Mind the Gap: What if we treated zip codes before treating disease?

Contributors: Ginger Pilgrim, Connie Yang and Kelechi Nwoku
To learn more about Ginger, Connie and Kelechi click here.

 

 

heart.jpgimage010.pngThink about your neighborhood...is it walkable? Are primary care providers nearby and easy to access? Are there safe parks and affordable grocery stores? If not, your health could be at risk.

Health can be determined by many factors, including geography. Neighborhoods that lack characteristics like green space, affordable grocery stores, and access to primary care providers can negatively impact residents’ health. Addressing place-based health factors like these creates the potential to produce healthier communities.

GEOGRAPHY HAS A SIGNIFICANT IMPACT ON HEALTH.

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There is a 20-year disparity in life expectancy across US counties, and the gap is widening.1 The areas where people live longest — an average of 87 years — tend to be well-off, highly educated communities like Marin County, California, or Summit County, Colorado. At the other end of the spectrum — where average life expectancy is just 67 years — are low-income neighborhoods in places like McDowell County, West Virginia, and Owsley County, Kentucky.That’s because the places where we live, work and play have a huge impact on our health. 

Take healthy food, which we know is a major factor driving cardiovascular health and type 2 diabetes. Over 13.5 million Americans live in “food deserts,” defined as urban neighborhoods more than 1 mile from a grocery store or rural areas where the distance is 10 miles or greater.2 Because residents are forced to rely on unhealthy food options from convenience stores and fast food restaurants, their health suffers. In Chicago, the death rate from diabetes in food deserts is twice that of other neighborhoods.3  

Even when people can access grocery stores, the healthy option is not always affordable. Higher-calorie, energy-dense foods are a better bargain, costing on average $1.76 per 1,000 calories, compared with $18.16 per 1,000 calories for low-energy-density nutritious foods.5

Air pollution is another example. Between 30 and 45 percent of the North American urban population lives “next to a busy road,” putting these individuals at greater risk for the onset of childhood asthma, impaired lung functions, premature death and death from cardiovascular diseases, as well as cardiovascular morbidity.4  

Neighborhood factors also can influence health when communities lack the resources to support physical activity — which is associated with type 2 diabetes, cardiovascular disease, and others.6  Population density plays a role, as growing up in a city doubles the risk of developing psychosis and heightens the risk of depression and anxiety.7 

WHERE YOU LIVE ALSO IMPACTS ACCESS TO HEALTHCARE.

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Place-based influences also impact the ability to access healthcare. Seventy-seven percent of rural counties are considered Primary Care Health Professional Shortage Areas (HPSAs) and 8 percent of rural counties have no primary care physicians at all.8 

This is not limited to rural areas. In a recent survey of an urban, low socioeconomic status area in Dayton, Ohio, 31 percent of residents had difficulty accessing healthcare due to lack of transportation.9  A 2016 survey of low-income patients in a New York City suburb found that patients who rode the bus to doctor appointments were twice as likely to miss their appointments as patients who drove cars.10 

Access to transportation affects illness management as well. A 2013 review published in the Journal of Community Health discovered that patients who reported lack of access to transportation also missed filling prescriptions more than twice as often as patients without access issues.11

 

EVEN WHEN TREATED, PROGNOSIS IS OFTEN WORSE IN CERTAIN ENVIRONMENTS.

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To compound the issue, even when patients receive treatment for health conditions, environmental factors impact their response to treatment and prognosis. A 2008 study showed that for patients treated for myocardial infarction in Olmsted County, Minnesota, poor neighborhood-level income was a powerful predictor of mortality.12

Environment affects mental health prognosis as well. In a 2009 study examining the effect of socioeconomic status on outcomes and attrition in the treatment of depression, researchers discovered that lower socioeconomic status correlated to lower effectiveness of treatment and less mental health improvement overall.13

BUT WHAT IF WE TREATED ZIP CODES BEFORE DISEASE? THERE COULD BE HEALTH AND FINANCIAL BENEFITS.
As healthcare moves towards preventive care, what if we targeted specific place-based influences in our communities? What would be the health and financial benefit if we could be more proactive in treating “zip code” factors before they lead to poor health outcomes? For instance:

