Addressing Upstream Causes of Poor Health: UCSF’s Dr. Kirsten Bibbins-Domingo on Embedding Social Determinants Into Healthcare

Kirsten Bibbins - Domingo

[ Music ]

Margaret Flinter: Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation , health policy , care delivery and the great minds
who are shaping the health ca re of the future.

This week Mark and Margaret speak with Dr. Kirsten Bibbins -
Domingo, Professor of Medicine and Chair of the Department of
Epidemiology and Biostatistics at the University of California at San
Francisco.

Dr. Bibbins - Domingo is a member of t he National Academy of
Medicine, where she recently chaired a panel on social determinants
of health and issued a comprehensive report on how to address social
determinants in health care.

Lori Robertson also checks in , the Managing Editor of FactCheck.org ,
look s at misstatements spoken about health policy in the public
domain , separating the fake from the facts and we end with a bright
idea that’s improving health and well - being in everyday lives.

If you have comments please e - mail us at chcradio@ chcone.co m or
find us on Facebook , Twitter , or wher ever you listen to Podcast and
you can also hear us by asking Alexa to play the program
Conversations on Health Care .

Now stay tuned for our interview with Dr. Kirsten Bibbins - Domingo
from UCSF here on Conversation s on Health Care .

Mark Masselli : We’re speaking today with Dr. Kirsten Bibbins - Domingo, Professor of
Medicine and Chair of the Department of Epidemiology and
Biostatistics at the University of California at San Francisco.

She is also inaugural Vice Dean of Population Health and Health Equity
and is the co - Founder of the UCSF Center for Vulnerable Populations
at Zuckerberg San Francisco General Hospital .

Dr. Bibbins - Domingo is also a member of the National Academy of
Medicine, where she recently chaired a pa nel on social determinants
of health. She earned her BS in biochemistry at Princeton, completed
her PhD in biochemistry, her medical degree and residency at the
University of California , San Francisco. Dr. Bibbins - Domingo , welcome
to Conversations on Healt h Care.

Dr. Kirsten: Thank you very much for having me.

Mark Masselli : Well , Kirsten , we really just admire all of the work that you have done.
You recently chaired a panel at the National Academy of Medicine
and how best to address the social determinants o f health .

Kirsten Bibbins - Domingo

I think most of our listeners know the importance that social
determinants play in terms of housing and food and transportation
and its impact on their health outco mes and your committee drafted
a report integrating social care into the deliver y of health care moving
upstream to improve the nation's health. This is a really wonderful
report . I wonder if you could talk a litt le bit about the impact of a
social determinants and how this rep ort offers a roadmap for
addressing them.

Dr. Kirsten: As you said, we know that social factors are important for health,
where we live, where we work, what we eat; it all determines our
behaviors that relate to our health . The report lays out the way in
which the health care organizations can think about integra ting social
care into the delivery of health care, as well as the components that
need to be in place in order to do that most effectively .

We described two types of activities that really relate to how social
needs can be addressed for individu al patie nts ; a health care delivery
system might provide assistance , so if they have problems getting to
an appointment, to provide vouchers for t ransportation, maybe using
tele health to avoid trans portation needs.

Some of these things are not just doing things one p ati ent at a time,
but rather also aligning with community organizations in both
alignment and advocacy activities to really change policies and other
structures within the communities that might systematically address
n eeds within a community.

Margaret Fli nter: I think it's clear that in the community health center world, perhaps
the VA world, there are a number of systems, there's always been a
keen awareness of the social determinants, right ? Then we move
from and we ought to do something about them in he alth care to o.
W e really need to do them , and then o f course, the spectrum , and
how do we pay for doing this , because in fact, it calls upon the skill
sets of often other members of the team than the ones who we are
used to paying for .

In this domain, we'v e really seen quite a bit of change in progress in a
relatively short period of time and maybe you could talk a little bit
about what you're seeing as the trend, not just in the safety net
settings of community health centers in the VA and all throughout t he
health care system and health plans are beginning to look at how they
might incentivize or pay for this. Tell u s a little bit about what you're
seeing is major trends there ?

