1 00:00:00,650 --> 00:00:03,150 This is the Becker's Healthcare Podcast. I'm Molly Gamble, 2 00:00:03,180 --> 00:00:08,030 vice President Editorial, and today I'm spending time with Dr. Esmail Porta. Dr. 3 00:00:08,290 --> 00:00:10,750 POA is the president and c e o of Harris Health System, 4 00:00:10,750 --> 00:00:13,790 which is the primary healthcare safety net system of Harris County, 5 00:00:13,790 --> 00:00:15,590 which includes the city of Houston and Texas. 6 00:00:16,220 --> 00:00:20,190 This system includes Ben TA Hospital in Lindon b Johnson Hospital, 7 00:00:20,680 --> 00:00:24,550 along with a network of community health centers and clinics. Dr. Porta, 8 00:00:24,550 --> 00:00:26,910 welcome. Thank you so much for being my guest today. 9 00:00:27,240 --> 00:00:28,790 Where does this podcast find you? 10 00:00:30,000 --> 00:00:31,900 Uh, as you mentioned, Houston, Texas. 11 00:00:32,930 --> 00:00:34,960 Great. Well, Dr. Po, 12 00:00:35,120 --> 00:00:39,120 I shared just a little bit there in my opening remarks about Harris Health 13 00:00:39,120 --> 00:00:42,480 System, but beyond those fast facts and figures, 14 00:00:42,950 --> 00:00:46,160 what do you think is the most important thing for our listeners today to really 15 00:00:46,160 --> 00:00:47,680 understand about Harris Health? 16 00:00:48,640 --> 00:00:51,490 Yeah, well, first of all, thank you for the opportunity to do this. 17 00:00:51,610 --> 00:00:53,710 I really appreciate it. Um, 18 00:00:53,850 --> 00:00:58,470 and not so much specific to Harris Health System, but I would really like to, 19 00:00:58,690 --> 00:01:02,690 uh, share with our listeners is, uh, 20 00:01:03,650 --> 00:01:07,110 all the public health systems similar to Harris Health System and what, 21 00:01:07,110 --> 00:01:09,950 what they mean to the communities that they serve. You know, 22 00:01:10,050 --> 00:01:11,750 we happen to be one of the largest, 23 00:01:11,850 --> 00:01:16,450 if not the largest public health system in Texas. Uh, 24 00:01:16,450 --> 00:01:19,890 but there are several and other states as well. 25 00:01:22,050 --> 00:01:24,750 You know, it is true that as a safety net hospital, 26 00:01:24,970 --> 00:01:27,510 Harris Health System and other systems like us, 27 00:01:27,510 --> 00:01:31,630 we have a statutory mandate to take care of the uninsured and underinsured. 28 00:01:31,630 --> 00:01:33,510 That's a given. That's, that's why we exist. 29 00:01:34,290 --> 00:01:39,190 But there is so much more to a public health system like us and 30 00:01:39,190 --> 00:01:41,630 others, uh, that serve the same purpose. 31 00:01:41,930 --> 00:01:45,070 And I just wanted to very briefly focus on those couple of points. 32 00:01:46,530 --> 00:01:47,363 That'd be great. 33 00:01:47,450 --> 00:01:52,150 We are major training sites for the future doctors and 34 00:01:52,150 --> 00:01:56,840 healthcare providers, nurses, techs, you name it. In our instance, 35 00:01:57,500 --> 00:02:02,080 you know, we are in partnership with two nationally and renowned medical school, 36 00:02:02,140 --> 00:02:05,440 bay College of Medicine, and UT Recover medical School, both in Houston. 37 00:02:06,980 --> 00:02:11,040 We train more than 3000 students and residents every year. 38 00:02:11,590 --> 00:02:16,440 What that means to this community is a currently almost 50% of all 39 00:02:16,440 --> 00:02:20,960 the doctors that are licensed by the Texas Medical Board 40 00:02:21,840 --> 00:02:26,180 to practice in Houston and Harris County did their training actually at Harris 41 00:02:26,180 --> 00:02:27,013 Health System. 42 00:02:27,930 --> 00:02:30,830 And that's something that I don't think people appreciate when we're talking 43 00:02:30,830 --> 00:02:34,030 about safety net hospitals. You know, you mentioned our hospitals, 44 00:02:34,030 --> 00:02:36,790 Ben Top adult level one trauma center, 45 00:02:37,490 --> 00:02:39,550 lbj adult level three trauma center. 46 00:02:40,840 --> 00:02:44,490 They do a lot more than just safety net care of the indigent, 47 00:02:44,490 --> 00:02:46,010 the uninsured and underinsured. 48 00:02:46,010 --> 00:02:50,330 They provide lifesaving care to all Houstonians. And again, 49 00:02:50,910 --> 00:02:52,930 I'm using Harris, Harris Health System as an example. 50 00:02:52,950 --> 00:02:56,130 That's what happens in other large safety net hospitals as well. 51 00:02:57,050 --> 00:03:00,100 We're also a huge economic engine to the community, and, 52 00:03:00,120 --> 00:03:04,580 and folks don't, uh, routinely, you know, consider it, 53 00:03:04,960 --> 00:03:07,940 uh, for every dollar in tax support, for example, 54 00:03:07,940 --> 00:03:09,660 that Harris Subsystem receives, 55 00:03:10,270 --> 00:03:15,080 they return almost $6 back to the Harris County last year. 56 00:03:15,590 --> 00:03:20,120 That amounted to almost 5 billion in economic impact to the county. 57 00:03:21,870 --> 00:03:23,690 And we also add capacity, 58 00:03:24,290 --> 00:03:28,250 capacity to the local healthcare ecosystem 59 00:03:29,780 --> 00:03:32,920 in terms of our emergency rooms and hospital beds. Yes, 60 00:03:33,540 --> 00:03:35,720 we don't have the largest share of the system, 61 00:03:36,060 --> 00:03:38,640 but what we do provide really does matter. 62 00:03:39,220 --> 00:03:42,630 And I'm gonna use an example and then I'll stop. Uh, 63 00:03:42,630 --> 00:03:44,510 this is something really important, and again, 64 00:03:44,510 --> 00:03:48,670 something that people overlook when they think about safety net hospitals. 