Why social determinants matter for children’s health: An interview with Michael Fisher

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The president and CEO of Cincinnati Children’s Hospital explains how social determinants of health (e.g., education, housing, social support) affect children’s health outcomes, and how organizations that invest and intervene early can generate both near- and long-term value.

DISCLAIMER: The views and opinions expressed are those of the interviewee(s) and are not necessarily those of McKinsey and Company.

Following is an edited transcript:

Erica Coe:

Michael, it's great to be speaking with you today about the social determinants of health. Such a critical topic, given 40 percent of health outcomes are determined by social determinants. I’d love to start with just understanding how did you find yourself leading a children's hospital?

Michael Fisher:

Erica, it's great to be with you. I had the privilege to be on our board of trustees, and it gave me a firsthand view of the incredible work that we were doing for children, both on the research and clinical-care side, but also to make a difference in the lives of children, their families, and our community. And having been an entrepreneur for many years, I really saw the opportunity to give back to our community, to bring some of that innovative spirit, and that notion of better serving customers, in this case, patients, families, and communities.

Erica:

What were some of the pivotal moments growing up that shaped who you are as a healthcare leader today?

Michael:

I was fortunate to be in a loving and caring home, had great parents as role models, who taught me how to care for others, and treat everyone with respect and dignity, and try to make a difference. I also went to a large urban public high school and really began to appreciate the values of diversity. I had a chance to go to Stanford, and I think there, learned a lot about collaboration, pursuit of excellence, innovation, and then I spent the bulk of my career growing an automotive supplier globally, and learned a lot about what was going on internationally. But I think specifically, on the healthcare side, I’ve learnt so much from great mentors and teachers.

From colleagues at Cincinnati’s Children’s Hospital who are highly skilled pediatric clinicians and researchers to people like Maureen Bisognano and [former Centers for Medicare & Medicaid Services’ Administrator] Don Berwick from IHI [Institute for Healthcare Improvement] who taught me so much about what healthcare quality means and how to continuously strive for it, and so many others. And I think there was an event early in my time as the CEO at Cincinnati Children's where we lost a little boy. That had a profound impact on me. I already knew the importance of being focused on safety and quality. But I think that incident just drove into me the enormous responsibility we have for children, and the responsibility we have to the community.

I would say, in the early shaping, [my goal] was to spend time with new mothers out in the community, outside the hospital. And hear the challenges they were grappling with in these areas of social determinants, or what some are increasingly calling health drivers. And it became clear to me that we, as a children's hospital, and certainly as an anchor institution, had to find ways to do more and to be a better partner.

Erica:

Picking up on your point around social determinants, I think it is an understatement to say that Cincinnati Children's Hospital has been a leader in this space, and with this topic. There's been considerable research demonstrating that social and environmental experiences in childhood can affect outcomes later in life. I’d love to understand from you either a bit more about your experience in the community with those new mothers, or more broadly, how you see social factors, whether it be education, housing, violence or other trauma, food insecurity, playing a role in children's health?

Michael:

We see this in our primary care clinics. We've put in food pantries because it's been clear to us that for some of these children, their families literally don't know where their next meal is coming from. So of course, the ability to be healthy, to be on a medication regimen is compromised in that kind of way if they don't have basics, like food. And so, for a decade-plus, we have built in thoughtful and appropriate screening to determine whether it's food insecurity, whether it's housing issues, whether it’s education issues like lack of appropriate support for learning disabilities, or whether it’s personal safety issues such as violence in the home or the neighborhood, or other factors that might inhibit a child from being healthy.

How to build that into the initial intake of a child during a well visit, and then to connect them with all of the right partners who we work closely with to help address those issues is critical. Children don't choose to be in poverty. It is, in this case, they are born into the circumstances of their parents or guardians. So, I think we've also realized that we need to take a multigenerational approach, not only focused on the child.

Erica:

It’s an interesting point. I'm curious how addressing social determinants may be different for a pediatric population, compared to an adult population?

