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4 of biggest challenges facing Healthcare today:

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4 of biggest challenges facing Healthcare today:

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Info and service integration, Effective payment methods, Protecting the devices that protect public health, and looking for a win-win outcome with pharma companies

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Medical and technology innovations have together produced radical service delivery advancements. Despite monumental improvements, society is only experiencing the beginning phase of this process. While today is a time of growth, it is also a time of growing pains. Duly, the medical field currently faces four prominent challenges: service integration, service quality, Internet connected medical device security and publicly sustainable pharmaceutical pricing. While innovations promise to change healthcare service delivery forever, it will take some time before the advancements reach their full potential.

A Period of Sweeping Changes

According to a report issued by the healthcare consulting firm PwC Health Research Institute, patients have multitudinous innovations available due to recent healthcare reform and technological innovation, resulting in service delivery when and where patients want and need it. [1] The advancements come at a time when patients need detailed information to manage new, complex and increased caregiving expenses. As a result, many clients rethink and improve how they manage their retirement funds. This prudence will likely carry over into other fields connected to healthcare service delivery.

2016 marked the year the medical community expected significant healthcare delivery improvements due to enhanced access to patient information and groundbreaking technology incorporation. For the first time, the concept of virtual hospitals exists with service delivery limited only by Internet connectivity, while the medical community experiments with alternative payment models and big data management tools. These combined advancements will soon create sweeping changes in the medical field.

While these changes are monumental, they will take place at a moderate pace. Caregiving organizations want empirical evidence that each innovation will provide quantifiable returns, and while a unified patient database moves toward fruition, conflict over information rights - for consumers and organizations - slows progress substantially. Finally, legislative wrangling over healthcare delivery policies further slow advancement in the medical field.

Challenge 1: Information and Service Integration

The medical community easily welcomes big data advancement, but implementation is not as fluid. Non-relational databases merge patient information from many sources, providing actionable metrics. The technology presents itself at the perfect time to fill the need to exploit newly available patient information stores.

Traditionally, care providers use relational databases to store and access patient information. However, relational databases cannot efficiently manage unstructured information, such as clinical notes and transcripts. Only a small percentage of care providers have been able to transition from relational to non-relational databases using traditional electronic health records (EHRs). Most organizations successfully implementing non-relational information technology are large and financially capable.
Non-relational databases fully exploit all recorded patient information despite the format. The technology helps care providers recognize traits typically lost once recorded or until individually reviewed. By making details such as these easily available, drug or equipment manufacturers gain stronger insight into how patients use medical products. Additionally, primary care providers discover more information to help them discover solutions for current patients.

In the United States, some care provider networks have already deployed advanced non-relational databases. Patients' willingness to share their medical information is critical for non-relational database success. While most patients have no qualms providing medical information to caregivers, significantly fewer are willing to share their information with third parties, such as drug manufacturers.

Because many care providers have only recently adopted electronic health records, they are unwilling to implement new non-relational database technology. With additional investment, care providers can increase database effectiveness markedly.

Because of limited access to patient information, drug manufacturers waste immeasurable expenses on research and development, which is passed on to consumers. Educating patients on how information sharing reduces costs is essential to developing a free information flow facilitating medical advancements and helping care providers develop more personalized service delivery plans. Patients understanding these benefits are more willing to share medical records with third parties.

Challenge 2: Effective Payment Model Discovery and Implementation

A report issued by the nonprofit medical association Academy Health states that to decrease costs and increase service quality, insurers and benefactors have instituted new payment models. [2] Under the new models, financial incentives hinge on patient outcomes rather than service quantities. The new models include incentives, such as:

Bundled payments

Disbursements to patient-oriented care providers

Global payments

Shared savings

The medical community widely reproaches the way insurers disburse funds as the primary cause for high healthcare expenses in the United States. Because many insurers simply pay for services rendered, patient advocates believe traditional models incentivize care providers to deliver quantity rather than quality. Additionally, since care providers receive disbursements directly, they have little reason to work collaboratively with others. This typically results in increased expenses and unsatisfactory patient experiences.

