Until the white coats show up, this will amount to little more than a fad

March 9, 2016

By Kim DiGioia, MSPH

An interview with Lauren Taylor, MPH

Taylor will be speaking at the 2016 Lown Conference as part of a panel discussion entitled, “What Are the Real Harms of a Culture of Over-testing and Overtreatment? Perspectives from Patients, Clinicians and Communities” on Saturday morning, April 16. The panel discussion and Q&A will explore the ways in which overuse results in harm to patients, clinicians, and our communities.

As a student of public health, I have been following your work for a while. I understand that you are now in a doctoral program at Harvard Business School studying health policy. What are you working on?

A whole bunch of different things. One of the things I’ve gone back to doing is global health work, which is really fun. Prior to writing The American Health Care Paradox, I was exclusively a global health person– mental health policy in Ghana, health systems change in Ethiopia… Now that we’re three years out from the book, I’m getting to think hard about governance structures that make sense, how we should think about global health as an enterprise, and what it looks like for the US to collaborate on global health in a way that is not strictly self-interested.

Much more related to The American Health Care Paradox, I’ve been working on questions around how we can expect that health and social services really can come together to coordinate and collaborate. Being at the business school now, I’ve been able to view that through the lens of economics and think about transaction costs of collaboration across sectors, crowd-out effects of more spending in health care vs. social services, and spillover effects.

You and Dr. Bradley write in your book about the long history of health care and social services existing in silos in the United States. Part of the impetus for that came from the AMA, if I’m not mistaken. What can doctors do now to be allies in the work to improve population health by better integrating health and social care?

My sense has always been that doctors have a huge role to play. In my heart of hearts, I think that all of the PhDs in the world could come out and say that the more effective, efficient, humane way to create health in America is through social services and wraparound services, but until the white coats show up and say “yes, we agree” this will probably amount to little more than a fad. Doctors with their social and political status really are the lynchpins in this whole discussion.

It’s no secret that the AMA has been change-averse. Change is hard to anticipate and to manage, and it’s no surprise that they are loathe to change given that they are designed to protect a single profession. And their strategy to maintain the status quo is quite effective. To my eye, they stymie progressive legislation by saying it’s unrealistic that hospitals and doctors should be held financially responsible for population health. Hence we have few reimbursements schemes that tag money to outcomes. And then when you go to a group of doctors and hospitals and say let’s think outside the box about how to really create health, everyone shrugs and says “well, we’re not paid to do that.”

But many doctors get it; the best and the brightest of this generation really get it. They’ve seen the burnout and frustration of mid-career physicians and are saying “we’ve got to redesign and reimagine what our role as physicians is, in addition to redesigning the ecosystem in which we’re going to operate, if we’re going to have the sort of impact that we want to have on people, which is to help them have healthy lives.”

It seems that one of the greatest challenges in this work is the long time horizon between investment in social programs and improved health or reduced costs. I’m wondering if you can tell me a little bit about how you negotiate that in your work.

At the outset of my stepping into this world, I thought it was a bigger challenge than it was. There are some things that have a very long lead time, and they require expensive and complicated studies. We’re always thinking about those time horizons. How long until the payoff for the community, state, etc.? And so much of this stuff is under-researched; who’s going to give the 10-year grant to do individual student follow-up? Education is one of the long-term horizons.

In other areas, we’ve been pleasantly surprised by how quickly impacts can be seen. I remember talking to a woman in Vermont about long time horizons as one of the enduring challenges of this work. She said, ‘I’ve got to tell you, Lauren, it’s not as much of a long time horizon as you think. We put in sidewalks and, although infrastructure change is one of those things that people think will take a long time to pay off, we almost immediately saw BMI reduced.’ It’s wrong for us to resign ourselves to the idea that this work will take forever.

What are you most looking forward to about our conference?

Hearing Joanne Lynn will be very fun for me. There are also all these people who I’m Twitter friends with who I feel like I know. The conference will be an opportunity for me to get to know them in person, shake their hand and thank them for all the great work they do.