Introduction

Boston’s reputation for excellence in health care is well deserved. Our city can boast some of the best teaching and community hospitals along with a network of the highest quality primary and specialty medical services anywhere. In addition to providing the citizens of Boston and beyond with the security of knowing that quality care is within relatively easy reach, the economic impact of our health care industry from the largest academic medical systems and community health centers to the smallest practices and the myriad of services like pharmacies, visiting nurse agencies, durable medical equipment providers, and others, is substantial. It is therefore imperative that the leadership of our great city works to reinforce the greatness that defines health care in Boston. This means recognizing not only the great institutions that provide cutting edge care, critical research and the training of future professionals, but acknowledging the factors that can encourage or impede good health. It also means that, in order to address these factors, we must recognize the value of accessible community based care and must engage our public health infrastructure in new and innovative ways.

With the health care resources we have in our City, Boston should be the healthiest city in America, and as Mayor, I will forge the system of care that will allow that to happen.  Health is a habit, and needs to be brought forth by linking our schools, employers and other institutions with our health care system, supported by a campaign that supports Bostonians doing the things that create health – thereby creating a culture of health in our city.

Healthy Neighborhoods: Health Policy Overview

Bostonians, while generally healthy, face some unique health challenges relative to Massachusetts and/or the US overall including high rates of cancer, smoking among white adolescents, excessive alcohol consumption among adolescents, preterm births, infant mortality, homicide, suicide, rising rates of obesity, and like the rest of the nation significant health disparities by race and ethnicity.

The health of Bostonians is key to school achievement for all children, ensuring a healthy workforce, and lower health care costs.

A strong public health infrastructure and agenda are important to advance the health of Bostonians. Public Health should focus on a discreet number of issues that we will elevate as important areas of focus. Among them:

• Ensuring that children enter school ready to learn
  • Building collaborations and innovative learning environments like Codman Academy and the Lincoln School in Walla Walla Washington (discussed below) that address broad issues
  • Promoting access to nutritious food for children and their families
  • Healthy school meals and policies
  • Addressing trauma and violence in all neighborhoods not just after a media worthy violence episode
  • Making sure that schools have access to referrals and supports to address behavioral health needs of children
• Providing a healthier environment for adolescents
  • Making cigarettes and alcohol unaffordable/unavailable for youth
  • Expanding physical activity initiatives for adolescents in and out of school
• Addressing obesity
  • Pushing for a tax on sugared drinks and candy to decrease access to high calorie empty nutrient “foods” and generate public health dollars
  • Continuing to build on improving the healthy transportation initiatives that promote walking and biking including making biking safer
  • Improving access to high nutrient food in neighborhoods with food deserts
• Strengthening the primary care base
  • Promoting medical environments in which care for the patient is coordinated, communications among all care providers as well as the patient are ensured, and the patient is an empowered party in his or her own care.
    • Supporting funding initiatives that redirect funds to primary care for care coordination and care management and for integration of behavioral health and primary care
    • Promoting collaboration between public health and Patient Centered Medical Homes (PCMH’s) by ensuring that public health funds help to support initiatives that primary care providers will undertake to achieve better outcomes for chronic diseases such as diabetes.
    • Promoting neighborhood based physical activity – leaving the payments for disease management (asthma among children for example) to health insurance.
    • Promoting home assessments to determine exposure levels of lead paint, asthma inducing particulates and other health hazards in home environments.
    • Promoting expanded access to primary care to reduce emergency department visits
    • Promoting workforce development and retraining to account for the shift in care away from acute hospitals to more community based settings.
      • Creating career academies in our high schools to promote health careers
      • Developing partnerships with local colleges and community colleges to give Bostonians access to education and training for the health care jobs of the future including HIT, community based care workers, etc.
  • Holding hospitals accountable for helping to strengthen primary care supporting PCMH and other interventions to reduce unnecessary admissions, ED visits, and readmissions
  • Developing a sustainability plan for Community Health Centers
  • Developing a sustainability plan for Boston Medical Center

Access

The fact that excellent care in Boston is within reach does not mean that all who need such care can reach it. For many reasons the health status that such institutions should help convey is denied to large numbers of our residents.  Accordingly we need to reinforce the fundamental goal of guaranteeing access to high quality care, healthy foods, clean environments and good educations irrespective of income, culture, linguistic challenges and immigration status.

Moreover the definition of quality must be broad and must be seen as including first and foremost primary care that is affordable and can be conveniently accessed from one’s home or work place. Accessible care should include pediatrics, internal medicine, family medicine and ob/gyn. Other affordable and easily accessible care should include oral health, behavioral health, eye care, pharmacy, lab and specialty medical care that can be safely delivered in the community where one lives or works. These may include hospital settings, but just as often can be offered in community health centers. In fact, Boston can proudly point to its twenty six health centers, all of which offer comprehensive care that meets or exceeds stringent accreditation and licensing standards.

