bui AL, et al. Factors associated with increases in US health care spending, 1996-2013. JAMA. 2017;318(17):1668–1678. doi:10.1001/ jama.2017.15927 3. Key Health Data About Mississippi. Washington, DC: Trust for America’s Health; 2017. http://healthyamericans.org/states/?stateid=MS. Accessed April 10, 2018. 4. Chatterjee A, Kubendran S, King J, DeVol R. Checkup Time: Chronic Disease and Wellness in America. Santa Monica, CA. Milken Institute. http://www. milkeninstitute.org/publications/view/618. January 2014. Accessed April 10, 2018. 5. Kegler SR, Baldwin GT, Rudd RA, Ballesteros MF. Increases in United States life expectancy through reductions in injury-related death. Population Health Metrics. 2017;15:32. doi 10.1186/s12963-017-0150-4. 6. Goetzel RZ, Pei X, Tabrizi MJ, et al. Ten Modifiable Health Risk Factors Are Linked to More than One-Fifth of Employer-Employee Health Care Spending. Health Affairs. 2012;31(11):2474-2484. doi:10.1377/hlthaff.2011.0819. 7. Centers for Disease Control and Prevention. Ten Great Public Health Achievements – United States, 1900-1999. Morbidity and Mortality Weekly Report. 1999;48:241-3. 8. Ma J, Ward EM, Siegel RL, Jemal A. Temporal trends in mortality in the United States, 1969-2013. JAMA.2015;314(16):1731–1739. doi:10.1001/ jama.2015.12319 9. Dental Caries (Cavities): School-Based Dental Sealant Delivery Programs. The Community Guide. https://www.thecommunityguide.org/findings/dentalcaries-cavities-school-based-dental-sealant-delivery-programs. Accessed April 13, 2018. 10. Community Preventive Services Task Force: All Active Findings March 2018. The Community Guide. https://www.thecommunityguide.org/sites/default/files/ assets/All-Task-Force-Findings.pdf. Accessed April 16, 2018. 11. Tobacco Use and Secondhand Smoke Exposure: Smoke-Free Policies. The Community Guide. https://www.thecommunityguide.org/findings/tobaccouse-and-secondhand-smoke-exposure-smoke-free-policies. Accessed April 19, 2018. 12. McMillen R, Hill A, Valentine N, Collins R. The Starkville and Hattiesburg Heart Attack Studies: Reductions in Heart Attack Admissions Following the Implementation of Local Smoke-Free Ordinances. Starkville, MS. Mississippi State University. https://mstobaccodata.org/wp-content/uploads/2015/08/ HeartAttackReport_Oct10.pdf. October 2010. Accessed April 11, 2018. 13. Glantz SA. Meta-analysis of the effects of smokefree laws on acute myocardial infarction: An update. Prev Med. 2008;47(4);452-453. doi:10.1016/j. ypmed.2008.06.007.
14. Lightwood JM, Glantz S. Declines in acute myocardial infarction following smokefree laws and individual risk attributable to secondhand smoke. Circulation. 2009;120(14):1373-1379. doi:10.1161/CIRCULATIONAHA.109.870691. 15. TanCE,GlantzSA.AssociationBetweenSmoke-FreeLegislationand Hospitalizations for Cardiac, Cerebrovascular, and Respiratory Diseases: A Meta-Analysis. Circulation. 2012;126:2177-2183. doi:10.1161/CIRCULATIONAHA.112.121301. 16. Been JV, Nurmatov UB, Cox B, Nawrot TS, vanSchayck CP, Sheikh A. Effect of Smoke-Free Legislation on Perinatal and Child Health: A Systematic Review and Meta-Analysis. The Lancet. 2014;383(9928):1549-60. doi:10.1016/S01406736(14)60082-9. 17. TanCE,GlantzSA.AssociationBetweenSmoke-FreeLegislationandHospitalizations for Cardiac, Cerebrovascular, and Respiratory Diseases: A Meta-Analysis. Circulation. 