COUNCIL OF THE CITY OF PHILADELPHIA COMMITTEE ON PUBLIC HEALTH AND HUMAN SERVICES Room 400, City Hall Philadelphia, Pennsylvania Tuesday, June 15, 2010 10:25 a.m. PRESENT: COUNCILWOMAN MARIAN B. TASCO, CHAIR COUNCILMAN JAMES KENNEY COUNCILWOMAN BLONDELL REYNOLDS BROWN COUNCILMAN CURTIS JONES, JR. RESOLUTION 100260 - Resolution authorizing the Committee on Public Health and Human Services to hold hearings to investigate the emergence of infant mortality as an epidemic in Philadelphia... RESOLUTION 100316 - Resolution calling for Hearings before the Committee on Public Health and Human Services to Examine the Department Human Services' Policies and Procedures Concerning Adoption and Foster Care. - - - 2
Good morning. I'd like to call the Committee on Public Health and Human Services to order. I'd also like to note the air conditioning is on its way, so if you see me fade away, but it should be here soon. Good morning. We'd like to have the Clerk read the resolutions that are on the schedule today.
Resolution 100260, a resolution authorizing the Committee on Public Health and Human Services to hold hearings to investigate the emergence of infant mortality as an epidemic in Philadelphia, the causes of infant mortality; the racial and ethnic disparities in the prevalence of infant mortality; and to evaluate infant mortality prevention and reduction initiatives in order to reduce the rates of infant mortality. Resolution No. 100316, a resolution calling for Hearings before the Committee on Public Health and Human 3 6/15/10 - PUBLIC HEALTH - RES. 100260 Services to Examine the Department of Human Services' Policies and Procedures Concerning Adoption and Foster Care.
Thank you very much. Before we begin, let us recognize Councilwoman Blondell Reynolds Brown. Other members of the Committee will come. This is a hearing. We do not need a quorum, because it is a discussion about an issue. There is no legislation before us that requires a vote, so we will proceed so that we will not keep you here all day. The Chair recognizes Councilwoman Blondell Reynolds Brown to introduce some special guests.
Thank you very, very much, Madam Chair. Good morning. Let me first acknowledge and say a huge thank-you to Melita Jacqueline Jordan for bringing -- re-prioritizing this issue. The Chair of this Committee looked closely at this issue years ago, and she will speak to 4 6/15/10 - PUBLIC HEALTH - RES. 100260 that, but given recent dynamics happening in the Commonwealth, Melita Jacqueline Jordan called on the attention of Chairwoman Tasco and I to relook at this issue again. So we want to acknowledge all of those who care about the issue, and we especially want to acknowledge those who traveled afar to be here to speak on this issue. Let me also say also even before hearing the testimony of our health czar in this city, Dr. Schwarz, we know of his rich track record at Children's Hospital around this issue, and so we know we will all be, in many ways, speaking with a singular voice on what we need to do more to do better with regards to this important issue. Let me also introduce our diplomats. We want to ask you to stand as you hear your name. I am going to try my best to pronounce your name phonetically. I can say at the outset I'm not going to get it all correct, so 5 6/15/10 - PUBLIC HEALTH - RES. 100260 please forgive me for that. But we're delighted to have Scott Burris, who is the Director of the Robert Wood Johnson Foundation, Public Health Law Research National Program Office. Why don't you stand. And welcome. You're doing extremely important work. We have with us Professor for the Department of Public Health, Pomeranian Medical University, and this is Professor Beata Maria -- help me out. PROFESSOR KARAKIEWICZ: Karakiewicz.
Thank you very much. We have with us the head of the Laboratory of Nursing, also at the Pomeranian Medical University, Dr. Elzbieta Grochans. Thank you. Our next guest is the lecturer for the Department of Public Health at the Pomeranian Medical University, Dr. Liliana Maria Zaremba-Pechmann, and 6 6/15/10 - PUBLIC HEALTH - RES. 100260 also a lecturer of the Department of Public Health, Pomeranian Medical University, Dr. Justyna Sobeyko. Terrific. Let's greet them. (Applause.)
Thank you, Councilwoman. And we welcome our guests here today and trust that your visit with us will be productive and that you gain some information about what's happening here in Philadelphia and the United States. On November the 15th, 2001, I introduced Resolution 010675 to hold hearings in this Committee regarding the causes and effects of continuing high levels of infant mortality in Philadelphia's African American neighborhoods. In 1999, the infant mortality rate was 16.7 for African Americans in Philadelphia as compared to 11.6 for the entire City. As a result of 7 6/15/10 - PUBLIC HEALTH - RES. 100260 these hearings and other work, we worked on various initiatives with the Health Department to address this issue. Programs like the Maternity Care Coalition's MOMobile were viewed as innovative ways to address this issue. Sadly, we are here again today. In 2007, the African American infant mortality rate was 15.9 percent and the citywide rate was 11.4. These rates show little improvement over the past decade. With all of the work, more needs to be done to address this issue. We need to find new and creative ways to address the main sources of this issue. And I too want to thank Melita Jordan for her interest and her concern about this issue and bringing us together to have this discussion again. From this perspective, I hope that today's hearing will shine a light on a new pathway to a solution for this urgent health crisis. And I'm sure we'll get a lot of 8 6/15/10 - PUBLIC HEALTH - RES. 100260 information. The question is, when we come back next year, Dr. Schwarz and Melita, will we have made any greater significant changes. So we'll have to see what we can do. It's very sad. But we're here today to have this discussion. We welcome all of you here to participate. If you would like to testify and you have not signed up, would you please see the young Derek Green up here at the table so we can have your input on this important issue. I would like to state before we move on, if there's anyone here for the Resolution 100316, which has to do with adoption and foster care, we will recess that hearing to the call of the Chair. There will be no testimony on that resolution today. First, the Chair would like to recognize Dr. Donald Schwarz, Deputy Mayor of Health and Opportunity and our Health Commissioner. (Witness approached witness 9 6/15/10 - PUBLIC HEALTH - RES. 100260 table.)
And I'd like to say a fine Health Commissioner, very compassionate, and we love working with him. (Applause.)
Not that we haven't had other wonderful Health Commissioners. I don't want anybody to leave thinking we haven't, but I have a special place in my heart for Dr. Schwarz.
Chairwoman Tasco, members of the Committee on Public Health and Human Services, Councilwoman Blondell Reynolds Brown, I should start by congratulating you on your fluency in more than one language in the face of 10 6/15/10 - PUBLIC HEALTH - RES. 100260 adversity, and let me welcome the delegation here from Poland. I am Donald Schwarz, Health Commissioner, and I appreciate the opportunity to appear before you today to discuss the troubling issue of infant mortality in the City. As requested in City Council Resolution No. 100260, my testimony will speak to the epidemiology of infant mortality, the prevalence of racial and ethnic disparities in infant mortality, the causes of infant mortality, and prevention and reduction initiatives that have been undertaken to reduce the current rate in the City by the Health Department. The infant mortality rate is the number of deaths of children under the age of one divided by the total number of live births in that same period. This number is then multiplied by 1,000 for standardization. And I should point out 1,000, not 100. So we talk about infant mortality as deaths per 11 6/15/10 - PUBLIC HEALTH - RES. 100260 thousand live births as opposed to percent or per hundred, and that has to do with age-old convention on infant mortality, because it is now a more than 150-year measure of the health of communities in general. Infant mortality rates have been kept officially since 1950, and since then, clinicians, researchers and policymakers have used this measure to track the health status and well-being of women, infants and societies at large. I want to highlight here that infant mortality as a measure, as I mentioned, is more than a century old and was developed to track the many intangible factors in communities that contribute to overall, not just infant health. So it is used across societies to measure health within society, not only infants' health. 8 deaths per thousand live births. This ranks us 12 6/15/10 - PUBLIC HEALTH - RES. 100260 44th internationally and puts us between the Slovak Republic and Montenegro. Countries with the lowest infant mortality rates include Iceland, Singapore, Japan and Sweden. Sadly, Afghanistan has the highest rate of infant mortality with 165 deaths per thousand live births. In other words, nearly two in ten children, or 11 percent, die before their first birthday. 12 All the other nations in the bottom ten 13 for infant mortality are sub-Saharan or 14 West African nations. in 2000. deaths per 20 thousand live births. 6. 4 deaths per thousand live births. In Philadelphia, the infant 13 6/15/10 - PUBLIC HEALTH - RES. 3 in 2000. In the last decade, however, infant mortality has not changed significantly. And despite overall decreases, racial and ethnic disparities have been persistent over time. 1. Geographic disparities are also present with the highest infant mortality in West and Southwest Philadelphia. 0 in 2008. 3 rate in 2000 14 6/15/10 - PUBLIC HEALTH - RES. 4 rate in 2007, I want to highlight that from a statistical standpoint, this kind of change is probably within what's called the margin of error. So it's too small to be considered important, because while we have many births in Philadelphia and we have too many infants who die, the issue is that that change is within what happens just by statistical error. So we don't consider it a trend, up or down, but what we do say is, we have not seen a change in the infant mortality rate in the City in eight years. So rather than ask why the range has changed so little in the decade, what I'm hoping we can focus on, as you have indicated in the legislation that called for these hearings, we ask why are there such large differences across racial and ethnic groups. While Philadelphia's infant mortality rate remains high, other cities like New York, Houston and Los Angeles 15 6/15/10 - PUBLIC HEALTH - RES. 5 deaths per thousand live births.
Philadelphia's infant mortality rate most closely resembles that of cities like Detroit, which has a higher rate, Washington, which has a higher rate, and Baltimore where rates are comparable both for African Americans and for Caucasians and which have similar populations in terms of race, income and educational attainment. There are several factors that contribute to infant mortality. One way to understand infant mortality risks is to look at the categories of infant mortality. Neonatal infant mortality, defined as death in the first 28 days of life, accounts for the majority of infant deaths in the United States. Improvements in neonatal mortality have been achieved primarily through high-risk obstetrics and neonatal intensive care. About 80 percent of the disparity in neonatal mortality between whites and 16 6/15/10 - PUBLIC HEALTH - RES. 100260 blacks is due to a very high low birth rate among babies; that is, babies born at less than 750 grams who are preterm infants. 6 percent of births among black African American women were preterm. I should note that despite reductions in overall infant mortality rates in Philadelphia in the last 30 years, we have done little to change the rates of low birth weight birth. So infant mortality rates have come down. Low birth weight birth numbers proportionately have not changed. This helps us understand that infant mortality rate reductions achieved in the last part of the last century were due largely to improvements in the life expectancy of low birth weight infants. Same proportions being born, but living longer and less likely to die, not due to reductions in low birth weight birth itself. Low birth weight birth is highly 17 6/15/10 - PUBLIC HEALTH - RES. 100260 reflective of the social well-being of communities and the women in those communities. Postneonatal mortality is defined as death between one month and one year of life. S. include Sudden Infant Death Syndrome, or SIDS, that's also been called in the past crib death, about percent of 12 postneonatal deaths in Philadelphia; 13 congential anomalies, 20 percent in 14 whites, 15 percent of deaths in blacks; 15 and unintentional injuries, about eight 16 percent of postneonatal deaths. 17 One-quarter of the disparity between 18 whites and blacks is accounted for by 19 differential mortality rates due to SIDS. 20 Regarding SIDS, preterm birth 21 is a major factor. So over and over, 22 preterm birth is important in infant 23 mortality. Other risk factors include 24 maternal tobacco and illicit drug use. 25 We saw worrisome increase in postneonatal 18 6/15/10 - PUBLIC HEALTH - RES. 100260 deaths among black infants in Philadelphia from 2007 to 2008. The number of deaths increased from 51 to 82, which I believe may well be quite significant. Placing infants on their back during sleep is a highly effective way to prevent SIDS. However, efforts to convey information regarding appropriate infant sleep positions have been less effective in reaching lower-income families. With all this, key issues to consider in infant mortality prevention and disparity reductions are prevention of preterm and very low birth weight infants and appropriate treatment of very low birth weight infants. Preventing preterm births is challenging, because the causes of prematurity are in fact poorly understood, and even when identified, the degree to which each factor contributes to the risk of death is also not well known. A variety of factors have been 19 6/15/10 - PUBLIC HEALTH - RES. 100260 implicated, including income, housing, smoking, illicit drug use, particularly cocaine, and now more recently obesity. A recent national study showed that even for obese women who gain little weight during pregnancy, rates of infant mortality were nearly twice that of women of normal weight. Other societal factors such as relative deprivation, racial discrimination, racism, maternal stress and limited social capital in communities have garnered growing attention.
