Hospitals target nutrition, other social needs to boost health

Tom Shicowich "really, really, really liked Coca-Cola" before he began a new nutrition program targeting his Type 2 diabetes and weight. Being on a "very tight budget," he couldn't afford the fruit and vegetables he cut up for a living at his part-time grocery store job. Dinner was often a pizza or fast food meal he picked up on the way home.

Six months after getting free healthy groceries every week through the Geisinger hospital near his rural Pennsylvania home, Shicowich has cut his blood sugar level from nearly 11 to close to a normal level of 7. The 6' 5" former high school track team competitor has lost 35 pounds but is still nearly 200 pounds from his target weight of 250 pounds.

The Geisinger Health System is on its way to making its own numbers. On March 1, Geisinger plans to expand its five-patient pilot project to 50 more of its sickest and highest-cost diabetes patients. So far, all of those participating in Geisinger’s Fresh Food Pharmacy have lost weight, lowered their body mass indices, decreased their use of medication, lowered their cholesterol and improved their hemoglobin A1C levels, says Andrea Feinberg, an internal medicine doctor who is "clinical program champion."

Geisinger is what's known as an accountable care organization, which makes it fully responsible for the insurance and all health costs for their patients. They employ the doctors and own the hospitals and insurance company. The better-known Kaiser Permanente is another example. That means unlike other hospitals, their profits aren't based upon patients' visits and treatments.

"It is no coincidence that the health systems and hospitals that are doing it the best have aligned their incentives more closely to the health of their patients," says Joshua Sharfstein, a pediatrician who is a former secretary of health for Maryland and top Food and Drug Administration official. "It's very hard to ask a hospital that’s getting paid for every preventable admission to invest in ways that would eliminate those admissions."

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Feinberg specialized in pulmonary medicine and critical care for 25 years in Los Angeles before moving to Danville, Penn., when her husband, physician David Feinberg, became Geisinger's CEO in 2015. She always found that even the best medicine practiced on "sick, sick people was sort of missing the boat."

"By the time they got to the ICU (intensive care unit), they had multiple diseases," including chronic obstructive pulmonary disease and congestive heart failure, says Feinberg. "The more they have, the worse the outcomes."

Diabetes' crippling costs

No matter which side you are on in the health care debate, Feinberg says it's important to realize diabetes care is "going to cripple our health care system," when the amputations, strokes, kidney disease and costly insulin are considered.

It has come close to crippling Shicowich in more ways than one.

He incurred about $200,000 in medical bills about six years ago when he was hospitalized to have a toe amputated. To meet a payment plan and qualify for Medicaid, Shicowich liquidated an annuity that was the "nest egg" that allowed him to move back to his distressed hometown to care for his now-deceased parents. He also has kidney disease, severe arthritis and needs a knee replacement.

​"You're supposed to eat healthy but you have to be able to afford eating healthy," says Shicowich, 56. At his grocery store, "all I could afford was canned ravioli or a Hungry Man meal keep my belly full."

Feinberg got the idea for her new program while working as a volunteer in Danville packing backpacks for "food insecure" children to bring home to their families on the weekends. The food was "usually void in nutritional value, calorie rich, high sugar and low protein," she says.

About 95% of the diabetes case in the United States are Type 2, which Feinberg calls "a reversible disease."

Redefining health care

At Kaiser Permanente in Southern California, physician Nirav Shah is working with the non-profit Health Leads to "fundamentally redefine what counts as health care" by helping to coordinate social needs hospitals don't typically focus upon.

Shah, a former New York state health commissioner, says Kaiser Permanente decided to look at health care "as a math problem to determine how to maximize total health by looking at all parts of the equation."

For example, about 65% of U.S. residents have their high blood pressure under control, while 90% have it under control at Kaiser Permanente. The last 10% consists of some of the highest-cost and difficult to help patients, Shah says.

About 1% of Kaiser Permanente members incur about 23% of the group's total health care spending, Shah said in a recent New England Journal of Medicine article. That includes 40,000 of the more than 4 million Kaiser patients in southern California, where Shah is Kaiser's chief operating officer.

Those patients, Shah says, pay about $12,000 a year and cost the company about $98,000.

Kaiser, Shah says, is failing these people somehow, so now employees call these patients at home to see if they need help with food, housing transportation or paying their utility bills. "The answer was a resounding yes," he says.

It wasn't only the lowest-income patients, either. More than 20% had jobs and commercial insurance.

One of the more compelling cases involved an older woman with two dogs who was terrified about how she was going to find an apartment she could afford that would allow her to bring her dogs. She needed all the social supports in her current apartment complex, but kept falling on her two front steps. She needed medical attention for the falls and some chronic health conditions, which brought her to the attention of the administrators.

Once they realized the problem, Kaiser Permanente contacted a tenants' rights group that got the landlord to install at $60 handrail.

"We call her back every few weeks and she says, 'Thanks so much,'" says Shah. "Rather than being terrified about where she's going to live, she can focus on taking care of herself."

Addressing social issues

While there are strict federal rules around what is reimbursed by Medicare or Medicaid and others that prohibit what a hospital can give a patient for free, Geisinger and Kaiser have found a way to address social issues that would otherwise keep sending patients back for more care. Damon Francis, an internal medicine doctor who is Health Leads' chief medical officer, calls it "whole person care."

Stable housing is key to health. Some counties are doing housing-related work that is funded through Medicaid even though the program is not allowed to pay for room and board. It can, however, pay to help people search for their new homes and to move in to them. Local governments that previously paid for those services can then help pay the rent, says Francis.

While it's hard to get direct reimbursement, some health care providers will be funded through Centers for Medicare and Medicaid Services (CMS) grants under a new "accountable health communities" program.

The CMS grants will help provide the data that could lead to permanent government reimbursement of the kinds of things that are less expensive and more effective than traditional medical approaches.

Sharfstein is working on research on the so-called "social determinants of health" — including food insecurity, housing and violence — as the inaugural director of the Bloomberg American Health Initiative at the Johns Hopkins University school of public health.

"You need data to figure out how to identify the people who can benefit," says Sharfstein. "And data is important to target efforts and to find out if your efforts are working."

Back in Pennsylvania, Feinberg expects to see her project expand far beyond a pilot. Her husband David, the Geisinger CEO, said recently that he believes 90% of Type 2 diabetes could be solved with healthier eating.

"If this was a pharmaceutical pill, it would be a blockbuster," he said.

The Geisinger program was started with a $10,000 grant from Weis Markets and the Central Pennsylvania Food Bank is the health system's long-term partner on the program, which is expected to see more of the kinds of benefits Shicowich has.

"I have really changed a lot so far in my life and it's made a big difference as far as feeling good," he says. "Everything is heading in the right direction."