2012;126:2177-2183. doi:10.1161/CIRCULATIONAHA.112.121301 18. Ormond BA, Spillman BC, Waidmann TA, Caswell KJ, Tereshchenko B. Potential National and State Medical Care Savings from Primary Disease Prevention. Am J Public Health. 2011;101(1):157-164. doi:10.2105/AJPH.2009.182287. 19. Bloom DE, Canning D, Sevilla J. The Effect of Health on Economic Growth: Theory and Evidence. Cambridge, MA. National Bureau of Economic Research. 2001. Working Paper 8587. 20. Harrison B. State Revenue Slowdown Unusual. Northeast Mississippi Daily Journal. November 6, 2017. http://www.djournal.com/news/state-revenue-slowdownunusual/article_400fa06f-944a-5437-8e85-ccfdf02acdad.html. Accessed April 17, 2018. 21. Mays GP, Smith SA. Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths. Health Affairs. 2011;30(8):1585-1593. doi:10.1377/hlthaff.2011.0196. 22. Erwin PC, Greene SB, Mays GP, Ricketts TC, Davis MV. The Association of Changes in Local Health Department Resources with Changes in State-Level
Health Outcomes. Am J Public Health. 2011;101(4):609-615. doi:10.2105/ AJPH.2009.177451. 23. Schenck AP, Meyer AM, Kuo TM, Cilenti D. Building the Evidence for DecisionMaking: The Relationship Between Local Public Health Capacity and Community Mortality. Am J Public Health. 2015;105(S2):S211-S216. doi:10.2105/ AJPH.2014.302500. 24. Lang A, Warren M. A Funding Crisis for Public Health and Safety: State-by-State Public Health Funding and Key Health Facts. Washington, DC. Trust for America’s Health. March 2018. 25. Bradley EH, Canavan M, Rogan E, et al. Variation in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health Care. Health Affairs. 2016;35(5):760-768. doi:10.1377/hlthaff.2015.0814. 26. Mays GP, Smith SA. Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths. Health Affairs. 2011;30(8):1585-1593. doi:10.1377/hlthaff.2011.0196. 27. Weil DN. Health and Economic Growth. In: Aghion P, Durlauf S, eds. Handbook of Economic Growth. Vol. 2B. United States: Elsevier; 2013: 623-682.
Author Information Ms. Hanna is the founding director of the Center for Mississippi Health Policy, an independent non-profit organization that provides research on and analysis of health policy issues in Mississippi. Corresponding Author: Therese Hanna, MHS; Executive Director, Center for Mississippi Health Policy, 120 North Congress Street, Suite 700, Jackson, MS 39201. (thanna@mshealthpolicy.com).
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Honoring the Lives and Legacies of our Fellow Physicians Dr. Alfio Rausa died on January 3, 2018, in Greenwood at the age of 81.
Dr. James E. Calloway died on March 28, 2018, in Louisville at the age of 93.
Dr. Rausa graduated from St. Michael's Medical Center. He was a Public Health and General Preventive Medicine Specialist and served as District III Health Officer for the MS Department of Health at the time of his retirement.
Dr. Calloway graduated from University of Tennnessee Medical School and practiced Family Medicine. He was a member of the AOA Honory Society; past president of East Mississippi Medical Society; member of James E. Calloway, MD Mississippi Academy of Family Physicians; Member of Southern Medical Association. Fellow of the American Academy of Family Practitioners; member of the AMA; preceptor in Family Medicine of the UMMC School of Medicine. He practiced in Louisville, MS, at the time of his retirement.
