Intro: The following SHSMD Podcast is a production of DoctorPodcasting.com.

Bill Klaproth (Host): On this edition of the SHSMD Podcast, we talk about the blending of public health and population health with Dr. David Ansell from Rush University Medical Center in Chicago. He has written an article called The Future of Population and Public Health that will be featured in Futurescan 2024. It is really an important interview as we talk about how population health can really help lift up our impoverished and underserved communities. So, it's an insightful interview, it's impactful. And hopefully, it will move you to action. So, let us not delay. Let's get to it right now.

Host: This is the SHSMD Podcast, rapid insights for healthcare strategy professionals in planning, business development, marketing, communications and public relations. I'm your host, Bill Klaproth. And in this episode, we talk with Dr. David Ansell, a Michael E. Kelly Presidential Professor of Internal Medicine and Senior Vice President Associate Provost for Community Health Equity at Rush University Medical Center. He has written an article called The Future of Population and Public Health. It will be featured in Futurescan 2024. Dr. Ansell, it's a pleasure to have you. Thanks for being on the SHSMD Podcast.

Dr. David Ansell: Thank you, Bill. I'm pleased to be here.

Host: Yeah. We're going to talk about your article, The Future of Population and Public Health, that will be featured in length in the 2024 edition of Futurescan. So, let me start with this. How is the field of population health management evolving?

Dr. David Ansell: Well, let's just say it is evolving. But there's different definitions of population health. And a lot of people think of population health as the patients who are insured within a given insurance product that a health system is taking care of. But we think about it more broadly as all the people who live in our region or our neighborhood who might touch us, but might touch other health systems as well. When you're looking at it through an insurance lens, that's one approach. When you're looking at it through a community health lens, that requires you to think of different approaches to improving population health.

Host: So, it sounds like public health and population health are blending.

Dr. David Ansell: Yes. And I think if you look at the COVID pandemic, you could see based on our outcomes how difficult it was and, as a country, how poorly we did. Over a million dead more than in all the wars US has fought in. But what was pointed out is that those people who have been historically most marginalized, the impact of things like poverty, who's an essential worker or not, and even structural racism, determined life and death and more people died in the United States than had to. Had we been Canada, it would be half the amount of deaths. And had we been Australia, it would've been about 10% of the deaths. So, we certainly didn't fare well during that public health emergency with regard to public health. And it's because we haven't integrated well the delivery system, public health departments and those community organizations that are so important in the day-to-day life of populations.

Host: So, you used the word integrating. So, how are hospitals and health systems integrating their understanding of the larger picture of the community's health into their population health strategies?

Dr. David Ansell: Well, it's an evolving story and evolving more now because both CMS, the Centers for Medicare and Medicaid Services, and the Joint Commission have begun to set regulations that are asking health systems and clinics to begin to do this kind of integration across the clinical mission and the community missions of health systems and hospitals.

Host: So, do you have an example of a hospital or health system that is doing a good job of integrating their population health strategy?

Dr. David Ansell: Like I said, it's an evolving picture across the country. But let me talk about what we are doing. And I'll just give you an example from the pandemic, because I think it's most illustrative, but we're doing it post-pandemic. So on the one hand, you have these different insurance products with people who are signed up to see you or not. On the other hand, you get a global pandemic that requires you to respond. And from a population health perspective during the pandemic, we opened up our ICUs to patients in the safety nets in Chicago and took the sickest patients transferred in the most advanced treatments. And we found out that we had no racial or ethnic gaps in mortality at Rush. And that didn't matter whether you were directly admitted or transferred in. And we had up to about a thousand transfers in and the outcomes were just equal by race, ethnicity and gender as were directly admitted patients. And we had no racial gaps in mortality. And we were one of the highest volume COVID institutions in the state of Illinois, if not the highest, with one of the best outcomes in the United States.

So from a population health perspective, we could demonstrate that if people got great care, we could eliminate some of these racial and ethnic gaps and outcomes. And at the same time, we moved in in the community setting with others, many others, to provide care for people experiencing homelessness in other congregate settings through care delivery, testing and vaccination, partnered with the City Department of Public Health. And so, that sort of population health marriage or integration with a health system is I think the new frontier of where population health needs to go. It can't just reside in who's insured under an umbrella of a system, though that's critically important that we deliver that great care to everyone who's coming into the institution every day. But we also have to deliver it more broadly out to the community to touch those people who may not have the same access to care.