New payment models seek to alleviate these problems. Large organizations, such as Medicare, serve as proving grounds for the new models. The group has dedicated an entire business unit to developing, testing and implementing new payment models to improve patient outcomes and decrease costs.
The shared savings model has gathered the most attention among care providers. Many versions of this payment model exist, but accountable care organizations (ACOs) implement the most noted approach. Under ACOs, healthcare groups assume responsibility for improving patient outcomes and reducing costs. When they meet these criteria, the participants share the savings produced by their collaboration. This encourages providers to coordinate services and uniformly promote preventive practices.

It is a difficult to secure provider participation in the models and monitoring processes. Further complicating the matter is that the new payment models are adjustments, rather than complete overhauls, and measuring return-on-investment proves difficult. Consequently, truly transformative practices will emerge due to the efforts put forth by the handful of early adopters.

Challenge 3: Protecting the Devices That Protect Public Health

Many healthcare technology advances incorporate Internet connectivity, an industry forecasted to grow to almost $300 billion by 2020. [1] However, this convenience also extends to computer hackers. As the Internet connected medical device field matures, malicious cyber-attacks will increase.

In 2015, the United States government issued a warning that hackers can instruct infusion pumps to deliver lethal medication doses. The disclosure highlighted the possibility that malicious programmers can infiltrate medical devices and harm patients. Furthermore, hackers use medical devices to infiltrate care provider information networks, performing malicious acts such as stealing research and clinical trial data.

The US Food and Drug Administration (FDA) encourages medical device manufacturers to limit equipment access to trusted users. Additionally, the administration requires manufacturers to report and repair potential device compromises immediately.

To date, hackers have not compromised any medical device and prompted a mortal occurrence. However, cyber security analysts point out an attack against an unprepared care provider will devastate an organization in many ways. In 2014, almost all large health networks fell victim to cyber breaches with 20-percent of those attacks costing over one million dollars in recovery expenses.

Information technology experts suggest that medical organizations carefully consider how they structure proprietary networks. They recommend organizations bear the expense of segregating external consumer medical devices from internal devices on enterprise networks and in effect limit intruder access.
A PwC Health Research Institute poll reports that over 60-percent of respondents prefer device security over simplicity. Medical devices engineered without security protocols place patients and healthcare organizations at risk. Organizations implementing technological developments will incur added expenses implementing these precautions. The medical community will have to borrow many practices from secure industries, such as banking and government organizations. If left unchecked, these ongoing risks may cause legislators to shift from making recommendations to enacting full regulatory medical device security mandates.

Challenge 4: The Search for a Win-win Outcome with Pharmaceuticals

Patients, insurers and regulators join in lamenting that drug prices have grown exorbitantly. Pharmaceutical manufacturers counter that lower pricing will hinder product development. In the meanwhile, the two groups continue struggling to find a pricing consensus, while consumers struggle to keep up with prescription costs.

Under increased governmental pressure, drug makers must now substantiate their pricing. The enterprises are also under scrutiny from the public, insurers and pharmaceutical value assessment groups.
Many factors contribute to the fair drug pricing challenge. Spending on "complex specialty" drugs increased almost 30-percent in 2014. Brand name drug prices have risen higher than inflation every year since 2006. Generic medication, which typically reduces in price over time, increased in price almost 10-percent in 2014. Analysts predict these trends will continue.

Some pharmaceutical executives advocate for fair pricing and suggest that insurers reward organizations prescribing new, cost-effective drug treatments. Globally, several groups have formed to evaluate and monitor pharmaceutical pricing. Each develops its own formulae to measure price traits, such as:

Economic viability

Effectiveness

Patient outcomes

Toxicity

The information made available by these international groups helps insurers reduce prescription costs in the United States.

Almost 20-percent of patients request a less expensive alternative when physicians issue prescriptions. Difficulty and dissatisfaction are likely to increase as policyholders face increasing deductibles. Reliable drug pricing information is not available among manufacturers or insurers to help resolve this matter. With cooperation from insurers, manufacturers and patient advocates - the medical community can develop a continuous framework to ensure fair drug pricing. If pharmaceutical firms do not reach an accord with consumers and insurers, legislators are calling on drug prices determined strictly by manufacturing costs, which will significantly decrease medication fees.

