By Christopher Guadagnino, Ph.D

Published October 2000

• React to this article in the Discussion Forum.

Walter Tsou, M.D., M.P.H., became the health commissioner of Philadelphia at the end of April this year.

PND: What are your goals and priorities for the Philadelphia Health Department?

WT: First, to learn about the programs the department is engaged in now and then think constructively about how we can do some things better, more efficiently and in a more coordinated fashion. My major goals include promoting Healthy People 2010, which addresses the national health priorities and objectives for this nation for the next decade by seeking to increase the quality and years of healthy life and to eliminate health disparities. Eliminating health disparities is a particular challenge in Philadelphia. To improve access to care and services by minority populations is going to be an increasingly important agenda as the city’s minority population grows. A second issue I want to be very specific about is access to health care. I believe it’s an essential role for us as a city without a public hospital to have some source of care for those people without health insurance. I recognize that, while the hospitals are playing a major role in that, other major players are the eight primary care city health centers and the approximately 17 federally qualified health centers (FQHCs) in the region. I want to make sure we can strengthen and maintain the health center programs, recognizing full well that an increasing burden of the uninsured is falling on our health centers. My third goal is to try to coordinate services throughout the city, looking at HMOs, hospitals and health centers to see how all the health agencies can work together to help advance the goals of Healthy People 2010. We are going to hire a deputy health commissioner for policy and planning whose specific role is to work on Healthy People 2010, look at its 467 objectives and see which ones are doable within Philadelphia, then try to create coalitions and committees from the academic and provider communities to coordinate our services in a more efficient fashion. That’s going to be our agenda for the next four years. We’ve got to get started and, frankly, the city has notoriously been bad in not being coordinated and not showing public health leadership. We’re using data and statistics that come from the communities and neighborhoods of this city, but the people who live in those neighborhoods often have no idea about their own health statistics. It’s not sufficient anymore to let academics learn about what’s going on in these communities. So, we’re going to have community meetings, bring this data to the community, make it understandable and ask them to help us learn about what they think should be the solutions. For example, why is infant mortality rate higher in North Philadelphia or West Philadelphia? What can we do about reducing teenage pregnancy rates in some of these neighborhoods?

PND: What is the current status of the health centers and what are your specific plans to beef them up?

WT: There are some sobering statistics about the health centers. About 63 percent of our patients who come to the health centers have no health insurance. That’s an astronomically high number. That means that the city of Philadelphia contributes something in the area of $13 million every year to help support the centers. I believe that we need to maintain that support, but recognize that, until we have a national solution to the problem of the uninsured, this problem is likely to grow rather than get smaller. While we’re pleased and proud to be an important safety net for people who live in Philadelphia, we also realize that, just like every other hospital out there, we’re going to be just barely treading water to keep up with the rising number of uninsured in our community. We’re working very diligently on trying to improve the number of people who have health insurance to come to our health centers so that we can capture some third party payments. We’ve managed to attract some really excellent private doctors who actually like the mixture of public and private practice—some of them have been with us 20 years or more—so we have excellent continuity of care and we provide excellent quality. I think word of mouth is very important in trying to attract people with insurance to choose to come to our health centers. We’re also working on special grant programs that have helped offset some of our costs for pharmacy and some specialty services like mammography. But the core operating budget for the health centers and the staff support has to come right out of our own health department dollars. That’s an important commitment that I want to make. It means that I appear in front of the City Council and the mayor’s office and ask them to make sure that we have enough dollars to put into the city health center system so that we can take care of the 80,000 to 90,000 patients that come in every year.

PND: Does Gov. Ridge’s tobacco settlement allocation proposal include uncompensated care at the city health centers?

WT: It does not include uncompensated for the city health centers. Part of my testimony in front of City Council a few months ago was that that governor’s proposal should be modified so that city health centers and federally qualified health centers are also included in the uncompensated care pool. I personally think this would be an excellent way of directing money specifically to those groups who are providing primary care for the uninsured in the Commonwealth. There isn’t a groundswell among the community health center movement to out-lobby the hospital industry for that money. I’m sympathetic to the hospitals because they do provide a lot of uncompensated care, but I’m very sympathetic to community health centers who provide a lot of preventive and primary care up front for the uninsured. I think they deserve to get compensated also.

PND: What role do you think public health should play in Philadelphia’s current health care system?

WT: I have a very provocative answer, actually. One way of looking at the value of the city health centers is that, if we were to close all of them tomorrow, I can almost guarantee that the hospital emergency rooms would be inundated with people without health insurance. There would be many people who would delay health care and who will end up being hospitalized. We could probably greatly accelerate the bankruptcy of most of the hospitals in Philadelphia if we were to do that. One of the ways we help the hospitals’ infrastructure is by maintaining these health centers.

I think we need to be much more creative about the concept of disease management. The University of Pennsylvania invested millions of dollars in this disease management philosophy, providing best practices. When the ax had to come at Penn, the ax fell right on the disease management program. I think it’s tragic that that happened, but I also happen to think that disease management actually should not be placed in the realm of hospitals. Disease management should, by all rights, be a public health function. For chronic diseases like asthma, diabetes and congestive heart failure, it takes years to turn around the health statistics on these individuals. I think that most short-term, for-profit companies do not have the vision or long-term patience to reap the rewards from that. But public health departments, who are clearly invested in the communities that they serve, could do a disease management program with proper funding and could actually be contracted by all the hospitals and HMOs in the area in an effort to provide quality nursing, case management services.