65 00:03:48,770 --> 00:03:51,990 And the way I describe it is this, yes, 66 00:03:52,210 --> 00:03:55,470 we have a statutory mandate to take care of any insured and under insured. 67 00:03:55,470 --> 00:03:59,190 And unfortunately for a lot of reasons that we can discuss later, 68 00:03:59,920 --> 00:04:04,360 this population, uh, waits, uh, because of their, 69 00:04:05,060 --> 00:04:05,680 uh, 70 00:04:05,680 --> 00:04:09,560 adequate access to care until they're too sick and they show up to our emergency 71 00:04:09,560 --> 00:04:10,380 rooms, 72 00:04:10,380 --> 00:04:14,320 or they just show up to the emergency rooms as a habit rather than taking care 73 00:04:14,320 --> 00:04:15,880 of some of their routine care. 74 00:04:17,120 --> 00:04:19,500 And a primary care provider like you. 75 00:04:19,500 --> 00:04:24,280 And I would imagine a situation where Harris Health System or 76 00:04:24,280 --> 00:04:28,720 systems like US safety net hospitals fail to provide that service 77 00:04:29,520 --> 00:04:34,360 either because we are overwhelmed with increasing number of 78 00:04:34,360 --> 00:04:35,920 uninsured and underinsured, 79 00:04:36,740 --> 00:04:41,080 or because there is not enough support, financial support for our systems. 80 00:04:42,190 --> 00:04:42,480 Well, 81 00:04:42,480 --> 00:04:47,360 that population that currently seeks care at the Safety Net Hospital like 82 00:04:47,360 --> 00:04:48,240 Harris Health System, 83 00:04:49,300 --> 00:04:52,670 they are going to go elsewhere to receive that care. 84 00:04:52,670 --> 00:04:56,470 And that elsewhere is a non-for-profit and for-profit hospitals in the area. 85 00:04:57,910 --> 00:04:59,970 Couple of things happened. One, 86 00:05:00,960 --> 00:05:05,530 everybody else's access to emergent and urgent care decreases because now the 87 00:05:05,530 --> 00:05:09,420 emergency rooms, other emergency rooms are inundated, uh, 88 00:05:09,420 --> 00:05:14,090 with people that were otherwise received care at Harris 89 00:05:14,090 --> 00:05:17,070 HealthSystem. And number two, 90 00:05:18,240 --> 00:05:22,890 that provision of care to the uninsured and underinsured 91 00:05:23,590 --> 00:05:26,730 by non-for-profit or for-profit hospitals. Obviously, 92 00:05:26,860 --> 00:05:30,470 those hospitals are not going to, uh, 93 00:05:30,860 --> 00:05:32,630 take a hit to their bottom line, right? 94 00:05:32,930 --> 00:05:36,790 So they have to pass on that cost to someone 95 00:05:37,910 --> 00:05:39,700 where the biggest consumers, 96 00:05:40,140 --> 00:05:43,780 customers of non-for-profit and for-profit hospitals are the insurance 97 00:05:44,100 --> 00:05:44,933 companies. 98 00:05:45,710 --> 00:05:50,130 So that cost gets transmitted to the insurance companies. 99 00:05:50,130 --> 00:05:53,970 While the insurance companies are also in not in the practice of losing money, 100 00:05:54,640 --> 00:05:59,020 they have to transmit that cost to their customers and consumers. 101 00:05:59,020 --> 00:06:02,820 And that's you and I, everybody with a private health insurance. 102 00:06:03,820 --> 00:06:04,520 So at the end, 103 00:06:04,520 --> 00:06:08,600 what happens is that when a safety net hospital fails to provide the services 104 00:06:08,670 --> 00:06:10,680 that it does, for the reasons that I just mentioned, 105 00:06:11,850 --> 00:06:15,870 the overall cost of health healthcare actually increases in terms of 106 00:06:16,180 --> 00:06:19,710 out-of-pocket deductibles and health insurance premiums, 107 00:06:19,740 --> 00:06:23,270 when those costs have to trickle down to everybody else. 108 00:06:24,410 --> 00:06:29,070 So that in a nutshell is the role that Harris Health 109 00:06:29,070 --> 00:06:33,870 System and systems like us provide in the community that a lot of time gets 110 00:06:33,870 --> 00:06:34,703 overlooked. 111 00:06:35,010 --> 00:06:37,650 Mm-hmm. , I'm so glad Dr. 112 00:06:37,710 --> 00:06:41,570 Po said that you started there and that you established that context. 113 00:06:41,830 --> 00:06:46,170 For our listeners, the safety net institutions, especially in US cities, 114 00:06:46,790 --> 00:06:50,810 can so often go undersung in their value and the role they play in our 115 00:06:50,810 --> 00:06:51,643 healthcare system. 116 00:06:51,770 --> 00:06:56,610 I really think of them as the best of what healthcare can be in terms of 117 00:06:56,610 --> 00:06:59,890 their mission and their alignment with that mission. 118 00:06:59,910 --> 00:07:03,050 The people who choose to practice and work in safety nets, 119 00:07:03,440 --> 00:07:08,210 that is a choice that one makes to seriously give back to their community. Um, 120 00:07:08,270 --> 00:07:11,090 and the under uninsured, like you said. 121 00:07:11,640 --> 00:07:16,610 Just to ensure our listeners understand to Harris Health and what 122 00:07:16,670 --> 00:07:21,490 you are working with as c e o, do you mind sharing your payer mix with us? 123 00:07:22,420 --> 00:07:24,800 Not at all. I'd be happy to. Actually, you know, this is, 124 00:07:25,150 --> 00:07:28,040 this is information for everyone to, to have access to. 125 00:07:28,620 --> 00:07:33,460 So almost half of our patients are uninsured, uh, 50%. 