Service delivery innovations are on the verge of drastically improving community health. While the medical community and patients alike welcome these changes, making these innovations a reality presents several challenges. Despite the struggle to implement advancements, history will remember this era as the beginning of the next evolution in medical service delivery.

Learn More

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4 Major Challenges Facing Today's Health Care Industry

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Medical and technology innovations have together produced radical service delivery advancements. Despite monumental improvements, society is only experiencing the beginning phase of this process. While today is a time of growth, it is also a time of growing pains.

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In this post, we continue to discuss the results of our survey of affordable housing developers in New York State on their experiences of community opposition to their development projects. Out of 75 developers-nonprofit and for-profit-responding to our survey (a response rate of 50 percent), 70 percent have experienced at least one incident of community opposition. In our first post, we discussed why these developers pursue affordable housing projects, what types they build, and what funding sources they use. In our second post, we analyzed where opposition occurs, what types of developers and projects are targeted most, and when during the project cycle community opposition is most likely to occur.

In this post, we present who opposes affordable housing development projects in New York State, what specific concerns are raised by communities to justify their opposition, and what tactics they most commonly use.

Individual residents and organized resident groups are the most frequent sources of opposition, but public agencies and officials can also be vocal opponents. We asked developers to choose how local opposition is most typically organized, based on their experiences. As shown in the pie chart below, residents were the lead opponents according to almost three out of every four developers. For 38 percent of developers, resident opposition was typically staged by unorganized individuals. Another 35 percent said organized resident groups-such as neighborhood associations, homeowners associations, and community coalitions-led opposition efforts to their affordable housing development projects. Perhaps most surprising, almost one out of every five developers said that a public agency or public official was the primary source of opposition to their projects. Getting residents on board seems a critical strategy for developers to pursue.

This is an area where public officials and planners, and transparent planning processes and communication, could help, especially when coupled with our findings that local opposition is most frequently experienced at the time of local approval of the development project.

Community concerns about safety and crime, and the type of population served show specific biases against affordable housing versus general development. A lot of past studies on NIMBY have tried to differentiate between community concern about any type of development (such as BANANA opposition: "Build Absolutely Nothing Anywhere Near Anything") versus affordable housing specifically. Our results provide interesting insight into some specific reasons that communities may be opposed to any development, but are particularly fearful of affordable housing.

First, the most commonly reported reason for opposition is fear of increased crime and decreased sense of safety-heard by over three out of every five developers experiencing opposition. Half of the developers also regularly hear community concern about tax burdens. This concern comes into play with many development projects, but more typically with developments such as affordable housing that normally seek some type of property tax concession from local government, and thus are viewed as not paying their "fair share" of the costs of public services to the site.

Concerns about traffic, school impacts, and environmental impacts are also frequently employed, according to developers, but are not necessarily unique to affordable housing development projects. School impacts may be more of a concern when communities are operating under the assumption that households qualifying for affordable housing have a higher proportion of school-aged children than non-subsidized housing development, particularly when coupled with property tax concessions that will affect the school tax base, as well.

While recent research in New York State based on calculated multipliers by income and numbers of bedrooms has suggested that this assumption may not be true, more research is needed on how to address this area of community concern.

Perhaps the most direct indication that community opposition is specifically against affordable housing developments is that one out of every five developers mentioned opposition to the people they expected to be served by the development: "those people", "welfare recipients", "homeless", "special needs", and "renters". These arguments expose the fact that irrational fears and misinformation may drive some opposition, as one of us has explored previously. Such prejudices can be hard to challenge and change, but it seems clear that more work is needed to counter the root causes of opposition to affordable housing development projects.

Communities put a lot of effort into opposing affordable housing development projects using diverse tactics, from traditional communications strategies, to emergent technologies, and legal challenges. The most common form of opposition remains the use of news media, including newspaper ads, editorials and letters to the editor, with over half of developers reporting this tactic. Over 45 percent also said their development projects were targeted through information campaigns, such as flyers, petitions, and yard signs distributed throughout the community.