Alfio Rausa, MD
He was instrumental in the establishment and continued development of several Mississippi Delta health organizations, including moving Golden Age Nursing Home in Greenwood to a 180-bed modern brick facility, serving as part of a team that secured the funding to establish Life Help, a Greenwood based mental health center that serves a 12-county area, and serving as chairman of the board for the Fannie Lou Hamer Cancer Foundation in Ruleville. Dr. Rausa is survived by his wife Silvana, and two children. Dr. James Harvey Johnston died on February 11, 2018, at the age of 99. Dr. Johnston graduated from Tulane School of Medicine, New Orleans, LA. He practiced Surgery and was certified by American Board of Surgery and Board of Thoracic Surgery. He was a member of local, state, and national James H. Johnston, MD Medical Associations. He was a past President of Southeastern Surgical Association and Governor of the American College of Surgeons. He was also a Member of the Surgeon's Travel Club, Southern Surgical Assocation, American Society of Thoracic Surgeons, and International Society of Surgery. He established the Surgical Clinic PA and served as Clinical Professor of Surgery at UMMC. He was considered the “dean of Mississippi surgeons” for many years. Dr. Johnston was preceded in death by his parents; sister, Mrs. Edna Maie Ariail; and his beloved wife, Jane. He is survived by his four children: Ms. Jane C. Johnston and Dr. James H. Johnston, III (Elta) of Jackson; Dr. William E. Johnston (Lynn) of Belton, Texas; and Mrs. Elizabeth Johnston Beck (Tom) of Tallahassee. He is also survived by eight grandchildren, 15 great-grandchildren, and his sister, Mrs. Anita (Jack) Powell of Birmingham.
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He was honored by Mississippi Academy of Family Physicians as family physician of the year, 2014. Dr. Calloway was proceded in death by his parents, twin brother and first wife Marjorie Taylor Calloway. He is survived by his wife of 62 years, Edwina Kirkpatrick Calloway; three children: James Everett Calloway, III “Pepper”, Edwin Sand Calloway “Sandy” and Claudia Ann Perrier “Winkie”; 6 grandchildren: Nathaniel, Bess, Charles, Raymond, Will and Christopher and 3 great grandchildren: Eowyn, Ensley, and Loxley. Dr. Richmond Sharbrough died on March 10, 2018, in Vicksburg at the age of 87. Dr. Sharbrough graduated from UMMC and practiced Anesthesiology. He was a Fellow of the American Board of Anesthesiologists. He practiced at Mercy Hospital Street Clinic, Vicksburg, MS, until the time of his retirement.
Richmond Sharbrough, MD
Dr. Sharbrough is survived by his daughters, Susan Sharbrough Watson and her husband, Albert of Birmingham, AL, and Jacquelyn Bailey Sharbrough of Houston, TX; and their mother, Joan Bailey of Vicksburg. Also, his four grandchildren, Albert McDavid Watson Jr., Richmond Sharbrough Watson, (Susan’s children) and Graye Michael Taten and Skyler Lane Taten (Jackie’s children); and one great-granddaughter, Avery Elizabeth Watson. He also leaves his brother and sister-in -law, Dr. Frank Wilson and Lynda Sharbrough of Rochester, MN, and their children and grandchildren. His oldest daughter, Jo Ann Sharbrough, peacefully passed away after Richmond’s passing and her service was held jointly with his.
Dr. William R. Eure died on April 7, 2018, in Hattiesburg at the age of 87.
Medical Center, and Rush Foundation Hospital. He was a founding physician at the Meridian Surgery Center.
Dr. Eure graduated from UMMC and practiced Family Medicine. He was a Diplomate of American Board of Family Medicine and practiced in Bay Springs, MS, at the time of his retirement.
Dr. Billups is survived by his wife of 55 years, Linda Moss Billups; son Dr. William A. Billups, III (Mary) of Meridian, MS; daughter Carah Lynn Billups Arnold (Jay) of Huntsville, AL; brother Dr. Thomas Keener Billups (Judy) of Tupelo, MS; Cousin Dorothy Long Poole (Wain) of Memphis, TN; grandchildren Sarah Catherine Billups of Minneapolis, MN; Robert Billups of Cambridge, England; and Grace and Mary Adeline Arnold of Huntsville, AL.
William R. Eure, MD
He was instrumental in establishing Jasper General Hospital and served several times as Chief of Staff for the hospital. Dr. Eure is survived by his wife, Elaine Eure; son, Donald Craig Eure of Baton Rouge, LA; daughter, Janice Eure Hicks (John) of Meridian, MS; daughter-in-law Susana Eure of Brownsville, TX; 7 grandchildren and 4 great grandchildren. Dr. Willis Walker died on April 11, 2018, in Hattiesburg at the age of 92. Dr. Walker graduated from University of Tennessee College of Medicine Medical School and practiced General Surgery.