Place-based behaviors: Understand and address the factors that drive individual behaviors around diet, exercise, health screenings, etc., and especially how proximity to affordable, nutritious food can impact short- and long-term health outcomes

Access to healthcare: Understand the limitations to healthcare access in communities and generate opportunities to make services more readily available

Environmental hazards: Understand patients’ potential exposure to pollutants (air, water pollution) based on where they live, work, and spend time 

A recent study found that an investment of $10 per person in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could help save the country more than $16 billion annually within five years. That’s a return of $5.60 for every $1 invested. Out of the $16 billion, Medicare could save more than $5 billion and Medicaid could save more than $1.9 billion.14

More astounding are the opportunities around mental health. A World Health Organization-led study estimates that every $1 invested in managing depression and anxiety leads to a return of $4 in better health and ability to work.15  A 5 percent improvement in labor force participation and productivity is valued at $399 billion, and improved health adds another $310 billion in returns.16 

 

THE GOOD NEWS IS THAT SOME KEY PLAYERS IN HEALTHCARE HAVE STARTED THE SHIFT.

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University of Texas System Project DOC (Diabetes and Obesity Control): The lower Rio Grande Valley in Texas faces high diabetes prevalence (28 percent diagnosed and an additional 32 percent with pre-diabetes), medical deserts (40 percent fewer physicians per 100,000 population than the rest of Texas) and lack of access to health services (80 percent uninsured among Mexican-Americans in Brownsville).17  The University of Texas, in collaboration with PwC, area providers, and others, is focusing resources in the Rio Grande Valley to improve access to healthcare through technology-enabled care coordination and to modify behaviors through education, diet, and biometric monitoring. 

MedStar collaboration with Uber: Partnerships with ride-hailing companies are emerging around the country and are sometimes even covered by insurance. One such example is MedStar’s collaboration with Uber to address transportation barriers to accessing care for its patients in the Maryland and D.C. area.18 

 

HAVE YOU STARTED TO ASK HOW YOU CAN TAKE ACTION?

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Providers and payers are part of the communities they serve and, given the social and financial imperative to take action, they should understand the environmental factors that create the most health burden in their communities.

Taking action starts with asking the right questions:

What are the key challenges patients face in my community?

How can I better understand my patients’ physical environment?

Do patients in my community need help accessing care?

How can I help my patients make healthier food choices within their means and geography?

What are some of the environmental and cultural barriers in my community that impede an active lifestyle?

How can I influence policies that impact the health of my community?

Who do I need to partner with to get started?

Addressing place-based health factors has the potential to produce not only healthier communities, but also healthier businesses by improving employee well-being, reducing downstream medical costs from secondary and tertiary care, and building brand reputation and recognition. By addressing the right questions to treat zip codes before disease, organizations can help build a sustainable, profitable platform in the communities they serve.

Contact Ginger at:
901.619.8901
[email protected]

Contact Connie at:
646.228.5732
[email protected]

