Latest / Becker’s Healthcare - Clinical Leadership Podcast / Dr. Esmaeil Porsa, President and CEO of Harris Health System

Transcript

Dr. Esmaeil Porsa, President and CEO of Harris Health System · Becker’s Healthcare - Clinical Leadership Podcast

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  This is the Becker's Healthcare Podcast. I'm Molly Gamble,
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  vice President Editorial, and today I'm spending time with Dr. Esmail Porta. Dr.
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  POA is the president and c e o of Harris Health System,
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  which is the primary healthcare safety net system of Harris County,
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  which includes the city of Houston and Texas.
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  This system includes Ben TA Hospital in Lindon b Johnson Hospital,
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  along with a network of community health centers and clinics. Dr. Porta,
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  welcome. Thank you so much for being my guest today.
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  Where does this podcast find you?
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  Uh, as you mentioned, Houston, Texas.
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  Great. Well, Dr. Po,
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  I shared just a little bit there in my opening remarks about Harris Health
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  System, but beyond those fast facts and figures,
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  what do you think is the most important thing for our listeners today to really
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  understand about Harris Health?
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  Yeah, well, first of all, thank you for the opportunity to do this.
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  I really appreciate it. Um,
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  and not so much specific to Harris Health System, but I would really like to,
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  uh, share with our listeners is, uh,
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  all the public health systems similar to Harris Health System and what,
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  what they mean to the communities that they serve. You know,
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  we happen to be one of the largest,
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  if not the largest public health system in Texas. Uh,
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  but there are several and other states as well.
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  You know, it is true that as a safety net hospital,
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  Harris Health System and other systems like us,
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  we have a statutory mandate to take care of the uninsured and underinsured.
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  That's a given. That's, that's why we exist.
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  But there is so much more to a public health system like us and
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  others, uh, that serve the same purpose.
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  And I just wanted to very briefly focus on those couple of points.
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  That'd be great.
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  We are major training sites for the future doctors and
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  healthcare providers, nurses, techs, you name it. In our instance,
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  you know, we are in partnership with two nationally and renowned medical school,
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  bay College of Medicine, and UT Recover medical School, both in Houston.
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  We train more than 3000 students and residents every year.
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  What that means to this community is a currently almost 50% of all
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  the doctors that are licensed by the Texas Medical Board
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  to practice in Houston and Harris County did their training actually at Harris
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  Health System.
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  And that's something that I don't think people appreciate when we're talking
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  about safety net hospitals. You know, you mentioned our hospitals,
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  Ben Top adult level one trauma center,
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  lbj adult level three trauma center.
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  They do a lot more than just safety net care of the indigent,
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  the uninsured and underinsured.
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  They provide lifesaving care to all Houstonians. And again,
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  I'm using Harris, Harris Health System as an example.
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  That's what happens in other large safety net hospitals as well.
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  We're also a huge economic engine to the community, and,
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  and folks don't, uh, routinely, you know, consider it,
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  uh, for every dollar in tax support, for example,
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  that Harris Subsystem receives,
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  they return almost $6 back to the Harris County last year.
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  That amounted to almost 5 billion in economic impact to the county.
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  And we also add capacity,
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  capacity to the local healthcare ecosystem
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  in terms of our emergency rooms and hospital beds. Yes,
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  we don't have the largest share of the system,
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  but what we do provide really does matter.
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  And I'm gonna use an example and then I'll stop. Uh,
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  this is something really important, and again,
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  something that people overlook when they think about safety net hospitals.
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  And the way I describe it is this, yes,
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  we have a statutory mandate to take care of any insured and under insured.
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  And unfortunately for a lot of reasons that we can discuss later,
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  this population, uh, waits, uh, because of their,
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  uh,
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  adequate access to care until they're too sick and they show up to our emergency
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  rooms,
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  or they just show up to the emergency rooms as a habit rather than taking care
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  of some of their routine care.
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  And a primary care provider like you.
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  And I would imagine a situation where Harris Health System or
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  systems like US safety net hospitals fail to provide that service
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  either because we are overwhelmed with increasing number of
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  uninsured and underinsured,
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  or because there is not enough support, financial support for our systems.
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  Well,
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  that population that currently seeks care at the Safety Net Hospital like
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  Harris Health System,
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  they are going to go elsewhere to receive that care.