126 00:07:34,120 --> 00:07:36,860 And there is a large portion of our 127 00:07:38,600 --> 00:07:43,080 patients who are also on Medicaid or Medicaid managed care around around to 128 00:07:43,080 --> 00:07:47,880 20%, but is left at at 30%. There's about 20%, 129 00:07:48,290 --> 00:07:53,280 maybe a little less Medicare and about 10 or 12%, uh, private insurance. 130 00:07:53,660 --> 00:07:58,360 Uh, which really creates, as you can imagine, a, a situation where, 131 00:07:59,410 --> 00:08:02,790 uh, caring for the uninsured or underinsured, those are Medicaid, 132 00:08:03,230 --> 00:08:07,590 Medicaid managed care, uh, creates a situation where we cannot 133 00:08:10,710 --> 00:08:15,520 address the escalating costs of inflation and everything else that happens to 134 00:08:15,780 --> 00:08:18,800 our, uh, privately insured patients. 135 00:08:18,800 --> 00:08:22,240 Cause we just do not have that volume of insured patients. 136 00:08:22,700 --> 00:08:23,160 Mm-hmm. 137 00:08:23,160 --> 00:08:27,790 and even that mix and those ratios might even be in flux a bit 138 00:08:27,980 --> 00:08:31,670 just because of the Medicaid redeterminations that are ongoing. Right. 139 00:08:32,620 --> 00:08:37,470 Yeah. I'm so glad you mentioned that. I didn't know I'm, uh, aware, uh, 140 00:08:37,570 --> 00:08:41,190 the listeners are. So, because of the end of the public health emergency, 141 00:08:42,470 --> 00:08:47,450 the folks who for the last three years as a deal that was made with the federal 142 00:08:47,450 --> 00:08:52,390 government, nobody was coming off the Medicaid rules, uh, 143 00:08:52,390 --> 00:08:55,940 because of the additional dollars that the federal government was sending to the 144 00:08:55,940 --> 00:08:59,500 states. Well, since the end of the public health emergency, 145 00:08:59,500 --> 00:09:01,980 everybody has been put on notice that, uh, 146 00:09:02,080 --> 00:09:05,460 the states are going to go down through the, uh, 147 00:09:05,870 --> 00:09:10,450 their Medicaid enrollment roles and people are gonna come off of it. We, 148 00:09:10,510 --> 00:09:11,343 in Texas, 149 00:09:11,350 --> 00:09:14,610 we anticipate that more than 3 million people are going to be impacted. 150 00:09:15,560 --> 00:09:19,180 Harris County, unfortunately, this is the number not, uh, 151 00:09:19,180 --> 00:09:20,300 that we're not proud of, 152 00:09:21,050 --> 00:09:25,960 has the highest rate and number of uninsured residents of 153 00:09:25,960 --> 00:09:28,490 the county in the country. Currently, 154 00:09:28,490 --> 00:09:32,530 that number is 1.2 million uninsured residents of the county. 155 00:09:33,480 --> 00:09:37,220 And we anticipate some of that 3 million people are gonna be impacted coming 156 00:09:37,240 --> 00:09:40,180 off. The Medicaid rules are gonna be residing in Harris County. 157 00:09:41,060 --> 00:09:44,190 What is the total impact is when it remains to be seen. Uh, 158 00:09:44,190 --> 00:09:47,790 it's probably gonna take us a few months to figure out exactly who's going to be 159 00:09:48,170 --> 00:09:51,580 coming off the Medicaid rules, what you're correct. Uh, 160 00:09:51,700 --> 00:09:56,260 those percentages are surely to change, uh, for the negative. Mm-hmm. 161 00:09:56,300 --> 00:09:56,890 . 162 00:09:56,890 --> 00:09:59,460 Well, I think what, what you just shared, Dr of course, I mean, 163 00:09:59,770 --> 00:10:03,580 more than 3 million looking to be affected by the Medicaid redeterminations in 164 00:10:03,580 --> 00:10:07,500 Texas and then the highest rate in Harris County of uninsured in the country 165 00:10:07,610 --> 00:10:11,620 with one 1.2 million you said. So that number might even grow higher. 166 00:10:12,600 --> 00:10:14,260 Um, yeah, thank you for noting that. 167 00:10:14,260 --> 00:10:16,060 I think it's something we at Becker's are keeping an eye on. 168 00:10:16,060 --> 00:10:19,820 Every state has different timelines for those determinations, but like you said, 169 00:10:19,840 --> 00:10:22,380 so much does remain to be seen. And I know health systems are, 170 00:10:22,380 --> 00:10:27,340 are working hard to try to have people who can enroll or re-enroll. Uh, do. So. 171 00:10:28,080 --> 00:10:30,940 Um, you know, I wanted to talk a little bit about your background. 172 00:10:31,520 --> 00:10:36,380 You have such a rich background as an internist, a public health expert, 173 00:10:36,380 --> 00:10:37,300 public health leader, 174 00:10:37,980 --> 00:10:42,100 a system executive at really respected safety net institutions. 175 00:10:43,000 --> 00:10:47,700 How have your firsthand experiences really come to shape your philosophy 176 00:10:47,800 --> 00:10:50,740 and views on health equity and population health? 177 00:10:51,160 --> 00:10:54,340 If there are any specific experiences or moments you can point to as 178 00:10:54,340 --> 00:10:56,900 exceptionally influential, I, I would love to hear about them. 179 00:10:58,550 --> 00:10:59,880 Sure. You know, I, I, 180 00:10:59,960 --> 00:11:03,600 I described myself as somebody who has really basically devoted his entire 181 00:11:03,960 --> 00:11:08,490 professional life to, to public health. Um, 182 00:11:09,430 --> 00:11:13,370 is there a specific moment which I think was most impactful? 183 00:11:14,530 --> 00:11:15,363 Probably not. I, 184 00:11:15,450 --> 00:11:19,930 I would say that it is been an accumulation of experiences. 