The perfect healthcare storm?[ILLUSTRATION OMITTED]
Will a chronically sick population, a fragile healthcare system, and the current economic decline combine in Memphis to create the perfect healthcare storm? Providing effective healthcare to the areas population is an ongoing challenge. Now, forces may be converging to make the challenge even greater.
Memphis has one of the least healthy populations in the nation. However, the bottom line may be that the situation is about to worsen. The already frail health status of the population, an increasingly tenuous local healthcare system, and a grim economy have the potential to create a health crisis of unprecedented magnitude. The independent impact of each of these forces is significant, but the combined effect of their convergence could be catastrophic.
Force I--A Chronically Sick Population
The burden of poor health on Memphis and Shelby Country is well documented. The residents of our community suffer from a disproportionate share of health problems, and on virtually every "report card" issued Memphis is recognized as one of the least healthy cities or least safe cities, "most miserable," or fattest cities in the nation. Poor health is an everyday consideration for a large segment of the areas population, as acute conditions go untreated and chronic disease takes its toll.
There are frequent reports in the local press on the more sensational indicators of health status for Memphis residents. Memphis has long led the nation in its level of sexually transmitted diseases, and frequent coverage is given to unacceptably high levels of infant mortality. Less sensational but more devastating overall is the burden of chronic disease that characterizes much of the city's population. Memphians face a higher rate of chronic diseases such as diabetes, high blood pressure, chronic obstructive pulmonary disease, and other lifelong health conditions than most comparable communities. Further, hidden from sight is the high level of disability characterizing the population. For example, figures from the 2000 revealed shockingly high rates of disabled individuals in many of the area's neighborhoods.
All of these chronic conditions reflect lifestyle-related behaviors or are exacerbated by unhealthy lifestyles. Poor diets and lack of exercise are only the beginning as existing health problems are often made worse by drug and alcohol abuse and risky sexual behavior. Combine this with environments that are unhealthy or downright dangerous and the risks are multiplied. Poor housing conditions (and shockingly persistent problems with lead paint) and numerous toxic dump sites contribute to already poor health status.
For many, it is easy to "blame the victim" for his her health problems, especially given the above facts which indicate that much of the sickness (and death) affecting the Memphis population is self-inflicted. Whether or not this criticism is appropriate is being overshadowed by the fact that a growing number of those affected by health problems--including life-threatening chronic conditions--are children. As a population we rank high in adult obesity. Now, this condition is affecting school children and even preschoolers, with obesity having the ability to turn children into adults in terms of health status. Our healthcare providers are seeing adolescents and even younger children presenting (when they do present) with chronic conditions that historically affected adults.
Not surprisingly the high morbidity levels characterizing the population result in higher than average mortality. The Shelby County population death rate is relatively high, but when the most vulnerable populations are considered, the rate is even higher. An examination of the age-adjusted death rate indicates that the county overall has a worse mortality rate than its age structure should incur, with African-Americans in the community dying at a much higher rate than their age structure should dictate. Every year, the Memphis community records hundreds of unnecessary and preventable deaths.
The Shelby County population displays age-adjusted death rates that are higher than the national average for most leading causes of death. The overall rates are bad enough, but these averages mask the real tragedy of poor health in Memphis. If one takes any of the indicators of ill-health and applies them to the large segment of the Shelby County population that has minority status and low income, the rates jump off the charts. While the African American segment of the Shelby County population accounted for 54 percent of the county's total in 2005, it accounts for 67 percent of the deaths from diabetes and 92 percent of the deaths from AIDS. This does not take into consideration that the vast majority of the deaths from homicide occur within this population segment.
Numerous reports have highlighted the chronically high infant mortality rate for Memphis. Even as most communities across the nation have reduced their infant death rates, Shelby County continues to stand out as a dangerous place for newborns. It is one thing to bemoan the high infant mortality rate in the county, but the figures become really dramatic when it is realized that the rate for the county's African American population is three times the rate for the Caucasian population and twice the national average.