Dr. Kirsten: Yeah, I think this is really important. A key for this report was starting
out with the fact that, we're spending a lot of money for health care ,
and we're not quite achieving the outcomes we'd like to achieve .
Many of the trends in health care are shifting from volume to value,

Kirsten Bibbins - Domingo

right ?

Margaret Flinter: Right.

Dr. Kirste n: I'm a general internist. I always want to provide the best care for my
patients, but I get paid every time they come in to see me , I get paid
every time they're in the hospital, shifting to value is, coul d I be
incentivized to make sure that I have my d iabetics as best controlled
as they can possibly be and actually avoid a hospitalization?

I think that shift from volume to value forces healt h care delivery
systems to think a little bit outside the box . In my example, for
diabetics, if we're not achievin g the outcomes, do I need to
understand whether a patient can pick up their medications? Do they
have a pharmacist that's close by? Can they store their insulin in a
refrigerator? Or are they homeless? Do they actually have access to
healthy foods, if I un derstand that context, which is important for
achieving good outcomes in diabetes that then a lig ns incentives to
thinking about all of those factors that might be im portant for helping
my diabetic patients to have the best control possible .

Mark Masselli : I want to sort of pull the thread , I want to talk a little bit about the
leadership within health care organizations that are required .
Certainly , we've organized ourse lves around team based care, we
have the pods, and in the pods will -- might have a comm unity health
worker, an MA , certainly a nurse, a nurse practitioner, whole range of
people who are coming there.

It really requires re - conceptua lization, if you could talk a little bit
about that role of leadership and maybe give some guidance and
some hel pful hints for those who are listening about how you take on
this role ?

Dr. Kirsten: While we emphasize over and over again, in this report , how
important it is for all members of a health care team to be aware of
how social factors influence health, there are members or workers
who are really expert in addressing social needs . Like social workers,
historically have really been at the forefro nt of this, but also
community health workers, gerontologist , other people who might --
whose expertise is really in addressing those social factors, really
thinking about our inner - professional teams.

You describing community health centers and the VA that this has
really been woven into the fabric of the way health care is delivered
there , but it really has to happen i n other settings as well. While we're
moving from volume to value , it does mean that a recognition that
this workforce a lso needs to be considered essential for health care
delivery and be eligible for reimbursement , in many cases for the
systems that stil l exist.

Kirsten Bibbins - Domingo

There needs to be sort of the leadership to think about us as teams,
as we train as teams and as we think about the teams together . I think
that we're in a shifting landscape for how we pay for this all , but I
think leaders in health care delivery really need to be articulating, this
is the vision of where we're going and then putting these other things
in place so that we can get there effective ly .

Margaret Flinter: Well, K i rsten, back in 2007, I understand you founded the Center for
Vulnerable Po pulatio ns at Zuckerberg San Francisco General Hospital ,
w here you focus ed on the special a mong the special people with
complex , co - morbidities and where the line between soci al , biological
behavioral -- because these patients require much more focused care
coordination or as our leaders in that program like to say, the kind of
really great health care anybody w ould like to get , because you're
thinking about all the services , but in having that center to address
the needs of these patients, what have you lea rned about health
outcomes and the difference that all this makes ?

Dr. Kirsten: The term vulnerable populations is a little bit heavy controversial . It
doesn't capture fully that individuals also have extraordinary
resilienc ies to deal with adversity , thin king about how multiple
vulnerabilities together create the types of challenges that need to be
addressed . Not just what happens in the context of health care , but
also how they are in the community ?

Our center is a research center. It's c urrently directed by Margot
Kushel . I think many of the faculty in the Center for Vulnerable
Populations focus on specific high needs populations. Dr. Kushel
herself focuses on homeless populations and really understanding as
our homeless populations in the Bay Area are ag ing, their health care
needs and particularl y magnified by lack of housing.

We have faculty who focus on food and addressing food and security .
Then we're very interested in technolog y. We think that just because
we are working in th e safety net setting, a lot of times our high - tech
solutions actually can allow us to reach more people if they are done
with a partnership with the communities we aim to serve . We're
mostly focused on research and trying to be a t the leading - edge for
implementing strategies in clinical settings , in community - based
settings, as well as in the policy arena that can allow us to improve
the health of our most vulnerable in our area [inaudible 00:09:45] .