185 00:11:20,750 --> 00:11:25,500 Um, you know, I think back about my training, uh, 186 00:11:25,500 --> 00:11:29,060 many years ago. Let's not, let's not get into the details of how many years ago. 187 00:11:29,140 --> 00:11:33,260 I don't want to date myself, but needless to say, you know, 188 00:11:33,260 --> 00:11:37,820 when I did my medical school training and even the residency training, 189 00:11:39,740 --> 00:11:42,550 we as doctors, we became really, 190 00:11:42,610 --> 00:11:46,870 really good at understanding and treating 191 00:11:48,680 --> 00:11:52,000 diseases really good at, you know, 192 00:11:52,000 --> 00:11:56,780 understanding the pathology of hypertension and diabetes and, 193 00:11:56,880 --> 00:12:01,840 and stage renal disease and sickle cell disease. I think that you name it, 194 00:12:03,790 --> 00:12:07,050 you know, it really was not until later on when I, uh, 195 00:12:09,190 --> 00:12:13,780 enrolled in this school of public health just out of interest, 196 00:12:14,250 --> 00:12:19,220 that I, I realized how poorly we were trained, 197 00:12:19,320 --> 00:12:21,980 really had very, very little, if any, 198 00:12:21,980 --> 00:12:26,500 understanding of the concept of health promotion and disease 199 00:12:26,500 --> 00:12:27,333 prevention. 200 00:12:27,890 --> 00:12:32,620 We were so focused on treating illness that 201 00:12:32,760 --> 00:12:36,650 it, it would really just not occur to us that, you know, 202 00:12:36,650 --> 00:12:41,090 that that cliche and balance of prevention is, is worth a pound of cure. 203 00:12:41,510 --> 00:12:44,890 It, it was not in our vocabulary. You know, 204 00:12:44,910 --> 00:12:48,530 having gone through the school of public health and understanding the principles 205 00:12:48,590 --> 00:12:52,470 of population health and health equity, it, it, 206 00:12:52,490 --> 00:12:57,310 it was really an eyeopening opening. Um, not, not a single moment, 207 00:12:57,450 --> 00:13:01,390 but again, uh, an accumulation of experiences. Cuz after that, 208 00:13:02,740 --> 00:13:04,980 I remember at the time I was still actually, uh, 209 00:13:04,980 --> 00:13:09,940 providing care inside the inside Harris County jail. It occurred to me, 210 00:13:10,360 --> 00:13:11,193 uh, 211 00:13:12,900 --> 00:13:17,870 what an impact we can have as medical doctors and other 212 00:13:18,190 --> 00:13:22,710 providers, uh, rather than just treating next diabetic patient, 213 00:13:22,890 --> 00:13:27,310 the next hypertensive patient. Uh, so yeah, not, not a, 214 00:13:27,310 --> 00:13:30,110 not a single experience, but an accumulation of experiences. 215 00:13:32,650 --> 00:13:35,050 I think that's so relevant. And at Becker's, I mean, 216 00:13:35,050 --> 00:13:38,290 we've been having some recent conversations about medical schools, 217 00:13:38,510 --> 00:13:43,360 the need for some changes in curriculum and how 218 00:13:43,760 --> 00:13:45,720 students w work their way through medical schools, 219 00:13:45,750 --> 00:13:50,640 including the debt they can incur going through that educational chapter. So, 220 00:13:50,860 --> 00:13:52,760 Dr. Poa, to your point about the, 221 00:13:53,300 --> 00:13:57,830 the emphasis on disease management and treatment versus prevention, 222 00:13:57,830 --> 00:14:01,590 like you said, it, it, I know you mentioned it was a few years ago, 223 00:14:01,690 --> 00:14:05,830 but it seems like that is a huge opportunity for the next generation of 224 00:14:05,960 --> 00:14:08,070 physicians, nurses, healthcare workers, 225 00:14:08,570 --> 00:14:11,270 to have a bit more knowledge and, 226 00:14:11,330 --> 00:14:15,510 and familiarity with that important part of one's healthcare and health, 227 00:14:15,810 --> 00:14:16,643 health journey. 228 00:14:18,170 --> 00:14:21,660 Yeah. So that is true. You know, on an individual level, you, 229 00:14:21,660 --> 00:14:26,270 you're absolutely right. But, you know, at the system level, uh, 230 00:14:26,490 --> 00:14:30,980 as a nation, uh, we collectively need to, 231 00:14:31,280 --> 00:14:36,220 and I know that there, we are taking steps towards that, but the, 232 00:14:36,220 --> 00:14:40,460 the steps are painfully, painfully small and slow steps. 233 00:14:41,600 --> 00:14:45,900 Uh, but there needs to be a shift in our collective attention, uh, 234 00:14:45,900 --> 00:14:47,780 of resources, uh, 235 00:14:49,370 --> 00:14:54,100 and emphasis and focus on more and more disease prevention and health 236 00:14:54,100 --> 00:14:55,820 promotion. Because, I mean, and you know, this, 237 00:14:55,900 --> 00:14:58,940 I know I'm preaching to the choir, probably the listeners know this as well, 238 00:14:59,670 --> 00:15:04,170 you know, for the amount of money that this country spends on, on healthcare, 239 00:15:04,910 --> 00:15:09,250 we should be experiencing much, much better outcomes, uh, than we are. 240 00:15:09,390 --> 00:15:10,370 And we are not, you know, 241 00:15:10,370 --> 00:15:15,330 we spend more money per capita and in totality than any country on 242 00:15:15,330 --> 00:15:20,320 this planet. And when it comes to outcomes, we are not even in, 243 00:15:20,700 --> 00:15:23,720 in a top tier, uh, in terms of our health outcomes. 