At the same time, others have focused on understanding the biology of preterm birth in a more complete way. All of these areas deserve our continued attention in public health and in medicine. It's worth noting what while prenatal care has many benefits, receipt of services in and of itself does not affect rates of preterm birth. Targeted interventions on reducing smoking and illegal drug use have also shown limited 20 6/15/10 - PUBLIC HEALTH - RES. 100260 direct benefit in reducing infant mortality. With regard to the care of very low birth weight infants, access to high-risk obstetric and newborn services is clearly essentially. In Philadelphia, we are blessed by the fact that each of our current remaining six delivery hospitals has high-risk obstetric capabilities and neonatal intensive care units. As with all medical services, quality of care is essential. Through my work with the Chairs of the six delivery hospitals, I know that there is already a high degree of quality in these six institutions in Philadelphia, and they are looking to get better every day. So with this background, what have we done to address infant mortality in Philadelphia? Since 1991, Philadelphia has received federal Healthy Start grant funding to reduce rates of infant mortality, low birth weight birth and 21 6/15/10 - PUBLIC HEALTH - RES. 100260 other poor perinatal outcomes in communities with a disproportionate burden of these outcomes. In Philadelphia, funding is targeted to those sections of the City with the highest infant mortality rates: West Philadelphia, Southwest Philadelphia, lower North Philadelphia and South Philadelphia. Women are recruited for enrollment as early as possible in their pregnancies, and services continue until a child reaches the age of two years. Case managers help families to access family planning services, prenatal and pediatric care, and services for interconceptual care and perinatal depression. Over 300 women and their families are served each year. Direct services are provided by the staff of Maternal, Child and Family Health and through partnerships with a variety of community-based providers and institutions. Healthy Start services include prenatal outreach and education, 22 6/15/10 - PUBLIC HEALTH - RES. 100260 case management, in-home support for families with infants and young children, targeted support for women experiencing perinatal depression, and case management for families with special needs. 1 percent of the participants in West, Southwest and South Philadelphia Healthy Start programs who enrolled during their first or second trimester of pregnancy had low birth weight infants, which is significantly lower than the average for these neighborhoods overall. However, as you well know, we don't know from other such -- we don't know from other medical or social -- we don't know which other medical or social service programs these women have been enrolled in, and we don't know whether their risk tends to be lower. So lower-risk women, although they may look the same, lower-risk women actually are the ones who come to light for Healthy Start and so we miss higher-risk women. We don't have a way 23 6/15/10 - PUBLIC HEALTH - RES. 100260 to know that, because we don't randomize people. We take anyone who comes up until the point that we run out of funding. Over 80 percent of women receive case management services attending their -- to help attend their postpartum appointments. Ninety-two percent of their infants received age-appropriate immunizations and only five percent of women receiving interconceptual services had a repeat pregnancy within months, five percent 15 compared to six percent in the selected 16 neighborhoods as a whole. 17 Client surveys have revealed 18 that most women reported coming to 19 Healthy Start via referrals from medical 20 sources and that few women enrolled in 21 order to obtain perinatal care, insurance 22 or WIC.
Rather, general health concerns 23 around healthy pregnancies and babies 24 were much more common reasons for enrollment. Additionally, many women 24 6/15/10 - PUBLIC HEALTH - RES. 100260 reported family planning needs as a reason for enrollment. Based on these findings, many changes have been made or are planned. One, community outreach -- community-based outreach is being enhanced to encourage non-medical referrals. Two, to provide easy access for women at high risk, we have co-located Healthy Start services on site at District Health Center 5 at 20th and Berks in lower North Philadelphia. This helps ensure proper pre-conceptual, prenatal and postnatal care for women, including family planning. Three, we collaborate with and support a number of ongoing prevention initiatives in the City provided by hospitals, health centers, community-based agencies, universities and advocacy groups. Many of those partners are here today. Our links to the delivery hospitals are key. Not only 25 6/15/10 - PUBLIC HEALTH - RES. 100260 do hospital-affiliated clinicians provide prenatal care in our health centers, but they also identify and manage women with high-risk pregnancies. This link allows women to get specialized services that help to mitigate risks for preterm birth. For the last several years, the Health Department has also been working with the leaders of delivery hospitals to identify and address ways to improve the quality of care received by women during their pregnancy and at the time of delivery. Safe, high-quality, coordinated care for pregnant women requires that physicians have the right clinical information at the right time. In collaboration with the delivery hospitals in the region and the federally qualified health centers, we seek to create the nation's first citywide electronic prenatal care registry. It will ultimately serve as a virtual medical chart for every pregnant woman in Philadelphia and will be accessible to 6/15/10 - PUBLIC HEALTH - RES. 100260 every provider caring for them. Through this initiative, Philadelphia will use information technology to solve complex healthcare challenges, provide patients with the care that they deserve, and reduce the risks with delivery. A pilot will be launched in the fall of this year. These efforts are crucial to improving the health of women and infants, but we have to do more, particularly to address the complex, seemingly intractable challenge of preventing preterm birth and low birth weight that drive much of infant mortality. A necessary step in this work is to look at the health and well-being of women holistically. Some have described this as a life course approach. This approach looks at birth outcomes as the end product of not only nine months of pregnancy but of the entire life course of a mother leading up to her 27 6/15/10 - PUBLIC HEALTH - RES. 100260 pregnancy. Disparities in birth outcomes, therefore, are consequences of both differential exposure during pregnancy and differential developmental experiences across a woman's lifespan. To jump-start such efforts locally, our Division of Maternal, Child and Family Health will be hosting a day-long symposium on the life course approach on Tuesday, June 29th of this year at 440 North Broad Street. com. Over the next year, the Division of Maternal, Child and Family Health will also be developing a strategic plan incorporating the life course approach to reduce infant mortality. And I have to acknowledge the contribution to this from our State partners and particularly Melita Jordan, who is here and will testify soon. This will be a collaborative effort between the Department of Public Health in the City and the Pennsylvania Department of 28 6/15/10 - PUBLIC HEALTH - RES. 100260 Health, local and regional experts, medical and social service providers, and community-based organizations.
In parallel, the Health Department will continue to implement and advocate for policies that make it easier for Philadelphians to engage in healthy behaviors. It's one thing to tell women to eat more healthfully, but it's another thing to provide women with nutritional information, to make healthy foods more available and affordable in communities, and to make unhealthy foods less available. Philadelphia has already made significant strides in this arena. The City passed a groundbreaking, with leadership from people present here today in Council, trans fat ban in 2007, and in 2008 passed the strongest menu labeling law in the country, requiring chain restaurants to post calories on menu boards and to include information about calories, sodium, fat and carbohydrates 29 6/15/10 - PUBLIC HEALTH - RES. 100260 on menus. But we need to do more. The price of fruits, vegetables and milk has increased relative to the price of junk foods and sugar-sweetened beverages. People particularly in tough economic times let their wallets dictate food purchases. Although junk foods and sugar-sweetened beverages are cheap, over time they create huge health-related costs to individuals, employers and society at large. S. spent nearly $150 million in obesity-related health expenditures in 2008. The same goes for tobacco use. Nearly three in ten adults in Philadelphia smoke, a rate significantly higher than in cities like New York and Chicago. One key difference is that a pack of cigarettes costs just $5 in Philadelphia, but nearly $8 in Chicago and $10 in New York. Through Philadelphia's Recovery-funded Communities Putting Prevention to Work award from the Centers for Disease Control and Prevention, the 30 6/15/10 - PUBLIC HEALTH - RES. 100260 City will expand the Healthy Corner Store Initiative to include 1,000 stores through which they will receive training, technical assistance and mini grants to stock and sell healthy foods and to restrict sales of tobacco to youth; to establish new farmers' markets in low-income neighborhoods in Philadelphia; to implement a healthy Food Bucks program in farmers' markets so that Food Stamp 12 beneficiaries receive $2 vouchers for 13 every $5 spent on produce. And I should 14 tell you we're already doing it. To use 15 the media to warn smokers about the harms 16 of smoking and drive them toward quit 17 resources and to make cessation resources 18 more available through employers and 19 public and private insurance. 20 In conclusion, the Department of Public Health has provided a variety of services to reduce infant mortality over the years and I should say in partnership with this City Council. To date, these services have had limited 31 6/15/10 - PUBLIC HEALTH - RES. 100260 success in reducing the City's high infant mortality rate and eliminating the disparities that are the root cause of the problem in the City of Philadelphia in the last decade. The Department acknowledges the seriousness of this problem and has made a strong commitment to resolving the issue. It will use Title V dollars to fund the development of a strategic plan and leverage Healthy Start funds to support new programs and service approaches resulting from that process. During the coming months, the Department and its staff will also dedicate its efforts toward building a strong, diverse and broad network of stakeholders that will work together to plan, develop and implement the policies and comprehensive services necessary to achieve the desired infant mortality rates here in Philadelphia. Thank you.
Thank you very much. We appreciate your testimony. 32 6/15/10 - PUBLIC HEALTH - RES. 100260 We're going to hold the questions. I failed to ask Ms. Melita Jordan to come forward. She's part of this panel. We'll let you both testify and then we'll have open discussion. (Witness approached witness table.)
Thank you very much for allowing me the opportunity to be here today to testify before you. I appreciate the opportunity, Councilwoman Tasco and Councilwoman Blondell Reynolds Brown. It's been a pleasure working with Dr. Schwarz and his staff and his leadership as well on this initiative. We have been partners all along, and so I do appreciate that. I will try not to reiterate any of the comments that he's already made. I'll just try to highlight a couple of points from my perspective from the State. 33 6/15/10 - PUBLIC HEALTH - RES. 100260 Again, good morning. My name is Melita Jordan and I am the Director of the Bureau of Family Health in the Pennsylvania Department of Health. In this capacity, I serve as the State Title V Maternal and Child Health Director for the Commonwealth of Pennsylvania. I am also the Region 3 Director for the Association of Maternal and Child Health Programs. My background is a Certified Nurse Midwife and as an Advanced Practice Nurse who has worked here in Philadelphia with vulnerable communities and populations but also in the delta of Mississippi, as well as in New Orleans and in addition to Louisiana. I have more than 30 years of experience, so I hope this will give you some understanding of the context in which I will share my remarks. Again, I appreciate this opportunity to be with you today and to provide testimony on this important issue of infant mortality, which is very 34 6/15/10 - PUBLIC HEALTH - RES. 100260 germane and dear to me. My most important message to you today is that health disparities kill and health disparities cost and health disparities are preventable. Race is not a biological construct that reflects innate differences, but rather it is a social construct that precisely captures the impact of racism. I ask that you keep this in mind as I continue with my testimony. When compared with their white counterparts, racial and ethnic minorities consistently have higher rates of obesity, diabetes, heart disease, high blood pressure, infant mortality and cancer. Health disparities are evidenced by the incidence and prevalence of certain diseases and mortality rates and by the health status of minority populations. The call to eliminate health disparities is most compelling 35 6/15/10 - PUBLIC HEALTH - RES. 100260 when one examines the disparity in infant mortality rates amongst African Americans in this country. The infant mortality rate provides an important benchmark in the progress we as a nation are making in the battle over health disparities. Cities with the highest infant mortality rates tend to have larger populations of African American births. While strides have been made, Pennsylvania as a whole and as well as in the City of Philadelphia, we still struggle to eliminate the disparities in infant mortality. For example, as Dr. 2. 5. Compare this to the 36 6/15/10 - PUBLIC HEALTH - RES. 3 for Asian/Pacific Islanders. While the Asian infant mortality rates in Philadelphia decreased from 2003 to 2004, there was a significant increase in 2007, a trend seen for the City as a whole during this time period. The Philadelphia communities with the highest rates of infant mortality, a rate of or higher, are in 12 the West Philadelphia section, the 13 Southwest and the upper North 14 Philadelphia area. We at the Pennsylvania Department of Health have significant concerns with the racial disparity of infant mortality rates. Current initiatives in Philadelphia to address these needs of mothers, infants and children include: Over $50 million of WIC funding was provided to Philadelphia in federal Fiscal Year 2009. This $50 million was allocated in food dollars. Another $11 million was provided to 37 6/15/10 - PUBLIC HEALTH - RES. 100260 support administration, direct client services and outreach in the communities. 5 million in Title V funding for maternal, infant and child health services, and these dollars go directly to the Philadelphia Health Department.
SIDS Infant Safe Sleep, which is a funding opportunity that will be made available for a statewide initiative to provide prevention efforts, will begin in August and will be released actually in August. In addition, small grants for evidence-based community interventions to address risk factors that influence poor birth outcomes will be available beginning July 1 of 2010. It is only through working together at the federal, the state and the local level and in the community with evidence-based strategies that we will begin to effect change and document improvement. And I applaud this city for working towards the life course perspective. I also believe that the 38 6/15/10 - PUBLIC HEALTH - RES. 100260 reduction and elimination of infant mortality and the significant racial and ethnic disparities can be accomplished. I believe that we can do better. I believe that we must do better. I want to close with the words of John F. Kennedy: All of this will not be finished in the first 100 days, nor will it be finished in the first 1,000 days, not in the life of your administration, nor perhaps in our lifetime or on this planet, but let us begin. I end this quote with reminding you that remember that health disparities kill, health disparities cost and health disparities can be cured. Thank you.
Thank you very much for your testimony. The Chair recognizes Councilwoman Brown.
Thank you very much. 39 6/15/10 - PUBLIC HEALTH - RES. 100260 Dr. Schwarz, as you began to talk about -- I got a bunch of notes here. My question was going to be, are systems talking across each other, linking up. But then in your testimony -- I wrote that question down before you actually got to it in your testimony wherein you did speak that there's going to be a registrar of some type, correct? Is that the purpose of --
So I'm going to take your question at do systems talk to each other and say never enough, but yes. So there are a series of initiatives, Healthy Start being the probably longest lived at the moment where public health, community-based agencies, hospitals, healthcare providers are funded to talk to each other and there are workers who are employed to do that. We have a need, though, which was made clear to me, and you'll hear from the obstetric community in the City. For obstetric providers, somewhere 40 6/15/10 - PUBLIC HEALTH - RES. 100260 between and percent of births happen at a hospital where the prenatal care record isn't housed.