To a great extent, the inordinate burden of poor health borne by the most vulnerable populations is invisible to the remainder of the areas residents. Many in our population spend much of their lives unaware of the poor health status of the county's population. They may read an occasional news article about infant mortality or AIDS, but with their healthy lifestyles, employer-provided insurance, and a long-term relationship with a physician, these problems are largely invisible. Nevertheless, the healthy segment of the population does pay a price for the population's poor overall health status. This is reflected in the higher taxes that everyone pays directly to support the Regional Medical Center and indirectly to cover the costs of services for the chronically ill. The situation hits home directly when one visits an area emergency room to find it overrun by people who are there, not because they have an emergency, but because they have nowhere else to go. Ultimately, all residents of Shelby County pay in myriad ways for the high level of morbidity that characterizes its population.
The burden of poor health is also borne in many subtle and indirect ways by our residents. Workers are too sick to come to work (or they come to work too sick). Many cannot work at all because they must provide care for a sick family member, and many others have lost their jobs because of having to take time off to care for sick children or due to their own illness. Indeed, the morbidity level affecting the county's population would, if they knew, discourage the relocation of companies to the community. Undoubtedly, a sick workforce is not good for a local economy.
Many children are too sick to go to school (or too malnourished to pay attention when they do go). Many also start life with learning disorders--often as a result of premature birth, poor nutrition before and after birth, or environmental factors. The chronic conditions that are emerging among the young may go undiagnosed because the system doesn't look for high blood pressure in school kids. Unfortunately, those who face health disadvantages in childhood are destined to a life of ill health.
In fact, recent research suggests that much of the Memphis population suffers from a stress disorder that has serious implications for organ systems. This condition that some refer to as the "Memphis blues" pervades many communities in Memphis and results in despair, violence, and ill health. Human bodies are not designed to deal optimally with chronic and anticipatory stress. Constant mobilization of the body's response to stress increases the incidence of stress-related diseases in the gastrointestinal system and results in impaired cognitive, immune system, and sexual and reproductive functioning. Additionally, this response increases the risk and/or severity of symptoms of chronic diseases such as diabetes, hypertension, and obesity. The subjective feeling of stress involves a "double whammy" for the affected population, impacting both their physical and mental health.
Force II--A Fragile and Misaligned Health Delivery System
Memphis is a major medical center, housing two of the nation's largest health systems, a medical school, and a world-renowned children's research hospital. The city trains most of the state's doctors and has an inordinate share of health personnel and facilities. Even today, the Memphis medical center is considered the ultimate source of state-of-the-art healthcare for a hundred miles in any direction. Surely, with the resources that are available, the healthcare challenges noted above could be effectively addressed.
In reality, it could be argued that the local healthcare system is much less viable than it appears. While it is true that the city has more hospital beds per capita and more physicians per capita than most comparable cities, these figures may not be appropriate measures of the adequacy of the healthcare system. The resources available to local residents have to be adjusted to reflect their actual distribution within the population. Although most people will eventually get to a hospital if absolutely necessary, it has become increasingly difficult for residents to get access to a hospital without driving long distances. Over time, the county's hospital beds have become concentrated in the eastern part of the county to the detriment of the western portion. With the 2000 closing of the Baptist Hospital medical center facility, the number of hospital beds available to residents in the central city was essentially cut in half. The 1,500 beds that remain in the western half of the county are proximate to a population of around 600,000. The 2,000 hospitals beds in the eastern suburbs are proximate to a population of around 300,000. This does not mean that distant beds are inaccessible, but that the hospitals are increasingly inconvenient for the large portion of the population that is the least mobile and needs them the most. Here, as elsewhere, the healthiest population has the most health resources, while the sickest population has the least.
While a hospital admission is a relatively rare event, the use of hospital emergency rooms is more common. A patient is three times more likely to visit an emergency room than to be admitted to a hospital. The use of emergency rooms by the disadvantaged--and least healthy--is well documented. For many in this population, the emergency room is the primary care facility of choice. While a variety of factors may influence this preference, a major factor is lack of access to other primary care facilities. The lack of health facilities in inner-city neighborhoods in particular results in unmet needs that often get resolved at a hospital emergency room.
