EJB Talks Podcast

Soumitra Bhuyan, PhD, MPH

EJB Talks: Laying Bare Nationwide Health Disparities

April 23, 2020

Returning to the healthcare field amidst the COVID-19 crisis, host Stuart Shapiro welcomes Professor Soumitra Bhuyan, who teaches in the Bloustein School’s health administration program and Dr. Sabiha Hussain from Robert Wood Johnson University Hospital. Their discussion focuses on the social determinants of health; what they are and how they are affecting the outcomes of COVID-19 patients. The role of information technology (IT) and telemedicine are also playing a larger role in the crisis, as doctors seek to reach populations disproportionally affected by COVID-19 while at the same time reducing the burden on the healthcare system.

Stuart Shapiro
Welcome to another episode of EJB talks. I’m Stuart Shapiro, the Associate Dean of the Faculty at the Bloustein School. And the purpose of this podcast is to talk with my colleagues about issues affecting people in New Jersey, the United States, and the world. Today we return to healthcare amidst the COVID-19 crisis. And for the first time, we’re welcoming two guests. The first is my colleague Professor Soumitra Bhuyan, who teaches in our health administration program here at the Bloustein School. We’re also very lucky to have Dr. Sabiha Hussain from the ICU at Robert Wood Johnson University Hospital. Sumitra, Sabiha, thanks for taking a few minutes to speak with us today. Soumitra, can you tell us a little bit about your general area of research your connection to these issues?

Soumitra Bhuyan
Hi, good morning, Stuart. Thank you for having us today. My research focuses on understanding how information technology can improve health outcomes with an overarching goal to improve the health of the population, both locally here in the United States and globally. I think we should better leverage health IT to make our healthcare system safer, improve accessibility, and reduce cost. We spend about 18% of our GDP on health care. But the health outcomes and the indicators do not reflect that investment. At Bloustein, I also teach a graduate course on population health management.

Stuart Shapiro
Wonderful. And Dr. Hussain, can you tell us about your work at RWJ?

Dr. Sabiha Hussain
I work here in the ICU at Robert Wood Johnson in New Brunswick. I also teach at the medical school as medical school faculty. Recently, we’ve been dealing with this crisis but prior to that, I’ve been doing a lot of work looking at social determinants of health in the ICU and how they relate to our ICU admissions. And I’m not that surprised with the disparity that we’re seeing with this crisis. Because, you know, in the past, we’ve seen that a lot of our patients were actually having social determinants and that most of the individuals who were being readmitted–there was a 50% higher rate of readmissions of those patients who had social determinants. So, you know, this crisis I think just brings that more to par. And I do agree with Soumitra when he says that we do have to leverage IT to help us better access these patients.

Stuart Shapiro
So you mentioned social determinants of health, and that’s something we’re big on in the Bloustein School because we have people that study policy, planning, and health; we’re very convinced that it’s all one package, but can you explain for our audience what you mean by social determinants of health.

Dr. Sabiha Hussain
Well, social determinants of health are things that are outside you, just like heart disease and other factors that affect your health. Such as access to health care, being able to pay for medications, being able to get a ride to even go to see your physician, being able to pay utility bills, and have a refrigerator where you can actually keep your insulin so that you can take that. So, a lot of factors that are sometimes not necessarily under your control, but they do impact your health. And we recognize that — I know we’re sort of late to the game when it comes to actual providers thinking about this — we came to this game at around like four years ago. And when I talk to the social workers and our community partners, they’re like what took you guys so long? But I think that having these conversations, we realized, I was seeing patients that kept coming back to the ICU, and we’re like, we have to stop this. We can’t just have them. We fix them and they come right back. There’s something that’s bigger than us, that we need to be a part of. So that’s what we started doing very early.

Stuart Shapiro
Great. Soumitra, I know you’ve given some thought to this, to the role that disparities play, and the fact that COVID-19 has really laid bare those disparities for everyone to see. Can you talk about your perspective on why we see that happening?

