This is the Becker's Healthcare Podcast. I'm Molly Gamble,
vice President Editorial, and today I'm spending time with Dr. Esmail Porta. Dr.
POA is the president and c e o of Harris Health System,
which is the primary healthcare safety net system of Harris County,
which includes the city of Houston and Texas.
This system includes Ben TA Hospital in Lindon b Johnson Hospital,
along with a network of community health centers and clinics. Dr. Porta,
welcome. Thank you so much for being my guest today.
Where does this podcast find you?
Uh, as you mentioned, Houston, Texas.
Great. Well, Dr. Po,
I shared just a little bit there in my opening remarks about Harris Health
System, but beyond those fast facts and figures,
what do you think is the most important thing for our listeners today to really
understand about Harris Health?
Yeah, well, first of all, thank you for the opportunity to do this.
I really appreciate it. Um,
and not so much specific to Harris Health System, but I would really like to,
uh, share with our listeners is, uh,
all the public health systems similar to Harris Health System and what,
what they mean to the communities that they serve. You know,
we happen to be one of the largest,
if not the largest public health system in Texas. Uh,
but there are several and other states as well.
You know, it is true that as a safety net hospital,
Harris Health System and other systems like us,
we have a statutory mandate to take care of the uninsured and underinsured.
That's a given. That's, that's why we exist.
But there is so much more to a public health system like us and
others, uh, that serve the same purpose.
And I just wanted to very briefly focus on those couple of points.
That'd be great.
We are major training sites for the future doctors and
healthcare providers, nurses, techs, you name it. In our instance,
you know, we are in partnership with two nationally and renowned medical school,
bay College of Medicine, and UT Recover medical School, both in Houston.
We train more than 3000 students and residents every year.
What that means to this community is a currently almost 50% of all
the doctors that are licensed by the Texas Medical Board
to practice in Houston and Harris County did their training actually at Harris
Health System.
And that's something that I don't think people appreciate when we're talking
about safety net hospitals. You know, you mentioned our hospitals,
Ben Top adult level one trauma center,
lbj adult level three trauma center.
They do a lot more than just safety net care of the indigent,
the uninsured and underinsured.
They provide lifesaving care to all Houstonians. And again,
I'm using Harris, Harris Health System as an example.
That's what happens in other large safety net hospitals as well.
We're also a huge economic engine to the community, and,
and folks don't, uh, routinely, you know, consider it,
uh, for every dollar in tax support, for example,
that Harris Subsystem receives,
they return almost $6 back to the Harris County last year.
That amounted to almost 5 billion in economic impact to the county.
And we also add capacity,
capacity to the local healthcare ecosystem
in terms of our emergency rooms and hospital beds. Yes,
we don't have the largest share of the system,
but what we do provide really does matter.
And I'm gonna use an example and then I'll stop. Uh,
this is something really important, and again,
something that people overlook when they think about safety net hospitals.
And the way I describe it is this, yes,
we have a statutory mandate to take care of any insured and under insured.
And unfortunately for a lot of reasons that we can discuss later,
this population, uh, waits, uh, because of their,
uh,
adequate access to care until they're too sick and they show up to our emergency
rooms,
or they just show up to the emergency rooms as a habit rather than taking care
of some of their routine care.
And a primary care provider like you.
And I would imagine a situation where Harris Health System or
systems like US safety net hospitals fail to provide that service
either because we are overwhelmed with increasing number of
uninsured and underinsured,
or because there is not enough support, financial support for our systems.
Well,
that population that currently seeks care at the Safety Net Hospital like
Harris Health System,
they are going to go elsewhere to receive that care.
And that elsewhere is a non-for-profit and for-profit hospitals in the area.
Couple of things happened. One,
everybody else's access to emergent and urgent care decreases because now the
emergency rooms, other emergency rooms are inundated, uh,
with people that were otherwise received care at Harris
HealthSystem. And number two,
that provision of care to the uninsured and underinsured
by non-for-profit or for-profit hospitals. Obviously,
those hospitals are not going to, uh,
take a hit to their bottom line, right?
So they have to pass on that cost to someone
where the biggest consumers,
customers of non-for-profit and for-profit hospitals are the insurance
companies.
So that cost gets transmitted to the insurance companies.
While the insurance companies are also in not in the practice of losing money,
they have to transmit that cost to their customers and consumers.