The real challenge in addressing the healthcare needs of the most vulnerable populations is the lack of access to physician care. Historically, low-income neighborhoods typically boast one or more minority physician practices, perhaps bolstered by a primary care clinic sponsored by the Memphis and Shelby County Health Department. Some of these neighborhoods are lucky enough to merit a faith-based health clinic. And, generations of the disadvantaged rely on outpatient clinics at the Regional Medical Center for their care.
The past two decades have witnessed the virtual evacuation of physician practices from these communities--in fact, from all Memphis communities. The minority physicians who once served these neighborhoods have faded away, and the Health Department clinics have become increasingly irrelevant for the disadvantaged population as it has migrated away from traditional poverty neighborhoods. The establishment of federally-qualified health centers in some of these communities has partially offset the deficit, but these can only serve a fraction of the underserved population.
The paucity of medical services in the western portion of the county is reflected in the fact that most of the western half of Memphis is designated as a primary care shortage area by the federal government. (Shortage areas are designated based on the number of primary care doctors, dentists, and mental health professionals.) Even this is misleading in that the designation process cannot keep up with the changes constantly taking place, and additional portions of the city probably qualify for designation but have not received it yet. Based on generally-recognized standards, the TennCare population residing in the western portion of the city would require an estimated 40 primary care physicians to meet its basic needs. Today, most calculations would yield the equivalent of less than 20 physicians available to this population. (Note that this is not a phenomenon restricted to the disadvantaged population, as the Shelby County population should ideally be served by 3,000 primary care physicians--a figure that exceeds the total number of practicing physicians in the county.) As primary care practices have moved further east and become increasingly concentrated in a handful of medical centers, few neighborhoods are left with any local medical care. Indeed, a consistent pattern has been established: when lower-income residents move into a neighborhood, doctors move out.
The issue of access is even more critical for the disadvantaged population when it comes to specialty care. While significant numbers of specialists remain in the medical center around Methodist Hospital and The MED, the majority of specialists have migrated to a few suburban medical centers. There are essentially no specialists in the western portion of the county who have any attachment to a major medical facility. In effect, the disadvantaged residents of the western portion of the county--residents with high rates of chronic conditions that require specialty care--have limited access to the specialists who practice in Shelby County. This is an issue for this population overall but an even greater issue for the 80,000 or more low-income minority Medicare patients in western Shelby County who actually have the ability to pay but have limited access to the specialty care required by seniors.
When it comes to access, another consideration is the barrier that is created by participation in TennCare. While the intent of Tennessee's version of Medicaid was meant to facilitate access to health services for poverty-level individuals by providing them the ability to pay, a decreasing number of Shelby County physicians actually accept TennCare patients. So, not only are there virtually no proximate sources of medical care for the disadvantaged population, even distant sources of care may be inaccessible if they do not accept TennCare patients.
These factors taken as a whole add up to a significant barrier to care for a third or more of the Shelby County population. The lack of access to primary care results in the emergence of preventable conditions or the exacerbation of easily managed health problems. This leads to the need for specialty care that if not accessible results in emergency room use, often followed by emergency hospitalization. Not only does this situation result in a greater burden of illness on the patients, but results in higher costs for other patients and unnecessary expense for the healthcare system.
One consequence of this phenomenon is the overburdening of the parts of the local healthcare system that serve the medically indigent. Public facilities have become swamped as private practitioners cut back on their care to TennCare enrollees and the uninsured. This causes some facilities to close because of the financial burden and some private practitioners to no longer accept TennCare enrollees--putting increased pressure on the remaining practitioners who care for the medically indigent. With increased financial constraints and uncertainty about future funding, some providers are reluctant to accept new patients.
The financial pressure created by these trends has resulted in the further reduction of services in the Medical Center district and the closing of some facilities. The most significant development in this regard was the closure and ultimate razing of Baptist Memorial Hospital's 1,200-bed medical center facility. The Baptist towers had been icons in the Memphis medical center for over 50 years. When this aging and outdated facility was eliminated, hundreds of physicians were forced to relocate, and a major hole in the city's healthcare infrastructure remained. Although some of the eliminated beds were transferred to Baptist's East Memphis facility, the remaining medical center providers could not compensate for the shortfall in inner-city services.