Soumitra Bhuyan
So let me piggyback on what Dr. Hussain just said. You know, as a health services researcher, I’m studying this disparity for more than 12 years now. Although millions of Americans, they’re very surprised to see that people of color have worse outcomes from COVID-19 and they’re dying more, as compared to other races and ethnicities. Sadly those of us in the public health and health policy world and also in medicine, that is actually our worst fear come true. This was a ticking bomb waiting to explode. And COVID-19 just exacerbated the existing disability at a structural level in American society.

And I’m going to basically touch base on a few things doctors have already mentioned. One thing is Dr. Anthony Fauci, who said in one of the briefings about chronic illnesses, that chronic illness and diseases are a risk factor for high COVID mortality. And in minority individuals, specifically, the African American community has a higher percentage of those chronic illnesses in that population. For example, hypertension, diabetes, etc. And just giving an example the Trump administration repeatedly said that if you’re not feeling well first go and talk to your healthcare provider. But sadly, millions of Americans do not have any primary care provider to talk to, specifically in the states that did not expand Medicaid; millions do not have access to any health insurance.

Even in New Jersey after the expansion of Medicaid, about 8% of the state’s population does not have any insurance. So when we hear them say, go and talk to your doctor if you’re not feeling well, most of the time those people may not have a doctor to go and talk to. And most of the testing side does require some kind of prescription for testing. So there is also a concern that minorities or people of color are less likely to get tested. And also when someone has a chronic illness they need to have access to medication on time, and also have access to healthy food. Now what is happening with millions of children at home, some of these low-income families are using their SNAP funds to buy more food for more people, thus compromising on the quality and quantity of food. And maybe some people are also not spending money on medication and they’re buying food at this point because it’s a time for survival. And according to the current policies, SNAP recipients cannot purchase groceries online. So it also actually exposed that a lot of low-income minorities, they need to go to the grocery store to get those groceries and thus exposing themselves to the virus more.

Stuart Shapiro
So you know my background is public policy. So the first question I ask whenever I hear this is what can we do? What should we be doing differently? What lessons should we be learning? Obviously things that you knew for a long time, but now everyone knows about these disparities. What can we do to alleviate them?

Soumitra Bhuyan
I think immediately what we need to do, we have some data about mortality, right? Some cities, some states are reporting that among African Americans, Hispanics, there’s a higher mortality rate from COVID-19. But we also need the information for testing, so basically, do we have testing sites in the minority communities because they may not have reliable transportation to go to a far place to get tested, and when are they getting tested?

That’s another important question. New Jersey at this point is not releasing any data on race and ethnicity, but I think that will be very important; not only race and ethnicity data from the admission side of it but also from the testing side. And I just got this data from the New Jersey state website yesterday. We actually had about 161,000 tests so far in New Jersey, and among that population, about 72,000 were tested positive. So that number is around 45%, which is still very high. And if you compare that number with countries like South Korea or Germany, whose numbers are significantly lower, around 4% and 7%, respectively. So, I think there’s a long way to go here to address and tackle COVID-19. We are now only testing those people who are at higher risk, and I think the number needs to come down below 10% before we can think about going back to some kind of normal life that we had before COVID-19.

Stuart Shapiro
Dr. Hussain, what kind of changes within the healthcare system can we make to deal with some of these disparity issues?

Dr. Sabiha Hussain
I think it has to start from the very beginning. As Soumitra was saying, having primary care be a real focus in these communities where individuals who have chronic diseases like hypertension and diabetes are the same individuals who are in our ICUs, dying. They’re not the elderly population that everybody was talking about. They’re young Hispanic males, who are a little bit overweight, have some hypertension, have some diabetes. So I think primary care is something that we really do need to focus on, and making access to that kind of care for this group; something that’s real and something that they can go to.

And then also going on to make sure that we have a really strong public health system, which allows for people to get medications; allows for them to be able to be followed in a meaningful manner. We are trying to follow these patients who are COVID positive through our district clinics, and we’re finding that it’s really hard to even follow them because we don’t actually know how to culturally do it. I don’t think that we can just put it into one system fits all. A lot of people do not have access to good internet. They don’t have access to computers, and we can’t rely on reaching them in that way. We have to figure out in innovative ways.