And that's you and I, everybody with a private health insurance.
So at the end,
what happens is that when a safety net hospital fails to provide the services
that it does, for the reasons that I just mentioned,
the overall cost of health healthcare actually increases in terms of
out-of-pocket deductibles and health insurance premiums,
when those costs have to trickle down to everybody else.
So that in a nutshell is the role that Harris Health
System and systems like us provide in the community that a lot of time gets
overlooked.
Mm-hmm. , I'm so glad Dr.
Po said that you started there and that you established that context.
For our listeners, the safety net institutions, especially in US cities,
can so often go undersung in their value and the role they play in our
healthcare system.
I really think of them as the best of what healthcare can be in terms of
their mission and their alignment with that mission.
The people who choose to practice and work in safety nets,
that is a choice that one makes to seriously give back to their community. Um,
and the under uninsured, like you said.
Just to ensure our listeners understand to Harris Health and what
you are working with as c e o, do you mind sharing your payer mix with us?
Not at all. I'd be happy to. Actually, you know, this is,
this is information for everyone to, to have access to.
So almost half of our patients are uninsured, uh, 50%.
And there is a large portion of our
patients who are also on Medicaid or Medicaid managed care around around to
20%, but is left at at 30%. There's about 20%,
maybe a little less Medicare and about 10 or 12%, uh, private insurance.
Uh, which really creates, as you can imagine, a, a situation where,
uh, caring for the uninsured or underinsured, those are Medicaid,
Medicaid managed care, uh, creates a situation where we cannot
address the escalating costs of inflation and everything else that happens to
our, uh, privately insured patients.
Cause we just do not have that volume of insured patients.
Mm-hmm.
and even that mix and those ratios might even be in flux a bit
just because of the Medicaid redeterminations that are ongoing. Right.
Yeah. I'm so glad you mentioned that. I didn't know I'm, uh, aware, uh,
the listeners are. So, because of the end of the public health emergency,
the folks who for the last three years as a deal that was made with the federal
government, nobody was coming off the Medicaid rules, uh,
because of the additional dollars that the federal government was sending to the
states. Well, since the end of the public health emergency,
everybody has been put on notice that, uh,
the states are going to go down through the, uh,
their Medicaid enrollment roles and people are gonna come off of it. We,
in Texas,
we anticipate that more than 3 million people are going to be impacted.
Harris County, unfortunately, this is the number not, uh,
that we're not proud of,
has the highest rate and number of uninsured residents of
the county in the country. Currently,
that number is 1.2 million uninsured residents of the county.
And we anticipate some of that 3 million people are gonna be impacted coming
off. The Medicaid rules are gonna be residing in Harris County.
What is the total impact is when it remains to be seen. Uh,
it's probably gonna take us a few months to figure out exactly who's going to be
coming off the Medicaid rules, what you're correct. Uh,
those percentages are surely to change, uh, for the negative. Mm-hmm.
.
Well, I think what, what you just shared, Dr of course, I mean,
more than 3 million looking to be affected by the Medicaid redeterminations in
Texas and then the highest rate in Harris County of uninsured in the country
with one 1.2 million you said. So that number might even grow higher.
Um, yeah, thank you for noting that.
I think it's something we at Becker's are keeping an eye on.
Every state has different timelines for those determinations, but like you said,
so much does remain to be seen. And I know health systems are,
are working hard to try to have people who can enroll or re-enroll. Uh, do. So.
Um, you know, I wanted to talk a little bit about your background.
You have such a rich background as an internist, a public health expert,
public health leader,
a system executive at really respected safety net institutions.
How have your firsthand experiences really come to shape your philosophy
and views on health equity and population health?
If there are any specific experiences or moments you can point to as
exceptionally influential, I, I would love to hear about them.
Sure. You know, I, I,
I described myself as somebody who has really basically devoted his entire
professional life to, to public health. Um,
is there a specific moment which I think was most impactful?
Probably not. I,
I would say that it is been an accumulation of experiences.
Um, you know, I think back about my training, uh,
many years ago. Let's not, let's not get into the details of how many years ago.
I don't want to date myself, but needless to say, you know,
when I did my medical school training and even the residency training,
we as doctors, we became really,
really good at understanding and treating
diseases really good at, you know,
understanding the pathology of hypertension and diabetes and,
and stage renal disease and sickle cell disease. I think that you name it,
you know, it really was not until later on when I, uh,
enrolled in this school of public health just out of interest,
that I, I realized how poorly we were trained,
really had very, very little, if any,
understanding of the concept of health promotion and disease
prevention.
