Health Equity

Working upstream to achieve the quadruple aim

Timothy M. Smith , Contributing News Writer

“None of us went into this work to achieve mediocrity, to achieve a sub-standard level of care,” said Rishi Manchanda, MD. “We’re in it for excellence. For professional satisfaction. For joy at work. For impact.” Although Dr. Manchanda was speaking to medical and health professions students at a recent AMA Accelerating Change in Medical Education Consortium meeting, his talk held lessons for physicians at every stage of their careers.

In fact, he said, the key to achieving satisfaction is achieving a higher standard of care. And he had advice for how to do that.

“The better stream of care we can achieve has to involve understanding upstream issues,” he said. Upstream issues are the general socio-economic, cultural and environmental conditions—including living and working conditions, social and community networks and individual lifestyle factors—that lead to health problems and health care utilization downstream.

Rishi Manchanda, MD at AMA Accelerating Change in Medical Education Consortium meeting

Dr. Manchanda, an internist and pediatrician and the president of HealthBegins, a provider of upstream tools and resources, was speaking at the student-led Health Equity and Community-based Learning meeting hosted by the University of California, Davis, School of Medicine. His presentation, “Upstreamist Doctors,” focused on achieving the quadruple aim: better care, lower total medical costs, more satisfied patients and more satisfied physicians.

The key, he said, is the integration of social determinants in health care.

“Health care providers in the U.S. right now have no choice but to understand upstream issues better because there hasn’t been adequate investment in other social services,” Dr. Manchanda said. “Unlike all of our peer nations, we have more spending on health care than social services. That actually creates a scenario where you have a doctor talking about moving upstream.”

To illustrate his point, he cited a pilot medical-legal partnership he initiated while serving as lead physician for homeless primary care at the VA West Los Angeles Medical Center.

The challenge was how to provide better access to care and improve outcomes for high-utilizer homeless veterans. Instead of looking to add health care professionals to his staff, he brought in a public interest lawyer once a week to work with patients to identify unmet legal needs that were the drivers of their poor outcomes.

“[For example], if you have a jaywalking ticket and that ticket goes unpaid, it becomes a misdemeanor,” he said. “That record now prevents you from getting housing.”

The pilot cost the VA $525 per homeless veteran, but it had a return of more than six to one in disability and other cash benefits paid to patients. One hundred thirty-nine veterans participated in the program.

“That’s over half a million dollars in benefits. If you’re a guy who can’t afford an apartment, consider what $3,600 does for you in terms of creating economic opportunity,” Dr. Manchanda said, adding that, over the 11-month span of the pilot, health care utilization decreased by 24 percent.

“Is this better care? Is this a glimpse into the quadruple aim?” he asked the students. “Yes, when you see the quadruple aim in front of you, you have to name it. If you don’t name it, you forget it. If you forget it, you can’t replicate it.”

Without integrating social determinants, he added, physicians are working with one hand behind their backs, and the quadruple aim cannot be achieved. But he’s confident many providers and policy makers are coming around to this idea.

“Even though I’m a primary-care-trained provider, I’m not a specialist or a comprehensivist. I view myself as an upstreamist,” he said. “If we don’t name what we are as upstreamists, it’s hard for us to learn best practices, share them and actually amplify our impact.”