A Synod to Walk Together

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Hispanic Heritage Month: Everyone's Responsibility

 

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The underbelly of health care in America—and an answer

The New York Times’s recent coverage of the state of health care in the United States paints a very discouraging picture. Despite all the money going to health care in the country—which outspends other developed nations in spending on health care per capita—the US has a sorry record. In fact, Americans rank among the least healthy compared to other rich countries; they are also in a cohort that is most likely to die early. 

For example, life expectancy in Mississippi, which stands at 71.9, has fallen below the life expectancy in Bangladesh (72.4). An infant in the US is close to 70 percent more likely to die in the US compared to other wealthy nations. And for the first time in what might be a century, the likelihood that an American child will live to age 20 has diminished. Newborns in India, Rwanda, and Venezuela have a longer life expectancy than Native American newborns in the US. The life expectancy of a Native American adult male, at 61.5, is below that of the life expectancy in Haiti.

The so-called “healthy life expectancy—the years someone lives without suffering severe medical problems, like amputations, dialysis, or blindness—is 66.1 in the US, which is lower than that figure in Turkey, Sri Lanka, Peru, and Thailand, as well as other countries, all significantly poorer than the US.

The most gruesome statistic shows the US to be the “global leader in avoidable amputations,” resulting from grave shortcomings in the care and management of diabetes. These preventable amputations writes The Times, “are the most heart-rending symbol of America’s failure in health care. Patients fail to obtain blood sugar management, which leads to diminished circulation and diabetic wounds on the foot that can lead to amputation, first of the toes and next of the legs, both below and above the knee.

A patient whose leg is amputated above the knee generally dies within five years. Some 150,000 amputations are performed each year, of a toe, foot, or leg. The neglect of diabetes and other preventable conditions is really hurting Americans of all ages. The hardest hit are men with little education and low incomes, especially people of color. The poorest men in the US have life expectancies comparable to those of men in Sudan and Pakistan.

By contrast, the wealthiest men in the US live longer than the average male in any country, a Harvard study has found.

Being poor and having little education, makes Americans very likely to suffer from multiple conditions, in addition to diabetes, including hypertension, arthritis, and heart disease. The Times pins an important part of the blame on soda and -fast food companies, marketing their sugary and rich-in-fat products primarily to the underserved, people who struggle to get by, often lacking health insurance and relying on cheap fried food and sugary drinks. As it stands, 28 million Americans lack health insurance.  

Researchers have found that an estimated 183,000 Americans die each year because of poverty—far more than the number of homicides. Part of the solution must focus on overcoming “intergenerational poverty and despair,” which cries out for improvement in education, job training, pay, and opportunities for self-betterment. What would also hold promise is promoting diversity among health workers. It has been shown that Black patients do better with Black doctors.

Ethnic affinity is one of the keys to the success of SOMOS, a network of 2,500 doctors—most of them primary care physicians—in New York City. They provide some one million of the poorest and most vulnerable Medicaid recipients in the inner-city with quality care. Most patients are African American, Asian American, and Hispanic. Many of their doctors share an ethnic and cultural background with their patients, in whose communities they live and work. That shared identity contributes to the bond between patient and doctor.

That bond is also strengthened by the fact that SOMOS doctors have comprehensive knowledge of their patients’ needs. Community Health Workers are the doctors’ eyes and ears, as they are kept informed about patients’ family situations. These include awareness of social conditions, the so-called Social Determinants of health, such as housing conditions, poverty, or educational issues. Such social conditions can play a critical role in patients’ physical and mental health.

Patients also greatly value the fact that the doctor has a real sense of their circumstances, which is the foundation of a relationship of trust. This is how SOMOS delivers superior care to a population that has traditionally suffered from poor or mediocre care.

SOMOS doctors adhere to high standards in their practice. They have embraced a formula called Value-Based Care (VBC), which stipulates that doctors are compensated in accordance with the health of their patients. The better the patients’ health in the longer term, the greater the financial incentive for the doctor.