We were so focused on treating illness that
it, it would really just not occur to us that, you know,
that that cliche and balance of prevention is, is worth a pound of cure.
It, it was not in our vocabulary. You know,
having gone through the school of public health and understanding the principles
of population health and health equity, it, it,
it was really an eyeopening opening. Um, not, not a single moment,
but again, uh, an accumulation of experiences. Cuz after that,
I remember at the time I was still actually, uh,
providing care inside the inside Harris County jail. It occurred to me,
uh,
what an impact we can have as medical doctors and other
providers, uh, rather than just treating next diabetic patient,
the next hypertensive patient. Uh, so yeah, not, not a,
not a single experience, but an accumulation of experiences.
I think that's so relevant. And at Becker's, I mean,
we've been having some recent conversations about medical schools,
the need for some changes in curriculum and how
students w work their way through medical schools,
including the debt they can incur going through that educational chapter. So,
Dr. Poa, to your point about the,
the emphasis on disease management and treatment versus prevention,
like you said, it, it, I know you mentioned it was a few years ago,
but it seems like that is a huge opportunity for the next generation of
physicians, nurses, healthcare workers,
to have a bit more knowledge and,
and familiarity with that important part of one's healthcare and health,
health journey.
Yeah. So that is true. You know, on an individual level, you,
you're absolutely right. But, you know, at the system level, uh,
as a nation, uh, we collectively need to,
and I know that there, we are taking steps towards that, but the,
the steps are painfully, painfully small and slow steps.
Uh, but there needs to be a shift in our collective attention, uh,
of resources, uh,
and emphasis and focus on more and more disease prevention and health
promotion. Because, I mean, and you know, this,
I know I'm preaching to the choir, probably the listeners know this as well,
you know, for the amount of money that this country spends on, on healthcare,
we should be experiencing much, much better outcomes, uh, than we are.
And we are not, you know,
we spend more money per capita and in totality than any country on
this planet. And when it comes to outcomes, we are not even in,
in a top tier, uh, in terms of our health outcomes.
So a lot of things wrong. And I don't want to get, uh,
going on that tangent because you will never be able to stop me. But let me,
lemme say this because I think this is very important. I struggle with this,
you know, I, I think back about my training and, uh,
everything that was good and everything that was not so good with it.
One of the things that I struggled with in the, in the current training, uh,
as I'm thinking about, you know,
why is it that United States spend so much more money than
other nations? And, you know,
there's a lot of conversations about our overhead charges are so much higher.
You know, the cost is this, and united administrative cost is death. And all,
all of that is probably true. Uh,
I'm not saying that that there's a single thing,
but one thing that I have noticed is the,
the transition in the way we think about the art and science of medicine.
You know,
I remember as a young doctor how much I took
pride in my ability to
perform really sound, physical examination and,
and my bedside diagnosis abilities.
And I compare and contrast that to today. Uh,
when our young doctors, you know, finishing medical school and residency,
it, it, it seems they just do not have the same
capability, understanding capabilities to do the same. You know,
every complaint ends up with a very expensive diagnostic test.
You know, every abdominal pain gets an ultrasound, every headache gets an mri,
every cough gets a chest CT scan. And
that, I think also partly is, is
responsible for what we are seeing in terms of the high cost
of healthcare. Uh, we, we are so,
so concerned about not missing that one in a million chance
of a bizarre disease process that we are
really just breaking the bank, uh, and,
and taking care of some of the very routine things that should not be costing so
much. Anyways, I, I can can talk about this all day long. Let, let's,
let's move on. .
I don't blame you. I,
I wanted to go back to something you had shared in passing.
It sounds really interesting, and I wanted to make sure this didn't,
we didn't drive by this, but you mentioned working in the prison, um,
before you came to Harris Health, I believe you spent about half a decade,
right?
As the medical director of Parkland Health and Hospital System Correctional
health Program.
Can you tell us about that experience and also if there were any
valuable lessons you gained from that chapter of your career?
Yeah, absolutely. So actually you, so you're correct. Uh, but even before that,
I was, uh,
directly delivering care to the inmates at Harris County Jail about 12 years.
