Ep. 133: Whole Child Health with Dr. Larry Moss

According to Larry Moss, MD, FACS, FAAP, President and CEO of Nemours Children's Health, delivering on Whole Child Health is the next step toward creating the healthiest generations of children. This approach emphasizes accountability for every child's health — not just for those in geographic areas served by Nemours Children’s and not just for kids in need of medical care — for all children and to ensure care and partnerships that address all factors that influence children’s health and well-being. Whole Child Health includes education and literacy, food security, safe housing, and freedom from violence, in addition to medical care. Dr. Moss shares his vision for Whole Child Health in this episode of Well Beyond Medicine.

Watch the video episode on the Nemours Children's YouTube channel.

Guest:
R. Lawrence “Larry” Moss, MD, FACS, FAAP, President and CEO, Nemours Children's Health

Host/Producer: Carol Vassar

Views expressed by guests do not necessarily reflect the views of the host or management.

Subscribe, review or let your voice be heard at NemoursWellBeyond.org.

Transcript

Announcer:

Welcome to Well Beyond Medicine, the world's top-ranked children's health podcast, produced by Nemours Children's Health. Subscribe on any platform at NemoursWellBeyond.org or find us on YouTube.

Carol Vassar, podcast host/producer:

Each week, we'll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar. And now that you are here, let's go.

Music:

Well Beyond Medicine!

Carol Vassar, podcast host/producer:

Joining me on this episode of the podcast is Dr. Larry Moss, president and CEO of Nemours Children's Health. Now, Dr. Moss is the person whose vision of going well beyond medicine is the impetus really behind this podcast, yet there is more to his vision. And on this episode, Dr. Moss and I discuss what comes next, and what comes next is whole child health. What is whole child health, you might ask? Well, here's Dr. Moss to explain and share the immense positive impact, once accomplished, whole child health will have on all of us.

Dr. Larry Moss, President and CEO, Nemours Children's Health:

The whole child health model, which really is the guidance behind all of the care Nemours delivers and everything that Nemours does for children, is based on the concept that Nemours takes accountability and responsibility for the health of every child that we can possibly touch, not just those who are sick and need medical care. So it's not instead of medical care. We will always be there for the sickest kids who need the most complicated medical procedures and treatment, it's and what else? What about all those other kids who maybe don't need to come to the hospital this year? But there are major determinants of health that we can have an impact on.

Carol Vassar, podcast host/producer:

Why does this matter for long-term healthcare outcomes, not just for kids, but for the generations that follow them?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

So I love that question because people tend to think, "Oh, children's hospitals, children's healthcare, that's about healthy kids." Yes, it's about healthy kids, and it's about all of the rest of us. Never met an adult who didn't used to be a child. The four major killers of adults drags on our economy, drags on workforce productivity are: cancer, heart disease, diabetes, and Alzheimer's. We think of those as adult diseases, and yeah, they are adult diseases. And we spend four and a half trillion dollars a year trying to influence those diseases in adults and don't do very well. We can spend a massive amount of money and resources, and influence those diseases a little bit. We can buy people an extra month or improve their quality of life for a year, but if we spend a tiny fraction of those resources in childhood. We can change the incidence of those disease,s and we can change the trajectory in a profound way that we can't even think about it in adult healthcare.

Carol Vassar, podcast host/producer:

This makes so much sense. If we can nip it in the bud at the start, we won't have to worry so much about it as adults. How did you come upon this? What inspired you to go down this path of whole child health?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

I would say, Carol, it's my personal experience as a pediatric surgeon. So I spent most of my professional life before I came here to Nemours in my current role as an academic pediatric surgeon, taking care of the sickest of the sick. So my patients were the 1% of the 1% with severe congenital anomalies, advanced cancer - really complicated things. And if you have a child with one of those problems, there is nowhere else on the planet you want to be than America, because we have the best providers, the best technology, the most resources. It's the sweet spot of what we do. And it was a privilege to do that and to be able to affect the lives of those children and their families.