We also recognize the role of our safety net hospitals, especially Boston Medical Center, in supporting and partnering with our community heath centers and in offering state of the art facilities in which to provide the highest levels of care.

Community Based Health Care

We mention health centers not only because they provide access to high quality health care to a broad spectrum of our residents, including our most vulnerable, but because they are models for holistic care. In these models the economic and civic health of the community and the health of the individual are interdependent and must be addressed comprehensively. When a community health center can either offer, or can partner with other organizations that offer sports programs for at risk youth, academic preparation programs, programs that encourage civic engagement or job training, or most intriguing, charter schools that share their campuses and learning with the care offered at community health centers, we know how powerful the potential is for a revolutionary change in how health care can be delivered.

The Health Care Pipeline

To realize that potential however requires that we put our old thinking about health care aside.  Instead we need to think of health care in the broadest terms – as a pipe line that begins in pregnancy and leads to life enrichment in the community, in the family, in school, in the work place, and on through our senior years. Holistic approaches to health care and education will help to reshape our thinking about supporting the trajectories we take in life. For example Centering Pregnancy offers a model of group medical visits for pregnant woman that can be utilized for subsequent medical care. These group visits have the effect of providing patients with built in peer support in addition to the critical health care advice they receive from professionals through a process that can be applied to care throughout life.

And we need to start targeting resources to areas that encourage collaboration and recognize the connections among pre-natal care, educational achievement, economic stability, healthy and safe neighborhoods, good nutritional habits, physical fitness and general good health. Thus we can support and track the success of health care goals such as the prevention of youth obesity and consequent Type II Diabetes to how well we address these and other environmental factors.

Financing

Health care financing is as complicated as it is essential to the vitality of this crucial Boston industry. Perhaps the most significant recent development affecting how hospitals and medical providers get paid is that health care insurers and governmental payers are incorporating quality measures into their reimbursement methodologies. Further they are structuring their payments so that providers take on risk and responsibility for how they perform with respect to controlling the costs of care and for how their patients fare.

These capitation systems differ from those that characterized payments to HMO’s in the 1990′s in that patient outcomes and other quality measures are emphasized. Another key change is in the way that these risk based payment systems encourage integration and shared risk among hospitals, specialists and primary care providers. To the extent that these integrated systems – sometimes called Accountable Care Organizations or Integrated Care Organizations – proliferate, the roles played by the primary care sector will increase. This could have the effect of shifting a portion of the health care dollar away from inpatient care toward community based alternatives. Given the large network of hospitals and community based providers in Boston, our leadership must be prepared to encourage these common sense changes in payment methodologies, system accountabilities and organizational structures.

At the same time we must advocate in the State House and the U.S. Capitol for fairness in these systems. As a municipal government and as an employer itself, the City of Boston has a direct interest in the quality and cost effectiveness of health care delivery. We also have an interest in preserving the vitality of what is arguably the best network in the world of research, teaching, health and medical delivery institutions. These are compatible interests and must be supported in parallel.

Health Care Reform/Affordable Care Act/Boston Medical Center

We unambiguously support universal access to health care. As a nation we are fortunate to have a new law – The Affordable Care Act (ACA) – that helps support these and other access goals. We are proud of the role that our city and the Commonwealth of Massachusetts played in providing the blueprint from which the ACA was designed.

As a state we now have more than seven years experience with a system of near universal access to health insurance and we welcome the idea that the major principles of the Massachusetts model are incorporated into ACA. We understand that this new law is complicated and while conferring new benefits on our systems of care, might inadvertently place new burdens as well. We will work with our Governor and legislative leadership to minimize these burdens by presenting the very commonsense argument that our own state law is working well as designed and the ACA should not try to fix what is not broken.

One area the ACA does not deal with is the realities of reimbursement and how hospitals that have a high degree of public pay (Medicaid/Medicare) patients receive lower reimbursement than those who treat commercially insured patients.  As a result, hospitals like Boston Medical Center and Carney Hospital (with 75% and 81% public pay patients respectively) have difficulty competing for high quality staff, providing high quality infrastructure, and maintaining positive bottom lines.  The health care system and the City of Boston need to ensure that institutions that serve the poor and elderly are maintained.  This will require action by the state legislature to balance the reimbursement system so that those organizations that serve the poor and elderly are able to survive and thrive. The Mayor needs to be a leader in the effort to ensure that these institutions receive the support they need.

Confronting Toxic Stress Through Innovations in Education and Health Care Delivery

A compelling field of study has drawn dramatic connections between childhood trauma and subsequent difficulties such as behavioral problems, poor performance in school, poor health, obesity, diabetes, liver disease, cancer, suicide rates and a panoply of other life long problems. The challenges that confront young people in many of our neighborhoods in Boston include violence, chronic poverty, poor housing, and unhealthy environments among others, and these spill over into their social and educational experiences. The term applied to these phenomena is “toxic stress”. Strong evidence points to the physical and emotional toll that toxic stress places on children, including damaged brains and bodies.