Host: So, you mentioned insurance. How do we get around that then?

Dr. David Ansell: Well, it's not so easy. You know, we have an insurance system in the United States that doesn't reward health equity. The best example I can give you during the pandemic, after taking care of all of these patients, we quickly lost about a quarter of a billion dollars, which is because there are many uninsured or poorly insured patients who were sick with COVID. But I think increasingly, the insurance companies are being forced to do more around health-related social needs, meaning someone needs housing, having insurance pay for housing, if someone needs food as a social need to have that happen, it's not happened fast enough or quickly enough. But that's what has to happen because many of people are getting sick, not because of just the lack of medical care, access to medical care, but the problems with accessing their social needs or health-related social needs or structural community conditions that health systems can make it different with, and that's where the anchor mission of Rush and many other institutions across the United States come into play.

So, the insurance industry isn't quite there yet. We're not in a place where, for example, community health workers who can make such a big difference in the lives of patients, folks who come from the community, who help navigate people into care are being funded by the insurance companies. But the hope is in the future that will get better aligned and that the insurance companies from the public payers to the private payers will begin to fund these really critical types of social services that now hospitals are having to provide with their own infrastructures and actually quite slim margins that should be paid for by various insurances.

Host: So, you just used the term anchor strategy, I think you called it. What is an anchor strategy and what is it designed to address?

Dr. David Ansell: Yeah. Well, that's a great question. And just to take everyone back in 2016, Rush changed its mission to being the best in healthcare to improve the health of the populations we serve. And when we really thought about, again, the health of the populations we served, we realized that there were the social and structural determinants of health that were getting in the way of people being healthy.

And I talked a little bit about health-related social needs, hunger, housing. But at the structural level, poverty, lack of education, unsafe neighborhoods, people not having places to walk or there's no grocery stores in the neighborhood or even easy access to healthcare, we understood were new problems and it was very different when you're working on being the best in healthcare versus improving the health of populations. So, we adopted back in 2017 an anchor mission, which is a mission that's tied to leveraging your business units in the hospital to improve the health of the population and by hiring locally and creating career pathways within healthcare that lead to wealth creation, purchasing locally and supporting local business growth, investing locally, taking money from your unrestricted reserves and investing them in community projects that can build community infrastructure and, lastly, volunteering locally.

When we started doing this in 2016, it had been done with educational institutions, not a lot of healthcare organizations. So we, with about nine or 10 other healthcare organizations around the country, formed what's called the Healthcare Anchor Network, a national network of hospitals that are doing those very things that I mentioned. Because the idea is that hospitals like Rush are surrounded by many hospitals, communities, that are high poverty areas and sometimes areas of concentrated poverty. For example, literally outside our door is a neighborhood of Garfield Park, in which the life expectancy right now is 66, whereas you have the Chicago Loop two miles to our East where the life expectancy is in the 80s. And so we said, how can we leverage our business units to improve the conditions under which people live, work, and play to elevate, wealth-building, education, as we mentioned, the neighborhood built environment, and then even access to healthcare. So, that movement has been very active in the United States and any hospital can do it. And we've had terrific results from doing this work.

Host: I love this discussion. I think this is so important. And you just said any hospital can do it, and you talked about the healthcare anchor network. It sounds like it's mainly in urban areas, at least that's what it sounds like.

Dr. David Ansell: No, that's not true.

Host: Okay. Well then, let me ask you, does it make sense for a hospital or healthcare system then to have an anchor mission if they don't have the healthcare disparities or population issues, does it make sense to do that?

Dr. David Ansell: Well, I would say there's probably no hospital in the United States that are not only serving diverse communities, but serving economically diverse populations and those that have been historically marginalized or historically minimized. So, I don't think there's one hospital in the United States. And whether we like it or not, hospitals are anchor institutions in which we hardly make any money, but we buy a lot of stuff and do a lot of stuff. And at the end of the day, if you look around the United States, then 20% of the GDP is in healthcare. That's not all in hospitals, of course. And we are the biggest employer. And so, there's the opportunity. And many of our employees, particularly the low-wage, entry-level employees are coming from these very same communities with low life expectancy. We call it the death gap. This death gap in. So imagine in Chicago as an exemplar, if you live in the Loop, that's like the life expectancy of the highest in the world, Spain or Monaco. But if you live in Garfield Park, if it was a county, it'd be the lowest life expectancy county in the United States. Think Pine Ridge Sioux Reservation in South Dakota. And by focusing your economic engine and your employment to these neighborhoods, it's an opportunity to help build wealth in these communities, which will ultimately lead to better health. And most population health strategies at hospitals are not thinking about wealth building, but the anchor strategy is such a strategy.

