That’s an excellent question, and I think that the first thing is to answer to frame this as not only what individuals can be doing, you know, to make sure that they’re getting the best possible health care and advocating [for] themselves in different health care settings, but that it’s also a family, right? For a lot of us, whether it’s because you’re accompanying a spouse or child or a parent or some elderly relative, health care is not just about the individual. It’s about how the family can be, is engaged in supporting the health of that particular individual. My dad was a family physician. So, I learned about family focused based medicine, from him. And if we’re not, we have to make sure that as we’re designing systems and improving systems, that we are taking into consideration the fact that it’s not just a one-on-one thing.

And in fact, patients do better when they have someone else with them in appointments to help them ask the right questions, advocate for them, remind them if they forgot something, take notes if they need to. So that’s the first thing. It’s like, make sure that as a patient you are very clear about who’s like on your team, on your team in terms of family or friends who can be there to support you. Because most of the time when we go to get our health care, it’s because there’s something wrong and there can be anxiety and worry associated with that. And none of us are at our best when we’re worried and anxious. So being prepared with a buddy to help you think things through and remember things is really important. That’ll allow you to, in advance, really like, think of what are the questions you want to ask and make sure that you’re asking questions.

In many cultures, the doctor is somebody who people were trained to defer to and not question and not ask and not really converse with. And that is not the best way to get the best care that you can get. Right? So, making sure that you ask questions like, okay, so what are my options? And what happens if we do nothing? What does this word or this phrase mean? And then verifying, right? Like sometimes sadly, because of the way health care is paid for, doctors have to see a lot of people in little time. So, you want to make sure that they’re not getting things confused, right? Like making sure that did you, if they’re prescribing something like, well, how does that affect, how might that affect these other three medications I’m on?

Cause they may have not had time to check that, or how did that affect this other condition that I have? Because they might be a specialist for your leg and not be thinking about what’s happening in your lungs, right? And so, it’s really on the patient, unfortunately. I mean, wish it could be a little bit different, but it really is very much on the patient to make sure that they’re asking all the questions to make sure that everything is clear on what your next steps are and what the directions are. And if you’re not clear, ask and keep asking. And sometimes they may try to rush you, but you just say like, I’m sorry doctor, but I really want to make sure I understand this. So those are the kind of things that are really, really important to be in a position to ask your providers about.

So, I think we need to step back a minute and just talk about what we mean by health equity, right? And health equity is an idea that every single person has the ability to be as healthy as possible, right? Without barriers and especially without structural barriers that are impeding them from being healthy. Now, a chunk of that has to do with the kind of health care they can get, and a lot has to do with things that aren’t about health care, but have everything to do with health like the conditions in their neighborhoods and things like their experiences with racist inequities and structural inequities and income and education and language and a whole bunch of things, right? So, it’s important to understand that the actual clinical care you get is a very important part, but a relatively smaller part compared to everything else that I just mentioned.

So, for that reason, I think that a really excellent example of providing high quality care that centers equity and centers a patient are community health centers and other community-based providers because community health centers many of which are federally qualified, but not necessarily all of them were designed and created specifically to attend to the health of what often were underserved communities. And they have a lot of experience with, for example, providing care in different languages or providing care in rural areas or providing care that is culturally centered that includes, for example, community health workers that can help with the non-clinical sides of care, right? And so that is why it’s really important to look to where there are a lot of good stories, success stories and see how that can be adapted or incorporated into the rest of health care.

And especially, how does payment need to change so that the things that we know work can actually get paid for? How does payment need to change, for example, so that doctors can spend more than 10 minutes for their patient if they have more questions, right? Or how do we maybe pay for team-based care so that the doctor can deal with like purely clinical things, but then there is, there are other members of the care team, like a nurse or community health worker or someone else who can be assisting with some of the other needs that the patient has in order to be able to be successful with their health. And so, I do feel that models are out there, but what we haven’t figured out is how to effectively incent and pay for the care that we know is going to make a difference.

Well, I think that those are some of the best examples. And, I want to clarify, I’m not saying that we need to switch entirely our health system to have only community health centers. That’s not what I’m saying. I’m saying that there’s a lot of lessons to be learned about governance, about programming, about outreach, about representation that can be learned from those clinics. But I’ll give you a couple of examples that do come from community-based care. So, for example there were some interesting projects that were being done out in New Mexico, in very rural New Mexico, in an organization called Hidalgo Medical Center, which was a community health center where they realized that they had this 5% of the highest utilizers of the really, really expensive patients.

And one of the understandings they had is like, if you have somebody who’s at that top 5%, so many things have gone wrong with them already, right? Not just their health care. And so, what could we do if we got some extra money to have community health workers really from the community, right, get extra resources to help them work out whatever it is that they need, right? And they’re able to get this pilot done with a local managed care organization that they were contracting with. And what they found was like if you, and in this structure, the community health workers were their own department independent from independent, but equity, at the same level as physical health, mental health, and what was the other one? And behavioral health. And then there was like family services and support, right?