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  And that elsewhere is a non-for-profit and for-profit hospitals in the area.
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  Couple of things happened. One,
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  everybody else's access to emergent and urgent care decreases because now the
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  emergency rooms, other emergency rooms are inundated, uh,
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  with people that were otherwise received care at Harris
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  HealthSystem. And number two,
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  that provision of care to the uninsured and underinsured
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  by non-for-profit or for-profit hospitals. Obviously,
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  those hospitals are not going to, uh,
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  take a hit to their bottom line, right?
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  So they have to pass on that cost to someone
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  where the biggest consumers,
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  customers of non-for-profit and for-profit hospitals are the insurance
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  companies.
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  So that cost gets transmitted to the insurance companies.
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  While the insurance companies are also in not in the practice of losing money,
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  they have to transmit that cost to their customers and consumers.
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  And that's you and I, everybody with a private health insurance.
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  So at the end,
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  what happens is that when a safety net hospital fails to provide the services
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  that it does, for the reasons that I just mentioned,
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  the overall cost of health healthcare actually increases in terms of
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  out-of-pocket deductibles and health insurance premiums,
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  when those costs have to trickle down to everybody else.
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  So that in a nutshell is the role that Harris Health
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  System and systems like us provide in the community that a lot of time gets
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  overlooked.
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  Mm-hmm. , I'm so glad Dr.
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  Po said that you started there and that you established that context.
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  For our listeners, the safety net institutions, especially in US cities,
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  can so often go undersung in their value and the role they play in our
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  healthcare system.
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  I really think of them as the best of what healthcare can be in terms of
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  their mission and their alignment with that mission.
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  The people who choose to practice and work in safety nets,
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  that is a choice that one makes to seriously give back to their community. Um,
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  and the under uninsured, like you said.
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  Just to ensure our listeners understand to Harris Health and what
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  you are working with as c e o, do you mind sharing your payer mix with us?
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  Not at all. I'd be happy to. Actually, you know, this is,
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  this is information for everyone to, to have access to.
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  So almost half of our patients are uninsured, uh, 50%.
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  And there is a large portion of our
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  patients who are also on Medicaid or Medicaid managed care around around to
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  20%, but is left at at 30%. There's about 20%,
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  maybe a little less Medicare and about 10 or 12%, uh, private insurance.
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  Uh, which really creates, as you can imagine, a, a situation where,
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  uh, caring for the uninsured or underinsured, those are Medicaid,
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  Medicaid managed care, uh, creates a situation where we cannot
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  address the escalating costs of inflation and everything else that happens to
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  our, uh, privately insured patients.
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  Cause we just do not have that volume of insured patients.
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  Mm-hmm.
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  and even that mix and those ratios might even be in flux a bit
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  just because of the Medicaid redeterminations that are ongoing. Right.
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  Yeah. I'm so glad you mentioned that. I didn't know I'm, uh, aware, uh,
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  the listeners are. So, because of the end of the public health emergency,
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  the folks who for the last three years as a deal that was made with the federal
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  government, nobody was coming off the Medicaid rules, uh,
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  because of the additional dollars that the federal government was sending to the
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  states. Well, since the end of the public health emergency,
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  everybody has been put on notice that, uh,
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  the states are going to go down through the, uh,
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  their Medicaid enrollment roles and people are gonna come off of it. We,
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  in Texas,
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  we anticipate that more than 3 million people are going to be impacted.
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  Harris County, unfortunately, this is the number not, uh,
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  that we're not proud of,
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  has the highest rate and number of uninsured residents of
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  the county in the country. Currently,
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  that number is 1.2 million uninsured residents of the county.
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  And we anticipate some of that 3 million people are gonna be impacted coming
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  off. The Medicaid rules are gonna be residing in Harris County.
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  What is the total impact is when it remains to be seen. Uh,
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  it's probably gonna take us a few months to figure out exactly who's going to be
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  coming off the Medicaid rules, what you're correct. Uh,
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  those percentages are surely to change, uh, for the negative. Mm-hmm.
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  .
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  Well, I think what, what you just shared, Dr of course, I mean,
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  more than 3 million looking to be affected by the Medicaid redeterminations in
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  Texas and then the highest rate in Harris County of uninsured in the country
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  with one 1.2 million you said. So that number might even grow higher.
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  Um, yeah, thank you for noting that.