Is not housed. 8 So if a woman gives birth at the 9 University of Pennsylvania, for instance, 10 but received prenatal care at Jefferson, 11 her record isn't at the University of 12 Pennsylvania at the time of birth. If a 13 woman receives care at a community health 14 center, depending on the health center 15 and how records are managed, it's likely 16 that that record is not present at the 17 time of birth. So if she has had during 18 her pregnancy good prenatal care and 19 identification of a whole series of risks 20 and laboratory tests that are important, that information won't be available at the time of delivery. The obstetric community came to me. We talked early on about how could we create, with information technology, a 41 6/15/10 - PUBLIC HEALTH - RES. 100260 way to share some of that information. There are a thousand barriers to doing this, particularly around HIPAA and other health information sharing issues, and hospitals, I have to say, I think understandably, and healthcare providers are worried about their own risk as well as being committed to good birth outcomes. So we have agreed to begin the process of sharing laboratory information. It's easy, it's helpful, it's important, and it creates the infrastructure to do this, and fortunately the federal government has told everyone we're going to expect you to begin sharing information. So we have pilot money from Washington to begin the process. We have the six hospitals talking to each other. We have wonderful support from the Health Federation and a growing, I would say, momentum from federally qualified health centers in town to begin agreeing that laboratory data will be shared. So prenatal 42 6/15/10 - PUBLIC HEALTH - RES. 100260 laboratory data will be available at the time of delivery. That does a lot of good things. One, clinically it's important. Two, it reduces the time it takes for a healthcare provider to try to find that information.
And so when you say the Health Federation is supporting, is it fair to interpret that as they endorse this new uniformity that's really going to be useful and helpful around the issue of infant mortality?
I don't want to speak for the Health Federation, but I can say they've been a very strong and important partner.
Towards that end. Both of you stated in your testimony -- and this part I actually 43 6/15/10 - PUBLIC HEALTH - RES. 100260 remember from years past -- that West, Southwest and North Philadelphia are those locales where you have the highest infant mortality. Are those communities aligned also with the high poverty rates? And so --
So then it makes good sense from, I guess, a practicum standpoint that where you have high incidence of poverty, you also have high incidence of infant mortality. Fair to say?
Right, as you mention in your testimony. Okay. Chair Lady, you want to pick up?
Let me just ask a question. Picking up on her question about the geographics where most of the women in the South, Southwest, 44 6/15/10 - PUBLIC HEALTH - RES. 100260 North Philadelphia, we heard that back in 2000 when we had the hearings. They were the areas that targeted -- were targeted to have the highest rate of infant mortality. How much of that accounts for the increase of the 16.1 percent? Is that the largest percentage of those deaths in that area if you look at the City as a whole?
So, yes, they 16 account for the largest proportion of the deaths. What I would say is, when I started in Philadelphia and Healthy Start began years ago almost, 1991, yes, 20 what was the case was that West Philadelphia, North Philadelphia competed for the highest rates. Upper Southwest now has a substantially higher rate than the remainder of Southwest, West or South. So that's an emergence, I would 45 6/15/10 - PUBLIC HEALTH - RES. 100260 say. But if you look at the demographics of that area, poverty rates have increased in those neighborhoods, crime has increased in those neighborhoods, all the things that go with poverty have increased as well. So I won't say infant mortality by region is exactly the same over the long haul, but neither is poverty. And it is true that infant mortality follows poverty, unfortunately, in a major way, and I think both the burdens and stresses on women follow poverty. So I hope that answers --
So what is the average age of a mother in this group of women where these --
So the average age of the mother is about 20 years old?
20, 23, 24 years 46 6/15/10 - PUBLIC HEALTH - RES. 100260 of age.
How about -- well, we'll ask some of the providers. I was going to talk about high school students, young women. They're not 24. They're the to 18. 8 Is there a high rate, a linkage there? 9
So the issue is 10 the proportionate number of births. So 11 while we all worry about teen pregnancy 12 and teen birth, proportionate to births 13 for women from or up, it's a tiny 14 proportion of births. So if we want to 15 make a dent in infant mortality, we can 16 talk about what's the risk for younger 17 mothers, but if we really want to do the 18 whole infant mortality rate and, as you 19 said, make a tangible difference here, we 20 need to focus on older women, women who are in their 20's and up, because that really is the bulk of births and that is the bulk of deaths. So it's important to focus on teens, and there are a whole series of 47 6/15/10 - PUBLIC HEALTH - RES. 100260 issues with teens, but for infant mortality prevention, we really need to be sure we have services that go to women who are living in high-risk communities, particularly women who are in the peak years for reproductive capacity.
And if I could just add, there are a number of programs also from the State level that address teen pregnancy prevention, as well as family planning and outreach programs that is administered through the Department of Health, as well as from the Department of Public Welfare and the Department of Education that is centered here in the Philadelphia area.
I can certainly not speak for Councilwoman Jannie Blackwell, but what I do know about the Southwest community is that there you have a large emergence of immigrants, and that may or may not also contribute to the fact that -- please, Dr. Schwarz. 48 6/15/10 - PUBLIC HEALTH - RES. 100260
And it's one reason why Latino infant mortality rates are relatively low and Asian infant mortality rates are relatively low. You know, women who grow up in this country who are poor are really multiply and terribly disadvantaged, and I think we see that in the likelihood of babies dying. And women who come from abroad don't have the same risks, and whether it's behavioral or lifelong or whatever, it is the case that even for the same amount of poverty, ironically enough, they often have better birth outcomes.
So if we know that West, Southwest and North Philadelphia is where you have the greatest presence, do we have ample services, if you will, to match those 49 6/15/10 - PUBLIC HEALTH - RES. 100260 numbers? Because the bottom line question for me is, if both of you can look into a crystal ball and had to ID one or two solutions that would help drop these numbers in a tangible way, what would those one or two solutions be? Because at the end of this discussion, that's what we're in search of.
And let me piggyback on that. Since '91, most of the dollars and the programs have been targeted to those neighborhoods. Why is it that we haven't seen a change or a difference?
So I think if we added up the disparity in income and the disparity in jobs and the disparity in social status and capital in those neighborhoods, it would be in dollars far greater by -- very far greater than the amount we have to spend on infant mortality prevention as infant mortality 50 6/15/10 - PUBLIC HEALTH - RES. 100260 prevention. And years ago in 1991 when Healthy Start started and the federal government agreed to spend what was then an extraordinary amount of money in West Philadelphia on infant mortality prevention, a fair number of the people who had been at this even then a long time looked at each other and said, The problem with the federal government spending this much money is, we all know it's not enough and yet everyone is going to look at it and say, Boy, look at all we've spent on infant mortality prevention. Think of the value of that disadvantage, how disadvantaged people are. We've talked about women. It's their partners, it's their other children, it's their support system, it's their homes. What we would have to do to truly repair is huge. So are we spending enough? We're proportionately I believe spending based on where we have infant mortality. 51 6/15/10 - PUBLIC HEALTH - RES. 100260 So we're spending right amounts in the right neighborhoods. The issue is, we're just spending it on infant mortality. And what the life course perspective on women says I think is, we can't expect that we're going to fix the issues that lead to infant mortality, like racism, like poverty, like no housing, like whatever, in the nine months of pregnancy in some way and have healthier births. There was a study done in Philadelphia, randomized control trial, and I think there may be someone here who will talk about it, with women over a five-year period in the interconceptual period, taking women who had had a low birth weight birth, investing huge dollars in them, doing everything from state-of-the-art dental care, making sure they had housing, giving them clean clothes, all kinds of things in that period between their births to see did it make a difference to the low birth weight birth of the second child, and I believe 52 6/15/10 - PUBLIC HEALTH - RES. 100260 the answer is no. 3 So even with huge expenditures on targeted periods there, it suggests that for low birth weight birth, this is a lifelong issue and we really have to make a commitment to poor communities to raise poor communities. Now, does that mean we can't do anything about infant mortality? Absolutely not. Other cities have shown that we can chip away and we can make a difference.
I guess what makes us -- what puts us in the category of Detroit and Baltimore?
So if we look at overall infant mortality rates, African American infant mortality rates -- and I can give you a chart, which let me pull it out so I can make sure I get it exactly right, which is very telling, I think. It compares Philadelphia to other cities and looks across racial and ethnic groups. Anyway, what it essentially 53 6/15/10 - PUBLIC HEALTH - RES. 100260 says is that if we look at, for instance, Baltimore versus Philadelphia, Baltimore's overall infant mortality rate is actually lower than Philadelphia's, and it's lower because of the white infant mortality rate, not the black infant mortality rate. We have poorer white women as well as poorer black women. So we have racial disparities, but we also have disproportionate poverty in certain neighborhoods that affects everyone. And if we look at Washington, Washington has somewhat higher African American infant mortality rates. They have considerably low Caucasian infant mortality rates. So the problem is really complicated when we talk across cities, and I think there are structural issues, there are things we, I believe, will find we can do as we think about the life course of women in Philadelphia that we need to do and that they're targeted 54 6/15/10 - PUBLIC HEALTH - RES. 100260 investments we can make, and we need to continue to support and advocate for better care for infants who are sick, because, remember, an infant born at low birth weight needs to survive in Philadelphia at the same or even a better rate, because we have great healthcare, and you'll hear from the healthcare providers about that, but we need to recognize that we are, one, a poor city and, two, we're a city where we have very long histories of women being disadvantaged from birth on. Men too, but particularly if we talk about infant mortality, we know that there are issues in women's lives. Dental health, for instance, for women is a critical part in having a healthy baby. We know that there are correlations between dental health, long-term dental health, and the health of a newborn and premature birth. So the complexity of the issue is real. I think you're absolutely right, we need to look at this. We need 55 6/15/10 - PUBLIC HEALTH - RES. 100260 to figure out how we can do more with what we have. We need to get more efficient at it, but we also need to have a message come out of this, which is women's health from the time they're born is really critically important, and we have to nurture every child, and as we do, a generation from now we'll have lower infant mortality rates in Philadelphia, but we can do things in the interim as well. We can't wait.
I agree. I just wanted to add in response to your question as well is to say that from my perspective, I think in Philadelphia you certainly have had a deterioration within the neighborhoods that we have just mentioned. You have, again, in parts of West Philadelphia, North Philadelphia high unemployment rates among African Americans. You have high dropout rates of high school in those particular areas as well. You have housing that in many of those areas are infested with lead. 56 6/15/10 - PUBLIC HEALTH - RES. 100260 You have the high lead levels there as well. And so for years, there have not been the renovation in these particular areas where people live and, therefore, you have people living in poverty also with not having the wherewithal for the infrastructure in those parts of the City that have not been addressed. So it's not because there's a lack of, I believe, in some terms of nutrition being provided here in the City, because as I just mentioned, over $50 million has come into Philadelphia alone just for WIC, providing services in terms of food and nutrition. In addition, Philadelphia also received additional dollars for housing from the ARRA money that was provided here in Philadelphia to help also address not only housing but also lead remediation. And so there is opportunity here to eradicate some of the homes and do some remediation for the homes that are lead infested, in addition to 57 6/15/10 - PUBLIC HEALTH - RES. 100260 providing additional funding for that. But I think it's true that we have to work together. We have to work across all of the State and federal agencies to address this issue in terms of making sure that it's not only the healthcare but, as Dr. Schwarz mentioned, all of those other public health and social determinants of health that we need to address.
I think Councilwoman Brown -- I was just chatting with her -- she has introduced a bill to require removal of lead paint from rentals, and we know that rental properties -- we know that a lot of the properties in these communities are rental. They have gone from single-family homes to multi-family homes without the remediation of lead in those properties. She's getting some pushback, and we're going to need some support from the health community to say that this is an important thing that has to be done if 58 6/15/10 - PUBLIC HEALTH - RES. 100260 we're going to -- if that's one of the issues we have to address, we have to address it.
And the last thing I was just going to mention again is that, again, to apply the evidence strategies that have been proven in other states and other cities that have worked -- and I know Dr. Schwarz had been working for a very long time on some of the research as well as some strategies that he was working with at the University of Pennsylvania, but it's time that Philadelphia come together and really look at what the evidence and what the research is saying and apply those to the communities, and work at the community level as well, develop strong partnerships with communities and with organizations who have worked in this field for years and years and years and decades actually on this issue to address the matter, and also put the funding in the community as well to work with the 59 6/15/10 - PUBLIC HEALTH - RES. 100260 Health Department and across his other agencies. So, therefore, your housing department and the other agencies within the City need to be working together to address this. It's not just a health issue. It is an issue that crosses and spans all of your agencies here in the City of Philadelphia.
Thank you. That gives us another action to take, is to call all the groups together and have a discussion about that.
We'll be having hearings on the lead in the fall, so we will reach back to you both to assist us in building the required support, because we need the support of the professionals who live and breathe this issue around lead in children to ultimately for us secure nine votes to pass the legislation. Thank you very much.
Would you like the multi-city -- 60 6/15/10 - PUBLIC HEALTH - RES. 100260
Thank you. I know you have a business schedule. If you stay as long as you can, but if you have to leave, we'll understand that. The Chair recognizes that Councilman Kenney has joined us. He's a member of this Committee. Now we're going to call on the second panel. Ken Braithwaite, Senior Vice-President and Regional Director of Delaware Valley Health Corporation, I guess; Owen C. Montgomery, Dr. Owen C. Montgomery, Chairman of Obstetrics and Gynecology, Drexel University; Dr. Kevin Dysart, Thomas Jefferson University Hospital; Dr. Jay S. Greenspan, Thomas Jefferson University; Dr. Monique Fountain Hanna, ORO Region III Medical Consultant; and Dr. Brownsyne Tucker Edmonds, Robert Wood Foundation. (Witnesses approached witness 61 6/15/10 - PUBLIC HEALTH - RES. 100260 table.)
Good morning. Thank you all for coming. We appreciate you taking your time, and ask you to begin your testimony. Would you identify yourself for the record.