Host: So, wealth builds health?

Dr. David Ansell: Wealth builds health. Without wealth, you can't have health. Now, I'm not talking about being in the top 5% of income. What the data shows in really the United States, but it's across the world-- in the United States, when your income for your family falls below the median income of the United States, you begin to see divergence in life expectancy based on where you live. By the way, Rush wrote something called the Anchor Mission Playbook that's widely used in the healthcare anchor network on how to build the internal structures that you need to do in anchor mission. But at the heart of what we're doing is inclusive wealth building by supporting neighborhood businesses, by giving your own employees a chance to move up the career ladder with stackable certificates and skills. And we've been involved with all of that, not alone, not only nationally, but with a collaborative in Chicago that's called the Westside United, which has six hospitals partnered with the community and the AMA, by the way, around community wealth building.

Host: So, all of this sounds great, Dr. Ansell. So, what should a hospital or health system consider before beginning an anchor strategy? I would imagine there would have to be some kind of foundation in place before, even beginning to do this or strategize.

Dr. David Ansell: Well, you have to see this as part of this integrated population community health strategy, number one. And whether you like it or not, you're an anchor institution because you're hiring people and you're purchasing a lot. It's just directing this to those neighborhoods in a very organized way with a series of metrics that go up to senior leadership in the board, is a critical piece to this. But any hospital that wants to start, you contact the healthcare anchor network because we have a whole network around the countries, out of Washington, DC. It's easy to find the healthcare anchor network and those resources you can just download. But more than that, it's a national collaborative that's doing this work. I can tell you at our own institution, once a week, I have to get up in front of other senior leaders and say, "Where are we with local hiring?" Because we've set goals for local hiring from these community areas, 10 that we've identified as high-risk community areas, and we've set goals for that and I have to report on it. And we've set goals for screening patients for their health-related social needs as central to the operations of a hospital as preventing central line infections, for example. It's easy to embed this into the work. It just requires a structured approach.

 And I just want to add to this, as I was a former Chief Medical Officer at Rush, the Inaugural Chief Medical Officer, responsible for quality and safety. And the third mountain that we have to climb is the equity mountain. Because in every state in the United State, for conditions for which healthcare can make a difference, there are gaps between black patients and white patients, American Indian patients and white patients, Latinx patients and white patients in every state in the United States. There's not one state in which white people are doing worse than black people or American Indians in terms of healthcare outcomes. And we've got to think about new ways of reducing these gaps. And so, that's the opportunity in front of all of us, and it can't just be done through traditional insurance-based population health initiatives. That's necessary, but not sufficient.

Host: It sounds like you're doing community outreach all the time. Even when it comes to hiring, you're out in the communities.

Dr. David Ansell: Right. And think about what it means to hire directly from a community. We have to have people be able to get online wherever they are, and have someone help navigate a complex system like HR at a hospital. We realized we need people. So, here's the beauty of it, healthcare is growing. We need people. There have been a big shortage post-COVID. And I'm telling you, at this point in time, almost one out of five of our new employees are coming from what we're calling our anchor neighborhoods, communities that we've identified as being high poverty neighborhoods of concentrated disadvantage, and we can't hire enough. So, it's an opportunity for a win-win for community members, but also the hospitals.

Host: You're out in the communities of Chicago, to me, one of the greatest cities in America, but it certainly has its share of problems, as you mentioned with Garfield Park right next to you. So for these anchor neighborhoods, when you get out into those communities and say, "Hey, we have jobs. We want you to come to us," are you well received?

Dr. David Ansell: We're well received. But when we began to get into this, we didn't have much of a reputation. It was neutral to negative. And you could say, we've been around in Chicago since three days before the--

Host: Mrs. O'Leary's cow kicked over the lantern and started the fire, no?

Dr. David Ansell: Way before that.

Host: Way before that?

Dr. David Ansell: Way before O'Leary's cow, three days before the city was incorporated. So on the one hand, we said we had the least responsibility and accountability for the health in the neighborhoods, whether people were our patients or not. And at the same time, there was accumulated mistrust. So, we went on listening tours.

Host: Okay.