The use of web-based discussion boards, forums, and social media is also a significant means of communicating opposition today, with two out of every five developers indicating the importance of these emergent technologies. A handful of developers also mentioned that an entire website dedicated to opposing one or more of their affordable housing development projects was launched and maintained. This is a significant effort that requires further study as to who is more likely to use this tactic within communities (e.g. individual opponents or organized ones), who their target audience is (e.g. news media vs. local officials), and what effect this growing opposition strategy has on affordable housing development compared to more traditional means of opposition.

One out of every four developers experiencing opposition to their projects said they had been the target of a formal legal challenge. Roughly, that means if you are an affordable housing developer in New York State, you have around a 25 percent chance of facing a lawsuit against a proposed project (although realistically this probability will vary based on a variety of known and unknown factors we cannot explore with our small population in a single state, related to the developer, the project, and the community). While this may be higher or lower than the rest of the country, it should still be cause for concern. Every lawsuit represents a loss of monetary resources and time that could otherwise be spent on developing affordable housing or supporting other community building activities.

Organized protests, such as active picketing at construction site or public meetings, still occur, but perhaps not as much as we would expect. However, the same number of developers-over 1 out of every 5-also noted that individuals spoke up against their development projects at public meetings in less organized ways. And outside of these public meetings, local officials are still being pressured by their constituents to oppose affordable housing development.

These all point again to the importance of transparent, well-organized planning processes that acknowledge points of conflict and work through them in an equitable way that addresses the concerns of existing residents, but acknowledges the reasonableness of promoting affordable housing options within every community. Local officials, planners, and developers need to ask: Who is speaking out against the project? What are their primary concerns? Are they real concerns or assumed ones? Are they based on irrational fears and prejudice, or solid evidence? How can we cultivate a climate of two-way conversation, rather than jump directly to confrontation approaches such as protest, media campaigns, and legal challenges?

Our fourth post will take a look at how developers have worked to overcome community opposition and what they have found most effective in New York State. We will also summarize both the positive outcomes and negative outcomes of opposition.
To catch up on the rest of the series, read Part 1-"New York State's Affordable Housing Developers: What They Do, How They Do It," and Part 2-"NIMBY: Where, When, And to Which Developers It Happens."

Corianne Payton Scally is a principal research associate at the Urban Institute. She was formerly a senior research associate in the Metropolitan Housing and Communities Policy Center at the Urban Institute, and associate professor and director of the graduate Urban and Regional Planning Program at the University at Albany, State University of New York.

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Who, Why, and How Communities Oppose Affordable Housing

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In this post, we continue to discuss the results of our survey of affordable housing developers in New York State on their experiences of community opposition to their development projects. Out of 75 developers-nonprofit and for-profit-responding to our survey (a response rate of 50 percent), 70 percent have experienced at least one incident of community opposition.

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Education and Socioeconomic Status Factsheet

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The impact of socioeconomic status on educational outcomes and reducing slow academic skills development, low literacy, chronic stress and increased dropout rates.

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Few would argue that the state of our education system has plenty of room for improvement. However, developing a plan to take schools in the right direction is easier said than done. The first challenge lies in identifying underlying problems keeping students from learning today. This challenge, in part, is due to the fact that the problems may change considerably depending on who is labeling them, whether it is students, parents, educators or lawmakers. Consider this list of 10 major challenges currently facing public schools, based on the perspective of many involved in the world of education today.
Classroom Size
Many areas of the country are facing classrooms that are literally busting out at the seams. A report at two years ago discussed how schools in Georgia, in the midst of major funding cuts for schools, had no choice but to lift all class size limits to accommodate students with the faculty the school system could still afford to keep. More recently, Fairfax County in Virginia has been looking into a proposal to increase classroom sizes in the face of significant budget cuts. The Board of Education in South Carolina is also weighing their options in this area.
Poverty
Technorati reported last fall that 22 percent of the children in the U.S. live at or below poverty level. American Graduate defines poverty as a family of four with an annual income level of $23,050 or lower. American Graduate also cites a report from the Southern Education Foundation, which shows in 17 states across the U.S., low-income students now comprise the majority of public school students in those states. Some estimates put poverty levels for public school students at 25% in the not-so-distant future.