This development was accompanied by other less dramatic but perhaps more damaging reductions in care. In response to mounting losses, service reductions were introduced at The Regional Medical Center, and The MED's outpatient services--once the primary source of care for the medically indigent--were cut back in an effort to reduce the burden of non-paying patients. The once thriving outpatient services provided by the medical school's Department of Family Medicine were eliminated from the inner city and their resident staff transferred to a suburban location, not only resulting in a loss of primary care capacity, but in a shift away from the disadvantaged population Family Medicine traditionally served. Methodist Hospital eliminated its obstetrical service at its medical center facility, leaving The MED as the only place to deliver a baby within the interstate loop. Another mainstay of primary care for the indigent, the Health Department's primary care clinics reduced their staffing levels in the face of financial constraints, resulting in less care available to this population.
A near-crisis situation has resulted from cutbacks in psychiatric and behavioral health services. Psychiatric emergency care has long been in short supply, and there is currently no option available for the patient who is disruptive due to psychiatric problems. Most of these "patients" end up in the city jail, only to be released at some point without having received any treatment. The community holding beds available for emergency care of psychiatric patients is a thing of the past. Cutbacks in state funding for behavioral health have resulted in the reduction or elimination of many programs critical to the indigent population.
A number of factors have contributed to the reduction or elimination of services, particularly those serving the disadvantaged inner-city population. Changing practice patterns and increased financial restraints have been major factors. What is striking, however, is that most of these cutbacks occurred well before the current economic crisis. This reduction of services occurred at a time of increasing need without even factoring in the impact of a rapidly growing population of immigrants who are likely to require public health services. In other words, as bad as the stress on the system has been, it could get a lot worse: an already desperate population faced with increased barriers to care--the makings of a perfect healthcare storm.
Force III--The Local Economy: Between a Rock and a Hard Place
The economies of Memphis and Shelby County displayed signs of poor health well before the recent economic crisis. Never known for its robustness, the local economy was hit hard by the downturn of 2008; its impact has only become worse in 2009. Data for the third quarter of 2008, even before the full impact of the economic downturn was felt, present a dreary picture of the local economy. Retail sales were uniformly down among general retailers and car dealers in the Memphis area. Local manufacturing activity continued to decline, with several firms reporting plans to consolidate production and lay off workers. Some manufacturers plan to shut down operations altogether. The report estimates that throughout 2008 Memphis employment contracted more sharply than did the national average. Over the three-month period ending in October, Memphis employment fell much faster than did the national average. These economic indicators have only worsened since late 2008.
Home sales are a major indicator of economic health, and in 2008 sales were down 19 percent from the previous year. Year-to-date, single-family building permits are down 57 percent. Half of all those contacted reported a decline in demand for new residential mortgage loans. Tighter credit standards were reported by most.
The worst news on the housing front, however, has been the record number of foreclosures that are being reported. Well before the decline of 2008, Memphis was among the nation's leaders in foreclosures, with almost as many foreclosures as home sales occurring. The recent economic downturn has only made matters worse. Although certain Memphis neighborhoods historically have recorded the highest foreclosure rates in the nation, these areas have now been joined by increased rates in middle-class suburbs and even some foreclosure activity in the most affluent neighborhoods. One real estate tracking system found reported a 53 percent increase in foreclosure filings for the Memphis area between 2007 and 2008. High rates of foreclosure not only contribute to an increase in the number of homeless, but also indicate a growing population that will not be able to pay for medical care.
One other indicator of poor economic health is the high rate of both personal and business bankruptcies in Shelby County. Memphis has historically recorded some of the highest bankruptcy rates in the nation, and, as in the case of housing foreclosures, these have been concentrated in certain parts of town. And, like foreclosures, bankruptcies are now spreading to the more affluent parts of the community. A similar trend has been noted for business bankruptcies. Both personal and business bankruptcies reflect the economic environment, and there does not appear to be any quick resolution to the growing rate of bankruptcy filings.