Dr. David Ansell: So, we went with the community and said, "Listen, here's this death gap between the Loop and the west side. What do you think about it? What are the ways that hospitals..." We didn't do it alone, we got five other hospitals. "What are the way the hospitals could partner with the communities on these sorts of things? And the community told us the following: one is support local businesses; two, we need jobs that pay good wages; three, our kids are feeling hopeless. We don't have places to exercise. We don't feel safe. We need mental health services and so on. No one asks for another clinic. But they wanted the kinds of things--

And creating Westside United created this partnership that's really moved ahead. And they said, don't come for the short term, come from the long term. And I can tell you, like in Garfield Park, we just won the Chicago Prize. Now when I say we, the community partnered with Rush, partnered with the federally-qualified health center, partnered with the YMCA and so on and so forth, have won the Chicago Prize, a 10-million prize for constructing what's going to be called the Sankofa Wellness Village. The community did not want just a health center, they want wellness and all of those wraparounds. And this is going to have a health center, a YMCA, a bank, a coffee shop. Rush will be there. Westside United will be there. There'll be an art center, a grocer initiative and an entrepreneurial development arm of this and it's the first investment in Garfield Park since Martin Luther King was assassinated. And it's actually building on that visionary hope that Martin Luther King brought, that segregation and economic deprivation could be actually cured in Chicago. That's hopefully going to be shovels in the ground next year. But it brings hope to our community.

And I will say in a million years, maybe not a million years, and maybe I'm exaggerating a little bit, but Rush would never have thought of doing something-- it's called the Sankofa Wellness Village in Garfield Park, until we identified the life expectancy gap, took on the anchor mission and asked the community what they wanted. And we're very excited about it because it's not Rush going in and building its own thing. It's a partnership in which the wealth creation from that very building, building will be owned by the community, it'll generate income that'll be invested into local businesses, it'll provide a healthcare component, safe place to exercise and so forth. And without our anchor mission, without thinking broadly about community health and population health, we wouldn't be doing this. And if it can be done in Chicago, as Martin Luther King said, it's reasonable to believe that if the system can be changed in Chicago, it can be changed anywhere in the United States, whether you're an urban area or a rural area.

Host: So, is it safe to say that what people are asking for when you went on these listening tours, they're saying, "We don't need another clinic. We want a place to exercise. We want a place where we can do things." It sounds like what they want is traditionally what white neighborhoods have had all along. Is that fair?

Dr. David Ansell: Yeah. You know, when you look at it, white, black, there's so much unnecessary division in this country. It's important to look at racial ethnic gaps and outcomes or gaps by insurance type because it's unacceptable that we'd have people getting different outcomes. But actually, what people were asking for, including access to food, was what everybody wants. It's not a white neighborhood. People want that. It's not like a big surprise. What people want is what everybody wants.

But think about this. We started out at Rush. When I got there as Chief Medical Officer, and I'd spent 30 years in Chicago's safety net, and I had learned all of this through my patients and my observations, that they were carrying disease burdens that seemed beyond my ability to treat them. And then I understood it was their neighborhoods. You know, their neighborhoods were making them sick. And that insight as a doctor, when I got to Rush, really helped me think through that. If we didn't treat social pathologies like poverty, racism, et cetera, like we treated medical pathology, we wouldn't be able to solve the problem. But by beginning to understand that comes the solutions. And these solutions end up having hospital adopt an anchor mission and then become more embedded in these community spaces, not by doing all the work ourselves, but creating these partnerships, particularly partnerships that develop wealth. We're natural economic engines to begin with. You know, we have a lot of entry level jobs and like, for example, IT pays a lot, but it you just need a stackable skill and you can become an IT person. And I do think we have a lot of capacity to think outside of the box of traditional healthcare delivery, which when I became a CMO was improved quality, improved safety and now, the third step is reduce inequities. And so, it's a natural progression of that work, but it requires a deeper way of thinking about it.

Host: As you said earlier, we need to help people climb the equity mountain.

Dr. David Ansell: By the way, I do want to mention in a shameless self-promotion, after George Floyd was murdered and in the wake of COVID in which COVID demonstrated to all of us that it wasn't our biological vulnerability that determined who lived or died solely, it was our social vulnerability that determined who lived and died. And basically, COVID planted its roots in preexisting social chasms. Many of us made statements that racism itself was a public health problem, and we committed to doing things to reduce these unnecessary gaps in health outcome.