SOMOS's success was dramatically demonstrated by SOMOS’s ability to reduce by 25 percent both preventable visits to the ER and unnecessary hospitalizations. In the process, SOMOS saved

New York State taxpayers $330M. VBC clearly demonstrates that care for the underserved can be both excellent and cost-effective—an antidote to poverty being an obstacle to quality health care.

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There is a solution for Medicaid fraud—innovation

In 2020, Medicaid fraud was estimated to be close to $86.5M. It is a staggering figure burdening taxpayer. And clearly, more needs to be done to remedy a situation where fraud is so pervasively present in a program that cares for the most vulnerable patients.

The FBI lists several main types of fraud: double billing, submitting multiple claims for the same service; phantom billing, billing for a service visit or supplies that the patient never received; unbundling, submitting multiple bills for the same service, or charging more for a service that is usually part of a package; upcoding, billing for a more expensive service than the patient actually received; and over-billing, charging the government for medically unnecessary drugs, procedures, or drugs.

Medicaid patients are particularly vulnerable to physicians' fraudulent practices, as they have no easy access to their medical records. For example, a doctor might falsify or exaggerate a diagnosis to facilitate over-billing. The patient may be subject to unnecessary or unsafe medical procedures. 

They are also vulnerable to individuals asking for their insurance identification number and other personal information to bill for non-rendered services. Or their identity may be stolen, and they would find themselves enrolled in a fake benefit plan. 

To battle rampant Medicaid fraud, a new healthcare delivery model holds great promise: Value-Based Care (VBC). The VBC formula stipulates that doctors get compensated according to the longer-term well-being of their patients. The healthier the patients, the greater the compensation for the doctor. In sum, doctors are encouraged and put in a position to do their very best for the people under their care.

The model, as instituted by the New York Department of Health in 2014, was called Delivery System Incentive Payment Program (DSIRP). It provided for an iron-clad protocol that would make fraudulent practices pretty much impossible. Its success is exemplified by the achievements of SOMOS, a network of 2,500 inner-city physicians caring for some 1 million of New York City's most vulnerable Medicaid patients, mostly Hispanics, African Americans, and Asian Americans. 

To make the VBC model work, doctors must carefully maintain patients' Electronic Health Records (EHR), which would periodically be sent to the Department of Health for assessment. That is when it is determined if the patient population is showing signs of enduring health, which in turn governs the doctor's compensation level. Maintaining the EHRs is a job for both doctors and their staff. Fraudulent records would be readily flagged.

Record-keeping also plays a role in Patient-Centered Medical Homes (PCMH). SOMOS staff works with medical practices to turn them into a one-stop portal where a patient's entire care history is recorded, allowing the doctor to keep track of which services a patient receives, be they medical, behavioral, or social. The social refers to doctors keeping track of patients' social issues that may impact their health, such as substandard housing, unemployment, and poverty. Again, a careful electronic portrait of the patient is maintained, with both doctor and staff doing the record-keeping. Fraudulent entries would quickly be spotted.

Now, doctors prone to committing fraud would be ill at ease being part of VBC, even though such physicians would see their income increase, a factor that prompts their criminal behavior. Ideally, VBC would make honest men and women of them. However, it is hard to picture a less-than-ethical doctor in the SOMOS VBC system, which revolves around a close patient-doctor relationship. That bond is created as physicians earn the patients' trust by getting to really know them, their families, and their circumstances. For much of that intimate detail, SOMOS doctors rely on Community Health Workers as their eyes and ears in the community. Given the stature of SOMOS doctors, it is difficult to imagine fraud-prone physicians, with far less than adequate concern for the well-being of their patients, earning such a position of trust.

Above and beyond traditional Medicaid's vulnerability to fraud and waste, there is a relatively poor record of delivering health care to the most vulnerable. Needy patients, people of color among them, often have a difficult time gaining access to the care they need, given the labyrinthine network of doctors to whom, on paper, they have access. A famous Oregon study (conducted in 2009/2010) found that people with Medicaid coverage showed no significant positive effect on major medical conditions—including hypertension, diabetes, and high cholesterol—compared to those without coverage.