This recent economic decline must be interpreted within the context of the existing Shelby County tax structure. Identified as the third most regressive tax system among the nation's cities, Memphis and Shelby County governments depend primarily on sales taxes, use taxes, and real estate taxes for their revenues. Under ordinary circumstances, this does not represent a very effective means of generating revenue, especially since it relies heavily on those least able to pay for the bulk of the tax income. Today, with the economic downturn local government is hit with a double whammy as sales and use taxes drop with decreased income and higher unemployment and real estate taxes decrease as a result of declining property values.
An economic downturn such as this inevitably impacts the poverty rate. Despite an improvement in the local poverty status during the 1990s, data prepared by the City of Memphis indicate a return to higher poverty rates within the city since 2000. While overall income levels for Shelby County increased during the first years of this century, the median household income actually declined in many inner-city neighborhoods. Although it is too early to obtain poverty figures that reflect the current economic downturn, there is no doubt that the poverty rate is being adversely affected. Higher unemployment, less discretionary income, increased bankruptcies, and declining real estate values have a devastating effect on the local economy and reduce the revenue available to fund health services like The Regional Medical Center, the HealthLoop clinics, and state-funded behavioral services.
The Perfect Storm
The at-risk healthcare population is increasing in number and reaching up further into traditional middle-class households. As the effects of economic dislocations in the Mid-South expand, consumer spending will continue to slow, state and local tax revenues will continue to decline, and fewer dollars will be available for "safety net" health providers. More patients will become "uncompensated care," further weakening hospitals and physicians. The downward momentum created by these events will become increasingly difficult to reverse without major investments and economic expansion in the region. Add to this the constant cry of "crisis" from the news media and the daily notices of foreclosures, layoffs, bankruptcies, and families in need, and you have the additional challenge of fear and uncertainty pushing the public to believe that circumstances are even worse than reality.
The combined forces of poor pre-existing health status, a fragile healthcare system, and economic stress are combining to create a powerful force with dire consequences for the health of the population and for its ability to address health issues. And, as is usually the case, the most vulnerable--which is a significant portion of the Shelby County population--are the ones who suffer the first effects and the most extreme consequences. Even before new health issues arise, households may be forced to drop their health insurance due to an inability to pay the premiums. While this doesn't affect TennCare enrollees to the extent that it affects those covered by commercial policies, it is devastating for the working poor. The Church Health Center, a clinic established exclusively for the working poor who lack insurance, has become swamped with record numbers of patients. Many of them are presenting at the clinic for the first time and coming increasingly from affluent suburban communities. Operated using volunteer clinicians and funded through donations, the Church Health Center is hard pressed to address the burgeoning demand for care by the uninsured.
Even those with insurance may face access issues as, as noted above, healthcare providers have moved farther and farther from the populations with the most health problems. Transportation to health facilities is a chronic problem for the disadvantaged population that often has to beg a ride or pay for transportation. In times of economic distress, particularly when gasoline prices recently exceeded four dollars per gallon, transportation becomes one more barrier to accessing care.
Shelby County residents with insurance who must pay a co-payment or meet a deductible now find themselves delaying care or using a hospital emergency room for "free" care. Those with new conditions begin delaying treatment until the illness reaches a crisis, while those with chronic diseases discontinue their regularly-scheduled visits due to a lack of funds. The chronic disease rampant among the local population is made more serious by the increasing inability of patients to purchase necessary drugs.
Economic conditions have other far-reaching effects, such as housing foreclosures and evictions. The result is a growing number of homeless citizens, and, in these times, it is often families rather than the stereotypical single male that end up on the street. There is a dear correlation between homelessness and health problems of all types, both physical and mental. Some problems are obvious, such as the health risks of living on the streets, but even small things like not having a place to store medicine that must be refrigerated contribute to deteriorating health status.
The disadvantaged population in Memphis is notorious for its poor nutrition even in less stressful times. When economic stress requires that even that level of nutrition be reduced, the implications for health become even more serious.
There is a clear correlation between unemployment and various health problems. The unemployed tend to have more physical problems than the employed, not as a cause of unemployment but as a consequence. This is particularly true when it comes to behavioral health problems, with the stress of reduced income and the loss of the status associated with meaningful employment contributing greatly to psychiatric distress. This means that these vulnerable individuals resort to "self-medication" in order to cope with the increased stress. Alcohol and drug abuse increase, along with the associated negative side-effects of crime and violence. Already limited resources are diverted to use for coping with a hopeless situation.