Students living at or below poverty level tend to have the highest dropout rates. Studies show that students who do not get enough food or sleep are less likely to perform at their full academic potential. Schools know these truths first-hand, and despite efforts to provide students with basic essentials, teachers, administrators and lawmakers know there is simply not enough to go around.
Family Factors Technology
Kids Health Guide reports that students are more technologically advanced than many teachers today, putting instructors at a decided disadvantage in the classroom. However, a student's love of technology also tends to distract him from his schoolwork, according to NEA Today. When teachers don't have the techno-savvy to compete with those devices, by bringing education and technology together , it can be difficult to keep students' interest and attention to properly teach new concepts.

Technology needs to come into the classroom to keep up with the learning demands of the 21 st century. Schools that are already cash-strapped may find an unsurmountable challenge in coming up with the funding to bring computers and other forms of technology into their classes. Scholastic offers some tips for school districts that want to fit the bill for technology, including everything from asking individuals in the district for "big gifts" to going to Uncle Sam for the funding. The website also suggests negotiating prices on technology when possible and allowing student to bring their own from home.

Photo By Intel Free Press CC-BY-SA-2.0, via Wikimedia Commons
Bullying
is not a new problem, but it is one that has a profound impact on the learning aptitude of many students today. Technology has given bullies even more avenues to torment their victims - through social networking, texting and other virtual interactions. Cyberbullying has become a major issue for schools, as evidenced by the number of suicides that can be directly traced to bullying events . The fact that laws are still fuzzy regarding cyberbullying adds to the challenge - since parents, teachers and administrators are unsure of how to legally handle such issues.
Student Attitudes and Behaviors No Child Left Behind
NEA Today quotes Kansas special educator Shelly Dunham as saying, "Testing, testing, testing, what is the point of testing? Do we use the data to remediate those who do not measure up? No!" Many teachers believe they are forced to teach to the annual standardized tests, and activities like recess and lunch have been cut way down to make more time for academics in light of the new testing procedures.
Parent Involvement Student Health
has reached epidemic proportions in the U.S., and the same poor eating habits that led to the obesity problem may also be contributing to lower student achievement. Obesity also increases a student's risk for other conditions, like diabetes and high blood pressure, which could result in higher absenteeism and more academic issues.

Photo By English: Lance Cpl. Ryan M. Joyner [Public domain], via Wikimedia Commons
Funding
Budget cuts have created huge problems for most public schools in recent years. Less funding means smaller staffs, fewer resources and a lower number of services for students. While some argue that throwing more money at the education problems won't make them go away, others assert that lack of funding caused many of the problems in the first place.

There are many problems in public schools today, but identifying those issues is half the battle. With a laundry list of challenges to face, now is the time for educators, parents and lawmakers to come together and begin to find solutions - for the benefit of all students in public schools today.

Questions? Contact us on Twitter. @publicschoolreview

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10 Major Challenges Facing Public Schools - PublicSchoolReview.com

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Are our public schools in a state of crisis? Learn about the 10 biggest problems with public schools today, both from the perspective of the administrators and the teachers

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Tuition-free college News, Research and Analysis - The Conversation

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Browse Tuition-free college news, research and analysis from The Conversation

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Viewpoint from people who support free college

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Viewpoint from people who support free college

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Should College Be Free? (Published 2019)

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New Mexico unveiled a plan to make its public colleges and universities free. Should all states follow?

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a conflicting viewpoint on differing views healthcare

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a conflicting viewpoint on differing views healthcare

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Article on how living in certain areas can lead to exposure of harmful settings... "hazardous wastes and other toxins, ambient and indoor air pollutants, water quality, ambient noise, residential crowding, housing quality, educational facilities, work environments, and neighborhood conditions."

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Article on how living in certain areas can lead to exposure of harmful settings... "hazardous wastes and other toxins, ambient and indoor air pollutants, water quality, ambient noise, residential crowding, housing quality, educational facilities, work environments, and neighborhood conditions."