Absolutely. Good morning and thank you, Councilwoman Tasco, Councilwoman Reynolds Brown and Councilman Kenney and the entire Committee on Public Health and Human Services, for giving the Delaware Valley Healthcare Council this opportunity this morning to testify. My name is Ken Braithwaite. I serve as the Regional Executive for the Delaware Valley Healthcare Council here in Southeastern Pennsylvania. I also serve concurrently as the Senior Vice-President for the State association. Delaware Valley Healthcare Council and the Hospital and Health System Association of Pennsylvania is a membership organization representing more 62 6/15/10 - PUBLIC HEALTH - RES. 100260 than 100 healthcare facilities, including more than 50 acute and specialty-care hospitals and health systems, over 30 facilities providing inpatient behavioral health services and facilities 7 providing physical rehabilitation in 8 Southeastern Pennsylvania. 9 DVHC, as I mentioned, 10 appreciates this opportunity to express 11 the regional hospital community's 12 concerns about one of the most important 13 issues confronting Philadelphia, the 14 issue of infant mortality. DVHC's 15 testimony today will cover the City's 16 current infant mortality issue and 17 whether the closure of hospital 18 obstetrical units has impacted these 19 rates, the current stresses on the City's 20 hospital-based OB services and DVHC's recommendations for reducing infant mortality rates. As Dr. Schwarz clearly identified, Philadelphia's infant mortality rates are significantly higher 63 6/15/10 - PUBLIC HEALTH - RES. 100260 than the national average. However, they've remained fairly stable. However, since 1997, through the current year, the number of Philadelphia hospitals delivering babies has dropped steadily from units to six units, increasing 8 patient volumes at the remaining OB 9 units. For a three-month period in the 10 fall of 2008, we collected daily OB 11 utilization information from Philadelphia 12 hospitals. At that time, DVHC found that 13 the Philadelphia mothers and children 14 were receiving excellent care despite the 15 many stresses placed on the hospital OB 16 units by these increased volumes. 17 According to DVHC's 2008 data 18 collection in aggregate, for three out of 19 over four days of the survey period, the number of labor and delivery patients admitted exceeded 75 percent occupancy. That is the target occupancy rate recommended by some policy experts to allow for surges in OB patient volume. In addition, according to 64 6/15/10 - PUBLIC HEALTH - RES. 100260 DVHC's utilization reporting system in Fiscal Year 2008, average annual occupancy rates in three City OB units were well above 90 percent for the year. This average rate for the entire year means that on a day-to-day basis, occupancy rates were sometimes lower than 90 percent and sometimes much higher, even on occasions exceeding 100 percent. The reasons behind hospital obstetric unit closures in the City and region have been documented by the Hospital and Health System Association of Pennsylvania as well as DVHC, as well as others. Liability insurance for obstetrical service providers, including the hospitals and physicians, is one of the most costly types of medical liability insurance to purchase. For example, insurance from ProAssurance, one of the insurers here in Southeastern Pennsylvania providing coverage to Philadelphia OB/GYNs, the average annual cost is about $169,000 as compared to 65 6/15/10 - PUBLIC HEALTH - RES. 100260 about $37,000 for coverage for internal medicine. While medical liability insurance costs are high, hospital reimbursement rates for obstetrical services are low, especially for services provided to mothers and infants with Medical Assistance. Pennsylvania's Medicaid health insurance for low-income individuals on average for all types of acute hospital services pays less than 80 percent of the cost of care provided. And I know I've appeared before you before to testify to that.
Even with these financial challenges, the Philadelphia hospitals that continue to delivery babies devote significant resources to fulfilling this part of their mission and continue to use other service lines to subsidize our OB care. As noted in the resolution that convened this hearing, low birth weight is a key risk factor for infant 66 6/15/10 - PUBLIC HEALTH - RES. 100260 mortality. According to the Centers for Disease Control and Prevention and many other experts, early and continuous prenatal care helps identify conditions and behaviors such as smoking, drug and alcohol abuse, inadequate weight gain during pregnancy and repeat pregnancy in six months or less that can result in low birth weight babies. Babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight and five times more likely to die. I'll repeat that. Five times more likely to die than those mothers who have not received prenatal care. Philadelphia must reduce its infant mortality rate. The City must increase the percentage of expectant mothers who receive prenatal care. National health reform contains provisions that will help, including the elimination of co-pays and deductibles for pre and postnatal care. Coverage for labor and delivery services, sometimes 67 6/15/10 - PUBLIC HEALTH - RES. 100260 not included in the health plans, will be part of the essential benefits package required for inclusion in State health exchanges. But these changes are in the future, and Philadelphia must begin to act now to address the issue of high mortality rates. DVHC is supporting the National Healthy Mothers, Healthy Babies Coalition's text4baby campaign, working as part of a coalition assembled and led by the Maternity Care Coalition. Via free cell phone text messages timed to their due date or baby's date of birth, text4baby provides pregnant women and new moms the information to help care for their health and give their babies the best possible start. To help ensure that Philadelphia has enough physicians, midwives and other nurse practitioners to provide the full continuum of prenatal care, DVHC supports medical liability reform to improve the medical liability 68 6/15/10 - PUBLIC HEALTH - RES. 100260 environment of the State and especially here in the City. DVHC urges the State Legislature to evaluate all options for improving the medical liability environment, including using voluntary mediation to resolve medical liability issues and setting up health courts with special expertise in healthcare for hearing medical liability cases. We would ask for your assistance in that effort. Also to help ensure that hospitals are compensated fairly for obstetrical services and can continue to provide these services, DVHC supports the modernization of a Medical Assistant payment system, along with the Hospital Association of Pennsylvania. Today, the way hospitals are compensated for healthcare services provided to patients with Medical Assistance is based on a 20-year-old formula that no longer reflects the way that services are provided. The hospital community is 69 6/15/10 - PUBLIC HEALTH - RES. 100260 proposing a new payment system that would compensate providers more fairly and allow more doctors and hospitals to be able to afford providing obstetrical services. We ask you, Council, for your assistance in working with the State Legislature to support this Medical Assistance modernization, including ensuring adequate payment rates for obstetrical and neonatal services. In closing, DVHC is committed to being a partner in the City's efforts to address this important and critical issue and to working with the hospital community here in the region and across the State to enhance access to the entire continuum of obstetrical care. We must do all we can to ensure that the next generation of Philadelphians begin with a healthy start.
Thank you very much. I'm going to break the rule, because I want to ask you a couple of questions about the legislative effort in 70 6/15/10 - PUBLIC HEALTH - RES. 100260 Harrisburg. Who is leading the charge in Harrisburg on the issues that you talked about in changing some of the rules?
We're still working with legislative leadership, but Dwight Evans, Senator Scarnati, Senator Hughes and others all seem to be very supportive of our modernization initiatives.
Okay. Thank you. We will do what we can to be supportive of that effort. It's very important that the entire Philadelphia delegation understand and support your efforts. Have you gained that support of all of the legislators in Philadelphia?
Yes, ma'am. We're working with the Philadelphia 71 6/15/10 - PUBLIC HEALTH - RES. 100260 hospitals, including Einstein, who is represented here today, to assure that they are well aware of the importance of this, and to date, the feedback we've gotten has been very promising.
You talked about the liability insurance, and I've heard this before. Why is it so high for births, for delivery?
Well, as I understand it, one of the worst outcomes that could ever happen is to have a baby that was born with any kind of ailment, and occasionally that happens, and because of that and because of a lot of other mitigating factors, insurance rates are set very high for OB cases. Dr. Montgomery is here with us today and he might be able to give you a better opinion on that, but that's reflected not only here in Philadelphia and not only here in the State of Pennsylvania but around the country. Insurance rates for OB services are set 72 6/15/10 - PUBLIC HEALTH - RES. 100260 extremely high.
Thank you very much. We'll talk to the legislators in my district about this issue and just see where they are with it and what we might be able to do to help.
Thank you so much for coming back again. We appreciate your testimony. Dr. Montgomery.
Thank you for having the hearing, and good morning, Councilwoman. My name is Dr. Owen Montgomery. I'm the Chairman of the Department of Obstetrics and Gynecology at Drexel University College of Medicine. I'm also the Chairman of the District III of the American College of Obstetricians and Gynecologists, and that encompasses 73 6/15/10 - PUBLIC HEALTH - RES. 100260 Pennsylvania, New Jersey and Delaware. I'd like to thank you for bringing the complex issue of infant mortality in Philadelphia to the public's awareness through this resolution and this Council hearing. In my testimony I am representing the combined opinion of all six of the Chairmen of the remaining obstetrical programs in the City of Philadelphia. Every baby that dies is a tragedy, and as the providers of healthcare to the mothers and the infants of Philadelphia, we strive every day to provide the best care possible with the resources available to those few of us who are still providing obstetrical care. You've heard excellent testimony already from our Health Commissioner, and I would join you in applauding not only the compassion but the intellect and the hard work of our Commissioner that we have been working closely with for the last two years. 74 6/15/10 - PUBLIC HEALTH - RES. 100260 I don't think I need to reiterate the same statistics. You have it in my published testimony, but let me just point out a couple of the differences as also to echo my colleague who just commented about the reduction in obstetrical services.
Let me say that all of the testimony that has been presented to us, written, will be made part of the record in its entirety. So anyone who would like to summarize, know that their full testimony will be made part of the record.
And in interest of time and so as not to reiterate the same numbers that you've heard, I thought I would just go to a portion -- during the same decade where we have no longer seen an improvement -- as you heard the Health Commissioner say, there was dramatic improvement over the last several decades, but we've seen a stopping of that improvement over the 75 6/15/10 - PUBLIC HEALTH - RES. 100260 last decade. And during that last decade in Philadelphia, one of the unique things that's happened in Philadelphia compared to any other major city in the United States is that we've closed two-thirds of our obstetrical hospitals. And that's not the case in Washington and it's not the case in New York and it's not the case in Los Angeles. So if we look to other major cities in the United States with dramatically better infant mortality rates, and we aspire to be like them, one of the differences that we can see is that we are closing our obstetrical units and we're closing the obstetrical units in the poorest communities. One of the most recent ones we just closed was Northeastern Hospital, and that's in the part of North Philadelphia that we know has some of the poorest outcomes. And there are no obstetrical hospitals in South and Southwest Philadelphia. So I think that's one of the unique differences I think that we need to point 76 6/15/10 - PUBLIC HEALTH - RES. 100260 out. In fact, we're the only major city in the United States that even the Catholic church can't open and keep a maternity center open, and I think that's a real common thing you need to know. I believe that the events of the closure of the obstetrical units, the closing of the clinics associated with those obstetrical units and the trend in Philadelphia that we're no longer leading the United States in the kind of care and the outcomes, I think they're definitely related, and I would like to say that I think it's only the concerted effort of the healthcare community that you have representatives here, but the City government represented by yourself, the education and the commitment of all the citizens of Philadelphia that we're going to be able to change this trend in Philadelphia. We are fortunate in Philadelphia in that almost every pregnant woman has access to obstetrical 77 6/15/10 - PUBLIC HEALTH - RES. 100260 care either through the City or the federal health centers or the six remaining academic centers. There is no 5 significant financial or insurance barriers to care, but there are some delays, and sometimes at the overextended health centers, it might be four to six weeks before a woman who calls who is pregnant can get in to have care. And we know, and you've already heard documented, that late or no prenatal care dramatically increases the likelihood of preterm birth and infant mortality. One of the things that's different in Philadelphia is that looking at the trends -- and I think you have the data and the Health Commissioner has provided you with these statistics, and we certainly can get them if you would like -- is that one of the differences in Philadelphia is that the incidence of women not getting prenatal care in fact is getting worse and is higher than all the other cities listed in the document, 78 6/15/10 - PUBLIC HEALTH - RES. 100260 and, in fact, in all the other cities, the incidence of women getting prenatal care is getting better. So one of the disparities between Philadelphia and Los Angeles and New York and Chicago who have better rates than we do is that they are getting better at getting women into prenatal care sooner and we are getting worse. And what's one of the reasons that's happening?
Well, if you close the obstetrical hospital in the community that a woman can walk to, you've also closed the offices of the doctors who provide care and the midwives in that hospital, and, therefore, she now has to take a bus and sometimes two buses and maybe she has to take her children on the bus with her, and, therefore, you've put barriers to her getting care, and sometimes it's easier not to. And that's a very sad trend in Philadelphia, and that is something I think that we can address and something we can work on. Convenience of receiving 79 6/15/10 - PUBLIC HEALTH - RES. 100260 obstetrical care has been hampered by the closure of obstetrical units. And I 4 invite the City Council to put 5 resolutions in hearings on why it is that 6 Philadelphia is closing its obstetrical 7 units when we are unique in the United 8 States in that. 9 Fifteen percent of all the 10 women who deliver at a hospital, as 11 you've heard, now show up with having had 12 no contact with any provider at that 13 hospital, which means that all of her records and critical laboratories are unavailable. In fact, when she calls 9-1-1, she's actually taken to the closest unit, and that might not be the hospital that she had her care at. And maybe one of the things we could also look at is changing the rules of fire rescue that allow a woman to go to the hospital where she's had her care rather than simply the closest geographic hospital. In fact, if it were not for the 80 6/15/10 - PUBLIC HEALTH - RES. 100260 hospitals whose mission it is to train the doctors of the future, there would be no obstetrical services in the City at all. The remaining hospitals are all dedicated to education. Four of them are medical schools and two of them have independent residency programs. Any hospital that is not committed to education has closed its doors to pregnant women in the City of Philadelphia. In fact, most of the doctors who practice obstetrics have left Philadelphia and left private practice. There are only three obstetricians in the City of Philadelphia who still remain in private practice, and that's a 95 percent reduction in the physicians who practice obstetrics. It's as if all the small businesses in Philadelphia got up and left, and I think that's a critical difference between Philadelphia. In fact, Lloyd's of London is quoted in saying that Philadelphia is the single 81 6/15/10 - PUBLIC HEALTH - RES. 100260 worst city in the world to practice obstetrics because of the liability crisis in Philadelphia. We as the caregivers alone cannot correct the poverty that you've heard discussed. We cannot correct unplanned pregnancy or unfortunately non-compliance with recommended medical care. We cannot by ourselves correct obesity or the poor use of contraception. What's incredibly important to know is that there's a five times increased risk of preterm birth if the mom has significant medical problems. So as you've heard about the continuity of care, as the mom enters her pregnancy, if she is not healthy, the likelihood that she'll have a poor outcome is dramatically increased. We, as the obstetricians in Philadelphia, are committed to improving quality and patient safety in Philadelphia, and this was exemplified by the recent Quality Initiative Obstetrical 82 6/15/10 - PUBLIC HEALTH - RES. 100260 Conference that was held at Pennsylvania Hospital and co-sponsored by the Obstetrical Society of Philadelphia and the March of Dimes. And the transcript of that conference is available through the March of Dimes, and we'd be happy to make that available to the Council. Racial disparities in healthcare exist, and they exist partly due to genetic reasons for which we have not had sufficient scientific answers. But if 189 of the 286 deaths recorded in 2007 were in African American women and this is more than double that of their Caucasian sisters, this is something that we need to address.