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  I think it's something we at Becker's are keeping an eye on.
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  Every state has different timelines for those determinations, but like you said,
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  so much does remain to be seen. And I know health systems are,
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  are working hard to try to have people who can enroll or re-enroll. Uh, do. So.
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  Um, you know, I wanted to talk a little bit about your background.
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  You have such a rich background as an internist, a public health expert,
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  public health leader,
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  a system executive at really respected safety net institutions.
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  How have your firsthand experiences really come to shape your philosophy
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  and views on health equity and population health?
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  If there are any specific experiences or moments you can point to as
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  exceptionally influential, I, I would love to hear about them.
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  Sure. You know, I, I,
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  I described myself as somebody who has really basically devoted his entire
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  professional life to, to public health. Um,
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  is there a specific moment which I think was most impactful?
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  Probably not. I,
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  I would say that it is been an accumulation of experiences.
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  Um, you know, I think back about my training, uh,
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  many years ago. Let's not, let's not get into the details of how many years ago.
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  I don't want to date myself, but needless to say, you know,
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  when I did my medical school training and even the residency training,
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  we as doctors, we became really,
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  really good at understanding and treating
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  diseases really good at, you know,
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  understanding the pathology of hypertension and diabetes and,
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  and stage renal disease and sickle cell disease. I think that you name it,
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  you know, it really was not until later on when I, uh,
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  enrolled in this school of public health just out of interest,
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  that I, I realized how poorly we were trained,
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  really had very, very little, if any,
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  understanding of the concept of health promotion and disease
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  prevention.
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  We were so focused on treating illness that
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  it, it would really just not occur to us that, you know,
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  that that cliche and balance of prevention is, is worth a pound of cure.
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  It, it was not in our vocabulary. You know,
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  having gone through the school of public health and understanding the principles
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  of population health and health equity, it, it,
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  it was really an eyeopening opening. Um, not, not a single moment,
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  but again, uh, an accumulation of experiences. Cuz after that,
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  I remember at the time I was still actually, uh,
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  providing care inside the inside Harris County jail. It occurred to me,
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  uh,
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  what an impact we can have as medical doctors and other
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  providers, uh, rather than just treating next diabetic patient,
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  the next hypertensive patient. Uh, so yeah, not, not a,
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  not a single experience, but an accumulation of experiences.
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  I think that's so relevant. And at Becker's, I mean,
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  we've been having some recent conversations about medical schools,
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  the need for some changes in curriculum and how
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  students w work their way through medical schools,
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  including the debt they can incur going through that educational chapter. So,
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  Dr. Poa, to your point about the,
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  the emphasis on disease management and treatment versus prevention,
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  like you said, it, it, I know you mentioned it was a few years ago,
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  but it seems like that is a huge opportunity for the next generation of
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  physicians, nurses, healthcare workers,
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  to have a bit more knowledge and,
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  and familiarity with that important part of one's healthcare and health,
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  health journey.
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  Yeah. So that is true. You know, on an individual level, you,
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  you're absolutely right. But, you know, at the system level, uh,
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  as a nation, uh, we collectively need to,
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  and I know that there, we are taking steps towards that, but the,
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  the steps are painfully, painfully small and slow steps.
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  Uh, but there needs to be a shift in our collective attention, uh,
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  of resources, uh,
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  and emphasis and focus on more and more disease prevention and health
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  promotion. Because, I mean, and you know, this,
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  I know I'm preaching to the choir, probably the listeners know this as well,
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  you know, for the amount of money that this country spends on, on healthcare,
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  we should be experiencing much, much better outcomes, uh, than we are.
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  And we are not, you know,
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  we spend more money per capita and in totality than any country on
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  this planet. And when it comes to outcomes, we are not even in,
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  in a top tier, uh, in terms of our health outcomes.
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  So a lot of things wrong. And I don't want to get, uh,
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  going on that tangent because you will never be able to stop me. But let me,
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  lemme say this because I think this is very important. I struggle with this,
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  you know, I, I think back about my training and, uh,
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  everything that was good and everything that was not so good with it.
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  One of the things that I struggled with in the, in the current training, uh,
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  as I'm thinking about, you know,
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  why is it that United States spend so much more money than
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  other nations? And, you know,
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  there's a lot of conversations about our overhead charges are so much higher.