The Adverse Childhood Experience study (ACE) conducted by Feletti and Anda surveyed 17,000 Kaiser patients in San Diego probing childhood experiences before they were eighteen years old. The study in which a score of zero meant little or no childhood trauma and six to ten meant significant amounts, demonstrated a clear association between high scores and subsequent mental and physical health difficulties. Over time the study was shown to have predictive capacity as well given the authors’ access to Kaiser’s massive data base and the fact that all patients in the study received most of their health care exclusively from Kaiser. Nor were the effects of toxic stress or toxic stress itself shown to be limited to poor children. The ACE study demonstrated similar effects in children from middle class homes as well, where childhood traumas such as parents being separated or divorced or with addictions could lead to a lifetime of behavioral and health care deficits.

We strongly believe that schools and health care providers can play critical roles in helping to reshape the consequences of these experiences. We do not claim that we can eliminate all the problems our young people face simply by changing the academic environment of our schools or the way in which heath care is delivered. However, we contend that enlightened and innovative approaches to even our most at risk youth can pay large dividends and can lead to more success in school and better approaches to wellness.

Here at home and across the nation there are a number of inspiring examples that support this view. These include the Codman Academy (co-founded by Mr. Walczak) whose students come from homes where many of the factors that lead to toxic stress exist in abundance. Yet, the students consistently have among the highest scores on standard and non-standard tests, and have a 100% success rate in college admissions. Likewise the state of Washington recognized the value of the ACE study and applied its lessons to the Lincoln School  – a repository for some of the most troubled children in Walla Walla. The result has been remarkable with drop out rates falling and test scores increasing dramatically. In both examples an understanding of how childhood trauma impedes learning and the development of motivational tools that address these impediments resulted in increased self esteem and a desire to learn.

We also urge our health care institutions to become more proactive in integrating the realities of childhood poverty into their interventions. In a recent NY Times column, Dr. Perri Class, whose experience has included providing  pediatric care at Boston Medical Center and Dorchester House, argues for understanding childhood poverty as a disease that can negatively impact the individual’s entire life trajectory. Dr. Klass argues that “Poverty damages children’s dispositions and blunts their brains”.

These are troubling truths that the citizens in many Boston neighborhoods confront daily. But we can address them if we are willing to acknowledge the compelling evidence of their impact on the lives of those directly affected as well as on the entire city. Understanding toxic stress and childhood poverty as contributors to the health of our communities must and will be cornerstones of our health care policies and the services we provide or support throughout Boston.

We have developed our Education Blueprint (see billforboston.com) with these realities in mind, including connecting our health care system directly with education in the early years of life, ensuring two years of early childhood education before entering school, providing support services in early years, including tutoring, and access to primary care that supports early childhood education.

Information Technology

The past two decades in health care have witnessed remarkable developments in the field of information technology, especially with respect to access to and use of electronic health records (EHR) and electronically stored patient information. EHR’s and their companion integrated practice management systems are revolutionizing the accuracy and efficiency with which medical care is delivered. The potential benefits are enormous so long as we are aware of the dangers inherent in any accessible computer based information. Through its laws aimed at maintaining confidentiality (HIPAA) and the reimbursement incentives and penalties that are meant to encourage hospitals, physicians and other providers to achieve ambitious levels of “meaningful use” of electronic health information not the least of which are clinical quality measures, the federal government is looking to transform the entire health care system into responsible and effective users of these technologies.

Once again, Massachusetts has been a leader in this transformation. Many of our community health centers adopted EHR technology a dozen years ago, and some of our hospitals even earlier. Other providers have since adopted a variety of EHR’s and are participating in data warehousing projects that allow for safe and confidential epidemiological use of information in ways that were unimaginable only a few years ago. Likewise the ability of providers to access clinical information through health information exchanges in order to make and track referrals and to see results of specialty care among other uses, has offered tantalizing views of the ways in which medical care will be delivered in the future.

We see the very positive potential in the meaningful use of health care information technology for improved patient care and public health and will continue to encourage and support the adoption of new technologies as they pertain to these goals.

Patient Empowerment/Patient Centered Medical Home

The use of electronic health records is not exclusive to providers of care. Integrated portals give patients the opportunity to view and add information to their medical records and to use this access to quickly receive the results of lab tests and x-rays, request prescription refills, make appointments, provide pre-visit information to their medical teams, communicate though e-mail with their providers and in the spirit of PCMH’s become integral members of their medical teams. In fact one of the goals of the federal Meaningful Use initiative is to provide empowerment tools like health record portals to patients.

