Vacuums and Heat Aid: Stretching the Definition of Health Care

What makes or keeps us healthy often has nothing to do with what happens in our doctor's office or a hospital.

Angila Griffin made this discovery a few months ago when a community health worker stopped by to check on her kids, who have asthma. Jean Figaro came armed with vinegar and baking soda. They're cleaning products, he explained.

"Who would think to use vinegar to clean a household?" laughed Griffin as she told the story.

Griffin loves scented disinfectants and perfumed air fresheners. But she tossed them to help her son and daughter avoid asthma attacks.

"If I'm using the perfume and stuff, their asthma is acting up, their eyes are bloating up," Griffin said.

Figaro, who works out of an asthma clinic at Boston Medical Center (BMC), said "we complete the work the doctor starts at the hospital." In addition to the vinegar, he brought buckets and mops, pillow and mattress covers and a new vacuum cleaner.

"It's a very expensive vacuum," Griffin said. "When he brought it in, I'm like, 'Whoa.' It grips to the rug, it goes different levels, so it will really get down underneath the rug and pull everything up."

Before Griffin changed her cleaning routine, her son Torryn was in and out of the emergency room several times a week, sometimes staying overnight. Now, "Torryn hasn't had an outbreak in ... wow, it's been months, months," Griffin said, shaking her head.

BMC, through a federal grant, is spending $1,500 on a package of training and supplies for Griffin and 75 other families whose children have asthma. Dr. Megan Sandel, who runs this asthma pilot program, says Torryn's hospital care for the same period would cost $5,000 to $7,000.

"So instead of purchasing nurse time and doctor time in the hospital, you're now purchasing community worker time to go out into homes and you're purchasing vacuum cleaners," Sandel said. "In many ways this is a better allocation of health care resources and in the long run people are healthier than they were before."

Sandel is part of a growing number of doctors trying to shift health care spending to prevention.

"You have to be involved as a health care organization that's going to accept the total responsibility for care in everything," said Gene Lindsey, CEO of Atrius Health, the largest independent physicians group in the state.

Lindsey sees more and more care moving to a patient's home. He mentions case workers who visit the elderly and roll up scatter rugs to help avoid a fall. Traditional insurance plans don't pay for these home visits. They could be covered under a global payment, in which doctors negotiate a budget for their patient's yearly needs and decide how best to spend the money. Atrius, under Lindsey, is working with global payments to provide more preventive care.

"If an organization is going to be successful in global payments, they need to be thinking this way," Lindsey concluded.

But what to include under the umbrella of preventive care is an open question. At many community health centers around Boston, the health care team includes attorneys who help patients find and keep safe housing as well as counselors who help patients with heating and food assistance.

"Without heat my son would be in the hospital most of the time," said Khristia Kenney, whose son has asthma. On a recent day, Kenney met with her case worker, Marika Hewes, at Dorchester House, a community health center in Dorchester. Last winter Hewes helped Kenney with heating assistance. On this day they were talking about legal help with a public housing voucher.

The Dorchester House health care team includes volunteer lawyers from the firm Ropes & Gray LLP and a program called the Medical Legal Partnership who will assist Kenney. The clinic has a food pantry, finds shelter for the homeless, and provides car seats, toys and clothes for needy children.

Hewes said "at least 90 percent of our patients receive these services" -- services that many people don't think of as health care.

But there are limits on how far providers and insurers are stretching the definition of health care under global payments. A global payment contract does not pay for housing counselors or food pantries or help with heat, says Blue Cross Blue Shield of Massachusetts CEO Andrew Dreyfus.

"Organizations that accept global payments alone will not tackle some of these larger social and economic issues that contribute to high health care costs," Dreyfus said, "but global payments will be a much stronger partner with public health agencies in beginning to address these issues."

Public health advocates want to make sure they have the money to be active partners in the effort to keep patients healthy. They are lobbying for a 1 percent surcharge on health insurance plans that would fund a new "Prevention and Cost Control Trust." The trust would be a stable source of funding for school nutrition projects, exercise initiatives, programs to cut tobacco use and other means of improving health outside a doctor's office or hospital.

"We know that about 10 percent of our health status is due to care we receive," said Amy Whitcomb Slemmer, the executive director of Health Care for All. "The other 90 percent is related to our lifestyle and environment."

The trust would produce significant savings, argues Valerie Bassett, executive director of the Massachusetts Public Health Association. "If we reduced two preventable diseases, hypertension and diabetes, by 5 percent, Massachusetts could save half a billion dollars a year," she said, quoting a study in the American Journal of Public Health earlier this year.

The question of what health care issues a global payment should take into account is open to debate now on Beacon Hill. Legislators are preparing their version of a bill to get health care spending under control and improve the services we receive.

Spending more of our health care dollars on prevention is "the direction we're headed," said Sen. Richard Moore, the Senate chair of the Joint Committee on Health Care Financing. "The question is: how do we do it? It might be government finding ways to incentivize businesses and individuals to stay healthy so they don't cost as much."

Rep. Steven Walsh, the House chairman for Health Care Financing, says shifting health care dollars to prevention, including vacuum cleaners or air conditioners, "makes sense because that individual will see their premiums go down and if we make that person healthier the whole system will benefit."


So what would it take to make you healthier? How, if at all, should our health care system change to support you? I look forward to hearing from you.

[View the story "What's Health Care to You?" on Storify]

This story was produced, in part, as a project for the California Endowment Health Journalism Fellowships, a program of the University of Southern California’s Annenberg School for Communication & Journalism.