Map: Children’s Traffic Fatalities in Detroit 2004 – 2014

DETROITography

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In rethinking the Detroit Geographic Expedition and Institute’s (DGEI) maps on “where black children get run over” and “citywide patterns of child traffic deaths and injuries” it became apparent to me that the pattern was partially due to the distribution of children in Detroit (map). For example Southwest has a higher density of children and also more traffic fatalities of children. However, there are some anomalies, such as the higher numbers on North-South streets in the Lower Eastside, on John R. North of Highland Park, and on Conner near the City Airport.

Detroit is known its high infant mortality rate, high rates of gun violence, and poor education system that all contribute to a harsh environment for children. How do we better protect the children in our neighborhoods from cars?

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Data: 290,439 Michiganders signed up for new health coverage in 2015

MICHUHCAN

ACA_coverage_2015The U.S. Department of Health and Human Services (HHS) reports that 290,439 Michiganders signed up for health coverage that will start on February 1st.

The next enrollment period runs from February 15th – March 1st.

HHS says that about 6.5 million people have signed up or renewed their health coverage in the marketplace since November 15th.

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Data: Michigan Insurance Types 2013

MICHUHCAN

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Michigan has one of the 20 lowest uninsured rates in the country with only 11% of its population uninsured. The increase in the insured rate was largely due to the expansion of Medicaid, known as Healthy Michigan. The Census Bureau expects further increases in the insured rates across many states as a result of the Affordable Care Act (ACA).

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Michigan Health Insurance Mission Statements Text Analysis

MICHUHCAN

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Word clouds aren’t as often used thing these days, but I think it really helps to illustrate the difference between the officially stated “missions” of insurance companies versus the activities that they engage in, which could often times be defined as contradictory.
Few health insurance companies or plans in Michigan have specific mission statements, the majority have very broad missions. Based on the frequency of terms used across health insurance mission statements, more of these companies should be:

providing Michigan [residents] health care access.”

This simple concept of increasing access to health care has gained great prominence with the passage and acceptance of the Affordable Care Act (ACA). However, this composite mission statement is often placed secondary to the corporate and monetary interests of these insurance companies. The ACA has placed great emphasis on increasing access to health care while allowing the insurance companies to profit.

In the past, the insurance companies…

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Hot Air Balloon First Anniversary

Eight Twelve Eleven

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Nichole had the most amazing idea to go hot air ballooning for our First Anniversary. She found a place in northern Michigan near Traverse City where you float over the Traverse Bay in the early morning.

We made the long drive, but it was well rewarded by a perfect dinner at Amical in Traverse City. The most amazing seafood that we both thought had ever graced our stomachs. Nichole still wants to go back again. If you are in Traverse City, this is a place not to miss.

We camped out at Interlochen State Park along with numerous family reunions and pop-up trailers. We needed to purchase firewood before we reached the campsite and I was sure there would be some for sale along the way. We passed a few places, but never saw them in time to stop. Finally, we came upon an old white ranch style home with…

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following the money & the loss of primary care

Health statistics undoubtedly show the shortage of health workers and doctors around the world. Recently I wrote about the growth of hospitals in Detroit and the huge loss of primary care physicians. This is a health issue that is often associated with countries of the “developing” world, but the USA is facing a health shortage of a different kind: access to primary care.

Health financing has had the greatest effect on disparities in health care coverage as well as the structure of the health care system. Through our health care system, physicians have been incentivized to specialize as opposed to be a general medical practitioner. As technology has made medicine more efficient, it has not reduced costs, so “fees remained high, while the time and effort required to perform […] declined (Starr, 1982). The result was an increasing income disparity between physicians who specialized (Specialists) and primary care physicians (PCPs).

The advent of federal support for health care drove the income disparities between Specialists and PCPs. In 1946, the Hill-Burton Hospital Construction Act put $4 billion into the expansion of hospitals as opposed to ambulatory services (Starr, 1982). Ambulatory care services represent the single largest contributor to the increase of hospital expenditures and to decreased performance of the health care system in both the USA and many developing countries (Karpiel, 1994). In 1965, the start of Medicare and Medicaid allowed private insurance companies to continue their practice of providing higher reimbursements to procedural Specialists than to PCPs. Primary care was further marginalized when Medicare developed a policy that linked its teaching payments to a hospital’s level of inpatient, not outpatient, services. Medicare began giving extra payments to hospitals for residency training, pushing many hospitals to increase inpatient care in order to receive higher payments.

“Primary care brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface between the population and the health system. The features of health care that are essential in ensuring improved health and social outcomes are person-centeredness, comprehensiveness and integration, and continuity care, with a regular entry into the health system, so that it becomes possible to build an enduring relationship of trust between people and their health care providers.”