REFERENCES

  1. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, et al. 2017. “Inequalities in life expectancy among US counties, 1980 to 2014.” JAMA Internal Medicine, 177(7), 1003. doi:10.1001/jamainternmed.2017.0918.
  2. United States Department of Agriculture Food and Nutrition Service. n.d. “Food Desert Locator.” Accessed March 25, 2018. https://www.fns.usda.gov/tags/food-desert-locator.
  3. Mari Gallagher Research and Consulting Group. 2006. “Examining the impact of food deserts on public health in Chicago.” Accessed March 25, 2018. http://www.marigallagher.com/2006/07/18/examining-the-impact-of-food-deserts-on-public-health-in-chicago-july-18-2006/.
  4. American Lung Association. 2018. “Living near highways and air pollution.” Last modified Feb. 10, 2018. http://www.lung.org/our-initiatives/healthy-air/outdoor/air-pollution/highways.html.
  5. Monsivais P and Drewnowski A 2007. “The rising cost of low-energy-density foods.” Journal of the American Dietetic Association, 107(12), 2071-2076. doi:10.1016/j.jada.2007.09.009.
  6. Christine PJ, Auchincloss AH, and Bertoni AG,
    et. al. 2015. “Longitudinal associations between neighborhood physical and social environments and incident Type 2 Diabetes Mellitus.” JAMA Internal Medicine, 175(8), 1311. doi:10.1001/jamainternmed.2015.2691.
  7. Vassos E, Pedersen CB, Murray RM, et. al. 2012. “Meta-analysis of the association of urbanicity with schizophrenia.” Schizophrenia Bulletin, 38(6), 1118-1123. doi:10.1093/schbul/sbs096; Vassos, E., Agerbo, E., Mors, O. and Pedersen, C. B. 2016. “Urban-rural differences in incidence rates of psychiatric disorders in Denmark.” British Journal of Psychiatry, 208(05), 435-440. doi:10.1192/bjp.bp.114.161091; Kwon, D. 2016. “Does city life pose a risk to mental health?” Scientific American Mind, 27(5), 13-13. doi:10.1038/scientificamericanmind0916-13.
  8. Kutscher B. 2013. “The rural route: Hospitals in underserved areas taking different roads to recruit, retain physicians.” Modern Healthcare, May 4, 2013. http://www.modernhealthcare.com/article/20130504/MAGAZINE/305049953.
  9. Syed ST, Gerber BS and Sharp LK. 2013. “Traveling towards disease: Transportation barriers to healthcare access.” Journal of Community Health, 38(5), 976-993. doi:10.1007/s10900-013-9681-1.
  10. Silver D, Blustein J, and Weitzman BC. 2012. “Transportation to clinic: Findings from a pilot clinic-based survey of low-income suburbanites.” Journal of Immigrant and Minority Health, 14(2), 350-355. doi:10.1007/s10903-010-9410-0.
  11. Syed ST, Gerber BS, and Sharp LK. “Traveling towards disease: Transportation barriers to healthcare access.” Journal of Community Health, 38(5), 976-993. doi:10.1007/s10900-013-9681-1. 
  12. Gerber Y, Weston SA, Killian JM, et. al. 2008. “Neighborhood income and individual education: Effect on survival after myocardial infarction.” Mayo Clinic Proceedings, 83(6), 663-669. doi:10.4065/83.6.663. 
  13. Falconnier L. 2009. “Socioeconomic status in the treatment of depression.” American Journal of Orthopsychiatry, 79(2), 148-158. doi:10.1037/a0015469.
  14. The Trust for America’s Health and Robert Wood Johnson Foundation, n.d. “The Healthcare Costs of Obesity.” Accessed March 25, 2018. https://stateofobesity.org/healthcare-costs-obesity/.
  15. World Health Organization/World Bank Group. 2016. “Investing in treatment for depression and anxiety leads to fourfold return [Press release].” April 12, 2016. http://www.worldbank.org/en/news/press-release/2016/04/13/investing-in-treatment-for-depression-anxiety-leads-to-fourfold-return.
  16. World Health Organization/World Bank Group. “Investing in treatment for depression and anxiety leads to fourfold return [Press release].” 
  17. The University of Texas System. 2016. “UT diabetes project receives $3 million from health foundation to expand in Rio Grande Valley.” Sept. 8, 2016. https://utsystem.edu/news/2016/09/08/ut-diabetes-project-receives-3-million-health-foundation-expand-rio-grande-valley; Regional Healthcare Partnership. 2012. “Texas healthcare transformation and quality improvement program.” Dec. 31, 2012. http://www.hchd.org/1115/RHP%205%20Plan%20Final%2012-31-12.pdf.
  18. MedStar Health. 2016. “MedStar collaborates with Uber to provide a new option for accessing care [Press release].” Jan. 7, 2016. https://www.medstarhealth.org/mhs/2016/01/07/medstar-collaborates-with-uber-to-provide-a-new-option-for-accessing-care/#q=%7B%7D.