244 00:15:23,940 --> 00:15:28,280 So a lot of things wrong. And I don't want to get, uh, 245 00:15:28,530 --> 00:15:32,560 going on that tangent because you will never be able to stop me. But let me, 246 00:15:32,560 --> 00:15:35,800 lemme say this because I think this is very important. I struggle with this, 247 00:15:37,230 --> 00:15:40,250 you know, I, I think back about my training and, uh, 248 00:15:40,620 --> 00:15:43,490 everything that was good and everything that was not so good with it. 249 00:15:44,610 --> 00:15:48,590 One of the things that I struggled with in the, in the current training, uh, 250 00:15:48,770 --> 00:15:50,150 as I'm thinking about, you know, 251 00:15:50,210 --> 00:15:55,210 why is it that United States spend so much more money than 252 00:15:55,210 --> 00:15:56,410 other nations? And, you know, 253 00:15:56,410 --> 00:16:01,100 there's a lot of conversations about our overhead charges are so much higher. 254 00:16:01,280 --> 00:16:05,300 You know, the cost is this, and united administrative cost is death. And all, 255 00:16:05,440 --> 00:16:07,380 all of that is probably true. Uh, 256 00:16:07,760 --> 00:16:09,620 I'm not saying that that there's a single thing, 257 00:16:10,280 --> 00:16:14,060 but one thing that I have noticed is the, 258 00:16:16,460 --> 00:16:20,800 the transition in the way we think about the art and science of medicine. 259 00:16:20,820 --> 00:16:21,200 You know, 260 00:16:21,200 --> 00:16:26,040 I remember as a young doctor how much I took 261 00:16:26,410 --> 00:16:30,260 pride in my ability to 262 00:16:31,430 --> 00:16:34,600 perform really sound, physical examination and, 263 00:16:34,740 --> 00:16:37,320 and my bedside diagnosis abilities. 264 00:16:39,180 --> 00:16:42,480 And I compare and contrast that to today. Uh, 265 00:16:42,480 --> 00:16:47,200 when our young doctors, you know, finishing medical school and residency, 266 00:16:48,930 --> 00:16:53,350 it, it, it seems they just do not have the same 267 00:16:55,090 --> 00:16:59,120 capability, understanding capabilities to do the same. You know, 268 00:16:59,610 --> 00:17:04,120 every complaint ends up with a very expensive diagnostic test. 269 00:17:04,660 --> 00:17:09,080 You know, every abdominal pain gets an ultrasound, every headache gets an mri, 270 00:17:09,690 --> 00:17:13,780 every cough gets a chest CT scan. And 271 00:17:16,030 --> 00:17:19,400 that, I think also partly is, is 272 00:17:21,510 --> 00:17:26,270 responsible for what we are seeing in terms of the high cost 273 00:17:26,570 --> 00:17:29,550 of healthcare. Uh, we, we are so, 274 00:17:29,770 --> 00:17:34,630 so concerned about not missing that one in a million chance 275 00:17:34,810 --> 00:17:39,800 of a bizarre disease process that we are 276 00:17:39,800 --> 00:17:43,480 really just breaking the bank, uh, and, 277 00:17:43,480 --> 00:17:47,200 and taking care of some of the very routine things that should not be costing so 278 00:17:47,200 --> 00:17:50,700 much. Anyways, I, I can can talk about this all day long. Let, let's, 279 00:17:50,700 --> 00:17:51,700 let's move on. . 280 00:17:53,710 --> 00:17:55,030 I don't blame you. I, 281 00:17:55,150 --> 00:17:57,950 I wanted to go back to something you had shared in passing. 282 00:17:58,250 --> 00:18:00,950 It sounds really interesting, and I wanted to make sure this didn't, 283 00:18:01,170 --> 00:18:05,510 we didn't drive by this, but you mentioned working in the prison, um, 284 00:18:05,570 --> 00:18:09,310 before you came to Harris Health, I believe you spent about half a decade, 285 00:18:09,320 --> 00:18:09,670 right? 286 00:18:09,670 --> 00:18:13,870 As the medical director of Parkland Health and Hospital System Correctional 287 00:18:13,870 --> 00:18:14,703 health Program. 288 00:18:15,410 --> 00:18:19,310 Can you tell us about that experience and also if there were any 289 00:18:20,430 --> 00:18:22,990 valuable lessons you gained from that chapter of your career? 290 00:18:24,280 --> 00:18:29,170 Yeah, absolutely. So actually you, so you're correct. Uh, but even before that, 291 00:18:29,530 --> 00:18:30,363 I was, uh, 292 00:18:30,650 --> 00:18:35,610 directly delivering care to the inmates at Harris County Jail about 12 years. 293 00:18:36,030 --> 00:18:40,780 So it was probably more like 15, 16 years of my, uh, 294 00:18:40,780 --> 00:18:44,380 professional careers initially, uh, dealing with correctional health. 295 00:18:46,670 --> 00:18:51,460 You know, it, it, it goes back to the whole idea of, 296 00:18:51,640 --> 00:18:55,420 uh, health promotion, disease prevention, and health equity. I, 297 00:18:55,500 --> 00:18:56,620 I never forget this. You, 298 00:18:56,640 --> 00:19:01,510 you asked about a moment that may have been most impactful in 299 00:19:01,510 --> 00:19:04,870 my thinking about population have and health equity. 300 00:19:06,190 --> 00:19:09,570 You know, now that I'm thinking about my correctional health experience, 301 00:19:10,290 --> 00:19:15,160 I never forget this one morning. Um, I was, uh, early, 302 00:19:16,040 --> 00:19:17,200 I always get to work early. 303 00:19:17,420 --> 00:19:22,230 It was an early morning and people were getting lined up detainees. Uh, 304 00:19:22,230 --> 00:19:26,030 this was at Harris County, actually Dallas County Jail. Uh, 305 00:19:26,030 --> 00:19:27,990 they were getting lined up to go to court. 306 00:19:29,200 --> 00:19:32,980 And the way it works out for those who may not be familiar with the correctional 307 00:19:32,980 --> 00:19:34,860 setting is that, you know, in the mornings, 308 00:19:34,860 --> 00:19:38,220 everybody who needs to go to court basically goes to court and sits in the 309 00:19:38,220 --> 00:19:41,590 waiting rooms waiting for their, uh, hearing. 