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  You know, the cost is this, and united administrative cost is death. And all,
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  all of that is probably true. Uh,
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  I'm not saying that that there's a single thing,
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  but one thing that I have noticed is the,
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  the transition in the way we think about the art and science of medicine.
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  You know,
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  I remember as a young doctor how much I took
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  pride in my ability to
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  perform really sound, physical examination and,
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  and my bedside diagnosis abilities.
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  And I compare and contrast that to today. Uh,
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  when our young doctors, you know, finishing medical school and residency,
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  it, it, it seems they just do not have the same
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  capability, understanding capabilities to do the same. You know,
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  every complaint ends up with a very expensive diagnostic test.
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  You know, every abdominal pain gets an ultrasound, every headache gets an mri,
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  every cough gets a chest CT scan. And
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  that, I think also partly is, is
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  responsible for what we are seeing in terms of the high cost
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  of healthcare. Uh, we, we are so,
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  so concerned about not missing that one in a million chance
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  of a bizarre disease process that we are
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  really just breaking the bank, uh, and,
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  and taking care of some of the very routine things that should not be costing so
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  much. Anyways, I, I can can talk about this all day long. Let, let's,
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  let's move on. .
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  I don't blame you. I,
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  I wanted to go back to something you had shared in passing.
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  It sounds really interesting, and I wanted to make sure this didn't,
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  we didn't drive by this, but you mentioned working in the prison, um,
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  before you came to Harris Health, I believe you spent about half a decade,
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  right?
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  As the medical director of Parkland Health and Hospital System Correctional
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  health Program.
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  Can you tell us about that experience and also if there were any
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  valuable lessons you gained from that chapter of your career?
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  Yeah, absolutely. So actually you, so you're correct. Uh, but even before that,
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  I was, uh,
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  directly delivering care to the inmates at Harris County Jail about 12 years.
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  So it was probably more like 15, 16 years of my, uh,
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  professional careers initially, uh, dealing with correctional health.
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  You know, it, it, it goes back to the whole idea of,
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  uh, health promotion, disease prevention, and health equity. I,
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  I never forget this. You,
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  you asked about a moment that may have been most impactful in
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  my thinking about population have and health equity.
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  You know, now that I'm thinking about my correctional health experience,
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  I never forget this one morning. Um, I was, uh, early,
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  I always get to work early.
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  It was an early morning and people were getting lined up detainees. Uh,
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  this was at Harris County, actually Dallas County Jail. Uh,
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  they were getting lined up to go to court.
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  And the way it works out for those who may not be familiar with the correctional
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  setting is that, you know, in the mornings,
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  everybody who needs to go to court basically goes to court and sits in the
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  waiting rooms waiting for their, uh, hearing.
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  So there were two,
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  maybe 300 detainees that were lined up in a large area,
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  getting ready to go from the jail through the tunnel to the courts,
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  and there was a slope. Uh, so it was standing on,
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  on the top end of the slope,
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  and so moved down and folks who were lined up. And, you know,
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  it was very traumatic because what I saw was a
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  sea of young African-American male
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  detain. And it,
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  it truly was a light bulb moment, uh, in, in my head,
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  realizing that the,
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  when we talked about health disparities and health inequities and
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  social determinants of health,
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  and wonder why the health outcomes among
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  the different ethnicities are what they are,
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  i e our black and brown, uh,
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  patients have
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  worse outcomes in just about every disease process that you put your finger on
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  compared to, uh, a white patients. It,
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  it is not, it is not a genetic predisposition.
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  It is not really anything else other than
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  social
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  injustices that prevail in this country, unfortunately. And,
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  and that large part has to do with our correctional system. And,
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  and that's something that, again,
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  unless and until you are actually a part of it, you know, in it,
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  it is really difficult for people to,
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  to realize what a huge impact the correctional system in this
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  country has on the overall health of all of us. You know, United States,
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  you know, has about, uh, you know,
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  5% of the world population, and we routinely incarcerated,
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  about 20% of all the people who are incarcerated in the world
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  are incarcerated in the United States. Uh, that is a terrible number.
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  You know, every year about 10 million people get in and out of the jail.
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  And, you know,
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  the science is very clear on what happens when you are incarcerated.