Michael:

So, I think one of the other things that's unique when it comes to children and their health, and where these health drivers come into play is certainly, prenatally, we hope and maybe in the first year. We, as a healthcare provider, have the opportunity to interact with some regularity with the mother and with the child. But as they get older, we really don't have the chance to interact with them and see them quite as much. So, one of the things we are working hard on is our partnership with the public schools. Because this is where children are, in daycare or preschool settings or as they start elementary school.

We are increasingly working, in our case, with the Cincinnati Public Schools, and ultimately, others in our community on how [we can] help the school system, the teachers, bring in some of the same quality-improvement methodologies and mind-sets that we've been using to improve quality, improve safety, and so forth, in the healthcare setting into these school settings. And it's empowering teachers, it's allowing us to connect with these kids in a different way. And we're already seeing some evidence of improved third grade reading scores, in places where that training has happened. We're also providing school-based health clinics in these public schools which allows us to promote prevention, make sure children have well visits, and address more urgent needs. Being able to catch things early is palpable.

We know the tremendous burden of mental and behavioral health issues affecting society, and certainly, children and adolescents. But we know the earlier we can intervene, educate, give parents coping skills, children coping and behavioral skills, the better off they will be. So, we have started to embed psychologists into both primary-care settings and in school settings. And we think these are some differences that we can make earlier for children.

Erica:

As an industry leader, what do you think the role of health systems is in addressing these types of drivers of health?

Michael:

I can't speak for all health systems but what we see in our community is that partnerships are essential, elevating the importance of children and children's health not only on the altruistic and moral grounds, but for the benefit of society is really important. And so, we think we've got a big role to play, to bring our content knowledge and our passion and our expertise to convene various parties, whether it's social service agencies, government entities, and certainly schools, and businesses to the table.

The other critical thing that we have to work hard at every day, and is really important to this work, is building and sustaining trust. Getting a parent, a child, or an adolescent, and all of these other partners to come together. To stay together, to work on these kinds of issues together, I think is the work that we're talking about to address some of these social determinants.

Erica:

What has been your strategy to finance models of care that allows you to treat the whole child?

Michael:

I think to the notion of economic sustainability, of some of this work, we are fortunate, to have philanthropic support, foundation support, and some well-meaning businesses helping us.

I know in Ohio, we've been working with the state on home visitation for at-risk first-time mothers. Maybe some help on mental health provider support; both in school and other settings. And then on the core policy piece of that, particularly for the children on Medicaid. I think at an institution like ours, we are also an enormous research institution. And so, I think our ability to provide these kinds of partnerships and interventions, and do learning that is publishable, that might warrant research funding. So that we can come up with evidence-based interventions, as opposed to, purely altruistic ones.

I've personally been very involved in a multisector approach in our community called the Child Poverty Collaborative. And I think what we've been able to make the case for, increasingly to members of the business community, is this is good for their business, to have children who grow up to be capable employees, to have citizens who are productive. And it's sharing best practices on how to overcome transportation barriers for people with their job needs, or other interventions that employers will see in their self-interest for a more productive, more stable, more growing workforce.

Erica:

I'd love to pick up on something that you mentioned, the fact that you view partnerships as being essential. I think one challenge that often stakeholders find when trying to address social determinants is the fact that no single stakeholder can do it alone.

And often, not only is the healthcare industry fragmented, but the social-sector industry is also quite fragmented, and it can be challenging to work across many partners. With some of the success that you have had, do you have any advice or lessons learned on how you've incentivized different partners to come to the table with you?

Michael:

Well, I think it's a work in progress. And I think the incentive is children. So how can we come together around some shared goals for those children? How can we learn from each other? How can we share some of these improvement tools, so that we're all using similar methodologies to try to drive that?

So, for example, one area our team has been working on is using geo-mapping and other techniques to look at particulate matter in maybe a more condensed [area], near a highway, for example, or near a former industrial site. And we know those neighborhoods are going to have higher incidents of asthma and other kinds of respiratory diseases. We're able to pinpoint where some proactive interventions may be necessary, in terms of our care.