Yet patient portals are only one component of a much larger initiative aimed at transforming primary care practices – the Patient Centered Medical Home (PCMH). The PCMH initiative is lead by the National Committee for Quality Assurance (NCQA) which offers three levels of accreditation to primary care practices depending on how extensively they can meet a number of rigorous standards.  Although NCQA accreditation is a complicated and challenging process, the major principles behind it are worth the effort. They include patient empowerment and responsibility for participating in one’s own health care, and the responsibility of the primary care team for overseeing all aspects of the patient’s care. In other words, in the PCMH the patient and not the provider truly becomes the focus of care. That sounds logical but historically, too often this has not happened.

Together with developing information technologies, patients now have relatively easy access to information concerning their own medical care and about many aspects of the health care system that serves them. Meeting the requirements of Meaningful Use opens up that access, and the effective use of health care information is built into the standards for achieving PCMH accreditation as well. We believe that these are important advances for our city and will do all we can to help continue these trends in health care delivery.

Once again our state and city has been on the leading edge in supporting the accreditation of primary care providers, especially community health centers, as PCMH’s and we will continue to support these efforts throughout the city.

We will also encourage our city employees and the residents throughout Boston to avail themselves of the various public report cards that provide critical performance and cost information about hospitals, physicians and others. Web sites like Medicare’s Hospital Compare, rank hospitals in comparison to each other in specific areas like cardiac care, infection rates, etc.

Many of these rankings are being used even now by employers, insurers and group purchasers of health care like the Commonwealth’s Group Insurance Commission who are increasingly making decisions about coverage for employees based on value purchasing criteria. These would include the use of lower cost health care facilities – often community based – that demonstrate comparable outcomes to more expensive facilities – often teaching hospital based.

Along with the empowerment that such information may bring to patients, it will also require individual’s to think about the value of their health care purchases before they use particular providers. The failure to do so could result in financial burdens for them including higher co-pays and deductibles. As city leaders we will therefore use our communications to educate all of our residents about policies that require new financial considerations on patients as they make their health care choices. At the same time we will be vigilant advocates for them when they are facing abuses by insurers whose value purchasing policies result in arbitrary or punitive decisions regarding payments for medically necessary care.

Advances in Diagnosis and Treatment

Our focus on information technology is coupled with an emphasis on the role our city plays in offering leading edge technology for the diagnosis and treatment of a plethora of conditions. Led by our academic health centers this technology spans the field of medicine and includes such interventions as digital radiology, robotic surgery, organ and limb transplantation, cancer treatment, and hundreds of others in which Boston is looked to throughout the world for its research and technological advances in medicine. Our teaching hospitals are scientific leaders as well as major drivers of our local and state economy.  Of course they are also critical to the training of future health care professionals. As efforts are made to control the costs of health care we will partner with the teaching hospitals and medical schools to help them maintain their deservedly prominent positions in the health care industry.

Public Health

We recognize the importance of public health and will make that the cornerstone of our health programs. Public health practice and policy emphasize prevention and enhance the ability of community members to promote and protect environmental and community health.

Our public health program highlights a policy that assures adequate and sustained investment in the important determinants of health, using an ecological model that addresses the linkages and relationships among social, physical and environmental determinants of health. Our public health policy addresses specific areas of action and change.

We will address the health needs of all groups, by adopting a population-level approach, including the multiple determinants of social and physical health.

We will strengthen the governmental public health infrastructure of public health. Government and private funders of community health are essential to long-lasting change by supporting the institutionalization of effective programs.

Understanding the importance of public health infrastructures, we will build on the excellent reputation of the Boston Public Health Commission. Through the Public Health Commission we will use science to guide our initiatives, making sure families and individuals have the social supports they need, particularly around housing and environmental issues.

Aware of the need to address the inequities in the health of our community we strongly support the Commission’s Center for Health Equity & Social Justice to expand efforts to eliminate racial and ethnic health disparities.

We will partner with all sectors of the community to build capacity by using local assets and resources.

The first of these sectors is the community itself. Boston is home to many community-based organizations working on neighborhood health. Our role will be to empower these organizations and collaborate with them on planning, action and evaluation.  To further our engagement with community, we will support, and encourage, Community-Based Participatory Research, the partnership approach to research that equitably involves community members, organizations and formal researchers as equal partners.

As an extension of our community work and community based participatory research, we will expand our public health collaboration with academic programs. Boston is home to many excellent public health academic programs. We will encourage a significant expansion of supervised practice opportunities and sites, including community-based public health programs, delivery systems, and health agencies.

We will engage in joint efforts with the business community to strengthen health promotion programs by developing communication and information linkages, and recognizing business leadership in employee and community health.

By ensuring a strong public health infrastructure with the total community, we can address the inequities in health outcomes, decrease health care costs, and ensure the health of all Bostonians.