SOMOS saved US taxpayers $330M by reducing by 25 percent both unnecessary visits to the emergency room and unnecessary and costly hospitalization. That is the fruit of Value-Based Care. It is high time for traditional Medicaid to be dismantled and for VBC to be rolled out system-wide. Doctors, patients, and taxpayers stand to benefit greatly.

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SOMOS: May we be like the sandalwood tree…

Since its very beginnings, SOMOS Community Care was founded and has developed as an organization with the mission to create and cultivate a collaborative network of primary care physicians and their clinics. Our goal is to implement an innovative and revitalized model of healthcare that prioritizes the needs of our community’s most vulnerable and underprivileged individuals, focusing especially on migrants in New York City.

The highest moral principles inspire us in our pursuit of the common good and we dedicate ourselves to the health and well-being of those we serve. Strong ethical values guide our healthcare organization in the interpersonal relationships we form within the company as well as in how we manage all economic and administrative aspects of our operations.

Our doctors focus on primary and family healthcare with a preventive approach and aim to relieve the strain faced by hospitals. We do this by championing a model where hospital institutions attend to patients with the most urgent and prioritized needs.

Through the years, we can trace the success of our healthcare services, as I have said, to the integration of hundreds of physicians and their clinics, as well as the government funding we have secured through the DSRIP program for state healthcare system reforms. We have been awarded this funding based on our exceptional results and competencies, which allows us to continue developing our mission and vision already detailed above. These results include reductions in the statistics that track stress on hospital emergency systems and reductions in rates of unnecessary hospitalizations.

Our healthcare model emphasizes prevention over treatment, and, as much as possible, healthcare is delivered in the patient’s respective culture, customs, and language by physicians who are immigrants themselves. This model not only enhances the MEDICAID system, but it also reveals, let’s not forget, the difficulties that our organization’s work may face with the traditional hospital system, because, due to a lack of prior, personalized, and preventive care, large numbers of patients who do not need emergency services, or even hospital services at all, attend these facilities.

As the CEO of SOMOS, I can attest to the ethical standards, transparency, and honesty with which we manage our financial resources, the code of ethics that exists at the very heart of our organization, and the desire and spirit that drives us to continually improve our service to the health and well-being of all, particularly the most at-risk members of our city.

 We strive to ensure that all professional services contracted for the development or promotion of SOMOS are executed and compensated accordingly. Likewise, we also strive to guarantee that the healthcare services our network of affiliated physicians provides bear the hallmark of scientific excellence, efficiency, timeliness, and solidarity that the invaluable nature of healthcare demands.

At SOMOS, we are committed to promoting the highest and noblest values of the human spirit both within and outside our organization. We have fostered collaborative, non-denominational partnerships with various religious institutions, including Catholic, Muslim, Jewish, and Protestant denominations.

Our shared pursuit of the common good and the provision of healthcare, as integral values that support individuals, families, and society, has brought us together with these religious organizations. We have supported each other, especially during the pandemic, by utilizing their places of worship to facilitate health campaigns within their communities.

This collaborative work with religious communities has allowed us to personally connect with and draw inspiration from spiritual leaders such as Pope Francis, who continues to inspire us and all of humanity.

The prestige that SOMOS has earned with the passage of time can be traced to the vital healthcare services we have provided to our city, particularly during the COVID-19 pandemic. Also, our humanistic vision and solidarity with those who suffer the most have driven us to extend our services, focused attention, and targeted assistance to communities experiencing catastrophes and emergencies in Haiti, Cuba, the Dominican Republic, Puerto Rico, and beyond.

We aspire to continue to be an increasingly recognized and sought-after healthcare organization. We aim to expand and enhance our services over time, and to achieve this, we hope to continue relying on local, state, and national government support that aligns with our accomplishments, competencies, and workforce contributions.