And you know, another area where through community-health workers, and almost block by block, where we know which apartment buildings might have had a lead issue, or other kinds of issues. By literally targeting those neighborhoods, those streets, those buildings, and with trusted community-health workers and other members of the support system, we've been able to, in a couple of neighborhoods, dramatically reduce extreme prematurity. And so, part of it is knowing some of those social determinants, part of it is building the trust and relationship with those expectant moms, to make sure they're getting the appropriate prenatal care, and early childhood support. These kinds of changes don't happen instantly, but the opportunity and the payoff [are] immense. A lesson for us has been that we can’t do it alone and we need partners to do this with us, whether it is community health workers, community agencies who exist in these neighborhoods and intimately know the residents and their needs, or corporate partners who can bring their unique skillsets to help us address these issues. If you can make the case that reducing health inequities improves quality of life and wellbeing for all members of a community or a city, this seems to be a great incentive to pull together cross-sector stakeholders.

Erica:

Great. If you step back, what would you describe as the biggest challenges that your system is facing now, in an attempt to address social determinants?

Michael:

I think the biggest challenges are ones we've touched on in different ways. I think one is continuing to strengthen trust in urban settings like ours. I also think the scale of the problem, and the scale of the challenge is really large. And I think it's going to take a sustained, concerted effort to keep making progress on it. In fact, one of the biggest challenges I would argue for us to address would be the way in which we currently pay for healthcare. The potential impact of truly embracing, scaling, and adopting a value-based payment model and mind-set will help to drive innovation and sustain much of the work we are already doing around the social determinants of health.

Erica:

If you were to have the chance to reach out to other industry or government leaders, to really crack the code on social determinants of health, what questions would you raise?

Michael:

What is our responsibility to help our fellow human beings? And particularly, the most vulnerable among us. And are we doing all that we can? Not only do these children thrive better individually, but that we, society, benefit from healthier, more productive, better educated children, and as they become adults. So, wouldn’t we rather make smart evidence-based investments and interventions earlier?

How can we learn from other industries and apply their practices to improve child health? You know, the quality improvement movement in healthcare has been influenced heavily by learnings from industrial management practices, in particular the Toyota Production Systems (TPS) method which emphasizes lean principles. Hospitals that have applied the Toyota method have shown great success in improving the quality of care. What are some other common practices or unique strengths of industries outside of healthcare that if applied to healthcare could improve outcomes for children?

And how can we work better together? There are some interventions we've done in the safety arena with 130 children's hospitals, that show us that by sharing best practices together, by sharing common goals, and data, we can make real progress on what has otherwise seemed to be intractable problems.

I would not underestimate the importance of the health-system or health-provider side, but this would be true for the business entities, and social service entities, and schools. I wouldn't underestimate the importance and influence of boards of trustees and boards of directors to say, "This is who we are, this is a priority, and we're going to find a way to do our part on helping address these issues of social determinants." I think when the highest entities of our institutions put a stake in the ground, particularly when they partner with the senior management to do so, I think you can make a lot of progress.

Erica:

There's so much value in just prioritization from the top. So, given the current behavioral health crisis that our nation is in at the moment, with life expectancy declining and suicide on the rise, let’s return to the point that you made of the importance of mental health in a children's population, and really finding ways to intervene early. How do you view social determinants as being a potential important lever in addressing behavioral health needs?

Michael:

Well, I would first amplify, just this enormous challenge of mental and behavioral health that children and adolescents are facing. I think this is one we just have to dramatically pick up the pace, the investment, the interventions, the upstream that we need to do on it. I think on the social-determinant front, mental and behavioral health doesn't know any boundaries, when it comes to socioeconomic status, race status, it permeates every segment of society.

That said, of course issues around stress or what people often refer to as Adverse Childhood Experiences (ACEs), joblessness, or low income, food insecurity, transportation gaps, child care gaps, and inequities. You know, those things only exacerbate the kind of environment that a child or adolescent is growing up in, and it makes it that much more challenging for them on the mental and behavioral-health front. But again, I think it's really important when we talk about mental health to recognize this affects every segment of society regardless of income.

Erica:

Building off of the great progress and impact that you all have been having, are there any words of advice that you would leave others with?

Michael:

Well, I think we've just begun to make a little dent in our own community and through partnerships with our institution, and with parents, and children. If 40-plus percent of a child's health, and therefore life potential trajectory is influenced by these issues around income, then I think we as healthcare institutions, we as children's hospitals, we as society have to do something about it, and do our part.