New federal rules are changing the game for hospitals. Instead of just treating sick people who walk in the door, hospitals are now expected to help solve public health problems.
But while the federal government encourages this big-picture thinking, there’s not really much accountability. At least not yet.
Hospital consultant Ed Gamache says the health care industry is in the middle of a philosophical shift. Local non-profit hospitals are now expected to take the lead on issues of public health.
“They’ve always had a role in community health, but it’s been in terms of always being available to provide care to the needy when there are no other resources,” says Gamache.
Under the ACA, many of those needy people won’t need help from hospitals because they now have health insurance.
“And so the thought process is that as the need to support low-income and uninsured individuals declines, that there are going to be resources within hospitals to actually address some of these community needs," says Gamache.
Assessing public health
One of the first steps is something called a Community Health Needs Assessment, which is basically a survey hospitals do to find the most pressing health issues in their communities. The ACA requires hospitals to do the assessments every three years.
“The goal is really to reach out to our community, and see what they perceive as our needs in our community," says Christi Nowak, community health manager at Munson Medical Center in Traverse City.
Nowak says while the federal requirement is new, Munson has been doing health needs assessments since the 90s. During their last assessment, in 2013, they identified a few issues: maternal smoking, diabetes, obesity and access to care.
A lot of Michigan women smoke while they’re pregnant, and that’s especially true Up North. In Kalkaska County, for instance, more than 41 percent of pregnant women smoke. That’s double the state average.
Munson’s first job was to try to understand why so many women smoke during pregnancy. Nurse Betsy Hardy reached out to public health offices and local care providers.
“We also talked to women because we really wanted to hear the stories from people in our area," says Hardy. "We couldn’t figure out why. We knew we needed to know why.”
'The only release from a very stressful life'
Munson did a survey of women across the area. Hardy says she found women were willing - even eager - to talk about the problem.
“People were really open to talking about this because, interestingly enough, the majority of women we talked to aid they wanted to quit," she says.
Women told Hardy they know smoking is bad for their health - and their children’s health - but it’s just too difficult to quit.
She found the single biggest reason why pregnant women smoke is the extremely addictive power of nicotine in cigarettes. But underneath that, research shows a link between maternal smoking and poverty. Women living under tough economic conditions – especially in rural areas – told Hardy they smoked “just to have a break.”
“It’s sometimes the only release from a very stressful life,” she says.
Armed with new insight, Munson set out to make a dent in the problem. They trained providers on new techniques in “motivational interviewing” that emphasize cheerleading over preaching. They also re-evaluated all the “quit smoking” printed materials that are handed out in doctor’s offices and developed a new, up-to-date brochure.
A lag in accountability
But now it’s 2016, and Munson is working on a new health needs assessment. Christi Nowak can’t say if they’ve had any impact yet on maternal smoking.
“We don’t have any hard, quantitative data, to my knowledge," says Nowak. "The data lag is a couple years behind, and having done only a few of the focus discussions, I can’t really say.”
Ed Gamache says right now, the federal government is not coming back to check on what progress hospitals are making on public health. But Gamache says that’s coming, and hospitals know it.
“I think over time, absolutely, there’s going to be an expectation that you can demonstrate a difference,” he says.
Gamache says that in the absence of federal oversight, some states and local governments are taking matters into their own hands. New Jersey is threatening hospitals tax-exempt status if they can’t show improvements in public health.