But it bothered me from the very earliest days of my career, progressively more and more and more, that for the other 99.9% of kids, America is probably the worst place in the developed world to be. I mean, not just bad, the evidence would say it's the worst in terms of basic child health indices. And I couldn't finish my career without the opportunity to do something about that, and I had the incredibly good fortune of crossing paths with Nemours who I believe is better positioned than any organization in the country to make an impact on child health overall.

Carol Vassar, podcast host/producer:

When we talk about whole child health, you have a very succinct way of summing it up. I think there are three points. Can you delineate those points?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Yeah, it's very easy and it's what I believe is the key to health in our country. Number one, understand what health is. Number two, pay for health. Number three, start with children. And if we do those three things effectively, we can transform the health of this country in relatively short order.

Carol Vassar, podcast host/producer:

When it comes to that second point, paying for health, what does that look like in practice?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

So, paying for health is fundamentally about aligning financial incentives. In America's health system today, the system makes money, does well economically when patients are sick and when they're in the hospital. We don't pay for health in this country today. We pay for the opposite of health. We pay for volume and complexity of medical care delivered. So every financial incentive on America's health system says deliver as much healthcare as you possibly can... Or perhaps it would be better to say, deliver as much medical care as you possibly can and make it as complicated as possible. Operations procedures, MRIs, CAT scans, that's where the big bucks are. And I'm not suggesting that any individual physician or nurse or provider gets out of bed and doesn't want to do the best for their patient, but I am suggesting that the overall economic pressure on the system at every level is actually for the opposite of what we want, which is health. A pay-for-health model puts the onus on the people delivering the medical care to keep patients healthy. I believe we should have a system where hospitals like Nemours make more money when people are healthier and out of the hospital, and actually lose the money or suffer a cost when an excessive amount of medical care is necessary or needed to be delivered.

Carol Vassar, podcast host/producer:

When we talk about health, we've delineated, you have actually given a good reason for starting with children, which was your third point. How do you define the first point? What is health?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

So we know... And what I'm about to say is not my opinion. This is an established fact: that about 15% of health is due to quality of medical care. So, we can deliver the best medical care in the world, and that has about a 15% impact on overall health. For some select few individuals who need medical care more than anything else, it's wonderful and it's great, but when we look at the health of the population, that number holds up. The other 85% are things like education and literacy, food security, safe housing, freedom from violence, avoidance of adverse childhood experiences. Those things are critical determinants of health. And if we see problems like that and try to throw more and more expensive medical care at those problems, not only does it not work, it's extremely wasteful of resources that could be better directed.

Carol Vassar, podcast host/producer:

Why now? Why is this the time for transformation of this volume, this large turning of the ship, if you will?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Yeah, so it's always been the time. "Why not 100 years ago?" would be a legitimate question. This moment today is not about, "Oh, this is the time we should do this." No, we should have always done this. I would say this moment is the time that it's possible. I would push the question, "Why is it possible now?" I've had a 30-some year career in healthcare and I have never seen a moment like today where it is so possible for major change to happen in the health system. Things are on the table today that were never on the table before. And sure we can say it's a very partisan time and we're a divided country in many respects, but the concept of taking action that can make not only our children but our entire population healthier, that can boost workforce productivity, that can bolster our economy, anybody from any side of the aisle can get behind that.

Carol Vassar, podcast host/producer:

So much potential. One thing that is on the table and actually has come to fruition has happened in Delaware, and I understand that this is a history-making signing that happened in Delaware. It was the first pediatric global budget agreement with Delaware's Medicaid program. How does that shift healthcare from treating an illness to preventing it, and what does it mean for the families of Delaware? And is it an example to other states?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

I think it's super exciting. Let me start with some context. So Medicaid is the government-sponsored health insurance program for people who have limited resources. Medicaid provides care for more than half of America's children. Most people don't realize that. So when we're talking about doing something with the Medicaid program, we're talking about over 50% of kids. So that's an important context. The Delaware Global Budget Agreement is historic. It's the first pediatric global budget agreement in this country, and without getting into the arcane details of the finances, it essentially is a pay-for-health model. It's a model by which Nemours is financially accountable for the health of kids in Delaware on Medicaid. Which means we can, number one, benefit when we reduce the need for medical care and keep them out of the hospital. Number two, we can use precious Medicaid resources on things beyond medical care that can perhaps have a greater influence on that child's health than just throwing medical care at a problem.