Of course, economic stress leads to an increase in crime and in violence among populations that are already predisposed to cope in this manner. Property crimes increase as the financial plight for growing numbers becomes more desperate, and Memphis police figures for 2008 indicate significant increases in reported home burglaries, purse snatchings, and shoplifting. Although all types of violence tend to increase, the most serious actions occur in the arena of domestic violence as spousal abuse and child abuse become outlets for frustrated individuals who are trapped at home without a job or the gas money to escape. Recent crime figures for 2008 indicate an increase in reported domestic violence and a significant increase in reported aggravated child abuse for Shelby County. These figures probably understate the extent of the problem since many such incidents go unreported.
In the face of a financial crunch, it is often healthcare expenditures that are neglected. According to a survey recently released by Epocrates, Inc., a physician information provider, Americans with financial worries often skip needed prescription drugs in an attempt to save money. Nearly 95 percent of doctors in this national survey voiced concerns that patients may not be taking prescribed drugs correctly because of the economic climate.
Ultimately, only time will tell about the combined impact of a sickly population, a fragile healthcare system, and an economic catastrophe. In the meantime, there is no shortage of anecdotal and statistical evidence that the prognosis is poor. The impact on individuals and families is disastrous, and the healthcare system appears to struggle under the burden of increased volume and reduced costs.
In the aftermath of disastrous events such as the terrorist attack on the World Trade Centers and the destruction wrought by Hurricane Katrina, increasing attention has been paid to the preparedness of local communities in the face of a natural or manmade disaster. The conditions described in this article reflect the challenges faced by the healthcare system under ordinary circumstances. This article does not consider the impact of a major disaster on the healthcare system and its ability to cope. Yet, experts in a variety of fields believe it is not a matter of if but when a disaster will strike the Mid-South. Whether it will be the long-predicted violent earthquake, a surprise terrorist attack targeting area transportation hubs, a pandemic viral event, or an economic crisis, the Shelby County healthcare system will bear the brunt of the event and will have to live with its aftermath. While Memphis and Shelby County may be facing a perfect healthcare storm as a result of the current situation, one can only speculate as to the impact of a major crisis on the local population and the healthcare system.
Richard K. Thomas, Ph.D.
Dr. Richard K. Thomas has spent his entire professional career (30+ years) in health services research, planning, and business development. He is a partner in the Memphis-based consulting firm of Health and Performance Resources where he provides consultation to hospitals, physician practices, health plans, and other healthcare organizations. He is a recognized expert on health data and has been active in the development of the field of health demography.
Dr. Thomas holds a Ph.D. in Medical Sociology from Vanderbilt University, along with degrees in Economics and Geography. He has published dozens of articles on healthcare, authored or coauthored eighteen books (including Health Services Planning and Marketing Health Services), and previously served as editor of Marketing Health Services magazine. He has taught Sociology, Marketing and Healthcare Administration courses for a variety of institutions and is currently on the faculties of the University of Tennessee Health Science Center and the University of Mississippi.
Table 1. Mortality Rates for the U.S. and Shelby County by Race, 2005 * Shelby County African U.S. Total Caucasian American Crude Death Rate 8.3 8.5 9.0 8.2 Age-Adjusted Death Rate 8.0 9.1 8.2 11.8 (1) The most recent year for which fully audited data are available. Note: Per 1,000 population. Sources: Memphis and Shelby County Health Department and National Centerfor Health Statistics. Table 2. Age-Adjusted Mortality Rates by Cause for the U.S. and Shelby County by Race, 2005 * Shelby County African U.S. Total Caucasian American Heart Disease 211 267 232 320 Cancer 184 217 186 268 Stroke 47 70 57 88 Accidents 39 40 40 43 Chronic Lower Respiratory Disease 43 42 50 29 Diabetes 25 35 19 21 Influenza and Pneumonia 20 19 17 20 Homicide 6 18 7 28 HIV 4 13 4 25 * The most recent year for which fully audited data are available. Note: Per 1,000 population. Sources: Memphis and Shelby County Health Department and National Center for Health Statistics.