Mark Masselli : We're speaking today with Dr. Kirsten Bibbins - Domingo , Professor of
Medicine and Chair of the Department of Epidemiology and
Biostatistics at the University of San Francisco and is co - Founder of
the UCSF Center for Vulnerable Populations at San Francisco General
Hospital.

K irsten , let's talk a little bit about this reca libration of the health

Kirsten Bibbins - Domingo

system to do a better job in focusing on prevention . You're a
biochemist, researcher and a clinician . You're also a big believer in the
promise of precision medicine.

I should note that our health center was chosen by the National
I nstitut e of Health to be an early participant in the “ all of us ” study ,
making sure we have a population in that study that represe nts “ all of
us ” .

You've been very focused in on diversifying genetic studies . I'm
wondering , if you could tell us about some of the important research
in cardiovascular health, for example, and how precision medicine
techniques are helping you mine that data?

Dr. Kirsten: That's a great question. We live in a really extraordinary time , where
we can know so much more about those biological factors that put us
at risk for disease. When we combine that information with things
that we know about our individual behaviors over time and the
environments that we live in a re pulling all these strands of data
together with the computationa l power that allows us now to analyze
that data . That can really yield new insights for individual patients, but
also for grou ps and communities of patients .

Sometimes , i t's hard to know what te rms precision medicine means ,
but they mean to me more data th at we can th read t ogether in a way
with other types of data to really understand how the best target
both prevention and treatments for an individual .

In cardiovascular d isease prevention , one of the things that animates
me , in particular , i s how we start to do prevention earlier in life, that
we're not just waiting when somebo dy is 50 to say, “oh , yeah, take
your blood pressure medicines , ” but think what could we be doing at
the earliest possible stages?

How do we identify those fewer people amongst our ad olesce n ts and
young adults, who may be at very high risk and I think there's a lot of
promise for the types of -- efforts in the “ all of us ” initiative , in the
precision medicine initiative , to really, in the cardiovascular disease
space, help us say we ha ve to prevent at all stages in life , but those
people who are at high risk at early ages, we want to really double
down and make sure that we are aggressive in treating the types of
risk factors as they develop.

I also think there's potential there to reac h populations we've not
always reached that's w hy I'm really thrilled that “ all of us ” has made
such a concerted effort to increase the diversity. We know -- if we just
talk about genetic factors that determine outcomes , most of our
genome - wide association studies and our genomic studies are
disturbingly lacking in diverse representation , I think [crosstalk].

Kirsten Bibbins - Domingo

Yeah is 4% in our genomic studies, 4% represent the African -
American , Asian or Latino populations, which is really just
unacceptable .

Margaret Flinter : Yeah.

Dr. Kirsten: It’s al so, becau se the insights we get in biology come from
understanding the heterogeneity that exists . It's actually important
for all of us to have diverse participation in all of these studies .

Right now, w e live in an environment where data can be integrated in
ways that I actually think we can deliver care better in this way , so we
use this term precision population health or precision public health,
which basically says, a lot of what we're talking about in integrating
social car e and health care is like, well , can we use o ur health care
data to understand hotspots in the community for diabetes in poor
control and understand what is it in that environm ent?

In the report, we describe efforts to use [inaudible 00:13:41] that
people were using real - time , real data o n their use of inhalers to
understand environmental factors in a particular area and advocate
and so I think there's lots of innovative ways we can use real - time
data from individuals to improve individual health in the pre cision
medicine initiative , but also population health .

Margaret Flinter: Well, that's wonderful . I think you would be very moved to see the
wide range of people of all kinds of backgrounds , ethnicities that are
enrolling in this study. It's very powerful exactly what Francis Collins
set out to do , but I want to give you a chance to talk about something
that I know you're very passionate about and that is our work to train
the next - generation of health care providers ; and researchers and
health care provide rs who are researchers, which we think is really a
sweet spot.

You're at one of the country's best teaching hospitals, University of
California, San Francisco. As you thin k about this work that you're
doing to really reshape the American health care system , how are you
looking at training this next - generation in a different way?

Dr. Kirsten: One of the things that I think has been extraordinary at UCSF is really
how much what we are talking about here today. Social care and
health care has really been front and center with how our medical
school curriculum is designed .