So I like for people to understand that yes, this is a financial model of care that's unique and different, but that's not what you really need to know. What you really need to know is this is a partnership between Nemours and the state of Delaware to benefit the health of children in the state of Delaware. Typically, negotiations for Medicaid involve the health system, like Nemours, sitting on one side of the table arguing for more money, and the state on the other side arguing for less money. I would conceptualize this model is we're sitting on the same side of the table and saying, "How can we, together," Nemours and the state of Delaware, "decide how to best spend these precious resources to benefit kids the most?"

Carol Vassar, podcast host/producer:

Partnerships are really important here. Are there other partners, other collaborations? Who you see coming to the table who have brought benefit? And are there others who need to be at the table?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Everything about the whole child health model is about partnerships. So at Nemours, we're experts in delivering medical care. That's our sweet spot, and we've got standing and credibility, and we know what to do there. But for the other 85% of things that determine health - food security, housing, education we're not the experts. So we can't do it without the experts at the table. But what I believe we can do and what we want to demonstrate to our peer children's hospitals is that we can do and that it's possible for all of us is be the overall stewards of child health. So we can be the convener that brings these partners together, that gets the job done. If it's about education, it's about early childhood and public and private school educators that we need to partner with. If it's about food security, it may be food banks. It may be the federal SNAP program, it may be other statewide resources. If it's about housing, you can imagine the myriad of partners that we would want to bring to the table. Maybe think of it like a football team. We see ourselves as the quarterback. We can't play every position, but we can direct all of us to work together to benefit kids.

Carol Vassar, podcast host/producer:

Let's talk about some early wins, some early successes in this whole child health effort. Does anything come to mind aside from what has happened in Delaware that you talked about?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Yeah, I can think of all kinds of examples. I think of two big buckets of activity. One, what happens inside the hospitals and clinics, and the second, what happens out in the community. So let's start with inside the hospitals and clinics.

I'll tell you about a little girl named Amber who has very complex medical problems and has to see upwards of 10 to 15 specialists every year. So in year number one, before the whole child health model is applied, Amber's family, who lives 150 miles away from our facility in Delaware, made 22 trips to Nemours during that year for medical care, had eight operations on different days, back and forth. Amber missed 30 days of school. Her family missed 25 days of work. You get the whole picture. Year number two, where we had advanced care coordination focusing on making her care as efficient and family-friendly as possible, she had seven trips to the hospital in one year. Eight operations the following year were consolidated down to one where they were all done by different specialists under the same anesthetic. Her family missed only two days of work during that year, and she only missed a few days of school. That is possible when the focus is different. So that's an example inside the hospital.

Outside the hospital, a good example is school-based health centers, where at multiple locations at both the preschool, elementary and middle school level, we have health centers inside the schools, and so we're able to do well-child visits, vaccinations. When a child is sick and has something like a flare of their asthma or have caught a virus or is not feeling well, we're able to see that child and provide services on site without the parents missing nearly as much work, and sometimes getting kids right back to class rather than missing a whole day of school for a doctor appointment. So a lot of things we can do very well.

Carol Vassar, podcast host/producer:

Is there anything, as this rolls out, as this moves forward and sees the early successes that can be learned by the adult healthcare system, that can be transferable to what they provide?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

I think for the purposes of this conversation, I'd most like to focus on why concentrating on pediatrics can impact the population overall, as a whole. And there's a fundamental difference between child medical care and adult medical care in the sense that in adult medical care, the vast burden of chronic disease is already established. And really, the best we can do is put fingers in the dike and try to really play whack-a-mole and deal with problems as they pop up, and they pop up in many different ways and in many different places. Unless we get control of our health as a society, starting in childhood, that's the game we're always going to have to play with adult healthcare. So frankly, what the adult-dominated healthcare system can learn is that they're missing an opportunity by not putting more focus on child health.

