IHI 2018: Former CMS administrator Don Berwick on why healthcare can't afford to accept inequality anymore

A doctor sitting at his desk working on a laptop computer.
Don Berwick has some suggestions for starting points providers can use to get at the social determinants of health. (Getty/monkeybusinessimages)

ORLANDO, Fla—In New York City, the city’s D subway train could also serve as map to health differences between the city's most storied neighborhoods.

Don Berwick
Don Berwick (Center for
American Progress)

In the span of over 80 blocks, the train travels from Manhattan’s Upper East Side, where the average income is $180,000 per year and lifespan is 85 years, to the South Bronx, where average income drops to $45,000 annually and lifespan drops to 75 years, said Don Berwick, former Centers for Medicare & Medicaid Services administrator and president emeritus and senior fellow at the Institute for Healthcare Improvement.

By comparison, if a patient with heart disease is on statins for one year, they add about 20 days to their life, Berwick said. Those days “evaporate” in the equivalent of seven seconds riding the D train, he said.


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“We cannot achieve health and accept vast inequity—that is a bankrupt idea,” Berwick said as he addressed the IHI’s National Forum on Healthcare Quality Improvement. “The causes of causes are not ours to accept, they’re ours to change.”

RELATED: New NEJM series encourages doctors to take on the ‘structural determinants’ of health

Addressing the social determinants requires providers to get at the “causes of the causes,” and consider some uncomfortable personal questions, Berwick said. And physicians know that socioeconomic factors  such as housing or food insecurity play a crucial role in their patients’ health. But many feel it’s not their job to deal with those issues, or they are unsure how to get started.

But, for example, people with significant childhood trauma are at higher risk for a number of conditions including heart disease, lung disease and depression. That places it squarely in healthcare's wheelhouse.

RELATED: Industry Voices—Why are we treating the social determinants of health as another healthcare fad?

To address these factors, physicians will be forced to confront their role in the world and ask for more from people in power, Berwick said. “It’s a question about the kind of communities that we want, the kind of nation, we want the kind of world we want,” Berwick said.

Some providers and healthcare organizations have already taken on the challenge, and their work can highlight starting points for others on this issue, he said. IHI, for example, spearheads the 100 Million Healthier Lives campaign, a collaborative community health project that aims to improve the health of 100 million people by 2020.

Researchers at Rush University Medical Center created the “anchor institution” playbook, which aims to encourage providers to buy and hire locally to stimulate economic opportunities. Or, providers could work with Purpose Built Communities, which designs towns based on social needs.

If those programs don’t feel like the right starting point, providers can instead start with simply getting a better hold on the status of the communities they serve, Berwick said. A first step could be mapping the individual needs and challenges in different neighborhoods or mapping the assets available to do this work, just like that map for the D train in New York.

“One thing is for sure," Berwick said. "Those social determinants of health, they are monsters compared to what we throw at health."

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