Honing Unique Perspectives

Wednesday, May 13, 2015

Q&A: Graduation speaker encourages creative solutions

By Anthony Giornalista

Rebecca Onie, JD, the honorary speaker at Rush University’s commencement ceremony May 21, is the co-founder and chief executive officer of Health Leads, a company that connects patients with basic resources they need to be healthy. Onie comes from a different background than most in health care and wants tomorrow’s leaders in the field to bring their own fresh perspectives to health challenges. She recently talked about her career and the changing nature of health care.

You earned a doctorate in law, and you have an undergraduate degree in history and science. How and why did you end up in the world of health care?

Onie: In high school, I spent most nights at the dinner table arguing vigorously — and one of the few things my parents and I agreed upon was that I should probably be a lawyer.

So my freshman year as an undergraduate, I signed up for an internship in the housing unit of Greater Boston Legal Services. I showed up the first day ready to make photocopies and coffee — all the things I was qualified to do at 17. But instead, I was assigned to a righteous and deeply inspired lawyer named Jeff Purcell, who thrust me on to the front lines right away.

Over the course of nine months, I had dozens of conversations with low-income families in Boston, who would always present with housing issues because we were a housing unit — but when you scratched the surface, there was always an underlying health issue.

One of my clients was about to be evicted because he hadn’t paid his rent — but he hadn’t paid his rent because he was paying for his HIV medication, and he could not afford both. Or a mother who would come in — her daughter has asthma but wakes up covered in cockroaches every morning.

I became fixated with this connection between health and poverty — and also frustrated that we were intervening so far downstream. By the time families came to us, they were inevitably in crisis.

At the end of my freshman year, I read an article in the Boston Globe magazine about the work that Barry Zuckerman was doing as chair of pediatrics at what was then Boston City Hospital. The article talked about how Dr. Zuckerman had this radical but obvious vision that a pediatrics department should be a place where children get healthy.

His first hire was a legal services lawyer to represent patients. I cold-called him.

The doctors, despite their best efforts, never really had time for all the patients. Over the course of six months, I would corner them while they scrawled notes in the medical record or swallowed their lunches in the hallway. I would ask, “If you had unlimited resources, what is the one thing you would give your patients?”

They said the same thing again and again. They said, “Every day we have patients who come into the clinic, the child has an infection and we give the family medicine, but the truth is I know there’s no food at home. The truth is, I know this family is living with 12 other people in two bedrooms, and I don’t even ask about those issues because there is nothing that I can do. I have 13 minutes with each patient, I have patients piling up in the waiting room, I don’t know where to find food, I wasn’t trained to do this, and I have no help in doing so.” In that clinic, even today, there are two social workers for 24,000 patients. And frankly, that’s better than most of the clinics where Health Leads works.

Health Leads — and hence my entry into the world of health care — was born of these conversations. In the clinics where we operate, physicians can prescribe healthy food, heat in the winter and other basic resources they need to be healthy alongside prescriptions for medication. Patients then take those prescriptions to our desk in the clinic waiting room, where our corps of well-trained college student advocates “fill” those prescriptions by connecting patients out to the existing landscape of community resources.

How has the health care landscape changed since you first entered the field?

For the longest time, it felt like Health Leads was at the sidelines of the health care system, shouting, “This is important!” to institutions that we hoped would engage in the work of connecting patients to resources. Then, when the Affordable Care Act passed about five years ago, the whole health care ecosystem changed. Suddenly, Medicaid expansion flooded institutions with previously uninsured low-income patients. Institutions began moving to patient-centered care delivery models and exploring value-based payment models. Provider shortages created a surge in alternative workforces that allowed clinicians to operate at the top of their license. These forces pushed Health Leads from the bench to the field — from a “nice-to-have” service to a strategic imperative.

Health Leads tries to address patients’ basic needs as part of an overall treatment plan. Why is it so important to look beyond medication and medical procedures when addressing health issues?

Despite leading the world in health care spending, the U.S. continues to have the worst health outcomes of high-income countries. In Baltimore, Chicago, Los Angeles and elsewhere across the country, life expectancy for subsets of the population is lower than in some developing countries.

The failure of the U.S. health care system to translate spending into outcomes derives from a fundamental design flaw: Our system is built to provide care rather than deliver health.

When compared with social, environmental and behavioral factors that drive health, medical care contributes a relatively small amount to individual health.

Providers recognize this: In a 2011 study, 85 percent of the 1,000 pediatricians and primary care doctors surveyed said that patients’ social needs are as important to address as their medical conditions. But 80 percent reported that they did not feel confident in their capacity to meet these needs — lacking time during the typical 13-minute clinic visit and knowledge of the expansive, fast-changing resource landscape — and 75 percent wished the health care system would pay for the costs associated with connecting patients to resources that meet these needs if it is important for their overall health.

As Art Gianelli, former CEO of Nassau University Medical Center, once said, “I can pull every clinical care lever, but I’ll never be able to deliver the health outcomes or cost savings that the Centers for Medicaid and Medicare Services wants unless I have some way to get my arms around the realities of my patients outside the walls of our clinic.”

At the same time, due to the longstanding disconnect between public health and medicine, any efforts to address the “social determinants of health” — like building farmers’ markets or bike paths — exist nearly entirely outside the health care system. To get traction with health care quality and costs, we must at last leverage our massive, existing health care resources against not just what patients need to get healthy, but what they need to be healthy — to avoid getting sick in the first place.

What do you know now that you wish you had known when you were in school?

I had been at Greater Boston Legal Services for nine months — still a sophomore undergraduate — when I began to imagine the rough outlines of Health Leads. And I knew I had to tell Jeff Purcell, the lawyer I had mentioned earlier, that I was leaving. I was so nervous and so sure he would think I was abandoning the fight for our clients for some crazy, amateur idea.

I said, “Jeff, I have this idea — I think we could marshal hundreds of college students to address the real health needs of patients.” I’ll be honest: All I really wanted was for him to not be angry with me.

He said this: “Rebecca, when you have a vision, you have an obligation to pursue it. You must pursue it.” I remember thinking, “Whoa — that’s way more than I bargained for.” I wanted approval, not a mandate.

It was the best advice I ever received in any of my formal schooling — and I have spent most waking minutes since then chasing that vision.

Without giving too much away, what do you have planned for your commencement speech? What do you hope graduates will take away from your talk?

In more ways than I care to admit, I had no idea what I was doing when I started Health Leads as an undergraduate in the ‘90s — and as you noted, I haven’t spent a single day in a medical school or public health school classroom. After years of honing our model, people now turn to Health Leads for guidance on how to keep their patients healthy. In hindsight, my perspective as a newcomer to health care has proven time and time again to be an asset — and I’m eager to discuss how this new generation of leaders might fully leverage their own unique perspectives to bring about the change that we, and all patients, need to be healthy.