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  The impact that incarceration has on your ability
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  to have, first of all,
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  to obtain a job and then obtain a job that provides lovable wages,
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  uh, the impact that it has on your ability to go to college,
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  the impact that it has on your housing. Um, and you name it, you know,
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  when we talked about the social determinants of health, incarceration,
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  probably more than anything else,
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  touches negatively every single one of those social determinants of health.
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  Um, so I guess you can tell,
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  I I'm very passionate about the topic of corrections and correctional health,
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  because I think it's, it's, uh, it's the pillar
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  of
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  the lack of the foundational approaches to
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  healthcare that it's,
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  it's missed in the conversations when we were talking about health equity and
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  population health. It, it, again, it, it is a topic that unless,
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  and until you know about it and you are in it, it it is really difficult, um,
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  to be aware of it. But, but, but I think, and, you know,
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  have made it the mission, my mission, uh,
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  to speak about this at every opportunity that I get to,
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  to really shine the light and importance, uh, of this issue. Mm-hmm.
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  .
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  It's a really important perspective, and it's one that like, like you said,
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  is not often represented. And I think to, to your point too,
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  there's something to be said about how we treat our most vulnerable or the
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  weakest people in our society when they're in prison,
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  the healthcare access they have available to them.
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  And then also when people are
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  reintegrated into society after, after spending time in prison, it's,
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  it's firsthand, I've,
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  I've some experience too in seeing how inadequately prepared they can be, um,
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  whether it's for employment, whether it's for education,
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  they oftentimes there's turned back out with the belongings, uh,
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  the bag they went in with, with their clothes and, um, housing.
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  So I think also you do not want, as a society,
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  people coming back to return to their,
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  their life sicker than they were when they went into prison. Right. Right. Dr.
• 24:37
  Pos, that, that should be, when we're talking about public health,
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  an outcome that you would wanna avoid.
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  That you know, that, that that is exactly the point. Uh,
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  and I, you know, you,
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  you remind me of some of the conversations that I've had in my life with others.
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  When, you know, when, when you think of corrections,
• 24:56
  when people come to the jail, to your point,
• 25:01
  there are times that actually
• 25:04
  detainees when they come in contact with healthcare inside the jail,
• 25:10
  that that is the first time ever in their lives,
• 25:14
  that they have had the opportunity to interact with the healthcare provider.
• 25:17
  And that, that is the sad truth. But what a great opportunity,
• 25:23
  uh,
• 25:24
  for a society to take advantage of that encounter of,
• 25:29
  of that, uh,
• 25:31
  of that opportunity to impact the health of that individual. Because remember,
• 25:36
  the folks who go to the jail, they're gonna come back,
• 25:40
  they're gonna come back to the communities in which they reside.
• 25:45
  If we are able to address their healthcare issues
• 25:50
  while incarcerated so that they can return to the community
• 25:54
  healthier, that when they went into the jail,
• 25:58
  everybody wins. The individual wins, the society wins
• 26:04
  as far as the cost of care, the cost will decrease. And I mean, again,
• 26:08
  the science is very clear. When people leave the jail,
• 26:12
  if their healthcare issues are not addressed,
• 26:14
  that utilizations of the community emergency rooms, it, it is,
• 26:18
  it is a staggering, it is extremely high.
• 26:22
  So why not take it management that opportunity,
• 26:24
  and I say this realizing that not, not everybody, uh, accepts that or,
• 26:29
  or agrees with this concept. You know, I've had people who,
• 26:34
  uh, believe that, you know, when people are in jail,
• 26:37
  you're basically just keep them alive until they leave the jail,
• 26:40
  then that's your responsibility. I obviously,
• 26:42
  I disagree with for a lot of reasons. You know, you mentioned it, you know,
• 26:47
  I think our ethical responsibility to take care
• 26:52
  of our weakest and most vulnerable, uh,
• 26:58
  and and beyond that, it, it, it,
• 26:59
  it just makes economical and healthcare
• 27:04
  sense, uh, to take care of our detainees when you're incarcerated. Mm-hmm.
• 27:09
  mm-hmm. , I, I,
• 27:12
  I wanna wind down with a thought from you about, you know,
• 27:16
  we've talked about health equity in a number of ways throughout this
• 27:18
  conversation, and we could probably talk about it for days, Dr. Pera. Um,
• 27:23
  but you know, you have such a valuable perspective on this topic,
• 27:27
  and so often when you start talking about health equity,
• 27:30
  you get to a point every conversation where you confront the barriers,
• 27:35
  what stands in the way, whether it's underfunding, whether it's, um,
• 27:40
  a lot of commitments made verbally but not executed.