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Article relating to all 3 topics, but mostly rooted in how housing leads to different access to education and healthcare, those living in social housing had it worse and those living in wealthier neighborhoods had it easier.

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Article relating to all 3 topics, but mostly rooted in how housing leads to different access to education and healthcare, those living in social housing had it worse and those living in wealthier neighborhoods had it easier.

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Big article on how socioeconomic status affects healthcare, ton of good info

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Big article on how socioeconomic status affects healthcare, ton of good info

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Differences in socioeconomic status, whether measured by income, educational achievement, or occupation, are associated with large disparities in health status. This association persists across the life cycle and across measures of health, including health status, morbidity, and mortality. Although effects are largest for those living in poverty, gradients of disparity are seen across the socioeconomic spectrum.

This article discusses health disparities based on socioeconomic status in the context of urban health care. We begin by discussing the relationships among race, socioeconomic status, and health. We trace disparities in health based on socioeconomic status throughout the course of an individual's life and review potential explanations for this relationship. We conclude by discussing the implications of these disparities for the provision of health care to urban, low-income, and minority patients. Studies for this review were identified through selected Medline searches, bibliographic searches of key articles, and the authors' knowledge of the literature. The size of the literature on health disparities precluded a complete, systematic literature search.

The Interrelation of Race, Socioeconomic Status, and Health

Residential segregation, a product of long-standing institutional and individual racism, represents a fundamental cause of racial disparities in health because it perpetuates racial disparities in poverty, education, and economic opportunity that, in turn, drive disparities in health. The social and spatial marginalization associated with segregation reinforces substandard housing, underfunded public schools, employment disadvantages, exposure to crime, environmental hazards, and loss of hope, thus powerfully concentrating disadvantage.

Health Disparities Across the Life Cycle

Fetal and Neonatal Health

Child Health

Adolescent Health

Adult Health

Elderly Health

Health disparities among the elderly that are related to socioeconomic status begin to narrow slightly, perhaps due to healthy survivor effects. Nonetheless, elderly people of low socioeconomic status experience greater disability, more limitations in activities in daily living, and more frequent and rapid cognitive decline. Having achieved higher educational levels tends to be associated with the prevention of functional limitations, while a higher income level is associated with both prevention and delayed progression of functional decline.

Explanations

The relationship between socioeconomic status and health is complex. Socioeconomic status has been defined as potential or realized access to resources in three major domains: material, human, and social capital. Thus, it is not surprising that a relationship between socioeconomic status and health has persisted across time, place, and changes in epidemiology. Socioeconomic status represents a fundamental cause of health.

Reverse Causality

Undoubtedly, poor health can result in low socioeconomic status. Persons with disabilities, whether physical or psychiatric, often achieve lower educational, occupational, and income outcomes than do persons without such disabilities. Similarly, persons who experience serious illness or disability often face unemployment or downward mobility. While health status can affect socioeconomic status, there is compelling evidence that socioeconomic status strongly affects health. Longitudinal studies have documented that low education usually predicts a decline in health. Education is typically achieved during early adulthood when morbidity is relatively uncommon. Furthermore, disparities have been demonstrated among the fully employed. Thus, although poor health contributes to low socioeconomic status, there is convincing evidence that low socioeconomic status also causes poor health.

Genetic Confounding

Social Causation

The available evidence suggests that socioeconomic status affects health through myriad pathways. As illustrated earlier, disparities in health begin early in life. There is growing evidence to support the Barker hypothesis that fetal growth restriction is associated with higher rates of obesity, hypertension, diabetes, and cardiovascular disease. If this hypothesis is correct, then disparities in fetal health based on socioeconomic status likely predispose a person to disparities in adult health. Similarly, fetal exposure to the effects of maternal smoking have been linked to behavioral disorders in childhood. Multiple risk factors likely combine in complex ways to affect subsequent health. One recent study found that, at 24 months, low-income children exposed to both prenatal tobacco smoke and material hardship had the highest cognitive deficits.