And as an obstetrician, I think it's also important to point out that maternal mortality -- right now we're talking about infant deaths, but the absolute greatest tragedy in medicine is the loss of both mom and baby. And maternal mortality in the United States in African American women is four times as likely as their 83 6/15/10 - PUBLIC HEALTH - RES. 100260 Caucasian sisters. There may be some statistical aberrations in the way that we collect our data and we need to look at how we do statistics in order that we make sure we're comparing apples and apples with the Commonwealth and other states, and I think that's one of the things the Health Department is looking at and I think would be important for us to look at. For instance, the standardized birth and standardized death certificate, both in the State and in the City, would be a great help so that we make sure that what we're doing is documented and we can see progress. We, the Chairmen of the Philadelphia obstetrical programs, ask the City Council to support the Health Commissioner in declaring maternal and infant care in Philadelphia in crisis and empower him to work with the remaining obstetrical programs to ensure Philadelphia maintains adequate 84 6/15/10 - PUBLIC HEALTH - RES. 100260 healthcare providers and hospital obstetrical units. This includes innovative approaches and/or demonstration projects to improve quality and reduce medical liability to maintain the existing providers and the existing hospitals. We ask City Council to adequately fund and support the Health Commissioner's new City electronic health record and to build appropriate interfaces with the existing health system electronic medical records to ensure 24/7 access to critical obstetrical records for pregnant women needing care in the Philadelphia obstetrical units. I'd like to be able to tell you that we've now been able to demonstrate and will publish very soon that if you use an electronic record in Philadelphia, that we're able to have 100 percent availability of critical laboratories, such as hepatitis and HIV and group B 85 6/15/10 - PUBLIC HEALTH - RES. 100260 strep, and by having 100 percent availability, not only do we save dramatically in terms of costs by not having to repeat the laboratories but the babies are, therefore, spared the unnecessary treatment to prevent diseases for which they're not at risk, and this is in the savings of hundreds of thousands of dollars and unnecessary overtreatment of babies because we didn't have the correct laboratory. So we have that data, and it would save a lot of money but also, more importantly, would improve babies' care. We ask the City Council for increased health district staffing for access for appointments for women who are recently diagnosed as pregnant so they can have it on an immediate basis, without the delay when they're oversubscribed. We ask City Council for appropriate services and supplies at the health districts to care for all pregnant 86 6/15/10 - PUBLIC HEALTH - RES. 100260 women regardless of insurance and especially improve education and services for women who suffer with diabetes and obesity. Again, I'd like to thank you for caring and thank you for renewing the interest in the health of the women and the babies that we, as obstetricians, care for every day. Thank you very much.
Very interesting. Thank you very much for your testimony. Dr. Schwarz, the funding that we've provided for the Office of Technology, will that help address your electronic health records program? Is that part of their budget?
It's actually part of the Health Department budget and, in a minor way, part of the Office of Technology budget. So that it's in the capital budget, and by approving it in the capital budget, you approve the 87 6/15/10 - PUBLIC HEALTH - RES. 100260 dollars that we need over time to fund the electronic health record. Thank you.
Thank you very much. We appreciate having that information.
Dr. Schwarz, I have a follow-up on that same question. I want to say a huge thank-you to Dr. Montgomery for giving us the big picture, and it really just augments where Melita Jordan and Dr. Schwarz started. There's a much bigger issue here for us that we need to tackle as policymakers. So have all the barriers been removed, Dr. Schwarz, with regards to moving towards a standardized City electronic health record? Have all the barriers been removed to make that real? You've spoken to the capital funding of that.
We have funding 88 6/15/10 - PUBLIC HEALTH - RES. 100260 for an electronic health record in our health centers. What we don't have is yet funding for all of the linkages between City health centers, hospitals, other community-based health centers. But we are very hopeful that money that was put into the Recovery Act will actually help fund electronic health records in all of the federally qualified health centers, and ultimately federal dollars will help link us all together. There's something that was included called "meaningful use" in the federal criteria for receiving support going forward for Medicaid and Medicare, and it says meaningful use includes being able to link into a central registry. So we're very hopeful that if we can create a record of the caliber that the federal government requires for us to continue to receive federal funding, we have the money, which we think we do, to do that, we will ultimately be able to link our records to other records and create 89 6/15/10 - PUBLIC HEALTH - RES. 100260 something by 2014 that looks like an integrated health record in Philadelphia. So we're excited. The issue is to get us from here to there and to assure that we have, as Dr. Montgomery mentioned, access to shared laboratory information first, and I hope to expand beyond there so we figure out the operational pieces. We may have a record, but we have to figure out how to make it operational between the hospitals and the health centers as well.
Well, you answered my next question, because it was going to be, And so what's the long-term deadline. You're saying 2014?
2014. Well, 2013, 2014, depending on whether you're a hospital or a health center.
And you will lean on members of this Committee and professionals here to help you towards that end, where appropriate?
You have been 90 6/15/10 - PUBLIC HEALTH - RES. 100260 incredibly supportive and I think I salute your leadership on this, and the dollars from the hospital assessment that the City receives are being targeted in part toward the creation of that record, as well as dollars we expect to get from the State through Medicaid from Recovery to support that. So we've put that all together. That is in the budget that you approved, particularly the capital budget. So you've already been incredibly good partners in making that happen, and I thank you.
Let me follow up on a recommendation that Dr. Montgomery gave. He's asking City Council to support the Health Commissioner in declaring maternal and infant care in Philadelphia in crisis and empower him to work with the remaining obstetrical programs. How do we do that? What do you need from Council? 91 6/15/10 - PUBLIC HEALTH - RES. 100260
Well, I think my best answer is, as we identify issues, I've come to you and you've been supportive, and we'll continue to do that. So one of the things that I'm hopeful is that the meeting on the 29th of June will provide tangible, specific suggestions about this, and then we'll have conversations during the summer and we'll come back together in the fall. In addition, I have to say the Board of Health has substantial interest in this, and they're looking from a regulatory point of view and a reporting point of view under their authority how they can help. So we're trying to get all of the pieces in place to begin to do a concerted effort where everybody is moving in the same direction.
And let me ask one other question that was raised by Dr. Montgomery. Relative to our role in keeping the obstetric departments open, units open in the hospitals, I mean, what 92 6/15/10 - PUBLIC HEALTH - RES. 100260 is our responsibility? What can we do to prevent them from closing, other than advocating or talking to them? I mean, what else is available that you suggest?
The specific advocacy with colleagues at the State -- remember that the City's role in hospital operation is relatively limited. Other than inspecting their food services and their licenses inspections, things, the big issues that were raised as Mr. Braithwaite identified about advocacy for payment and relief around malpractice, those two issues are State controlled and are critical, and advocacy with the State to understand the need and I think to advocate for pilots in Philadelphia. If we can't do it statewide, we need to say Philadelphia has a crisis. We need the State to acknowledge that and figure out if differential payments, for instance, under Medicaid, higher payments under Medicaid around obstetric care make a 93 6/15/10 - PUBLIC HEALTH - RES. 100260 difference. Higher payments for prenatal care, more outreach services, as Melita Jordan said, focusing on this issue at all level of the State. Your concerted advocacy and conversation with the State, with your colleagues there, to educate them as we educate them is important. I think for the State Legislature to know that all of Philadelphia is speaking with one voice on this is very important.
Okay. Thank you very much. Thank you, Dr. Montgomery. I appreciate your testimony. Next --
The Chair 94 6/15/10 - PUBLIC HEALTH - RES. 100260 recognizes Councilman Jones.
Thank you for the courtesy of allowing me to speak. I am not on your committee, Madam Chair, but I have admired your work in this regard in conjunction with the Committee, but also Councilwoman Brown, who understands clearly that a lot of these issues are interrelated. Whether we're talking about nutrition or whether we're talking about healthcare access, there is a correlation between some of these issues and the food deserts and the other issues that are faced. My question, I understood that there was a study that showed municipalities, areas, urban centers and compared them both on the income ethnic side of it, and there was no determining factor that they could identify, even with food and this and that, that caused this statistical anomaly, but one factor that keeps popping up is an overall stress level that people in urban areas 95 6/15/10 - PUBLIC HEALTH - RES. 100260 live under that helps them to de-prioritize healthcare. So if you're worried about your gas being shut off, you don't make the appointment to the doctor, the prenatal presence. And that the only thing that they could come up with is that the overall stress level in the areas that they found this anomaly was extremely high, even higher than some war zone statistical anomalies about infant mortality in places like Iraq, in places like Afghanistan. Has anybody looked at that as a common factor as to why this anomaly exists in the inner City of Philadelphia?
You're referring to some work done out of Chicago and Philadelphia. There's a Dr. Jetty Culhane who worked at Drexel and University of Pennsylvania who did some of this work. The antecedents of prematurity are -- I'm Dr. Jay Greenspan, by the way. I'm coming up. 96 6/15/10 - PUBLIC HEALTH - RES. 100260 But many of the antecedents for prematurity have been discussed already. So it's education, it's poverty and it's stress. Other things include, less dramatic perhaps, but dental work and other things that have been discussed, but stress is what you're talking about. And it's true that the stress that's been discussed is multi-factorial and it's not just, I'm stressed today because I have to go to work, it's early in the morning. It's the stress of poverty and discrimination. It's the stress of being close to violence. So a study was done, a subset of the studies you're talking about was done where they looked at the likelihood of delivering prematurely if you've been within 500 feet of a recent gunshot-related death, and that was astronomically high. So that sort of fear for your life will cause what is believed is a reaction in you that will induce preterm labor. 97 6/15/10 - PUBLIC HEALTH - RES. 100260 Other segments of the studies talk about other forms of stress. So if you have had five -- this particular study by Dr. Culhane showed that if you had four or more births and you live in the City of Philadelphia and you are single and you're uneducated and you're African American, that you have somewhere around a 50 percent chance of being homeless in the next five years. And so the stress of not knowing where your next bed is or your next food source is is all -- it's all-encompassing in terms of the stress level that obviously creates an environment that is very -- is a very strong antecedent to preterm birth. So the stress we know causes a womb environment that is not conducive to a healthy term delivery.
It is phenomenal and shocking to understand that our stress levels in the inner City of Philadelphia can be higher than in a war zone. 98 6/15/10 - PUBLIC HEALTH - RES. 100260 I mean, we really in addressing this, Madam Chair, have to look at all of the relating factors and kind of treat it in a way -- I mean, it's a massive problem. But when I read or was given access to this information, it struck me in my heart. I mean, how do we, in a nation as great as ours, justify this level of infant mortality? I cannot understand it. I thank you for answering the question. I was actually trying to address it to Dr. Schwarz, but please believe -- no, no. 16 I just wanted to on the record, Madam Chair, say that I will never ever, ever again in public cite the fact that I don't have a public health center in my district. I won't do that anymore, because the health center that is federally funded in Haddington helped my daughter bring into the world my granddaughter. So you get a pass from now on. I will get my colleague, Wilson 99 6/15/10 - PUBLIC HEALTH - RES. 100260 Goode, to raise the issue that I don't have a health district in the 4th District, but I will never raise that again. And I want to thank them for the service that was delivered to my child that made my granddaughter come here healthy, and the University of Penn in particular, who did the actual delivery. It says that although we have some challenges before us, that we do have the infrastructure to deliver the best healthcare in the world. We just have to get some of the barriers out of the way and do what we need to do. Thank you, Madam Chair.
Thank you very much. We're going to proceed with the testimony so everybody can go on record, and then we'll continue with the questions, but as you testify, you raise the issues that we have to ask at that time. I just want to ask Dr. Braithwaite if he would give us some information as 100 6/15/10 - PUBLIC HEALTH - RES. 100260 to what we should be asking our legislators for, as well as any -- you don't have to do that today, but if you will send us something in writing. If you've introduced any legislation in Harrisburg, we need to know the number of the bill. If not, just what are some of the issues we should raise with our legislators, and then work with them to see what we can do to develop a strategy to move the process along in Harrisburg. They work with the budget so long, by the time they finish with the budget, it's time to do the budget again. So we have to make sure that this gets on their agenda. And we appreciate it. And so many of us in this room have connections with our State Senators and our State Representatives in Harrisburg that we can begin that open dialogue. Thank you. Next. Who is next?