310 00:19:42,450 --> 00:19:43,790 So there were two, 311 00:19:43,790 --> 00:19:48,190 maybe 300 detainees that were lined up in a large area, 312 00:19:48,500 --> 00:19:53,070 getting ready to go from the jail through the tunnel to the courts, 313 00:19:54,520 --> 00:19:57,780 and there was a slope. Uh, so it was standing on, 314 00:19:57,780 --> 00:19:59,540 on the top end of the slope, 315 00:19:59,720 --> 00:20:04,330 and so moved down and folks who were lined up. And, you know, 316 00:20:05,430 --> 00:20:09,770 it was very traumatic because what I saw was a 317 00:20:10,870 --> 00:20:15,540 sea of young African-American male 318 00:20:16,080 --> 00:20:19,010 detain. And it, 319 00:20:19,350 --> 00:20:23,610 it truly was a light bulb moment, uh, in, in my head, 320 00:20:23,960 --> 00:20:27,260 realizing that the, 321 00:20:27,370 --> 00:20:32,330 when we talked about health disparities and health inequities and 322 00:20:32,330 --> 00:20:33,810 social determinants of health, 323 00:20:34,700 --> 00:20:39,660 and wonder why the health outcomes among 324 00:20:40,120 --> 00:20:43,260 the different ethnicities are what they are, 325 00:20:44,340 --> 00:20:49,190 i e our black and brown, uh, 326 00:20:50,520 --> 00:20:53,000 patients have 327 00:20:54,540 --> 00:20:58,770 worse outcomes in just about every disease process that you put your finger on 328 00:20:59,810 --> 00:21:04,740 compared to, uh, a white patients. It, 329 00:21:04,760 --> 00:21:07,540 it is not, it is not a genetic predisposition. 330 00:21:07,800 --> 00:21:11,930 It is not really anything else other than 331 00:21:13,700 --> 00:21:14,533 social 332 00:21:16,170 --> 00:21:20,660 injustices that prevail in this country, unfortunately. And, 333 00:21:20,840 --> 00:21:24,840 and that large part has to do with our correctional system. And, 334 00:21:24,840 --> 00:21:25,960 and that's something that, again, 335 00:21:26,220 --> 00:21:30,080 unless and until you are actually a part of it, you know, in it, 336 00:21:30,660 --> 00:21:32,840 it is really difficult for people to, 337 00:21:32,860 --> 00:21:37,790 to realize what a huge impact the correctional system in this 338 00:21:37,790 --> 00:21:42,410 country has on the overall health of all of us. You know, United States, 339 00:21:43,480 --> 00:21:47,610 you know, has about, uh, you know, 340 00:21:47,610 --> 00:21:52,290 5% of the world population, and we routinely incarcerated, 341 00:21:52,300 --> 00:21:56,290 about 20% of all the people who are incarcerated in the world 342 00:21:57,150 --> 00:22:02,070 are incarcerated in the United States. Uh, that is a terrible number. 343 00:22:02,610 --> 00:22:07,250 You know, every year about 10 million people get in and out of the jail. 344 00:22:08,640 --> 00:22:09,473 And, you know, 345 00:22:09,480 --> 00:22:13,300 the science is very clear on what happens when you are incarcerated. 346 00:22:13,400 --> 00:22:17,690 The impact that incarceration has on your ability 347 00:22:18,310 --> 00:22:20,970 to have, first of all, 348 00:22:20,970 --> 00:22:25,830 to obtain a job and then obtain a job that provides lovable wages, 349 00:22:26,170 --> 00:22:30,270 uh, the impact that it has on your ability to go to college, 350 00:22:30,610 --> 00:22:34,910 the impact that it has on your housing. Um, and you name it, you know, 351 00:22:34,910 --> 00:22:39,380 when we talked about the social determinants of health, incarceration, 352 00:22:40,380 --> 00:22:41,820 probably more than anything else, 353 00:22:43,120 --> 00:22:47,930 touches negatively every single one of those social determinants of health. 354 00:22:49,220 --> 00:22:51,840 Um, so I guess you can tell, 355 00:22:51,960 --> 00:22:55,960 I I'm very passionate about the topic of corrections and correctional health, 356 00:22:55,960 --> 00:23:00,500 because I think it's, it's, uh, it's the pillar 357 00:23:02,140 --> 00:23:02,973 of 358 00:23:04,670 --> 00:23:09,050 the lack of the foundational approaches to 359 00:23:09,060 --> 00:23:11,750 healthcare that it's, 360 00:23:12,540 --> 00:23:16,270 it's missed in the conversations when we were talking about health equity and 361 00:23:16,270 --> 00:23:20,630 population health. It, it, again, it, it is a topic that unless, 362 00:23:20,890 --> 00:23:25,790 and until you know about it and you are in it, it it is really difficult, um, 363 00:23:26,730 --> 00:23:30,730 to be aware of it. But, but, but I think, and, you know, 364 00:23:30,730 --> 00:23:33,690 have made it the mission, my mission, uh, 365 00:23:33,790 --> 00:23:36,810 to speak about this at every opportunity that I get to, 366 00:23:36,870 --> 00:23:41,530 to really shine the light and importance, uh, of this issue. Mm-hmm. 367 00:23:41,570 --> 00:23:42,403 . 368 00:23:42,560 --> 00:23:45,700 It's a really important perspective, and it's one that like, like you said, 369 00:23:45,920 --> 00:23:50,380 is not often represented. And I think to, to your point too, 370 00:23:50,490 --> 00:23:53,980 there's something to be said about how we treat our most vulnerable or the 371 00:23:53,980 --> 00:23:56,980 weakest people in our society when they're in prison, 372 00:23:57,120 --> 00:23:59,460 the healthcare access they have available to them. 373 00:24:00,040 --> 00:24:03,500 And then also when people are 374 00:24:05,180 --> 00:24:08,780 reintegrated into society after, after spending time in prison, it's, 375 00:24:09,050 --> 00:24:10,500 it's firsthand, I've, 376 00:24:10,500 --> 00:24:15,180 I've some experience too in seeing how inadequately prepared they can be, um, 377 00:24:15,180 --> 00:24:17,820 whether it's for employment, whether it's for education, 378 00:24:17,930 --> 00:24:22,060 they oftentimes there's turned back out with the belongings, uh, 379 00:24:22,200 --> 00:24:25,620 the bag they went in with, with their clothes and, um, housing. 