Maybe as I was saying, having kiosks at the grocery store, so that they could potentially put in some of their data and be followed in that way. Also, testing is fine, but the issue becomes — if you test positive, how can you expect these individuals to isolate? They just don’t have the means; a lot of them have to work. So there has to be something that’s going on infrastructurally in the healthcare system, that makes sure that these individuals, who are very different in not just socioeconomics but also culturally. They are going to go to your laundromats and that’s where they socialize. And so perhaps that’s where we find them and follow up. We’re not able to necessarily just follow up; they’re not sitting at home, waiting to answer their phones, and that’s what we’re finding. It’s hard for us to follow them because we can’t find them.

Stuart Shapiro
There was a great op-ed in the Times this weekend about how we’ve allowed our public health infrastructure to degrade over the past 40 or 50 years and now we’re paying the price for it. You mentioned people have to go to work. Soumitra, I know you’ve written about paid sick leave. Can you talk about why that’s a component of dealing with some of these disparities?

Soumitra Bhuyan
Yes, I think paid sick leave is a very important determinant of a lot of things including access to timely care. And I strongly believe America needs a permanent solution to this issue. The U.S. is the only country in the developed world without a federal mandate for paid sick leave policy. We actually did a study before, and we found that the availability of paid sick leave resulted in significantly less ED visits. And other studies also found that, in terms of accessing primary care, preventive care, people who have paid sick leave, they are more likely to do those kinds of things. And despite that, millions of Americans, they actually do not have any paid sick leave.

Actually, there was a study conducted from UC Berkeley in 2019 found that about 53% of the hourly service sector workers at 91 large American companies, they do not have access to any paid sick leave. And just giving an example — it says that 70% of workers at McDonald’s they surveyed have no access to paid sick leave. And you know, think about that. So for example, a McDonald’s is now offering 14 days paid sick leave for employees in their corporate store. And about 95% of the McDonald’s are franchisee-owned. So, even though they have some kind of policies in the corporate stores, stores owned by the other franchisees, and those employees still do not have any provision of paid sick leave. So, under the CARES act the Trump administration signed recently it mandated that organizations or employers below 500 employees, need to give basic coverage if someone is sick with COVID-19 or some other family member is sick from COVID-19. However, there is no provision for employers over 500 employees. It’s important because a lot of these franchises actually have more than 500 employees and right now the policy on paper is that you either need to be tested positive for COVID-19, or the state or a company needs to put someone in quarantine in order to be eligible for this paid sick leave.

And we discussed some of the obstacles and some of the issues with getting tested, we do not have enough testing. So it makes it extremely difficult for a low-income individual, even if they feel a little bit awkward or are not feeling well, to skip their job because, by law, they’re still not eligible for those big sick leave policies. So I think and, I believe, we wasted a significant amount of time, at least at the beginning — at least a week or so — to actually navigate through this process of what to do with paid sick leave. And I think that time could have been better used to come up with our testing strategies rather than talking about paid sick leave, I think we need a permanent solution to this problem.

Stuart Shapiro
Yes — by the time someone tests positive, it’s really too late. They’ve probably infected a lot of other people at that point.

Switching gears a bit, Soumitra I know you’ve also written about telemedicine. I want to highlight that. What is telemedicine and why do you see its growth coming in the wake of the COVID-19 crisis?

Soumitra Bhuyan
So the whole concept of telemedicine has been here in the U.S. for a while. This is not a new concept. So it is basically having access to a healthcare provider by means of video, audio, or any other virtual means. Even though it has been a part of the healthcare system for a long time, there are significant regulations from our payor side, mainly the Medicare side of it for reimbursement for telemedicine services. And with COVID-19, I think the CMS has discussed actually lifting some of those requirements in allowing providers to get reimbursed. I think that’s a wonderful move because that will reduce the burden on our healthcare workforce. People with minor medical symptoms, they should be able to access the provider remotely.