The first week s of medical school , our m edical students are not in the
classroom, but they're actually out in the community and community
organizations to really understand the communities in our area , so it's
really woven in.

We listen to our studen ts, we have a diverse student body . Three

Kirsten Bibbins - Domingo

years ago , when they were protesting Black Lives Matter, they started
the movement, White Coats for Black Lives , and a lot of the activism
amongst our stude nts actually is reflected in the changes in the
curriculum , in the way that we weave together social determinants of
health structural factors that impede good health as well as health
care . My goal, I want all students to be inquirers . That's really key i n
our curriculum --

Margaret Flinter: Absolutely.

Dr. Kirsten: -- and we want some sub set of those students to actually pursue
research careers, right ? I think we were really fortunate at -- when I
was first starting and then in 2006, when we founded th is center that
there were people on our campus who basical ly said that we want to
be a full service res earch organization and so t raining the next -
generation to be outstanding clinicians is important, but also that they
become the people who are leading the scholarship in this area as
well .

Training in this area is going to be important for all of us . It's not just
an awareness of social determinants of health, but also skill building,
you all talk about these really powerful inner - professional teams .
Turns o ut, it's actually hard to work in inner - professional teams . To
the extent , we can train earlier on how to do that effectively, that
really allows us to build a workforce that's not just aware, but actually
has the skills to do this .

Then we talk a little b it about this extraordinary data - rich
environment that we li ve in. I want those clinicians who are interested
in this area , who think about data science to actu a lly think about how
can they apply those data science tools to -- ways to think about data
inte gration across the many sectors that we're talking about. That's
where the next wave of discovery and innovation that's going to
come .

Mark Masselli : I want to bring the P word into our conversation, not politics, but
policy . A good health policy w ith cert ainly the Affordable Care Act , but
I think you come from an interesting perspective as a clinician,
physician , leader . I know you've been very focused in on the great
disparities of health outcomes that have occurred, because really, we
haven't made good p olicy. It hasn't been informed by data. Talk to us
a little bit about some health policy initiatives that make sense to
you ?

Dr. Kirsten: This is such an important question. I think the voice of physicians, the
voice of researchers, to be able to speak and advocate directly with
policymakers is critica lly important. I work mostly with researchers
and we always want t o have that objective lens as researchers and
separate it from advocacy , but I think being able to disseminate our

Kirsten Bibbins - Domingo

findings and work closel y wi th policymakers , so that they can develop
evidence d - based policy is critical.

We started a new h omelessness initiative that has added [inaudible
00:18:05] taking the evidence d - base d and working directly with
policymakers , so that they can make more informe d policy choices
that we know impact the health of the patient s et we care the most
about.

We have a special initiative that we are launching at UCSF, which we
call “ evidence to impact , ” which is basically how can we get
researchers, clinicians to be able to speak on evidence directly with
policymakers and partner with them for change, in HIV , in tobacco , in
food policies.

When you talk about the national landscape and you ask me what's
going to be most important for dis parities. One is the extraordinary
pr ogress that has been made and just achieving more access to care,
because people have insurance coverage and I think -- while we talk
about the social determinants of health and they are critical , access to
high quality health care is also critical .

I thin k , in the report, we do talk about the financing m odels that are
really necessary to achieve integration of social care into the delivery
of health care . Even within our current structures, we could try many
more things and that much mo re innovation is pos sible .

I think we always want to be in a policy environment that allows those
of us on the ground practicing to try the things that we know is going
to be best for our patients. There's so many ways in which the policy
environment can really help us to dev elop our own solutions . I think
we're really encouraged by that.

Margaret Flinter: Well, we've been speaking today with Dr. Kirsten Bibbins - Domingo,
Professor of Medicine and Chair of the Department of Epidemiology
and Biostatistics at UCSF and a member of the National Academy of
Medicine , where she has just chaired the panel on social
determinants of health.

You can acces s their report at the nationalacademies.org/ SocialCare
or follow her work by going to ucsf.edu / kirsten.bibbins - domingo .
Kirsten , we want to thank you so much for your leadership, your
dedication to research and to practice and for joining us on
Conversations on Health Care today.

Dr. Kirsten: Thank you very much. It's been a pleasure.