Rates of unhealthy behavior, including inadequate physical activity, smoking, and poor diet, are more prevalent among persons of low socioeconomic status, but differences in these behaviors explain a relatively small portion of disparities in mortality. Furthermore, disparities in these behaviors are largely socially determined. They likely represent a combination of differences in the built and social environments, self-efficacy, and maladaptive responses to stress.

The Concentration of Risk

The effects of socioeconomic status on health are amplified because risk factors associated with low socioeconomic status tend to cluster within individuals, families, and communities. Risk factors are further concentrated by racial and socioeconomic residential segregation. Moreover, each of the three domains of socioeconomic status (material, human, and social capital) are correlated with each other. Consequently, a person with little education is at risk for being low income and jobless. People of low socioeconomic status likely share a household with others of the same status and reside in a low-socioeconomic-status community. Although there are more poor white than black persons in the United States, one reason for the greater adverse impact of poverty on African Americans is that poor blacks are markedly more likely than are their white peers to reside in high-poverty residential areas. Even if the health of a person of low socioeconomic status has not yet been affected, there is greater risk for ill health among his or her family members. Furthermore, living in a community of low socioeconomic status is associated with higher cardiovascular mortality independent of the socioeconomic characteristics of the individual. Low-income children, particularly those living in racially segregated communities, typically attend schools where risk factors are further concentrated. Given these contextual effects, persons with low socioeconomic status are more likely to be exposed to crime, violence, and drug trafficking, and they are less likely to be exposed to successful role models or social networks that facilitate upward mobility. The cumulative toll from these concentrated risk factors can be devastating to individual, families, and communities.

Implications for Urban Medicine

Unique Challenges

The number of patients presenting with complex biopsychosocial problems can be overwhelming to urban health care providers. Patients with low levels of health literacy require more time, not less, to explain treatment. Posttraumatic stress management among refugees requires working across differences in language and cultural beliefs. Specialty services are often not easily available for the uninsured. Caring for a handful of such patients is challenging. Caring for multiple patients with complex needs can be overwhelming in the absence of adequate systems of care. Preventive care services may be neglected in the face of multiple and competing providers' demands. Access to specialist, diagnostic, and behavioral health services may be limited.

Providing medical care to urban low-income populations also poses administrative challenges. Appointment-time scheduling can be problematic. Missed appointments are significantly higher at practices with patients from low socioeconomic status. A patient coming in for a routine diabetes checkup might suddenly disclose that she is homeless or that her son has been murdered. Practices frequently compensate for missed appointments by overbooking patients, which results in long wait times for patients.

Paperwork demands are considerable. These include certification of employability for welfare, assessment of temporary or long-term disability, worker's compensation, disabled parking permits, case management, job training, childcare certification, school enrollment, Medicaid preauthorization for medications, transportation services, increase in Medicaid visit or medication thresholds, and medication refills. Although completing paperwork has become routine in primary care, the volume is magnified in practices with patients of low socioeconomic status who often lack adequate ancillary support.

Despite the greater amount of time and expense required to work with low-income patients, reimbursement is significantly lower. Medicaid reimburses physicians at significantly lower rates than does other insurance. Moreover, most persons living at or below federal poverty are not eligible for Medicaid; many have no health insurance or have health care coverage that fails to cover needed prescriptions, and high prescription costs deter adherence. Even among patients with private insurance, reimbursement may be lower. Existing billing codes do not adequately capture the complexity, time, and expense involved in caring for patients in low-socioeconomic-status urban areas. For example, use of language interpreters can add from six to nine minutes to office visits. Given these challenges, it is hardly surprising that many physicians eschew working with poor or uninsured patients.

Health Care Quality

Implementation of these measures should reduce disparities in health care quality based on patients' racial, ethnic, or socioeconomic status and facilitate progress towards the Healthy People 2010 goal of eliminating disparities in health. However, achieving this goal will likely require more than the elimination of disparities in health care; it will require a sustained national commitment to addressing the fundamental causes of disparities in health.

References

46.Malaty HM, Graham DY. Importance of childhood socioeconomic status on the current prevalence of Helicobacter pylori infection. Gut. 1994;35:742-5.