380 00:24:26,040 --> 00:24:28,780 So I think also you do not want, as a society, 381 00:24:28,840 --> 00:24:32,940 people coming back to return to their, 382 00:24:33,390 --> 00:24:37,420 their life sicker than they were when they went into prison. Right. Right. Dr. 383 00:24:37,440 --> 00:24:40,380 Pos, that, that should be, when we're talking about public health, 384 00:24:40,440 --> 00:24:42,260 an outcome that you would wanna avoid. 385 00:24:42,930 --> 00:24:47,580 That you know, that, that that is exactly the point. Uh, 386 00:24:47,600 --> 00:24:48,980 and I, you know, you, 387 00:24:49,000 --> 00:24:53,750 you remind me of some of the conversations that I've had in my life with others. 388 00:24:53,940 --> 00:24:56,590 When, you know, when, when you think of corrections, 389 00:24:56,700 --> 00:24:58,670 when people come to the jail, to your point, 390 00:25:01,260 --> 00:25:03,290 there are times that actually 391 00:25:04,810 --> 00:25:09,460 detainees when they come in contact with healthcare inside the jail, 392 00:25:10,510 --> 00:25:13,160 that that is the first time ever in their lives, 393 00:25:14,270 --> 00:25:17,720 that they have had the opportunity to interact with the healthcare provider. 394 00:25:17,820 --> 00:25:22,660 And that, that is the sad truth. But what a great opportunity, 395 00:25:23,720 --> 00:25:24,480 uh, 396 00:25:24,480 --> 00:25:29,350 for a society to take advantage of that encounter of, 397 00:25:29,410 --> 00:25:31,520 of that, uh, 398 00:25:31,580 --> 00:25:36,080 of that opportunity to impact the health of that individual. Because remember, 399 00:25:36,580 --> 00:25:40,180 the folks who go to the jail, they're gonna come back, 400 00:25:40,180 --> 00:25:43,980 they're gonna come back to the communities in which they reside. 401 00:25:45,120 --> 00:25:48,790 If we are able to address their healthcare issues 402 00:25:50,320 --> 00:25:54,770 while incarcerated so that they can return to the community 403 00:25:54,880 --> 00:25:58,340 healthier, that when they went into the jail, 404 00:25:58,970 --> 00:26:02,700 everybody wins. The individual wins, the society wins 405 00:26:04,740 --> 00:26:08,760 as far as the cost of care, the cost will decrease. And I mean, again, 406 00:26:08,760 --> 00:26:12,000 the science is very clear. When people leave the jail, 407 00:26:12,060 --> 00:26:14,200 if their healthcare issues are not addressed, 408 00:26:14,550 --> 00:26:18,000 that utilizations of the community emergency rooms, it, it is, 409 00:26:18,620 --> 00:26:21,280 it is a staggering, it is extremely high. 410 00:26:22,780 --> 00:26:24,800 So why not take it management that opportunity, 411 00:26:24,980 --> 00:26:29,560 and I say this realizing that not, not everybody, uh, accepts that or, 412 00:26:29,660 --> 00:26:33,560 or agrees with this concept. You know, I've had people who, 413 00:26:34,880 --> 00:26:37,260 uh, believe that, you know, when people are in jail, 414 00:26:37,260 --> 00:26:39,980 you're basically just keep them alive until they leave the jail, 415 00:26:40,100 --> 00:26:42,060 then that's your responsibility. I obviously, 416 00:26:42,060 --> 00:26:46,820 I disagree with for a lot of reasons. You know, you mentioned it, you know, 417 00:26:47,420 --> 00:26:52,270 I think our ethical responsibility to take care 418 00:26:52,270 --> 00:26:55,910 of our weakest and most vulnerable, uh, 419 00:26:58,280 --> 00:26:59,860 and and beyond that, it, it, it, 420 00:26:59,860 --> 00:27:04,860 it just makes economical and healthcare 421 00:27:04,910 --> 00:27:09,660 sense, uh, to take care of our detainees when you're incarcerated. Mm-hmm. 422 00:27:09,700 --> 00:27:12,500 mm-hmm. , I, I, 423 00:27:12,540 --> 00:27:16,100 I wanna wind down with a thought from you about, you know, 424 00:27:16,100 --> 00:27:18,700 we've talked about health equity in a number of ways throughout this 425 00:27:18,700 --> 00:27:23,580 conversation, and we could probably talk about it for days, Dr. Pera. Um, 426 00:27:23,600 --> 00:27:26,820 but you know, you have such a valuable perspective on this topic, 427 00:27:27,160 --> 00:27:30,420 and so often when you start talking about health equity, 428 00:27:30,440 --> 00:27:34,580 you get to a point every conversation where you confront the barriers, 429 00:27:35,050 --> 00:27:38,580 what stands in the way, whether it's underfunding, whether it's, um, 430 00:27:40,560 --> 00:27:43,320 a lot of commitments made verbally but not executed. 431 00:27:43,510 --> 00:27:47,560 Sometimes it can be dwelling in research and analytics and not putting in 432 00:27:47,830 --> 00:27:50,840 solutions and moving into different neighborhoods to provide care. 433 00:27:51,420 --> 00:27:55,920 But I wanted to check in with you and see what you see as the main barriers or 434 00:27:56,200 --> 00:27:57,400 obstacles that, 435 00:27:58,300 --> 00:28:02,240 and thwart efforts to achieve more equitable he health outcomes. 