The Philadelphia area also has a unique system of some 30 nursing centers that are run by advanced practice nurses and serve as training programs for future nurse practitioners. But they also provide primary care services and case management for people who have no health insurance or are in disenfranchised populations that are usually located in housing projects or in poor areas of the city. One of the things nurses learn a lot about is how to do health education and provide excellent instruction on medication use and so on. I think that nursing centers could be one of the focal points for a disease management program where people would be trained in asthma management or diabetes management and then doctors and hospitals and HMOs could refer some of their really tough patients to these programs.

PND: Are there other roles you think public health should play in Philadelphia’s health care system?

WT: One of the things we do is gather vital statistics and communicable disease statistics. I don’t think we’ve used them in the full, proactive fashion that we could, and I think most doctors are largely unaware of what the statistics look like for their local neighborhoods—the same way that the communities are unaware. We could do a better job helping to inform doctors about what’s going on in their neighborhoods in terms of cancer rates, communicable disease rates, sexually transmitted disease rates, and so on. We can use that information to help tell doctors to be on the lookout for these illnesses and/or to develop more intensive training programs so that doctors are up to date on some of the diseases that they’re seeing in these neighborhoods. Right now, very few doctors actually ever ask us for vital statistics for their neighborhoods and we have actually never put out reports that were neighborhood-specific or directed specifically to the physicians’ communities. We could inform them at community meetings or in professional newsletters that we could send out.

I think that most doctors, after they’ve practiced for a while, understand that there’s a limit to what you can do in medicine. But the more we can do in terms of prevention—whether it’s organized tobacco cessation programs, exercise programs, healthier eating and nutrition programs—we’re going to do a lot more in the long run for improving the health status of our communities. That’s very much in the domain of what public health departments could and should be doing.

PND: What are your plans for working with the private practice medical community?

WT: Private doctors are the eyes and ears of what’s going on in the community. We hope that we can have an ongoing dialogue with the doctors out there so that they understand what we can do as a health department to help them. For example, if we organized tobacco cessation, diabetes management or asthma programs, they would know that there was a program they could refer patients to and know that it would be there at no cost or low cost. Doctors have some responsibility to us as a health department: one is that they have to report communicable diseases and vital statistics to us so that we can improve our surveillance systems. Another area is this issue of the uninsured, which is a huge burden. So, if doctors could volunteer some of their time or actually want to work with us in our city health centers or do some programs for the homeless population, even if it’s a little bit, those things add up and can be very helpful for the public health community at large.

PND: What level of support do you expect to get from the Street administration?

WT: The mayor has been supportive of everything we’ve asked him to do, for example, to help support our neighborhood health centers. He could say, "I think we should privatize everything the health department does," and he has not said that to us. The mayor has never turned us down for any of our budget requests. That’s about supportive as I could possibly ask for. I think that the mayor has been focused on several areas, but public health is not his top priority. That actually is acceptable in the sense that his higher priorities are neighborhood transformation and education, and public health plays a very important role in those areas. For example, to get kids ready for school we have an extensive prenatal program and health education program for mothers, a lead screening program for their kids, drug treatment programs for kids who go the wrong way or maybe have sexually transmitted diseases and that’s their first entree into the health care system—we’re often the first face they see in the public health department and we help get them back on the right road. Under neighborhood transformation, you can rebuild all the homes in the neighborhoods but ultimately it’s the people who live in them and how they live their lives that’s going to be important for neighborhood stability.

PND: What are the most serious and challenging obstacles that the Philadelphia Health Department faces?

WT: One of the biggest obstacles is how we finance health care. I’ve been vocal over the years about my displeasure over the market-based approach to health care because it does allow a privileged number of people to get some type of health services, but there are many people who are pushed out of the loop with this system and it’s hard to change how we finance health care to help benefit those people who don’t have much of a voice. There are people who have unusual conditions—people with special needs or disabilities, people with HIV, individuals who have cancer or advanced illnesses—who often find that the system is not friendly to them and there are too many bureaucracies and hurdles they have to go through. One of my hopes is to try to fight against, sometimes hospitals and sometimes HMOs, to help advocate for those individuals to get what they need and also realize that at other times hospitals and HMOs could be allies for those very same individuals. It is true that the city is a huge bureaucracy and moves in very slow and mysterious ways. One of my major challenges is to try to move a bureaucracy like that to make it quick, responsive and timely because all of that is very important in bringing back credibility to the government.

PND: The state health department plans to use local health departments as lead agencies for allocation of the tobacco settlement funds. Have you made any plans for the use of those funds?

WT: The Centers for Disease Control (CDC) Best Practices will form the basis for our plans. We’re going to look seriously at each of those nine areas under best practices and see which ones we can do well in Philadelphia, and which local coalitions and groups are already doing those types of functions. We’re hoping that those people will be part of our response to the Request For Proposals and that we will be able to craft a very Philadelphia-user-friendly approach to tobacco control.

PND: City council has asked you to convene a study group on second hand smoke in the workplace. What are your plans and what do you hope to achieve?

WT: The study group will be meeting through September and October and we’re going to bring in people from the hospitality industry, the public health community and the heating and ventilation contractors. We’re going to take a serious look at the issue of how do we do accommodations: the tobacco industry’s hope for allowing people to smoke but also improving the ventilation system. We’re going to look at that issue carefully and see if we can craft something that we can live with. But if we can’t and if it turns out that it doesn’t work, then I think all of us will be better informed about what our choices really are and we’ll hopefully make a wiser decision about the economics of going smoke-free for the city.