“Primary Health Care – Now More Than Ever”
World Health Organization (WHO) Annual Report 2008

In a 2008 survey of Michigan physicians, 34% identified themselves as PCPs, which follows the national trend that two thirds of physicians are Specialists (Michigan Physician Profile, 2009). The report showed that numbers had not changed since 2005 and the number of PCPs entering the workforce equaled those leaving the workforce. The report also highlighted the rising costs of medical education and the debt that many young physicians will carry into the workforce. With this high level of indebtedness, why wouldn’t younger physicians look towards becoming a Specialist as opposed to a PCP with fewer financial incentives? A friend of mine studying to become a doctor noted that many of her colleagues were having conversations about whether to go into primary care or to specialize. Unfortunately the system seems to choose the path for young doctors as opposed to giving young doctors the choice to go into a medical field that they enjoy.

Health care reform has represents a huge win for those fighting for increased access to care along with the Affordable Care Act (ACA) providing a positive framework for many living in poverty. However, the largest reform may have been one that was minimally addressed by the ACA, including 10% bonuses for PCPs under Medicare and $300 million to recruit PCPs for underserved areas. I don’t think 300 million today goes as far as 4 billion did in 1946, nor does a 10% bonus equalize decades of subsidies for Specialists. The health care reform added $11 billion in support for community health centers, but some of that was cut in the 2011 budget deal. The inability of the current health care system to keep up with this new rising demand for PCPs on top of the increase of chronic diseases and an aging population that lives longer, represents the need for reform in our health care financing not just access to health care.

We have a health system that has subsidized specialized care for too long, taken health care to large technology driven hospitals, and limited the ability for new, young doctors to infuse our health system with much needed passion. The real health care reform should have included increasing support for primary care facilities (no cuts) and more for training.

If we want all people to be able to access health care affordably then we need to provide them with the necessary health workforce that can meet them where they are. For many urban poor the Emergency Department (ED) has become their primary care facility. Many individuals working in health care finance world note the cost of ED visits is covered by the premiums of the insured (roughly $1200-$2000/ year) .

Its exciting to see widespread support for increasing access for the uninsured, its amazing to see funding to bolster primary care facilities, but  if we are going to have young doctors who aren’t living paycheck to paycheck, then there needs to be a concerted effort to get doctors into those primary care facilities and greater incentives to join the growing trend in supporting community health through primary care.

too much health care in Detroit?

Detroit is a city where major landmarks are often its hospitals. The Henry Ford Health System (HFHS) operates three hospitals within the city limits and the Detroit Medical Center (DMC), recently bought by the private Vanguard Group, operates nine different health complexes. The St. John’s Providence group also runs two hospitals in the city. However, Detroit’s hospitals are just one side of health capacity in Detroit. The Detroit Wayne County Health Authority (DWCHA) lists thirty-six community health centers across the city, twenty of which are free or have a minimal fee to see a doctor. Not to be overlooked, Wayne State University’s (WSU) School of Medicine works with both HFHS and DMC as well as runs a number of health outreach programs for HIV, Diabetes, Asthma, Childhood Obesity, etc. to manage care for chronic conditions.

With such a wide array of health facilities and such a strong focus on health care it seems as though the population of Detroit should be one of the healthiest. Unfortunately, the socio-economic barriers faced by Detroit’s population leave it with the lowest numbers of individual with health insurance in the state, high rates of non-communicable/ chronic diseases, as well as a growing obesity crisis. From 2009 to 2010, in Detroit: median income dropped, numbers of insured decreased, and the numbers of those living below the poverty line increased. Likewise, the Michigan Department of Community Health (MDCH) doesn’t list all of Wayne County as a Medically Underserved Area/ Population (MUA/P), but much of the Detroit area has been given an MUA/P designation. So many health facilities, so little health care for the population.

American Public Media’s (APM) Marketplace and NPR’s Changing Gears ask if its health care overkill. With another new hospital proposed in Oakland County (next to Wayne County), politicians are hoping to bring in more jobs and revenue in the only sector that hasn’t been hit by the economic recession. “[…] there are already six existing hospitals within a 30-minute drive time that average occupancy is 55 percent. So it isn’t a hospital that’s needed by the community, it’s a hospital needed by one health system to capture market share from its competitors.” says Dennis McCafferty who represents a coalition of Michigan businesses and labor unions. Is it about the market or is it about access to care?

“Since about 1997, we’ve lost about 60 percent of our primary care physician capacity [in Detroit].” – Dr. Herbert Smitherman

As a result of the loss of primary care options, the cost of care is significantly increased for the uninsured. Over the past five years, Dr. Smitherman and the Health Centers Detroit Foundation, tracked 33,000 uninsured patients in Wayne County and moved 55% of them out of emergency rooms and into coordinated care through the Voices of Detroit program, which gave access to a primary care physician at reduced cost. The majority of patients are low income and uninsured, usually on medicaid. Dr. Smitherman says, “It is a very difficult population because often, when we want to adjust things and I want to prescribe a medication, they’re uninsured. People are literally having strokes and heart attacks because they can’t get access to a very simple medication. It is 50 times more costly to deal with that. It’s very frustrating as a practitioner that we don’t have the basic access to insurance products, etc. for people to cover their basic needs.”