Back to the population health piece of it, with a Commonwealth Fund, Rush with University of Chicago, the Illinois Health and Hospitals Association have developed a Racial Equity Progress Report that hospitals can take. You can do an assessment of where are you on your journey and embedded in that is some of this anchor work. Because the changes we have to make to improve population health is in the healthcare delivery system. It's in our employees, making sure our employees are generating wealth, making sure that our leadership is reflecting the communities and making sure we have authentic partners with communities themselves. And only by doing this work across all of those domains will population health have the opportunity to improve.

Host: So, where can someone get this Racial Equity Progress Report?

Dr. David Ansell: Well, you can Google it, the Racial Equity Progress Report. And maybe, Bill, I can send you a link and that can be shared.

Host: We'll put it in the show notes. Absolutely.

Dr. David Ansell: Yes. I wanted us leave everybody with the idea that, you know, I came up through medicine in a very traditional way and academic medicine, and I've had a number of jobs, including being a chief medical officer, this is the next step in the journey. And maybe it sounds more complex, but it's actually very structured and straightforward and any hospital or healthcare system can do it. The tools are out there. We're all at the beginning of our this health equity journey in the United States. It's been long standing, but I think we can all move ahead together.

And at the end of the day, we have to look at our gaps. And if they're racial gaps, if they're gender gaps, we have to ask ourselves why. And then if racism is a root cause, then let's do the work to eliminate it. If we have age gaps and ageism is driving differential care, we've got to reduce those gaps. It's quite straightforward.

Host: Let's do the work.

Dr. David Ansell: Let's do the work. We need no more studies, the gaps that we've seen for a long time. But this work is something that health systems could all do, could make a big difference and if we all did it together. We need more than health systems. Of course, we need other sectors involved, but at least we have to start it.

Host: Well, you really hit me when you said neighborhoods are making people sick, where these people live and what they have available to them. That just really crystallizes the whole issue for me.

Dr. David Ansell: Yeah.

Bill Klaproth (Host): I've never heard it phrased that way. Neighborhoods are making people sick.

Dr. David Ansell: It's neighborhood conditions. And there's a phenomenon, a biological phenomenon of weathering. And so, the people exposed particularly to concentrated poverty, concentrated disadvantage, where everyone around you is experiencing the same thing you are, it can make you ill. And people think, "Well, it's homicide, it's gun violence, it's overdoses," yes, those are problems. It's cardiovascular disease. It's cancer. And imagine like in Chicago, you got our hospital, by the way, top ranked on US News and World Report Honor Roll, ranked by Newsweek as one of the top hospitals and health systems in the world. And we're living between the Upper East Side of New York and the Loop and Pine Ridge in Garfield Park. And Garfield Park is a neighborhood of terrific assets. It's had capital extracted and wealth extracted, and we just got to put the potential for that neighborhood to have a renaissance by our actions. And that's the opportunity and why I'm optimistic about this work.

Host: Dr. Ansell, thank you so much for your time. This has been fantastic. Give us your takeaways, your final word. The floor is yours.

Dr. David Ansell: Well, I want to say why we should be hopeful in the face of everything we've seen with COVID, with growing life expectancy gaps, it feels like we've slid backwards, and we're pulling ourselves out of it. And I just want to say I've seen how this work can be transformative, not only for healthcare institutions, but for communities. And sometimes people think, well, hope is being idealistic or, unrealistic. But hope is a muscle that has to be flexed and used, and I'm talking in a very pragmatic way. I've seen the impact that this broader view of population health can do in a community like Chicago with a lot of problems, we have our set of problems. But I think anyone listening here and certainly hospital CEOs and leaders should know that you can make a big difference by adopting this sort of methodology.

Host: I love that optimistic note. That is a great way to end, Dr. Ansell. This has been very inspiring and informative. And you can read more from what Dr. Ansell has written in the future of population and public health, which will be featured in length in the 2024 edition of Futurescan. Dr. Ansell, thank you so much for your time. This has been wonderful.

Dr. David Ansell: Thank you, Bill, for having me.

Host: And once again, that's Dr. David Ansell. And make sure you read Futurescan 2024. There's so many great articles. And I know you're going to get a lot out of it. And if you found this podcast helpful and of course, how could you not, please share it on all of your social channels. And please hit the subscribe or follow button, so you get every episode chock-full of goodness. This has been a production of Doctorpodcasting. I'm Bill Klaproth. See ya!