The Wages of Health
Manmeet Kaur and Prabhjot Singh made a commitment to serving their community. Despite enduring a terrifying act of violence, they haven’t broken it.by Paul Hond Published Winter 2013-14
When Manmeet Kaur and Prabhjot Singh moved into East Harlem in 2010, the health crisis there had long been dire.
Seven years earlier, the Journal of General Internal Medicine published an article stating, “The toll diabetes takes on residents of communities of color, such as East Harlem, is staggering ... Hospitalizations among persons 65 years and older for diabetes-related amputations in this neighborhood are nearly 5 times those for NYC overall.” In 2007, the New York State Health Foundation reported that East Harlem residents are hospitalized for diabetes at a rate ten times that of people on the Upper East Side. In 2006, N. R. Kleinfield of the New York Times, covering diabetes in East Harlem, wrote of “the human behavior that makes dealing with Type 2” — the common form of diabetes, in which the body cannot produce enough insulin to maintain a normal blood-sugar level — “often feel so futile — the force of habit, the failure of will, the shrugging defeatism, the urge to salve a hard life by surrendering to small comforts: a piece of cake, a couple of beers, a day off from sticking oneself with needles.”
Despite this attention, the problem only worsened. ‘DIABETES EPIDEMIC’ DECLARED AS NEW YORK CITY DEATHS TIED TO THE DISEASE HIT ALL-TIME HIGH, ran a New York Daily News headline in June 2013. Around the same time, the New York City Department of Health and Mental Hygiene found that 667,000 New Yorkers have diabetes — a 33 percent increase from a decade ago. And East Harlem (population 108,000), half Latino, a third African-American, with an influx of professionals, mostly white, filling the new residential buildings — a neighborhood of high obesity rates and gang activity, where 38 percent of residents live below the poverty line — is New York’s diabetes epicenter: as many as one in five people here has the disease.
For Kaur ’05BC, ’12BUS and Singh, a SIPA professor, this quiet catastrophe points up a fatal failure in the US health-care system. It also presents a bold opportunity.
Two women from East Harlem sit facing each other inside a large room with a mirrored wall in a Mount Sinai Medical Center clinic on East 94th Street.
“I had a horrible day,” says the younger woman. “Half the day I was feeling drowsy, irritable, dizzy, confused. I don’t like to check my glucose but once a day, so I didn’t even check it after that.”
“You know that when the doctor prescribes your insulin,” says the older woman, her voice gentle and firm, “he prescribes for you to take it just before you eat.”
A sigh. “I know, but sometimes I get thrown off schedule.”
“Yeah, I understand. We all get busy, and life doesn’t wait for us. But be careful, because there can be a lot of side effects, like you felt last night.”
At a long table, a small group of community-health workers, called coaches, observe the two women, who are also coaches. Led by nutritionist and diabetes educator Jamillah Hoy-Rosas, the coaches are rehearsing for the real-life encounters awaiting them outside.
“I don’t wanna feel like that no more,” says the younger woman. “Is it because I doubled up?”
“Yes, it’s because you doubled up. Then you didn’t eat. When you double up on your insulin you’re gonna feel bad, and it could be dangerous.”
Hoy-Rosas takes notes. She’s the clinical care manager for City Health Works, a nonprofit community-health organization started by Manmeet Kaur. Prabhjot Singh is the lead adviser. Last September, in the shadows of the impending government shutdown over opposition in Congress to the Patient Protection and Affordable Care Act (ACA), City Health Works began a pilot project to demonstrate its approach.
It’s October now. As the shutdown enters its second week, the machinery of health reform cranks forward. The ACA has accelerated a fundamental shift in financial incentives, supporting innovations in payment and delivery that reward quality of care over quantity.
“Traditionally, doctors and hospitals have been paid on a fee-for-service basis,” explains Kaur, thirty, seated in the City Health Works office at the East 94th Street clinic. “The insurer pays the doctor or clinic for each visit, each test, each screening. But the fee-for-service structure hasn’t improved outcomes or controlled costs.” The office has peach walls, filing cabinets, carrels, nutrition posters. “Hospitals have never been incentivized to care about wellness and prevent illness,” Kaur says. “They profit if you’re sicker.” She chuckles. “This is at the heart of why the system is so perverse.”
At City Health Works, Kaur and Singh have zeroed in on a critical gap in the health-care system: a lack of access to primary care in low-income areas. This gap has always been a reality for patients, but now, for the first time, doctors and hospitals are feeling the financial effects. “Health reform is saying, We’re not going to pay for all these people that are bouncing back over and over again,” says Singh, thirty-one. He notes that the fee-for-service model is being replaced by strategies like global payments, in which hospitals manage the risks of all of their patients with lump sums: if they do it for less, they save money; if they do it for more, they lose money. “So there’s a massive incentive,” he says, “to build this community-health infrastructure.”