Neither individuals nor institutions are immune to the challenges of competition, power dynamics, economic fluctuations, and political turbulence that are intrinsic to every society. At SOMOS, we see ourselves as a vital and dynamic component of the social fabric, embracing the risks associated with being an active and productive entity within society. We appeal to the trust of all in our vision and commitment to healthcare as we continue to grow and thrive.

Acknowledging the difficulties that all of us may encounter, individuals and organizations alike, be they due to internal or external causes, we, at SOMOS, strive to be, in the words of Nobel Laureate Rabindranath Tagore, like the sandalwood tree that perfumes the very axe of the woodcutter that lays it low.

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A BETTER KIND OF POLITICS

I appreciate this invitation to participate in this Seminar of Catholic Leaders.

I have been asked to share with you some reflections on THE CULTURE OF ENCOUNTER AND CIVIC FRIENDSHIP from the Magisterium of Pope Francis, and what these categories and doctrines pose – as challenges – for the life and political participation of Hispanic Catholics of this Nation.

In his Petrine Magisterium, and especially in the Encyclical Fratelli Tutti of October 3, 2020, Pope Francis invites us to build a better world through the fraternal coexistence to which Jesus of Nazareth invites us all in his Gospel. He exhorts us to make possible better relationships and communities through civic, citizen, or social friendship; friendships that make possible the “culture of encounter.” The “civic friendship” and the “culture of encounter” are two categories that are not the doctrinal or ideological property of Christianity or anyone else. Rather, they are the heritage of all humanity.

The “culture of encounter” assumes, in individuals, “civic virtue,” which traces its roots to the philosophy and teaching of great Greek philosophers such as Plato and Aristotle (especially in his Nicomachean Ethics). It assumes civic virtue and all that it implies in terms of civic and social life, which entails a form of citizen ethics, a normativity that regulates our indispensable and necessary social coexistence. It assumes a civic virtue that, if practiced among citizens, can strengthen civic or social friendship and, with it, enable a “culture of encounter” as an ideal for human coexistence. We can achieve an understanding that civic virtue is a motivation to act as the good that society requires of us, where self-interest does not take precedence over that which is good. Thus, selfish motivation cannot be virtuous in any case https://www.scielo.org.mx/scielo).

Civic, citizen, or social friendship does not consist of the good manners of civility that we must observe in personal and social relations. Rather, it deals with the relationships that should occur among citizens in the pursuit of the common good. This means that, regardless of our particular interests or our political, religious, etc., differences, there are – in social life – issues (education, health, etc.) where we must all put our best effort in the pursuit of the general social good.

Therefore, civic friendship, while demanding respect for individual human rights, is located at a level of higher interests and rights, which concerns the pursuit of the well-being of all. Civic friendship thus becomes the condition we need for Aristotelian “peaceful and social concord,” because friends watch over the good of all friends.

Pope Francis, “acknowledging the dignity of each human person,” earnestly hopes that “we can contribute to the rebirth of a universal aspiration to fraternity… as a single human family, as fellow travelers sharing the same flesh, as children of the same earth which is our common home…” (FT 8). He hopes that we can contribute to a universal fraternity that is “without borders,” which must be built – and precisely for this reason – amidst “shattered dreams,” “insufficiently universal human rights,” or “conflict and fear,” “globalization and progress without a shared roadmap,” amidst “dark clouds over a closed world,” pandemics and other scourges of history, etc.

Universal fraternity – according to Pope Francis – opens us to the hope to “engender an open world,” having love as its only value, in societies where everyone is integrated, with a solidary and universal love, which promotes people and “rights without borders,” as long as men and women discover the concept of giving freely in everyday life, with “a heart open to the whole world,” to all humanity.

With these assumptions, Pope Francis builds his doctrine of “a better kind of politics,” affirming that “the development of a global community of fraternity based on the practice of social friendship on the part of peoples and nations calls for a better kind of politics, one truly at the service of the common good. Sadly, politics today often takes forms that hinder progress towards a different world.” (FT 154)

We must build this kind of politics upon the foundation of “political love,” and it must be effective, one that integrates and joins us together, through kindness and the pleasure of recognizing the “other.” It is through social dialogue, truth and consensus that we will make possible – in social friendship – the emergence of a new culture: the culture of encounter.