Good morning. My name is Kevin Dysart. I'm a 101 6/15/10 - PUBLIC HEALTH - RES. 100260 neonatologist at Thomas Jefferson University Hospital. I thank you for the opportunity to address you regarding the complex medical challenge that is infant mortality. As has been mentioned, infant mortality is a public health measure really of all infants born alive but who fail to survive to their first birthday. Infant mortality is an important reflection of health of a community and is impacted by social and economic conditions and healthcare delivery, as we've already heard, in any given geographic area. Infant deaths are classified either as in the neonatal period -- that's from birth to 28 days of life -- or death in the postneonatal period, those deaths that occur between 29 days and 365 days of life. Premature birth is the leading cause of death in the first month of life for infants of all races and the leading cause of death in the 102 6/15/10 - PUBLIC HEALTH - RES. 100260 first year of life for African American infants. Birth weight and gestational age at time of delivery are the two most important predictors of an infant's health and survival. Infants born too small or too soon have a much greater risk of death than infants born at term, which is 37 to 40 weeks, and much greater risk of death in infants who are born with birth weights greater than 2,500 grams. Because of their much greater risk of death, infants born preterm at the lowest birth weights and at the shortest gestational ages have a large impact on overall rates of infant mortality. For example, infants born weighing less than 1,000 grams account for less than one percent of all births, but they account for nearly one-half of all infant deaths in the United States. Conversely, almost 92 percent of infants born in the United States in 2008 weighed 103 6/15/10 - PUBLIC HEALTH - RES. 100260 more than 2,500 grams, but these infants accounted for less than one-third of the infant deaths. Most premature babies require a newborn intensive care unit, which is specialized medical staff and equipment that can deal with the multiple problems faced by premature infants. While we neonatologists have become very effective at caring for babies born preterm, reducing our rates of infant mortality will require a comprehensive agenda to identify, test and implement effective strategies for the prevention of preterm birth rather than the treating of preterm infants. One such strategy that we're piloting with the March of Dimes is an educational intervention to reduce repeat preterm birth among mothers whose preterm newborn is being cared for in a neonatal intensive care unit at Jefferson. Women who have delivered a baby preterm are at a much higher risk of delivering a subsequent preterm birth. So we are 104 6/15/10 - PUBLIC HEALTH - RES. 100260 focusing on educating these new moms about their increased risk of preterm birth and encouraging them to obtain pre-conceptual care before they become pregnant again. Understanding the factors that impact preterm birth and accompanying infant mortality, developing programs to reduce these risks, and providing the specialized care that women need will help us to address the many complex issues related to infant mortality. In closing, may I say that the March of Dimes supports the recommendations of our obstetric leadership presented this morning by Dr. Montgomery. We encourage the Council to coordinate public and private resources to improve the services to pregnant women throughout the City. Thanks.
Thank you very much. We appreciate it. Councilman Kenney. 105 6/15/10 - PUBLIC HEALTH - RES. 100260
Thank you. Thank you, Doctor, for your testimony. What kind of partnerships are institutions like yours entering into with healthcare insurance companies? It would seem to me that it would be in their financial interest to prevent the costs associated with treating an intensive care child than it would be providing resources for this kind of preventive programming. Is there an actual connection between IBC, for example, or Aetna or any of those companies to help promote this kind of education?
I think actually the greatest example I work with day in and day out is probably a relationship with kind of a case management company that works as an outsourcing agent named Alere. So basically what this company does is, they go to large insurance companies like IBC and says to IBC the problem of infant mortality and preterm 106 6/15/10 - PUBLIC HEALTH - RES. 100260 birth as in absolute dollars, probably fairly small actually, compared on a global perspective because of the relative low numbers of preterm babies compared to 55-year-old men with hypertension who have heart attacks.
But aren't NICU children generally -- I mean, is there an average cost for a NICU child?
Yeah. So then the paradox is that on a per-patient basis, they're among the most expensive that we deal with. And so this company deals -- kind of is a fourth party that helps those insurers manage. And we actually, Dr. Greenspan and I both, Dr. Greenspan first, work with them to do research to kind of understand neonatal health outcomes, because they maintain a massive amount of data. And they help us actually. They bring education materials into the newborn setting, at a newborn care setting.
So you're 107 6/15/10 - PUBLIC HEALTH - RES. 100260 saying the actuarial analysis doesn't show that that's a large cost in the scheme of their overall membership?
Dr. Greenspan. It's a great question, and March of Dimes has worked with particularly the Medical Assistance programs, the Keystone Mercy Health Partners and others, but it is interesting to me why there's not more interest from the major payers in terms of prevention of prematurity or preventing, once the preterm birth has occurred, further complications. Getting these people together has been a challenge, at least for us locally at Jefferson and in the individual hospitals, and perhaps one of 108 6/15/10 - PUBLIC HEALTH - RES. 100260 the things we could be talking about is how to get them at the table with us to deal with this problem, because it is fiscally beneficial for them.
I've been on the IBC Board for about years, and 8 what I would like to do, if possible, is 9 to make some inquiries with our chief 10 executives to see whether or not we can 11 do some kind of analysis or collaboration 12 or something, or maybe they're just, from 13 an insurance company perspective, they're 14 looking at it from a different side than 15 you guys are looking at it on the ground. 16 So, I mean, it may be an interesting 17 exercise to see if there's something 18 there to help contribute to the resources needed for the prevention side. So I'll get a hold of you through the Chair and maybe we can make some contact.
Okay. Because you're right, from the ground up -- someone's covering the intensive care unit today so we can be here, but I know 109 6/15/10 - PUBLIC HEALTH - RES. 100260 there's multiple babies I left this morning whose cost per patient will exceed sums of money that are -- would be deemed exorbitant.
But the prevention of one could provide the resources to prevent ten more?
Thank you very much. I see Letty Thall shaking her head. She seems so grateful, Councilman. Thank you. Dr. Greenspan.
Sorry. Yes. Good morning. My name is Dr. Jay Greenspan. I. duPont Hospital for Children in Wilmington. I'm also a neonatologist. Thank you very much for hosting this hearing on infant 110 6/15/10 - PUBLIC HEALTH - RES. 100260 mortality. Allow me to build on some of the background provided by my colleagues on the link between preterm birth and pediatric morbidity and mortality. So to be clear, from our perspective, it's not just enough to save a life. You want to have the life be of good quality for many reasons, and reducing infant death and disability does require -- does not require revamping of the treatment of the medical care given to the preterm infant. So one of the things we don't need really is better intensive care nurseries. We have -- Philadelphia's fortunate to have many high-quality intensive care nurseries for the care of these infants. Once born, the outcome of an infant in Philadelphia is superior to infants born with similar risks anywhere in the world. Reducing infant mortality depends on delivering healthy full-term babies and begins long before conception with women maintaining a healthy 111 6/15/10 - PUBLIC HEALTH - RES. 100260 life-style, as has been discussed, reducing stress and accessing regular medical healthcare, as Dr. Montgomery suggested strongly. Once pregnant, women need early and regular prenatal care, effective and timely treatment of medical complications during pregnancy. The ideal result, of course, is a term infant without all the unnecessary interventions for the delivery of this healthy infant, who is then placed in a family which is a loving home with adequate resources. Reducing infant mortality requires a healthy and positive environment that supports the physical and emotional needs of the family, and that is not the experience that many of the women and moms in Philadelphia face, where one in seven babies are born prematurely and may go home to a household of poverty and dismal social support. The lack of social support for women of low socioeconomic status leads 112 6/15/10 - PUBLIC HEALTH - RES. 100260 to adverse maternal behaviors and risks to the entire family and future children. So women in this stressful environment will tend to have both adverse behaviors and get pregnant quickly again. Once a preterm infant is born, this new family member is then incorporated into this mother's fragile home environment and parenting becomes an incredible challenge. As you know, parenting of a healthy child in a good environment can be a challenge, but women with limited means in Philadelphia who are parenting a sick preterm infant with many associated complications are at extreme risk. Our pediatric units are filled with the results of failure to prevent preterm birth, and the legacy of the associated costs and risks will continue for generations. So these preterm birth babies, if they survive, can be sick, can be readmitted many times over, causing stress for the family and economic 113 6/15/10 - PUBLIC HEALTH - RES. 100260 hardship. Preventing further escalations of the complications of prematurity requires a medical home and the necessary time and expertise to coax a parent through the challenging process of nurturing their infant. Pediatricians and primary-care physicians are not given the time and resources needed to assist these families. And this comes back to some of the issues that Councilman Kenney was talking about. We have found that in our practice at Jefferson, a special babies practice, for instance, which specializes in the care of former preterm infants, we can effectively assist families and optimize the growth and development of these fragile infants by reducing rehospitalization and medical risk. Yet, support for such programs is lacking. The payment is similar to regular healthy kids. Premature babies face an increased risk of chronic disability, 114 6/15/10 - PUBLIC HEALTH - RES.
100260 such as mental retardation, learning and behavioral problems, cerebral palsy, lung problems, vision and hearing loss. Two recent studies also suggest that preterm babies may be at increased risk for autism, and studies also suggest that babies born very prematurely may be at increased risk for certain health problems, such as diabetes, high blood pressure and heart disease. So the legacy of complications continue once preterm birth is not prevented. So this is a complex problem with significant economic and social ramifications, along with a cycle of recurrence and further risk and expense. Yet, the concepts of care that we are discussing here are really quite simple. One, we want to prevent preterm birth by supporting all women of child-bearing age with adequate care and social medical resources. Two, we want to prevent preterm birth delivered by targeting these very 115 6/15/10 - PUBLIC HEALTH - RES. 100260 high-risk moms, especially those ones with a previous preterm birth, with interventions that may reduce the risk of a subsequent preterm birth or womb attack. So the March of Dimes talks about a womb attack similar to what we would know as a heart attack. So if we were at our age to have a heart attack, God forbid, we would go in and the physicians and care team would prevent future heart attacks by doing things like blood pressure control, weight control, exercise, lowering your cholesterol, dietary interventions, et cetera. The womb has a similar risk factor. So high blood pressure, diabetes, poor nutrition, all the things that have been discussed, have been shown to increase preterm birth. So we at the March of Dimes, we call this a womb attack, and you'd want to prevent the next womb attack, once you've had one especially. So one of the interventions 116 6/15/10 - PUBLIC HEALTH - RES. 100260 would be to suggest that these women at high risk be counseled and coached and helped to prevent a further womb attack, which is some of the work we're doing with the March of Dimes. We certainly could use more support ongoing. And No. 3, we want to optimize the outcomes of preterm births and preterm babies by supporting evidence-based programs and the medical home to reduce the complications and enhance and optimize their growth and development. So prevention of this problem and its complication is much more effective and less expensive than the treatment of the ramifications. Thank you very much for your time.
Thank you very much for your testimony. Councilwoman Brown has one question.
To all of the professionals that have spoken, this 117 6/15/10 - PUBLIC HEALTH - RES. 100260 is really what my daughter would call off-the-wall, another-planet idea, but if we're looking to innovative ways to address the reality you painted for us, Dr. Montgomery, then I believe we should be open to any weird idea. Can you imagine obstetric type of services being provided in Keystone STAR child care centers where you have a professional that's linked or tied with one of our six remaining hospitals, but they are tritched (ph) in the neighborhoods at the ground floor where you have children coming anyhow and you have instances where you have siblings coming? Is that feasible? Of course, we have to look at child care regulations, what the State requires in terms of a space devoted to that service to infants, but is that even conceivable? Just a gut reaction.
You have 118 6/15/10 - PUBLIC HEALTH - RES. 100260 to come to the table and testify. (Witness approached witness table.)
You have to state your name for the record so we know who is talking.
Melita Jordan, Pennsylvania Department of Health. In answer to your question, Councilwoman, the answer to that is yes. Many of you may know that President Obama just released the home visiting grant, had just became available to every state, and Pennsylvania will be applying for that. And, again, the home visiting program or evidence-based programs, it will be addressing how we can provide and do linkages with medical homes, with the obstetrical community, with the child advocacy community. It will span all areas of providing maternal/child health services in the Commonwealth, but specifically also Philadelphia will be a part of that. And so Keystone STARS will 119 6/15/10 - PUBLIC HEALTH - RES. 100260 be probably one of the areas. When you look at the nurse partnership -- Nurse-Family Partnership program that has already been implemented in the State of Pennsylvania that addresses those particular issues that you just named, but we will also be expanding some promising practices, as well as looking at other evidence-based home visiting programs to address that. So, yes. And there are a number of medical homes also here in the City of Philadelphia as well as across the State that is funded to support that kind of coordination that Dr. Montgomery and Dr. Greenspan have spoken of.
Thank you, Councilwoman. Owen Montgomery, Chair of Drexel. First of all, the obstetrical provider community is absolutely 120 6/15/10 - PUBLIC HEALTH - RES. 100260 interested in any idea. No idea is off the wall if it gets us to where we need to go. We collaborate with providers, not just physician providers, of course, but nurse practitioners and nurse midwives, who actually serve the Philadelphia extraordinarily well by actually be the front-line care in our health districts as well. And one of the reasons I wanted to make sure I answered the question was that, any place that we can see pregnant women in an environment that they'll get to in their community, that they don't have to take two buses because we've closed the local center, would be a great idea. We could send healthcare providers to the community, to the medical home, to the local health center. Wouldn't this be a wonderful reason to have that City electronic health record that the nurse midwife takes with her so that when she does the visit, it's incorporated back into the City health record? And we actually, in 121 6/15/10 - PUBLIC HEALTH - RES. 100260 working with the Health Commissioner, are able to take a wireless electronic medical record to every health district in the City of Philadelphia. We just need to make sure that we continue to fund the Health Commissioner so we can make sure they talk to each other.