Dr. William Hall Preston, Jr. died on April 23, 2018, in Booneville at the age of 85. Dr. Preston, Jr. graduated from University Of Tennessee School Of Medicine in Memphis, TN. He practiced Obstetrics & Gynecology. He was a member of the American Board of Obstetrics and Gynecology, Fellow (FACOG) American William H. Preston, MD Congress of Obstetricians and Gynecologists. He practiced in Booneville, MS, at the time of his retirement.
He was one of the original staff members of the Willis Walker, MD Forrest General Hospital when it opened in 1954, and he practiced medicine as a general surgeon and general practitioner in Hattiesburg for 38 years.
Dr. Preston, Jr. is survived by his wife of 60 years, Jane Anderson Preston of Booneville, MS; son William Anderson Preston MD and wife Kimberly of Jackson, TN; brother John Preston and wife Sara of Farmington, NM; grandchildren William Anderson Preston Jr. and Abigail Paige Preston; several nieces, nephews, other relatives and a host of friends.
Dr. Walker is survived by his wife, Sharon Franklin Walker; his children: Dr. Linda Kyle Walker, Mrs. Laurie Walker Karstens, and Mrs. Sharon Elizabeth Walker Campbell, and 6 grandchildren.
Dr. Carl P. Bernet, Jr. died on May 19, 2018, in Greenwood at the age of 91.
Dr. William Alonzo Billups died on April 19, 2018, in Meridian at the age of 77.
Dr. Bernet, Jr. graduated from University of Cincinnati in Pediatrics. He practiced Pediatrics in Greenwood until his retirement.
Dr. Billups graduated from UMMC and practiced General Surgery. He was a member of the Mississippi State Medical Association, the East Mississippi Medical Society, and the Mississippi Thoracic Society. He was a William A. Billups, MD Fellow, American College of Surgeons; Fellow, Southeastern Surgical Congress; Fellow of the American College of Surgeons and a member of numerous other medical societies. He practiced general surgery in Meridian for 45 years until his retirement in 2017. He was a member of the Medical Arts Surgical Group and on the staff at Riley Memorial Hospital, Anderson Regional
Dr. Bernet, Jr. is survived by two sons; Carl P. Bernet, MD Christopher K. Bernet of Oxford, MS, Carl P. Bernet, III (Vicki) of Magnolia, TX; two daughters; Beth Hays of Madison, MS, Nan Bush (Daryl) of Greenwood, MS; seven grandchildren; Callie Moser (Joe) of Oxford, MS, Taylor Rivers Bush of Greenwood, MS, Heather Hays of Covington, LA, Kati Coates (Cody) of Calgary, Canada, Becca Huffine (Dale) of Katy, TX, Carl P. Bernet, IV (Christiana) of Denver, CO, Maggie Bernet of Durango, CO, four great grandchildren and very special friends, Cathy and Eddie Barnes and Thelma Hester. He was preceded in death by his wife, Janet Wright Bernet and two grandchildren, Christopher Alban Bernet and Lance Bush.