436 00:28:02,580 --> 00:28:03,800 I'm sure this list is long. 437 00:28:04,090 --> 00:28:08,560 Maybe there's one that isn't as acknowledged as much as it should be that you, 438 00:28:08,560 --> 00:28:09,440 you can share with me. 439 00:28:11,410 --> 00:28:14,650 Yeah, , this is actually, 440 00:28:15,320 --> 00:28:19,750 this is a topic that I probably talking about if, if not every day, 441 00:28:19,990 --> 00:28:24,430 probably every other day. And, and I talk about it with, with my folks, uh, 442 00:28:24,540 --> 00:28:27,430 with the people that work with me. You know, as you mentioned at the, 443 00:28:27,430 --> 00:28:29,310 at the top of our conversation, um, 444 00:28:30,370 --> 00:28:35,060 I've basically devoted my entire life to the principles of health equity and 445 00:28:35,060 --> 00:28:40,000 population health and, you know, be, have the population health department, 446 00:28:40,380 --> 00:28:42,400 uh, at Harris Health System. And, you know, 447 00:28:42,540 --> 00:28:44,920 we we're focused on health equity and, and, 448 00:28:45,140 --> 00:28:49,700 and it's really intriguing to me that I routinely and repeatedly 449 00:28:50,570 --> 00:28:54,660 have to remind folks when you were talking about, 450 00:28:55,400 --> 00:28:58,940 you know, what, what is one barrier, uh, 451 00:28:59,610 --> 00:29:01,340 that I believe, uh, 452 00:29:01,360 --> 00:29:04,780 is preventing us from moving the needle is, 453 00:29:04,840 --> 00:29:09,060 is lack of clarity and lack of focus. You know, when when, 454 00:29:09,090 --> 00:29:13,420 when we say, you know, population health, what do we mean by it? Exactly. 455 00:29:14,650 --> 00:29:18,420 When we say health equity, what do we mean by it? Exactly. 456 00:29:18,530 --> 00:29:23,320 When we say we wanna improve health equity, exactly. What do mean by that? 457 00:29:24,360 --> 00:29:29,300 Uh, I really believe that if we can create more clarity 458 00:29:30,760 --> 00:29:34,060 and focus on what it is that we're trying to do, 459 00:29:34,650 --> 00:29:38,660 realizing that no one, I don't care how big of a system you are, 460 00:29:38,740 --> 00:29:40,340 I don't care how much resource that you have, 461 00:29:41,180 --> 00:29:43,280 no one will ever be able to boil the ocean. 462 00:29:44,660 --> 00:29:47,240 If we can bring focus to one or two 463 00:29:49,710 --> 00:29:51,650 top line, most important, 464 00:29:52,040 --> 00:29:56,900 most impactful interventions in an 465 00:29:56,900 --> 00:30:01,700 area of our community that is most negatively impacted and, 466 00:30:01,700 --> 00:30:05,540 you know, be able to move the needle, uh, I think that's what's lacking. Again, 467 00:30:05,620 --> 00:30:10,210 a a lot of times we fall into the trap of really getting excited and we should 468 00:30:10,210 --> 00:30:13,650 all be excited about the principles of health equity and population health, 469 00:30:13,750 --> 00:30:16,090 but not to the detriment of losing track, 470 00:30:16,790 --> 00:30:18,850 of being able to 471 00:30:20,820 --> 00:30:24,140 continuously move forward and onwards, um, 472 00:30:26,020 --> 00:30:30,390 more than anything else. Uh, I think, I think that's the problem that, uh, 473 00:30:30,490 --> 00:30:35,350 we locally, individually, uh, and as a society, 474 00:30:35,850 --> 00:30:36,390 uh, 475 00:30:36,390 --> 00:30:41,360 struggle with lack of focus and lack of clarity among 476 00:30:41,500 --> 00:30:43,800 the principals, uh, that we're discussing. 477 00:30:46,570 --> 00:30:49,090 I appreciate that. I think even as a member of the media, 478 00:30:49,320 --> 00:30:52,730 it's something we have to be incredibly careful about because to your point, 479 00:30:53,160 --> 00:30:55,890 there's so much support for the cause. There's buy-in, 480 00:30:55,890 --> 00:31:00,530 people do want to act on these problems, but like you said, if it's, 481 00:31:00,720 --> 00:31:05,130 it's how we channel that energy, right, toward really targeted causes, 482 00:31:05,150 --> 00:31:07,130 really specific outcomes that are, 483 00:31:07,130 --> 00:31:12,010 we're working to achieve versus just kind of talking about it in a categorical 484 00:31:12,150 --> 00:31:16,850 or blanket term that won't make the progress we want to see 485 00:31:17,030 --> 00:31:17,863 in the short term. 486 00:31:19,010 --> 00:31:21,940 Exactly. You know, what, what is it that, uh, 487 00:31:22,020 --> 00:31:26,060 a journey of a thousand miles starts with the first step, right? It is. 488 00:31:26,060 --> 00:31:27,900 Those is those incremental, 489 00:31:29,290 --> 00:31:33,990 sustained focused efforts that will pay 490 00:31:34,230 --> 00:31:35,063 dividend at the end. 491 00:31:37,470 --> 00:31:41,450 Dr. Course, I wanna thank you for your time today. You are a deep thinker. 492 00:31:41,970 --> 00:31:46,450 I learned and got so much from our conversation. I know our listeners did too. 493 00:31:47,030 --> 00:31:49,930 Um, president and c e o of Harris Health System, 494 00:31:50,350 --> 00:31:53,050 the primary healthcare safety net of Harris County in Texas. 495 00:31:53,730 --> 00:31:58,410 I wanna wish you continued luck and progress in all the work you're setting out 496 00:31:58,410 --> 00:32:02,530 to do with Harris and as a safety institution, one of the greats of our, 497 00:32:02,550 --> 00:32:06,210 our country, and I hope we can check in with you again soon at Becker's. 498 00:32:07,070 --> 00:32:08,460 Thank you, Molly. I appreciate it.