So it was probably more like 15, 16 years of my, uh,
professional careers initially, uh, dealing with correctional health.
You know, it, it, it goes back to the whole idea of,
uh, health promotion, disease prevention, and health equity. I,
I never forget this. You,
you asked about a moment that may have been most impactful in
my thinking about population have and health equity.
You know, now that I'm thinking about my correctional health experience,
I never forget this one morning. Um, I was, uh, early,
I always get to work early.
It was an early morning and people were getting lined up detainees. Uh,
this was at Harris County, actually Dallas County Jail. Uh,
they were getting lined up to go to court.
And the way it works out for those who may not be familiar with the correctional
setting is that, you know, in the mornings,
everybody who needs to go to court basically goes to court and sits in the
waiting rooms waiting for their, uh, hearing.
So there were two,
maybe 300 detainees that were lined up in a large area,
getting ready to go from the jail through the tunnel to the courts,
and there was a slope. Uh, so it was standing on,
on the top end of the slope,
and so moved down and folks who were lined up. And, you know,
it was very traumatic because what I saw was a
sea of young African-American male
detain. And it,
it truly was a light bulb moment, uh, in, in my head,
realizing that the,
when we talked about health disparities and health inequities and
social determinants of health,
and wonder why the health outcomes among
the different ethnicities are what they are,
i e our black and brown, uh,
patients have
worse outcomes in just about every disease process that you put your finger on
compared to, uh, a white patients. It,
it is not, it is not a genetic predisposition.
It is not really anything else other than
social
injustices that prevail in this country, unfortunately. And,
and that large part has to do with our correctional system. And,
and that's something that, again,
unless and until you are actually a part of it, you know, in it,
it is really difficult for people to,
to realize what a huge impact the correctional system in this
country has on the overall health of all of us. You know, United States,
you know, has about, uh, you know,
5% of the world population, and we routinely incarcerated,
about 20% of all the people who are incarcerated in the world
are incarcerated in the United States. Uh, that is a terrible number.
You know, every year about 10 million people get in and out of the jail.
And, you know,
the science is very clear on what happens when you are incarcerated.
The impact that incarceration has on your ability
to have, first of all,
to obtain a job and then obtain a job that provides lovable wages,
uh, the impact that it has on your ability to go to college,
the impact that it has on your housing. Um, and you name it, you know,
when we talked about the social determinants of health, incarceration,
probably more than anything else,
touches negatively every single one of those social determinants of health.
Um, so I guess you can tell,
I I'm very passionate about the topic of corrections and correctional health,
because I think it's, it's, uh, it's the pillar
of
the lack of the foundational approaches to
healthcare that it's,
it's missed in the conversations when we were talking about health equity and
population health. It, it, again, it, it is a topic that unless,
and until you know about it and you are in it, it it is really difficult, um,
to be aware of it. But, but, but I think, and, you know,
have made it the mission, my mission, uh,
to speak about this at every opportunity that I get to,
to really shine the light and importance, uh, of this issue. Mm-hmm.
.
It's a really important perspective, and it's one that like, like you said,
is not often represented. And I think to, to your point too,
there's something to be said about how we treat our most vulnerable or the
weakest people in our society when they're in prison,
the healthcare access they have available to them.
And then also when people are
reintegrated into society after, after spending time in prison, it's,
it's firsthand, I've,
I've some experience too in seeing how inadequately prepared they can be, um,
whether it's for employment, whether it's for education,
they oftentimes there's turned back out with the belongings, uh,
the bag they went in with, with their clothes and, um, housing.
So I think also you do not want, as a society,
people coming back to return to their,
their life sicker than they were when they went into prison. Right. Right. Dr.
Pos, that, that should be, when we're talking about public health,
an outcome that you would wanna avoid.
That you know, that, that that is exactly the point. Uh,
and I, you know, you,
you remind me of some of the conversations that I've had in my life with others.
When, you know, when, when you think of corrections,
when people come to the jail, to your point,
there are times that actually
detainees when they come in contact with healthcare inside the jail,
that that is the first time ever in their lives,
that they have had the opportunity to interact with the healthcare provider.
And that, that is the sad truth. But what a great opportunity,
uh,
for a society to take advantage of that encounter of,
of that, uh,
of that opportunity to impact the health of that individual. Because remember,
the folks who go to the jail, they're gonna come back,
they're gonna come back to the communities in which they reside.