We understand “culture” through Francis’ definition: “something deeply embedded within a people, its most cherished convictions, and its way of life. A people’s “culture” is more than an abstract idea. It has to do with their desires, their interests and ultimately the way they live their lives.” (FT 216)

So, “to speak of a “culture of encounter” means that we, as a people, should be passionate about meeting others, seeking points of contact, building bridges, and planning a project that includes everyone. This becomes an aspiration and a style of life. The subject of this culture is the people, not simply one part of society that would pacify the rest with the help of professional and media resources.” (FT 216)

“A better kind of politics,” “social friendship” and a “culture of encounter,” in the vision of Pope Francis, have as their ultimate purpose the construction of peace or the reign of God (in biblical theology) through forgiveness, as an expression of universal and evangelical love; a task that all religions in the world have to serve. (FT Ch. 8) Because “in many parts of the world, there is a need for paths of peace to heal open wounds. There is also a need for peacemakers, men and women prepared to work boldly and creatively to initiate processes of healing and renewed encounter.” (FT 225)

This dream, this longing of Pope Francis contains many implications for our daily life as citizens and, therefore, for our life and political participation, in the broadest Greek sense of the meaning of the term “politics,” as a search for the common good of the “polis,” of the city and of all citizens in it.

Thus, civic life as an exercise of politics or the exercise of politics as a partisan professional choice and electoral and governmental tasks is not, first of all, a matter of laws but of ethical coexistence, that is, of coexistence that seeks – through the gift of friendship among men – the good of all.

Politics is not an exercise in publicity, untruthful speeches, or the search for privileges and particular interests. Politics is, above all, a daily exercise of shared values and common interests in the search for the common good, especially those most in need of the polis, of society.

Every day, the news tells us that joint efforts benefit us all, but that the exercise of individualistic, selfish politics, full of ambitions for power and profit, leads also to social ruin.

The exercise of daily politics, with our deeds, words, and citizen attitudes, or the professional exercise in socio-political leadership makes us sink or swim together, because we are deeply interconnected and share responsibility both in good and in evil.

Today, unfortunately, especially in the professional and partisan exercise of politics, the concept of friendship is associated with that of complicity in corruption in the management and administration of public affairs.

But selfishness and individualism in the public sphere and political corruption due to the absence of “social friendship” and fraternal and universal sense in civic life, are undermining democratic institutions and generating “social discord,” which translates into tragic forms of violence, injustice, inequality, and death.

Ladies and Gentlemen, you are leaders in different areas of life in society. You are leaders of the Hispanic community present in this Nation.  

You are called to organize, guide, and lead people in your Hispanic professional and community environments in building social friendship for the culture of encounter, a “better kind of politics,” and social peace.

You are charged with forming, educating, and leading our Hispanic communities for the daily exercise of citizenship for the benefit of all and for the best causes.

You have the capacity and responsibility to “give freely what you have received freely,” to build the world of which Francis dreams and of which we all dream: a world in universal fraternity and with an abundance of life for all.

A world in which we all respect our rights and fulfill our duties.

A world in which we go from being anonymous individuals aggregated socially or partners and competitors to recognizing ourselves as brothers and sisters with a common destiny, in a common home.

A world in which, as disciples of Christ, and through the commandment of love, we all live together as brothers, children of the same Father.

We all share a responsibility in creating, for present and future generations of Hispanics in the United States, better and greater citizen and political participation and, with it, better lives and a better Nation.***

Thank you very much!

***The words and phrases in quotation marks are from FRANCIS, in his Encyclical Fratelli Tutti.

Mario J. Paredes is a member of the Board of Directors of the Latin American Academy of Catholic Leaders.