[Music]

Mark Masselli : At Conversations on Health Care w e want our audience to be truly to

Kirsten Bibbins - Domingo

know when it comes to the facts about Health Care reform and policy ,
Lori Robertson is an award winning journalist and Managing Editor of
FactCheck.org a non - partisan, non - profit consumer advocate for
voters that aim to r educe the level of deception in U.S. politics . Lori,
what have you got for us this week ?

Lori: Democratic Presidential candidate Beto O'Rourke has faced a backlash
from Republicans and some Democrats for his advocacy of a
mandatory buyback program for so - c alled assault weapons ; but
Senator Chuck Schumer went too far when he said he didn't know of
any other Democrats who agree with O'Rourke .

There are at least two democratic senators running for president , who
agree with O'Rourke 's proposal. All of the leadi ng Democratic
presidential candidates support a ban on the sale of certain semi -
automatic weapons, but most of the candidates have expressed a
preference for either a mandatory or voluntary buyback of such
weapons , currently owned by Americans.

Senator Kam ala Harris told reporters in New Hampshire that she
supports a mandatory buyback program. Senator Cory Booker also
supports such a proposal. One other candidate, Julián Castro said , he
at least supports a v oluntary buyback program , but “ I'm willing to
hear the argument s on mandatory . ”

The NRA says , the AR - 15 is “ America's most popular rifle. ” That rifle
was used in several mass shootings, including at schools in Newtown,
Connecticut, and Parkland, Florida ; estimates on the number of
privately - owned assault weapons range from 3.3 million to 16 million.

As for the public an NPR/PBS NewsHour/Marist Poll found 46% said
Congress should pass legislation to “ create a mandatory buyback
program of assault guns . ” That's my fact check for this week. I'm Lori
Robertson, Managing Editor of FactCheck.or g.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenber g Public Policy
Center at the University of Pennsylvania . If you have a fact that you'd
like checked, email us at chc radio.com. We'll have FactCheck.org ’s
Lori Robertson, check it out for you , here on Conversations on Health
Care .

[Music]

Margaret Flinter: Each week Conversation ’ s highlights a brig ht idea about how to make
wellness a p art of our communities and to everyday lives. Louisville,
Kentucky has consistently been on a top 20 List of U.S. cities you don't
want to live in , if you have a lung disorder, surrounded by the nation's
leading rubber manufacturing entities. This is a cit y that has grappled
with pollution. Several years ago, the city's newly hired Chief of

Kirsten Bibbins - Domingo

Innovation made a decision to tackle the issue.

Ted Smith : Maybe the risk is co ncentrated in certain places . If we knew where
the risk was concentrated, maybe there will be something we could
do about it.

Margaret Flinter: Ted Smith had learned of a t ech - enabled smart inhaler that when
synced to a person's phone, acted like a GPS for whenever that
person needed to use their rescue inhalers .

Ted Smith: To put a GPS transpo nder on top of your inhaled medication , so that
when you took a puff of your medication, it would take a snapshot of
what time it was and where you were, and you're capturing it in real
time.

Margaret Flinter: Smith dubbed the program AIR Louisville , and t racked 1 , 100
participants over the course of a year. He said , they were able to chart
environm ental triggers in any given area , where an asthma attack
occurred giving them some great public health epidemiology data.

Ted Smith: One pa rt of the use of the te chnology is the su rveillance , but another
part of the technology is the feedback loop to the user , who learns
how poorly controlled or not their asthma is . There is an immediate
effect people end up getting better control of their respiratory
disease .

Marg aret Flinter: Reliance on emergency inhalers dropped 78% among participants and
the city was now armed with data that could help them devise
pollution mitigation strategies .

Ted Smith: With a harder problem , people are exposed to levels of pollution that
w e are going to have to work hard to figure out how to remove --

Margaret Flinter: A tech enabled smart inhaler that informs public heal th officials how
they might reduce the burden of asthma health costs , while teaching
asthma sufferers to better control their disease and stay healthier.
Now that's a bright idea.

Mark Masselli : You've been listening to Conversations on Health Care . I'm Mark
Masselli .

Margaret Flinter: I'm Margaret Flinter .

Mark Masselli: Pe a ce in health .

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at chcradio . co m, iTunes or wherever you
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Kirsten Bibbins - Domingo