So if we're going to distribute the healthcare, we need to make sure we connect it back.
Access to the records as well. Very helpful. Thank you. Thank you, Madam Chair.
Thank you very much. I'd just like to add a personal note here, and I probably should not, but I have to say to Thomas Jefferson, about years ago we had the need for one of 23 your intensive care nurseries of my granddaughter, who was born 2 pounds, 14 ounces, but who is now fighting obesity. 122 6/15/10 - PUBLIC HEALTH - RES. 100260 So she turned out to be quite a healthy young lady, and we're fighting with her with her weight. Strong and healthy. Next we have two ladies. Who is going first?
I'll go first. Good afternoon, Councilwoman Tasco and Councilwoman Reynolds Brown.
Excuse me. If you doctors have to leave, we appreciate your testimony, but please feel free to stay, because we may have other questions or something may come up. But for those of you who have testified and have to leave, we certainly appreciate your being here, and I thank you for waiting. Go ahead, please. You've been here before.
I've met you before, yes. Good morning -- or good afternoon, I think it is now. I'm Dr. Monique Fountain Hanna of the Health 123 6/15/10 - PUBLIC HEALTH - RES. 100260 Resource Services Administration, also known as HRSA. I'm with the Philadelphia Office of Regional Operations where I sit as the Regional Medical Consultant and Maternal and Child Health Liaison. I'd like to thank you for the opportunity to testify today about HRSA's ongoing commitment to reducing and eliminating disparities in the nation's infant mortality rates. S. Department of Health and Human Services, is the principal federal agency charged with increasing access to basic healthcare for those who are medically underserved. HRSA's mission is to provide the national leadership, program resources and services needed to improve access to culturally competent, quality healthcare for the uninsured, underserved, vulnerable and special-needs population. Currently in the United States each year, approximately four million 124 6/15/10 - PUBLIC HEALTH - RES. 100260 women become pregnant. While most women have a safe pregnancy and deliver a healthy infant, that is not the experience for all women. Major and persistent racial and ethnic disparities continue to exist. Emergent research indicates that environment, biological and behavioral stressors occurring over the lifespan of the mother from her earliest life experiences until she delivers her own child may account for a significant portion of these disparities. And I think we've heard that sort of echoed over and over again today. It may take specific interventions consistently provided to several generations before the factors responsible for the disparities have been overcome. Since 1912, HRSA programs have provided a foundation and structure for assuring the health of mothers and children. The Maternal and Child Health Bureau, or MCHB otherwise known, is 125 6/15/10 - PUBLIC HEALTH - RES. 100260 charged with promoting and improving the health of our nation's mothers and children. Under Title V of the Social Security Act, Maternal and Child Health Bureau administers the Maternal and Child Health Block Grant. I think you heard Melita Jordan and the Commissioner also refer to these. As it relates to programs and specific services to mothers and infants, the Title V block grant seeks to assure access to quality care, especially for those with low incomes or limited availability of care. We also seek to reduce infant mortality; provide and ensure access to comprehensive prenatal and postnatal care to women, especially those low-income and at-risk pregnant women; provide toll-free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Medicaid. The Title V block grant program 126 6/15/10 - PUBLIC HEALTH - RES. 100260 provides support to all 59 states and jurisdictions. In Fiscal Year 2010, the block grant appropriated over $660 million under the formula grant program and other related programs. Pennsylvania received more than million of those 8 dollars. 9 HRSA's Maternal and Child 10 Health Bureau also administers the 11 National Healthy Start Program since 12 1990, which you heard also referred to 13 earlier. Healthy Start is a 14 community-based program targeted to 15 eliminating racial and ethnic disparities 16 in birth outcomes in high-risk 17 communities. The goals of Healthy Start 18 are to improve the quality of local 19 perinatal systems of care, to enhance the 20 cultural competence of providers who work 21 within that system, and to improve 22 women's access to the system of care. 23 These objectives are accomplished through 24 outreach, health education, case management and enhanced community 127 6/15/10 - PUBLIC HEALTH - RES. 100260 collaboration. In Fiscal Year 2010, the State of Pennsylvania was the recipient of seven of the 100 Healthy Start grants nationally, for a total of $8 million in total grant funding.
More funding, as you heard also earlier from Melita Jordan, more funding will be coming to the states in the near future, thanks to the recent enactment of the Patient Protection and Affordable Care Act. 5 billion over five years for a state-based early childhood home visitation program for children and families who reside in at-risk communities. In conclusion, as the nation's health access agency, HRSA and the Maternal and Child Health Bureau envision optimal care for all, including mothers and infants. We remain committed to exploring the emerging science on gene-environment interactions and 128 6/15/10 - PUBLIC HEALTH - RES. 100260 continuing to provide the national leadership the necessary resources and services to promote the complete elimination of disparities that exist within the infant mortality rates in this country. Because of clearance issues, I will not be able to take questions today, but I'd like to thank you for the opportunity to share. And I provided a full testimony. I just gave you mine in brief.
So I can't ask you one question? Is that $1.5 billion for the country?
For the country. That's all. Thank you. We'll ask Ms. Jordan how much we're going to get in Pennsylvania. We'll wait until -- we'll come back. Go ahead, ma'am. Dr. Edmonds.
Good afternoon. Thank you for the opportunity to testify. 129 6/15/10 - PUBLIC HEALTH - RES. 100260 My name is Brownsyne Tucker Edmonds. I'm an obstetrician/gynecologist and a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania. In addition to my medical training, I'm trained in public health and public policy, and my research centers around improving healthcare delivery and eliminating health disparities in maternal and child health. My goal today is to reframe the discussion about infant mortality. My message for you is that if we as a medical and public health community are truly invested in having healthier babies, we have to invest in healthier moms. That investment should start before a woman becomes pregnant, and Medicaid can play a critical role in moving toward achieving this goal. You've already heard a great deal about the crisis we face as a city and state with regards to infant mortality. Too many babies are dying. 130 6/15/10 - PUBLIC HEALTH - RES. 100260 Too many are born too early. Too many are born too small. As horrible as those outcomes are and as important as it is to keep babies alive and well, infant deaths only tell the very last part of the story. The real opportunities to change the outcomes actually happen long before the baby's even born. So as you heard about sort of the life course perspective, we should look to where the story begins. We should shift our focus to mom. Consider the following illnesses in mothers that increase the risk of preterm labor, low birth weight and infant mortality. Moms with high blood pressure before pregnancy are six and a half times as likely to deliver a very low birth weight infant. And those are babies born weighing less than 1,500 grams, which grams are hard for people, so I'd say it's a little over three pounds. Obese moms, particularly African American moms, are more than twice as 131 6/15/10 - PUBLIC HEALTH - RES. 100260 likely to have babies who die in the first month of life. And moms who have diabetes before pregnancy are more than eight times as likely to have a premature delivery as non-diabetic moms. If their blood sugars are not well controlled, they have much higher rates of miscarriage and birth defects, and their perinatal mortality rate -- that means the chance that their babies will die in the womb as a stillbirth or within the first seven days of life -- is tripled. We know that there are many other risk factors for delivering babies born too early or too small. Some we've already heard about today. Some of these behaviors are behaviors that moms can change, like smoking or substance abuse, and some are illnesses that can be treated, like depression or gum disease. But all of these are conditions that can be identified before a woman is pregnant so that she can receive counseling or treatment from the beginning of her 132 6/15/10 - PUBLIC HEALTH - RES. 100260 pregnancy to help her have the best chance of having a healthy pregnancy. Unfortunately, many low-income and minority women enter prenatal care having never been diagnosed with or treated for these conditions, because they do not have access to healthcare before they get pregnant. So how does Medicaid sort of make this problem or contribute to this problem? Since the 1980s, states have been required to provide Medicaid coverage for pregnant women with incomes less than or equal to 133 percent of the federal poverty level. What does that mean? Today that's a monthly income of about $2,000 for a family of three. They are guaranteed full coverage during pregnancy, delivery and up to 60 days after delivery. But in almost all states, after those 60 days are up, women lose their pregnancy Medicaid coverage. And after that, you have to be much poorer to actually qualify for full 133 6/15/10 - PUBLIC HEALTH - RES. 100260 Medicaid coverage as a non-pregnant mother of dependent children.
For example, in Pennsylvania, non-pregnant mothers only qualify for full Medicaid benefits if their income is 34 percent of the federal poverty line, and that amounts to about $520 a month or $6,200 a year for a family of three. So what does this mean for me and my patients? It means that I see a patient who's never had regular care from a physician and I discover that she has thyroid disease at her first prenatal visit. And she can see the thyroid specialist while she's pregnant, but doesn't necessarily have coverage after pregnancy to continue care. Or more typically I'll see a patient with undiagnosed high blood pressure who needs a primary-care physician to adjust her medications after her six-week post-delivery visit, but the first available appointment may not be for three months in the community health 134 6/15/10 - PUBLIC HEALTH - RES. 100260 center, and by the time three months have passed, she may have forgotten or missed the appointment. And I wish I were describing sort of the occasional patient that I care for, but in previous studies, an average of one million people lost Medicaid benefits every month, and 65 percent of them became uninsured during those lapses. So you can see how the current eligibility policies can lead to long periods where women may lack insurance before and between pregnancies and are unable to receive ongoing care for illnesses or even preventive care until they become pregnant again. Unfortunately, by then it may be too late. Studies have shown that low-income women who don't have Medicaid coverage before they get pregnant are less likely to start prenatal care in their first trimester. Therefore, by the time these mothers enter prenatal care, the developing baby may have already been 135 6/15/10 - PUBLIC HEALTH - RES. 100260 exposed to very high levels of blood sugar or harmful medications. So when women are lost to follow up or fall between the cracks in the system, we miss opportunities for prevention and for early intervention to improve their pregnancy outcomes. What can be done between and before pregnancy to prevent future pregnancy complications? People have spoken about preconception and interconception care in passing, but preconception care is the care given before pregnancy and interconception care, or care given between pregnancies, can help to prevent and manage medical, behavioral and social risks to future pregnancies. The care can include risk assessments for poor nutrition, depression and stress. It can also include smoking cessation, substance abuse treatment, genetic testing or disease management. However, there are two important challenges to providing 136 6/15/10 - PUBLIC HEALTH - RES. 100260 preconception care. One, identifying every potential mom before she gets pregnant. It's hard to do when everyone is not connected to the healthcare system. And, two, half of the pregnancies in this country are unintended. So women are unlikely to go and get checked out if they aren't planning to become pregnant, and that's certainly also difficult if they're uninsured. But we should certainly be able to identify patients who are at risk once they've already had a baby and then connect them to a doctor and a support network to ensure they don't get lost in the system. This type of interconception care would be beneficial for all women, but it's particularly important for high-risk women, those with pre-existing conditions, multiple risk factors for bad pregnancy outcomes and a previous history of a poor pregnancy outcome. So how could Medicaid make the 137 6/15/10 - PUBLIC HEALTH - RES. 100260 problem better? Medicaid is uniquely positioned to make interconception care available for low-income, minority and at-risk moms, because it is already providing them care when they are pregnant. Medicaid covers more pregnancy-related care than any other insurer in the nation.
It pays for 31 percent of all the deliveries in Pennsylvania, and as of 2007, three out of ten of the State's low-income women were enrolled in the program. Because low-income women are at higher risk for diabetes, high blood pressure, obesity, depression, smoking, all of the things that we've been discussing today, then mothers receiving Medicaid are more likely to have illnesses that increase their risk for poor pregnancy outcomes. Therefore, from a risk standpoint, Medicaid is an obvious area to focus policy recommendations to address the gaps in coverage for care for women before and between pregnancies. 138 6/15/10 - PUBLIC HEALTH - RES. 100260 In response to these issues outlined above, I would recommend the following actions be taken at the State and local level: With health reform on the horizon and expansions in Medicaid proposed, the City should advocate for the following long-term strategies to increase access to interconception care and improve pregnancy outcomes. One, we could expend the duration of Medicaid's postpartum benefits to high-risk populations. Two, we could increase Medicaid income requirements for non-pregnant mothers of dependent children. Three, we could cover at least interconception services or at least one interconception visit beyond the traditional six-week postpartum visit within that first year after delivery, particularly in high-risk Medicaid recipients. And there's been mention of sort of the medical home, and there may be opportunities there to sort of 139 6/15/10 - PUBLIC HEALTH - RES. 100260 coordinate care for mom with sort of -- with the established sort of pediatric visitation schedule and address things like birth spacing or reinforcing breastfeeding and monitoring for development of diabetes or hypertension. More immediately, though, at the State level, the City could also advocate for required reimbursement for interconception services, like substance abuse treatment or smoking cessation, nutritional counseling. At the local level, in order to improve continuity and coordination of care, obstetricians and primary-care providers in the City health centers and federally qualified health centers could come together to develop plans to coordinate and prioritize postpartum follow-up visits for primary or specialty-care providers for women who have been identified with chronic illnesses or high-risk conditions during pregnancy. And, lastly, the City can 140 6/15/10 - PUBLIC HEALTH - RES. 100260 expand efforts to partner with these home visitation programs and other community-based organizations that support postpartum women in order to conduct more interconception risk assessments and to ensure that new moms are attending their postpartum visits and follow-up -- scheduled follow-up. These recommendations will require significant investments. 8 billion each year hospitalizing preterm and premature infants. So in my mind, the investment in healthy mothers could be well worthwhile if we have healthier infants and children to show for it in the future. This concludes my comments. Thank you for your time.