Carol Vassar, podcast host/producer:

Will we arrive, or is this an ongoing whole child health effort that is going to continue for generations? How will we know if we've had success with whole child health efforts?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

So we'll know by looking at the kind of measurement that we typically don't look at in healthcare. We tend to measure hospitals by re-admission rate, or hospital-acquired infections, or survival rate after open-heart surgery, and standard measures. Those are really important measures of quality of medical care. They're nearly worthless in terms of measuring the health of a population. So the kind of things that Nemours is starting to measure and will publicly report include things like kindergarten readiness, third-grade reading level, high school graduation rate, infant mortality, population-based rates of hospital admission for various conditions. Those are the kind of things that are indicators of the overall health of children in a community, in a state, or whatever your unit of measure happens to be. We're committed to measuring those, reporting those, and ultimately influencing those to make them better.

Carol Vassar, podcast host/producer:

How will families like Amber's family know, see this when they are coming to Nemours or any pediatric healthcare system that is implementing this kind of change? How will they see that at the bedside, at the doctor's office?

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Yeah. Well, hopefully, we are so successful in executing it that it becomes the expectation and they don't even notice because they've come to expect that, but that's markedly different than where we are today. I think we as a society will see it in a healthier population, and ultimately, that will very, very rapidly translate to adult health. For example, the economic burden of chronic disease in adults in this country is on the order of trillions of dollars a year when we look at its impact on gross domestic product and productivity. Imagine if we had those trillions of dollars back and if we didn't spend four and a half trillion dollars on medical care every year, but maybe we spent two and a half trillion dollars? This country would look very different. Opportunities for the next generation would look different. The freedom for people to pursue things they want to pursue would look different. Our national defense would look different. Our position in the world would look different. It's a profound impact.

Carol Vassar, podcast host/producer:

As we finish up here today, Dr. Moss, give us some words of wisdom from your point of view to get everyone listening on board with this whole child health effort.

Dr. Larry Moss, President and CEO, Nemours Children's Health:

I think a lot about how frustrated Americans are and should be with our healthcare system, and I think most Americans see it as something external to them, which happens in Washington, and they can't do anything about it. Our health is about us and it's about our children, and every American can have an influence. You can have an influence in the way that you interface with your physician, and ask that extra question, "Is that test really necessary? Why are we doing this? What are we going to do with the outcome?" If you have employer-sponsored health insurance, as do the vast majority of Americans, take a little more time looking at those plans and choose the plan that is more oriented towards the type of whole child health model or whole health model that we're talking about. If you own a business, you have impact on what kind of plans are offered. And so there are many, many ways that every American can have a voice in their own health and in their own healthcare.

Carol Vassar, podcast host/producer:

You have the power, folks.

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Absolutely.

Carol Vassar, podcast host/producer:

Dr. Larry Moss, President and CEO of Nemours Children's Health. Thank you so much for joining me on the podcast.

Dr. Larry Moss, President and CEO, Nemours Children's Health:

Always a pleasure. Thank you, Carol.

Carol Vassar, podcast host/producer:

Once again, thank you to Dr. Moss for joining us on this episode of the podcast. As you just heard, partnerships are so vital to achieving the vision of going well beyond medicine and achieving whole child health. Here on the podcast, we do our part. We bring you the stories of how that manifests in so many ways across myriad organizations. If you have a story idea that exemplifies Well Beyond Medicine and whole child health, we want to hear about it. Visit our website, NemoursWellBeyond.org, and leave us a voicemail. You can also go there to subscribe to the podcast and leave a review. That's NemoursWellBeyond.org. You can also send your podcast ideas to Producer@NemoursWellBeyond.org. And don't forget, you can get the podcast on the Nemours YouTube channel and your favorite podcast app.

Thanks to the team that has been vital to putting this podcast episode together: Susan Masucci, Cheryl Munn,  Lauren Teta, and Logan Dehlin. Join us next time as two noted healthcare IT security experts provide their assessments on the state of healthcare cybersecurity. I'm Carol Vassar. Until then, remember, we can change children's health for good, well beyond medicine.

MUSIC:

Well Beyond Medicine!