And they were equally important. They each had their own, their independent funding source because they were getting this additional per member per month just for those high utilizers. And the outcome was like, for every dollar that they spent, they saved four. Right? It’s incredible, that’s one example of how building on community assets, being those experts in the community who know how to navigate, who are trusted, already made a huge difference, not just in their health, but in the bottom line. Another example is from right here in DC which is the area that I’m in, which is again, a managed care organization in DC trying to figure out how to address a terrible maternal health crisis among Black and other women of color in DC decided to, I’m going to contract with a Black woman run/led organization that has doulas and other kinds of community health worker and community education and contracted with them for their patients to say like, they’re not even, they don’t do any clinical care, but they do all of what needs to go around it.

And it really made a difference. It made such a difference in the outcomes that the insurance company decided to expand the program, right? And so, what those have in common is that rather than looking at a community that’s struggling and saying like, what is wrong with this community, they were looking at a community that was struggling and saying, well, what are the existing assets in those communities? And at the end of the day, the assets were its people, it’s the people that were trusted, that were understood, that had cultural congruence, that had language congruence. And so, to the extent that we can make it so that there is more real partnership and investment in community assets in a coordinated way, the better our outcomes are going to be.

Well, I think they’re two different things. Like the more person-centered care is something that is as much culture as it is payment. Right? And workflow and how institutions are coordinating care and what kind of staff they have, and do they actually are they screening for social determinants? Do they have partners in the community to address those social determinants? I mean, there’s things that can be done outside of, or independently of the payment systems they’re in because it has a lot more to do with in many ways with culture and with just how they do hiring. Right? Right. However, when it comes to the payment side, when it comes to what is needed for, to create more equity, it’s really important that it, that we’re sure that it’s not just a question of throwing money at the problem because let me be very clear in a lot of these communities, you’re going to be spending a lot of money in the beginning to get things up to where they need to be before we really, I mean, we need to stop measuring re return investment for health care in dollars, right? The return on investment needs to be on, like, are people healthier? That’s how you measure. Are people missing less work? Are people missing less school? Like a social return investment is going to be really, really important or else we’re never going to get ourselves out of this kind of like catch 22 of like, well, we want to improve outcomes, we can only do it by saving money. And that is not a six-month turnaround in most cases, that is not even something that can be measured in the same balance sheet, right?

Like, it might be that we need to spend more earlier with middle-aged people in primary care so that Medicare can save money 10 years later. Like, there’s, there’s a lot of issues with how we are counting progress and counting success. So it’s, but at the same time, there’s things that are really clear that are going to be needed outside of health care for it to be successful. Like as long as there’s a digital divide, which is a real thing, digital red line is a real thing. Right now about, I believe it’s about 60% of rural hospitals don’t have broadband. And so like, how do we even move forward on advanced payment models and data and all of that if they don’t have broadband, right? And so, there are, there is a bigger picture that needs to happen around infrastructure and the care infrastructure and the data infrastructure that’s needed. And addressing things that are really affecting people’s health outside of the four walls of a clinic, like the air they breathe and the food they eat and the water they drink.

So, what I would say is that I’d like to get us to, I mean, again, this question can be answered whether like on the one on one and then more systematically, right? Yeah. On the one on one, I think that there’s a lot of good work being done with things like implicit bias training and a lot that has been done around things like patient centered care and trauma informed care, and making sure that doctors understand more about the context of a patient when they’re trying, when they’re developing care plans, right? And that all of that can be a little less one way and more collaborative and more understanding of the patient’s context, right? So, like, I remember my dad telling me when I would ask him as a little girl, what’s the difference between family medicine and being just a regular general doctor?

And he said, well, I’m thinking about how family’s going to be affected. So if a mom is sick, and I say, well, you’re just going to have to be in bed for two weeks, I know that that is a ridiculous thing to tell a mom without actually talking to her about what is a plan who can help you, well, maybe we actually need to put you in the hospital because that’s the only way you’re going to get off your feet, having those levels of conversation. Yeah. And then I think the other thing is how can we get to a place more systematically where, for example, a community health worker is available to anyone who needs it, right? Because we’re paying for team-based care and there’s always a community person on the team. Like, I can tell you that with all of my background and good insurance and all of that, with a lot of my son’s health issues because he was a high utilizer, the insurance company gave us a nurse to help us figure out things like, where the hell do they have this particular medication that we can’t find anywhere?

Right? And I was a professional person with a lot of resources, and it was so helpful also to my stress and anxiety that to know that somebody was helping me find this medication that they couldn’t find anywhere, right? Yeah. Like, who, where is there, a therapist, a child therapist that I can find in my plan anywhere in the within 20 miles. Like, those are the kind of things that if it became like just a common thing that people could get help, as long as we’re going to have as fragmented and complex health care system as we have, we’re going to need people to help them navigate it. Because what ends up happening is like, people will just give up and either they got a heart attack from the stress, they gave up and aren’t doing what they’re supposed to be doing for their health and end up in the ER over and over again, they don’t do well, right? We lose them. And so those are all things that our health system can do a lot better. And it’s like making it more user friendly and I don’t, seamless I think is a lot to ask, but at least less, less complicated and convoluted so that people who really do want to get the care they need when they want it, and when they need it, can actually do it without losing their job because they had to miss work. They’re all of these different ways that we’re making, being healthy so, so complicated for people that we can fix.