However, as Dr. Hussain mentioned, there is a digital divide in our society. Individuals from certain racial and ethnic backgrounds, and even individuals in more rural areas, they do not have access to reliable internet. So that, I think, remains to be seen how this telemedicine service can be effective. To empower those communities, minority communities and the communities in rural areas,

Stuart Shapiro
My wife and kids had a remote appointment with their allergist this morning. But we fall right in that category you’re talking about, you know, we’re upper-middle-class, we have good internet access and this was a minor issue. So it fits for that. But I do wonder how broadly it can be applied. Dr. Hussain, what do you think about the adequacy of care we can provide remotely?

Dr. Sabiha Hussain
I think right now, as you can imagine, we’re doing a lot of remote care for patients. I do pulmonary critical care. So a lot of my patients I really do need to listen to their lungs and be able to assess them in a meaningful matter. I mean, there is something to be said about, you know, touching your patient. I think that is a very important concept where you do get us. When I walk into a patient’s room, I can get a sense of the entire flavor of that patient within just that brief interaction which you lose in telehealth. But I think that it has its place. There are a lot of patients that cannot leave their house to come to see me because they’re short of breath. And I could potentially do a meaningful, short visit with them. So it has its role. I think that what it has done for us, it has allowed us to push forward with this, we’ve always wanted to be part of the whole telehealth scene. And it has moved the medical school to that in a much faster manner than we would have ever thought. And so we’re all doing telehealth right now. I think it definitely has its place. But it, of course, doesn’t fit every patient with every scenario.

Stuart Shapiro
Well, I would be remiss if we wrap this up without getting a picture from you Dr. Hussain, on what’s life like on the front lines? I mean, I conduct these podcasts from the comfort of my home office and can talk about the policy stuff. But I think really our listeners would like to hear your experience and how things are going on the front lines and what you’ve seen this past month.

Dr. Sabiha Hussain
I have to be honest, I’ve been doing this for 17 plus years and I’ve never experienced anything like this. I think that the disease process itself is very, very challenging, and very daunting to us. I mean, we’ve seen a lot of patients. I’ve had patients bleed out on me, die in front of my eyes, those things have happened. But this disease process itself is so inclusive. It involves so many body systems, that you are basically going down and rethinking the entire way that you’ve actually approached patients in the past. And I’m relying on a lot of, unfortunately, a lot of the consultants are not here. A lot of them are actually at home working from home. So you’re relying on them to give you insight from there. Most of the critical care doctors are, of course at the bedside taking care of these patients.

And what I’m actually seeing is that there’s a push more of a surge in the ICU patient population, because now you’re going into your like four-week, five-week, mark of these patients. And those patients who are in the hospital, who didn’t get better within a couple of days and were able to be discharged, they’re lagging and now they’re actually crashing and ending up in the unit. So our unit numbers have actually picked up some in the past week or so. And it has to do with the fact that they didn’t get better and they’re now ending up in the ICU. I see this as really long term, unfortunately.

We’re going to be in this for a while and the follow up has to be as well as it was for the World Trade Center victims, where they had to follow up and they still are being followed up in those clinics. I think that you’re going to have that for this COVID-19 population. A subset of those populations who required oxygen and may not oxygen, you’re going to see some sequelae, either bronchiectasis or pulmonary hypertension. A lot of these patients we’re sending home on blood thinners. So there has to be an infrastructure and this may be the push to actually have a very good public health infrastructure that supports this entire healthcare system. I think this may be the thing that does it for us. But we do have to do something.

Stuart Shapiro
And I certainly hope you’re right about that. And I don’t think we’ve really grappled with the long-term implications of still dealing with COVID-19. We’re so understandably wrapped up in the moment and the numbers of the moment and such, but I think you’re absolutely right. This is a long-term problem, and hopefully, it motivates us to come up with long-term solutions. I’d like to thank you both for coming onto the podcast today. Dr. Hussain, I’d like to add a special thanks to you for being a non- Bloustein guest and of course for everything you are doing on the frontlines of this crisis.

Also, a thank you to our production team–Tamara Swedberg, Amy Cobb, and Karyn Olsen. We’ll be back in a few days with another talk from another expert from the Bloustein. School.

Soumitra, Sabiha. Thank you very much.

Dr. Sabiha Hussain
Thanks so much.

Soumitra Bhuyan
Stuart, thank you so much. Take care.

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