With the Obama Administration’s health care overhaul Dr. Smitherman notes there will be added benefits for the uninsured.

About 56 percent of all those who are uninsured are people of color. Obviously, Detroit is 89 percent African American. – Dr. Smitherman

He notes that the many people who seek care in the most expensive environments: emergency rooms and hospitals, will have the opportunity to find a primary care physician instead of paying “10 to 20 times the cost” in the emergency room.

New options for the poor and uninsured are popping up across Detroit from the field of telemedicine. One such program is a partnership between CVS/Pharmacy and HFHS. CVS’s MinuteClinic’s, open 7 days a week and staffed by nurse practitioners and physician assistants, will have the added benefit of having the Henry Ford Physician Network doctors on-call. Henry Ford doctors won’t actually see patients in the clinics, but will consult with MinuteClinic staff as needed and will work with them each month to review patient charts. Patients who are visit a MinuteClinic and don’t have a primary care doctor will be given a list to help them find one. RiteAid is also launching NowClinic, which gives people a free call with a nurse or the option to pay $45 to talk with a doctor.

Governor Rick Snyder has called for better health and wellness across the state. Snyder’s proposal highlights the economic connections to a healthy population. He notes that everyone has a part to play whether business, nonprofit, or government.

Health is the foundation for Michigan’s economic transformation—it allows our children to thrive and learn, it readies our graduates for meaningful careers, and it permits our current workforce to grow and adapt to a dynamic economy. In this message, we lay the groundwork for a healthier Michigan, a Michigan in which residents of all ages prosper and contribute.

He has been innovative in hoping to create a database of children’s BMI’s to track the rise of childhood obesity and has called on the Michigan legislature to take action on a Michigan health insurance marketplace, where all can be insured to receive the proper health care. This seems to be the one area where Snyder isn’t cutting benefits for the poor or making it harder for them to access services.

To conclude, the health care landscape is rapidly changing across the State of Michigan and across the world. Many people are developing solutions to solve our lack of capacity in the health system through innovative programs and technologies. Politicians are on board, private companies are creating ideas, and nonprofit groups are making important connections for people without the right resources. What will be critical moving forward is to focus on patient needs as opposed to simple outcomes. People need solutions that they can control and maintain for themselves and their families. The future of health care must be collaborative.

outsource to detroit: it’s like brazil

I caught a recent news brief from the Detroit News reporting from the Mackinac Policy Conference put on by the Detroit Regional Chamber of Commerce and was surprised by the headline.

“Outsource to Detroit”

That’s a bit different than Chrysler’s “Imported from Detroit” tagline. I’ve been following this idea and imagery of Detroit. I’ve written previously about how misinformed the image of Detroit is, some critics call this “ruin porn,” while others (some academic professors) call Detroit Michigan’s “third world” city.

For these reasons I am not too surprised to read a headline that is generally associated with sending jobs to developing countries (“third world”). The article highlights the growth of businesses moving into downtown Detroit because of the low cost of office space and the surplus of technical talent. The technical talent may be reference to wider metro Detroit and the many existing technology companies, but I know that I often see billboards in Detroit promoting web and technology job opportunities.

In an interview with Tim Bryan, GalaxE Solutions, the CEO said,

“A hundred percent of the work we’re doing in Detroit is health-care related and is coming from outside Michigan. It validates our model to outsource to Detroit.” […] enable[ing] GalaxE to serve customers for roughly the same cost as operating from Brazil.

I would not call this outsourcing, since the primary idea with outsourcing is that the job leaves the USA for another country where business is cheaper. There are plenty of examples of companies shifting locations because of varying economic climates in different States. Case in point, GM moving production from Michigan to Tennessee because of different business regulations and tax breaks. Brazil is an up and coming developing economy with its hand in many international markets – is it bad to be like Brazil?

Detroit is quickly becoming an technology hub for Michigan, which is an amazing reversal from its manufacturing past, as well as innovating for better health care. Wayne State University School of Medicine is leading incredible research projects to improve health care along with the Detroit Medical Center’s (DMC) nine specialized hospitals, Henry Ford Health System, and Michigan State University’s College of Osteopathic Medicine.

If this is the future for Detroit, then things are looking good. This is an excellent example of economic growth in a downturn via two growing industries: health care and technology. If Detroit lawmakers play the cards right, everyone in Detroit could get the best of both worlds: job creation and city revitalization. These are important steps to pay attention to for a better Michigan future.