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Health Disparities Based on Socioeconomic Inequities:... : Academic Medicine

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ns with a discussion of the complex relationship among socioeconomic status, race, and health in the United States. It highlights the effects of institutional, individual, and internalized racism on the health of African Americans, including the insidious consequences of residential segregation and concentrated poverty.

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Topics: Housing (JB green), healthcare (JY red), education (JN purp) 

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Topics: Housing (JB green), healthcare (JY red), education (JN purp) 

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When Tracey Mixon walks out her door in San Francisco's Tenderloin neighborhood, she is more likely to meet another black person than in most places in the city.

The Tenderloin is where many of the city's homeless services are centered, making it a hub for the unhoused as they seek help. In a city where the black population teeters between 5% and 6%, 37% of its growing homeless population is black. "They sleep outside of my building," Mixon, 49, said.

"They're people I've known for years. They went from having places to live to being out out there on the streets. With me living in the Tenderloin, I see a lot of these people all the time and it hurts for me to see so many black people out there."

In a state where a housing crisis has given way to a surge in homelessness, a disproportionate number of those experiencing housing instability are black. In Los Angeles, 37.5% of the homeless population is black, while in Oakland, where 70% of the homeless population is black, whole homeless encampments are dedicated to black and Latinx people.

The disparity is reflected nationwide. Although black people made up 13.4% of the overall population, according to the latest US census data, 39.8% of all homeless people were black.

Mixon joined a group with the Coalition on Homelessness on Thursday, going from office to office in San Francisco City Hall to bring attention to this racial disparity during Black History Month. Just nine months ago, Mixon was homeless too, along with her nine-year-old daughter. For almost a year, she said, she and her daughter lived in shelters, hotel rooms and on the couches of family and friends.

"It was tough," said Mixon, who is now a peer organizer for the Coalition on Homelessness. "I made sure she was in school every day. I made sure I was at work every day. Just because we were homeless, I didn't want our routine to be stopped."

More and more throughout California, the homeless find themselves in similar circumstances as Mixon and her daughter: holding down jobs, making a decent living, going to school - just not able to find an affordable place to live.

In the office of the San Francisco lawmaker Rafael Mandelman, Miquesha Willis broke down in tears talking about her current situation.

Miquesha Willis, center with a folder, is homeless despite her job in contstruction. Photograph: Vivian Ho/The Guardian

Willis, 32, makes $30 an hour at her construction job. But she and her two-year-old son are homeless, staying with her mother on good days and scrambling to find shelter on bad days.

"It's a cycle, and there's nothing you can do about it," she said in an interview. "My wages are OK, but it's not enough for San Francisco. It's not enough for market-rate rent. It's too much for below market-rate rent. I'm still trying to increase my wages to beat homelessness here. It's crazy."

In cities like San Francisco, black communities are getting pushed out as rent prices get jacked up. Between the 2000 and 2010 censuses, the black population fell by 19% in San Francisco and almost 23% in Oakland. Black residents are forced to move farther inland to places where housing is cheaper, such as Antioch and Stockton - even though for many, their jobs remain in the city.

Willis tried moving to Antioch but couldn't make the commute work. Her job required her to clock in before public transportation began running on some days, and her car broke down, making it impossible for her to get to work.

Like so many people her age, Willis is questioning what she wants to do for a living - if it would be worth it to finish college, to try starting her own business, to switch careers. San Francisco made its name this century as the hub for the latest tech boom, where anyone with a startup idea could come and achieve their dreams. But Willis has found that San Francisco is only a welcoming place only for some, for those who can afford the privilege to fail.

"There are people who are trying to make things happen for themselves and trying to grow in their career and make something happen for their families," she said. "This is one of the highest-paying cities. Why are so many people struggling here?"

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'It's a cycle': the disproportionate toll of homelessness on San Francisco's African Americans

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When Tracey Mixon walks out her door in San Francisco's Tenderloin neighborhood, she is more likely to meet another black person than in most places in the city. The Tenderloin is where many of the city's homeless services are centered, making it a hub for the unhoused as they seek help.

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Gale article on homelessness, poverty and housing

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