If we are able to address their healthcare issues
while incarcerated so that they can return to the community
healthier, that when they went into the jail,
everybody wins. The individual wins, the society wins
as far as the cost of care, the cost will decrease. And I mean, again,
the science is very clear. When people leave the jail,
if their healthcare issues are not addressed,
that utilizations of the community emergency rooms, it, it is,
it is a staggering, it is extremely high.
So why not take it management that opportunity,
and I say this realizing that not, not everybody, uh, accepts that or,
or agrees with this concept. You know, I've had people who,
uh, believe that, you know, when people are in jail,
you're basically just keep them alive until they leave the jail,
then that's your responsibility. I obviously,
I disagree with for a lot of reasons. You know, you mentioned it, you know,
I think our ethical responsibility to take care
of our weakest and most vulnerable, uh,
and and beyond that, it, it, it,
it just makes economical and healthcare
sense, uh, to take care of our detainees when you're incarcerated. Mm-hmm.
mm-hmm. , I, I,
I wanna wind down with a thought from you about, you know,
we've talked about health equity in a number of ways throughout this
conversation, and we could probably talk about it for days, Dr. Pera. Um,
but you know, you have such a valuable perspective on this topic,
and so often when you start talking about health equity,
you get to a point every conversation where you confront the barriers,
what stands in the way, whether it's underfunding, whether it's, um,
a lot of commitments made verbally but not executed.
Sometimes it can be dwelling in research and analytics and not putting in
solutions and moving into different neighborhoods to provide care.
But I wanted to check in with you and see what you see as the main barriers or
obstacles that,
and thwart efforts to achieve more equitable he health outcomes.
I'm sure this list is long.
Maybe there's one that isn't as acknowledged as much as it should be that you,
you can share with me.
Yeah, , this is actually,
this is a topic that I probably talking about if, if not every day,
probably every other day. And, and I talk about it with, with my folks, uh,
with the people that work with me. You know, as you mentioned at the,
at the top of our conversation, um,
I've basically devoted my entire life to the principles of health equity and
population health and, you know, be, have the population health department,
uh, at Harris Health System. And, you know,
we we're focused on health equity and, and,
and it's really intriguing to me that I routinely and repeatedly
have to remind folks when you were talking about,
you know, what, what is one barrier, uh,
that I believe, uh,
is preventing us from moving the needle is,
is lack of clarity and lack of focus. You know, when when,
when we say, you know, population health, what do we mean by it? Exactly.
When we say health equity, what do we mean by it? Exactly.
When we say we wanna improve health equity, exactly. What do mean by that?
Uh, I really believe that if we can create more clarity
and focus on what it is that we're trying to do,
realizing that no one, I don't care how big of a system you are,
I don't care how much resource that you have,
no one will ever be able to boil the ocean.
If we can bring focus to one or two
top line, most important,
most impactful interventions in an
area of our community that is most negatively impacted and,
you know, be able to move the needle, uh, I think that's what's lacking. Again,
a a lot of times we fall into the trap of really getting excited and we should
all be excited about the principles of health equity and population health,
but not to the detriment of losing track,
of being able to
continuously move forward and onwards, um,
more than anything else. Uh, I think, I think that's the problem that, uh,
we locally, individually, uh, and as a society,
uh,
struggle with lack of focus and lack of clarity among
the principals, uh, that we're discussing.
I appreciate that. I think even as a member of the media,
it's something we have to be incredibly careful about because to your point,
there's so much support for the cause. There's buy-in,
people do want to act on these problems, but like you said, if it's,
it's how we channel that energy, right, toward really targeted causes,
really specific outcomes that are,
we're working to achieve versus just kind of talking about it in a categorical
or blanket term that won't make the progress we want to see
in the short term.
Exactly. You know, what, what is it that, uh,
a journey of a thousand miles starts with the first step, right? It is.
Those is those incremental,
sustained focused efforts that will pay
dividend at the end.
Dr. Course, I wanna thank you for your time today. You are a deep thinker.
I learned and got so much from our conversation. I know our listeners did too.
Um, president and c e o of Harris Health System,
the primary healthcare safety net of Harris County in Texas.
I wanna wish you continued luck and progress in all the work you're setting out
to do with Harris and as a safety institution, one of the greats of our,
our country, and I hope we can check in with you again soon at Becker's.
Thank you, Molly. I appreciate it.