AUGUST • JOURNAL MSMA
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AY FARINHOLT-JONES, MD, FIRST FEMALE MEMBER OF MSMA – Our association was progressive in integrating women into its ranks and leadership. More than fifty years after the first female in the United States received a medical degree (Elizabeth Blackwell,1849), our MSMA admitted into its ranks in 1901 its first female member and the state’s first licensed female physician, May Farinholt-Jones, MD (1866-1940). A native of Virginia and a graduate of the Woman’s Medical College of Baltimore in 1897, Jones became the first woman to take and pass the state medical board examination. She specialized in student health medicine, becoming the physician for the all-female Mississippi State College for Women (now MUW) in Columbus and later Professor of Hygiene and Sanitation and resident physician for the Mississippi Normal College (now USM) at Hattiesburg in 1912. In 1919, she went to the Mississippi State Sanatorium for tuberculosis, where she finished out her career in 1929. This brilliant pioneer was embraced by our association, being asked to address members at annual session as well as to take on leadership roles. She delivered scientific lectures on subjects from typhoid fever to influenza. No doubt, she was a gifted mind and excellent physician. MSMA leaders recognized this brilliance, and our own MSMA would become one of the first state associations in the country to place one of their female members in a high office when in 1903, she was elected as second Vice President of the association, its third highest office. Dr. Farinholt-Jones, while serving at Mississippi Normal College, explored with her teaching students how to present effectively hygienic facts to children. The result was the popular children’s textbook “Keep-Well Stories for Little Folks,” first published in 1916, which was used in the primary schools of several states. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n – Lucius M. “Luke” Lampton, MD; JMSMA Editor
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Am I Going to Get a Shot? [Editor's Note: This month, we print a humorous poem by John D. McEachin, MD, FAAP, a Meridian pediatrician and the Journal’s unofficial poet laureate. “Am I going to get a shot?” is inspired by his long years in pediatric practice. He writes the editor that this poem, like many of his others, focuses on “some of the comical type events that occur in office practice – the humor of MD self-infliction and patient/family interpretation of instructions gone awry, plus various other incidents that added to the fun and zest of our medical interpersonal relations.” He adds: “Only harmless end results allow us to smile at those events which make private practice so delightful. In a pediatric practice, we had the bonus of child, parent, grandparent interactions which were at times both frustrating and hilarious. With infants and children, we were both informative and multi-lingual consultants.” For more of Dr. McEachin’s poetry, see past JMSMAs. Any physician is invited to submit poems for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] — Ed.
I heard commotion down the hall; Mother consoling little Scott. A constant query from his lips--“Am I going to get a shot?” I intruded to calm things down, And soon, Scott was holding my hand. “Am I going to get a shot?” No let up! His constant command!
C. C. was fever and sore throat! Mouth open! Now I’m “on the spot!” My eyes downcast, Scott’s gentle plea: “Am I going to get a shot?” No question, now! Scott’s got Strep Throat! I was sure hoping it was not! So, now it’s my turn to “fess up,” “Yes, son, you’re going to get a shot!”
We all entered an exam room, Plopped this ten-year-old on a cot— Still ringing in our ears, this plea: “Am I going to get a shot?” “Scott. Let me check you over, son. I don’t even know what you’ve “got!” He was still! He was compliant! “Am I going to get a shot?”
I pressed Scott’s arms close to his chest. Surprise! He relaxed! Not a peep! “Shot is coming!” His calm request, “Doctor, could you put me to sleep?”
— John D. McEachin, MD Meridian
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Welcoming Our Newest Members
ALLEN, WILLIAM, Greenwood, Emergency Medicine
KUSEMIJU, OLADIPO, Picayune, Family Medicine
BARBA, JOSE, Natchez, Radiation Oncology
LAWTON, BRIAN, McComb, Otolaryngology
BELL, KEISHA, Jackson, Obstetrics & Gynecology
PENDERGRASS, DESIREE, Jackson, Preventive Medicine
BORCHELT, MARK, Gulfport, Endocrinology
PENDERGRASS, PETER, Jackson, Preventive Medicine
CARTER, CORY, Pascagoula, Internal Medicine
SAUL, KENNETH, Meridian, Dermatology
GRANT, JALARNA, Mound Bayou, Obstetrics & Gynecology
TWYNER, CHANNING, Jackson, Anesthesiology
HARDEN, JEFFREY, Greenwood, Emergency Medicine
WALKER, EVELYN, Ridgeland, Family Medicine
MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com
About the Cover (Continued from page 329) Pictured are (L to R) the late Aaron Shirley, the late Dr. Albert Britton, Dr. Helen Barnes, Dr. Robert Smith and Dr. James Anderson (seated). Their courageous efforts to identify and address the social determinants of health in Mississippi, even before their importance was scientifically documented, have been recognized by professional and social justice organizations worldwide. Some of the details of their work have been reported in books, articles in this Journal, and are expanded now in a new book, The Racial Divide in American Medicine (University Press of Mississippi, 2018). This photo, from the book, is provided to the JMSMA courtesy of the well-known Mississippi African American photographer, Jay D. Johnson. n
388 VOL. 59 • NO. 8 • 2018
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