• 27:43
  Sometimes it can be dwelling in research and analytics and not putting in
• 27:47
  solutions and moving into different neighborhoods to provide care.
• 27:51
  But I wanted to check in with you and see what you see as the main barriers or
• 27:56
  obstacles that,
• 27:58
  and thwart efforts to achieve more equitable he health outcomes.
• 28:02
  I'm sure this list is long.
• 28:04
  Maybe there's one that isn't as acknowledged as much as it should be that you,
• 28:08
  you can share with me.
• 28:11
  Yeah, , this is actually,
• 28:15
  this is a topic that I probably talking about if, if not every day,
• 28:19
  probably every other day. And, and I talk about it with, with my folks, uh,
• 28:24
  with the people that work with me. You know, as you mentioned at the,
• 28:27
  at the top of our conversation, um,
• 28:30
  I've basically devoted my entire life to the principles of health equity and
• 28:35
  population health and, you know, be, have the population health department,
• 28:40
  uh, at Harris Health System. And, you know,
• 28:42
  we we're focused on health equity and, and,
• 28:45
  and it's really intriguing to me that I routinely and repeatedly
• 28:50
  have to remind folks when you were talking about,
• 28:55
  you know, what, what is one barrier, uh,
• 28:59
  that I believe, uh,
• 29:01
  is preventing us from moving the needle is,
• 29:04
  is lack of clarity and lack of focus. You know, when when,
• 29:09
  when we say, you know, population health, what do we mean by it? Exactly.
• 29:14
  When we say health equity, what do we mean by it? Exactly.
• 29:18
  When we say we wanna improve health equity, exactly. What do mean by that?
• 29:24
  Uh, I really believe that if we can create more clarity
• 29:30
  and focus on what it is that we're trying to do,
• 29:34
  realizing that no one, I don't care how big of a system you are,
• 29:38
  I don't care how much resource that you have,
• 29:41
  no one will ever be able to boil the ocean.
• 29:44
  If we can bring focus to one or two
• 29:49
  top line, most important,
• 29:52
  most impactful interventions in an
• 29:56
  area of our community that is most negatively impacted and,
• 30:01
  you know, be able to move the needle, uh, I think that's what's lacking. Again,
• 30:05
  a a lot of times we fall into the trap of really getting excited and we should
• 30:10
  all be excited about the principles of health equity and population health,
• 30:13
  but not to the detriment of losing track,
• 30:16
  of being able to
• 30:20
  continuously move forward and onwards, um,
• 30:26
  more than anything else. Uh, I think, I think that's the problem that, uh,
• 30:30
  we locally, individually, uh, and as a society,
• 30:35
  uh,
• 30:36
  struggle with lack of focus and lack of clarity among
• 30:41
  the principals, uh, that we're discussing.
• 30:46
  I appreciate that. I think even as a member of the media,
• 30:49
  it's something we have to be incredibly careful about because to your point,
• 30:53
  there's so much support for the cause. There's buy-in,
• 30:55
  people do want to act on these problems, but like you said, if it's,
• 31:00
  it's how we channel that energy, right, toward really targeted causes,
• 31:05
  really specific outcomes that are,
• 31:07
  we're working to achieve versus just kind of talking about it in a categorical
• 31:12
  or blanket term that won't make the progress we want to see
• 31:17
  in the short term.
• 31:19
  Exactly. You know, what, what is it that, uh,
• 31:22
  a journey of a thousand miles starts with the first step, right? It is.
• 31:26
  Those is those incremental,
• 31:29
  sustained focused efforts that will pay
• 31:34
  dividend at the end.
• 31:37
  Dr. Course, I wanna thank you for your time today. You are a deep thinker.
• 31:41
  I learned and got so much from our conversation. I know our listeners did too.
• 31:47
  Um, president and c e o of Harris Health System,
• 31:50
  the primary healthcare safety net of Harris County in Texas.
• 31:53
  I wanna wish you continued luck and progress in all the work you're setting out
• 31:58
  to do with Harris and as a safety institution, one of the greats of our,
• 32:02
  our country, and I hope we can check in with you again soon at Becker's.
• 32:07
  Thank you, Molly. I appreciate it.