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Value-Based Care holds promise to transform healthcare— especially for the underserved

By 2030, the Centers for Medicare and Medicaid Services plans to see all Medicare beneficiaries and most Medicaid beneficiaries enrolled in Value-Based Payment (VBP) or Value-Based Care (VBC) programs. Simply put, VBC links the compensation of healthcare providers to patients’ health outcomes in the longer run. The formula holds doctors more accountable for improving the well-being of the people under their care and provides them with sufficient freedom and incentive to deliver the right care at the right time.

VBC is a remedy for the pitfalls of the traditional fee-for-service system. Fee-for-service means doctors and hospitals are compensated for each service they deliver; they are rewarded for volume—they are paid more if they deliver more services, even if these do not achieve the desired result. VBC changes that dynamic by incentivizing the provision of quality care for the good of the patient—bringing costs down in the process.

VBC also offers a solution for the troubled state of healthcare in the US. The country spends a greater percentage of its GDP on healthcare than other countries. Yet, the US sees the highest incidence of preventable deaths and has the highest infant mortality rate. What’s more, longstanding inequality of access to healthcare leaves people of color and the underserved more vulnerable to illness and disease than the rest of the population. VBC promises to revolutionize healthcare for the most vulnerable.

VBC produced significant savings for taxpayers, as better health keeps people out of ERs and costly hospital beds, and all along, doctors are rewarded for doing a better job. The latter depends to a large degree on the coordination of a patient’s care; that means a primary care physician keeps close track of all the services a patient is getting or needs. This includes medical care as well as behavioral health services. Significantly, doctors are also encouraged and rewarded for being aware of patients’ social needs. Such needs would never be attended to in the fee-for-service model.

Quality of care in the VBC is driven by key dimensions, including efficiency, meaning doctors only use resources that are needed; equity in care stipulates that quality of care does not vary based on race, gender, or income; care is centered on the patient and respects values, preferences, and particular needs; and timeliness means care is given without lengthy delays.

VBC models feature different approaches to doctors’ risks. There is an upside-only risk, with doctors getting more revenue if meet or exceed standards when it comes to quality, cost, or equity. A two-sided risk means doctors also stand to lose revenue if they fail to achieve specific measurements of success. This formula is believed to discourage risk-averse doctors from joining VBC programs.

There are also non-financial rewards for doctors who join VBC programs. The freedom to deliver the right aid at the right time can give providers a sense of purpose and mission. Participation in VBC also enhances a doctor’s reputation.

There is growing interest in VBC models on the part of the commercial healthcare sector. It seems clear the significant growth of the model will require that VBC models become more accessible and offer greater incentives, especially for those providers serving disadvantaged populations. Overall, more research is needed to determine the impact of VBC models on patients, doctors, and the healthcare system at large.

There is a success story in New York City, where SOMOS, a network of 2,500 doctors—most of them primary care providers—is serving some one million of the city’s most needy Medicaid patients. Caring for Hispanics, African Americans, and Asian Americans, the organization has been developing a VBC program since 2014, when it joined New York State’s Delivery System Reform Incentive Payment (DSRIP) program—one of the country’s first such programs.

SOMOS puts its doctors in the optimal position to deliver superior care to their patients. Thanks to the work of Community Health Workers—who visit patients’ homes to remind patients to keep medical appointments—doctors learn of the social circumstances of the patients’ households. These are the Social Determinants of Health. For example, mold in subpar housing may impact physical as well as mental health, while poverty can mean that there are no means to buy fresh and healthy foods.

SOMOS transforms doctors’ practices into Patient-Centered Medical Homes, a gateway to all the care needed for patients, with staff keeping close track of, for example, care given by specialists and its contribution to the patient’s overall health. SOMOS doctors bring another dimension to the job: in many cases, they share a cultural and ethnic background with their patients in whose communities they live and work. Their intimate knowledge of their patients’ health needs and their personal circumstances make doctors into trusted figures and leaders of their communities. This dimension is key to SOMOS’s VBC success. That success translated into savings of $330M through a reduction of 25 percent in the number of ER visits and the number of unnecessary hospitalizations.

There is no doubt that the transformation of US healthcare—especially for the neediest Americans—will require the adoption and embrace of VBC programs. Both doctors and patients are the better for it.