Well, thank you very much for your testimony, and I know Dr. Hanna can't say anything, but certainly this testimony brings home some interesting challenges -- not 141 6/15/10 - PUBLIC HEALTH - RES. 100260 challenges. Well, yeah, challenges to the Medicaid system, so maybe you could take that information back to the department to show how the connection and some of her testimony talks about the continuum of the health coverage for these women would help down the road with future pregnancies. So it would be helpful if you could help us. Thank you.
Thank you very much. Thank you so much for your testimony. Quite informative. Thank you. Thank you, Dr. Montgomery. We appreciate your testimony, too. It's been very informative. Now we're going to have Panel 3, and while they're coming forward, we're going to take about a three-minute break. Vijaya Hogan, Natalie Levkovich, 142 6/15/10 - PUBLIC HEALTH - RES. 100260 Eileen Tyrala, Letty Thall and Rorng Sorn. (Short recess.) (Witnesses approached witness table.)
Thank you very much for coming in to testify. We'll now resume the hearing. Would you identify yourself for the record, please.
Yes. My name is Vijaya Hogan. I'm Clinical Associate Professor in the Department of Maternal and Child Health at the University of North Carolina at Chapel Hill.
Thank you. Well, Madam Chairwoman, member of the Committee, thank you for this opportunity to testify for this resolution. I submitted my full testimony. I'll give you the abbreviated version to stay within the time limit, but there's more 143 6/15/10 - PUBLIC HEALTH - RES. 100260 information that I hope you do refer to. Now, the elimination of health inequities in infant mortality appears to be impervious to our best efforts because they're caused by more complex factors than those we currently address. Successfully reducing infant mortality and eliminating disparities requires a re-conceptualization of the underlying causes and contributors, as well as a re-conceptualization of our approach. The good news is that the public health community has a more accurate conception of the causes of health disparities, and I submit Exhibit A that's in the full packet for you to refer to. It would be a mistake to fall back on more of the same solutions that currently fail to address the root problems. It's now time to translate these updated frameworks and knowledge into concrete approaches towards infant mortality reduction and disparity elimination. So I'll quickly summarize the 144 6/15/10 - PUBLIC HEALTH - RES. 100260 major challenges we face in reducing infant mortality and eliminating disparities. First, we don't have an evidence base for addressing the root causes of infant mortality, and even less so for the disparity. However, we do know enough to begin to put into place reasonable actions that promise to lead to improved outcomes. The evidence base gets developed from that point forward. Second, our current approach of relying solely on prenatal care is not effective at eliminating the underlying causes of infant mortality. The pathways leading to the causes of infant mortality unfortunately begin before the pregnancy, thus we need to provide women's preventative care to ensure that the population of women of child-bearing years is the healthiest possible before they get pregnant. And I'd also submit that prenatal care disproportionately advantages white women because it 145 6/15/10 - PUBLIC HEALTH - RES. 100260 addresses the contributors that are specific to that population. Women's preventative health or care before pregnancy advantages black women more so than prenatal care does. But that leads to the third point, which is that healthcare, no 9 matter when it occurs, consists largely of medical monitoring and health education focused on promoting behavioral change. The underlying assumption is that all we need to do is prescribe or provide information and then people will be able to go home to their communities and their homes and just do the healthy thing. The fact is that people's ability to practice healthy behaviors is defined by the context in which we live. If we continue to emphasize individual behavior, we need to ensure that the neighborhood and community environments support health and healthy behavior as the default option. Neighborhoods determine whether it's safe or feasible 146 6/15/10 - PUBLIC HEALTH - RES. 100260 to exercise. Earning a living wage determines whether a woman can afford the tools of health, et cetera and et cetera. Further, it's not just the medical providers' responsibility, but also all of our community institutions, from schools to banks to workplaces to businesses. We have to change institutional structures in our community so that they support at all times and never inhibit people's ability to be healthy and to choose healthy options. Intervening individual by individual as we do now is labor intensive, has a small impact, whereas addressing social and environmental context will have a huge impact across the population and all along the life course. And I submit Exhibit C, which is an illustration of how that principle works. Lastly, I think it must be stated for the record that current disparities are, in a large part, a 147 6/15/10 - PUBLIC HEALTH - RES.
100260 result of past inequities. No matter how equivalent the provision of care is in the current time, one group will always be fighting to get from behind. To illustrate, I'd like for you to imagine a marathon race. In fact, a relay marathon race where once you arrive at a certain point, you pass the baton on to your next generation. Further imagine that one group in that population is systematically required to wear a 500-pound weight while they run. Now, of course, this group will be systematically left behind and their children will continue to be left behind over the generations. Then imagine after ten generations, the community revolts and realizes that it's not fair, no one should have to run with the extra weight on their back. So the weights are removed and everybody rejoices that now everything is equal. Except that it's not equal, because no one bothered to 148 6/15/10 - PUBLIC HEALTH - RES. 100260 undo the effects of past inequity. In case you haven't gotten the analogy, which I'm sure you have, the 500-pound weight is slavery, Jim Crow, overt and covert discrimination that has burdened a segment of the population and continues to define the existence of the disparities that we see now. It will not be easy to address social and historical context. However, what we are doing now in relying on improving prenatal care and changing individual behavior as a sole strategy is also not easy, it's expensive and, most of all, it's not working. At one time it was believed that cracking the human genome was an utter impossibility, but once political will, economic resources and brainpower were applied, success was not far behind. So I implore you to provide the political will and economic resources and the effective solutions, and significant progress are not far behind. 149 6/15/10 - PUBLIC HEALTH - RES. 100260 Thank you.
Thank you very much for your testimony, and thank you very much for coming from North Carolina to participate and making that trip.
Who is next? We'll have everybody testify and then we'll come back with questions.
Ms. Levkovich has very generously offered to allow me to go next, as I have patients scheduled at 1:30.
I'm Dr. Eileen Tyrala and -- first of all, let me say good afternoon, I believe it now is, Councilwoman Reynolds Brown and Councilwoman Tasco. I am a physician who is a pediatrician and neonatologist and am currently a practicing general 150 6/15/10 - PUBLIC HEALTH - RES. 100260 pediatrician here in Philadelphia. I am here today as a representative of the Pennsylvania Chapter of the American Academy of Pediatrics, which represents over 2,300 pediatricians in the State of Pennsylvania. It's a great honor for me to have this opportunity to discuss an issue of vital importance to the health and welfare of infants and families in Philadelphia. The sudden and unexpected death of a newborn infant is one of the most tragic events that a new family can experience. Unfortunately, it happens all too frequently, affecting the lives of over 40 families each year in Philadelphia. Despite the fact that there are many positive things that physicians can do to provide healthcare to children and their families, there is still nothing we can offer to a family who has a child who presents to emergency responders already lifeless and beyond the ability to respond to all life-saving 151 6/15/10 - PUBLIC HEALTH - RES. 100260 efforts. For many years, we had no 4 explanations for these types of deaths and had no way of telling families how to protect their infants from this silent killer. We called it SIDS, or Sudden Infant Death Syndrome. That meant that after a complete review and investigation of all of the circumstances of death and a complete autopsy, that there was still no explanation that could be found for the death. S. health organizations, launched the national Back to Sleep campaign, which endorsed and promoted the placement of all infants on their backs for sleeping and napping. This highly successful campaign changed the behavior of many new parents as they placed their infants to sleep on 152 6/15/10 - PUBLIC HEALTH - RES. 100260 their backs for the very first time. The incidence of prone or tummy sleeping decreased in the United States from 70 percent to ten percent. 055 per thousand or about 2,200 deaths per year. S. S. national averages. And the majority of the deaths that were occurring in Philadelphia were occurring among African American infants. It is clear now that placing infants to sleep on their backs has become the fundamental principle upon 153 6/15/10 - PUBLIC HEALTH - RES. 100260 which all other recommendations for infant safe sleep are based. Since that time, much progress has been made, as we have identified other important threats to infant safety that also demand a behavioral change in how we put our infants to sleep. In 1996, the Center for Disease Control and Prevention, at the request of Congress, developed and issued protocols for use by medical examiners and coroners' offices throughout the United States for gathering information on the death scenes of infants who succumbed to a sudden and unexpected death. With the use of these protocols, child death review teams all over the country, including those here in Philadelphia, were now able to collect comparable data at the death scenes of all infants, regardless of where in the United States these infants died. This allowed for the analysis and comparison of much larger numbers of infant deaths with the ability 154 6/15/10 - PUBLIC HEALTH - RES. 100260 to identify common factors. This led to the recognition of additional hazards in an infant's sleep environment that increased the risk of an infant dying suddenly and unexpectedly. It resulted in many infant deaths that had been previously labeled as SIDS, because they were thought to be completely inexplicable, to be reclassified as deaths by asphyxia or suffocation due to the infant having been placed in an unsafe sleep environment.
, in 2005 the American Academy of Pediatrics' Task Force on Sudden Infant Death Syndrome issued new recommendations on maximizing SIDS and sudden, unexpected infant death risk reduction. These recommendations stressed the need for a safe sleep environment, in addition to reaffirming the importance of the back only sleep 155 6/15/10 - PUBLIC HEALTH - RES. 100260 position. A key area that was identified as particularly hazardous for the sleeping infant was placing the infant to sleep on a soft surface, such as an adult bed or mattress. We now understand and know that placing an infant to sleep on his stomach and on soft adult bedding increases the risk of death fold as 10 compared to a baby who sleeps on his back 11 on a firm crib mattress. The AAP 12 strongly recommends the use of a firm 13 sleep surface such as a crib mattress for 14 infant sleep. 15 Similarly, the AAP task force 16 recognized that an infant's crib 17 environment must be free of all 18 extraneous objects, including toys, 19 stuffed animals, quilts, sleep 20 positioners, thick bumpers or heavy 21 blankets, basically describing everything that I put in the crib of my children, which I now know better. Each of these types of objects have now been shown to have the ability to find their way up and 156 6/15/10 - PUBLIC HEALTH - RES. 100260 around the baby's face, particularly when the baby begins to move around, which is around two to four months of age, which is the peak time period for these types of deaths. All of this leads to the creation of a situation where the infant's ability to breathe is diminished because of objects that find their way up and around the face and the nose. Some infants cannot overcome this added stress to their ability to breathe and they tragically die, and it has been shown that it's been particularly difficult for infants to overcome these additional stresses when they have been exposed to smoke, either from mom who smoked during her pregnancy or smoke in the postnatal environment. An additional risk factor is having another person sleep in the same bed with the infant. This is because of the risk not only of an overlay death where the adult or child literally rolls over onto the infant, which does happen, 157 6/15/10 - PUBLIC HEALTH - RES. 100260 but also a death due to suffocation from the close proximity of either the adult or child, or objects that are in an adult bed, such as blankets, comforters and pillows, which can also find their way up and around the baby's nose and face. The AAP strongly recommends that infants should not bed share or sleep in the same bed with any other individual at any time, including the parents, because of the risk for suffocation and/or an overlay death. Other risk factors for sudden, unexpected infant death include smoking either by the mother during pregnancy or by any other household member after the baby is born, as I alluded to. Additional risk factors include an overheated sleep environment, such as might occur if the infant is bundled too heavily or if the room temperature is too high. It is important to mention that there is nothing about these safe sleep 158 6/15/10 - PUBLIC HEALTH - RES. 100260 recommendations that preclude successful breastfeeding. The AAP strongly supports breastfeeding for all infants for at least the first six months of life. Successful breastfeeding does not require bed sharing. Indeed, it has been shown that the safest place for an infant to sleep in the first six months of life is in their parents' room, but not in the same bed. In December 2008, all this type of information was crystallized by a report that was issued by the CDC, who issued a periodic report on preventable childhood deaths in the United States, and this report covered the time span from 2000 to 2006. They identified during that time span the most common cause of preventable death in infants is suffocation.
And 66 percent of 5,883 infant deaths, or 3,882 babies, lost their lives due, during that time period in the United States, due to having been placed in an unsafe sleep environment. 159 6/15/10 - PUBLIC HEALTH - RES. 100260 In recent years, there have been dramatic changes in how infant deaths are investigated here in Philadelphia. This has resulted in a better understanding of the circumstances and causes of many infant deaths that previously would have been labeled as SIDS or basically mysterious in which they had no explanation and now are able to be labeled differently. In 2008 to 2009 -- and this is data that I just received last Friday, so this is new data -- we know that there were 82 sleep-related infant deaths among Philadelphia residents. Sixty-three of these 82 sleep-related infant deaths occurred under conditions of an unsafe sleep environment, with 54 or 87 percent of them involving bed sharing. Only 12 deaths during that entire time period were officially classified as SIDS. So if you were to see SIDS data for the City, you would see unbelievable drops in our numbers for that, but it 160 6/15/10 - PUBLIC HEALTH - RES. 100260 doesn't mean that fewer babies are dying. It just means that we are calling babies that we used to call SIDS now calling them babies who have died of suffocation or asphyxia due to circumstances under which they're placed to sleep. This revelation is no accident and reflects the increasing work and effort of both the Medical Examiner here in the City and the support from the Health Commissioner of the City to acquire as accurate information as possible about the true nature of these deaths and, hence, to more accurately classify and define them. If we think about it in this way, this accounts for one death occurring every 11 days in the City of Philadelphia to an infant just because they were placed in an unsafe sleep environment and died of suffocation. If we had one child dying of whooping cough or polio every 11 days in Philadelphia, it would be considered a public health 161 6/15/10 - PUBLIC HEALTH - RES. 100260 crisis and emergency, yet these types of deaths continue to occur. Now, we have made a lot of progress, but the message is clear. All new parents and caregivers for infants here in Philadelphia need to hear a clear and consistent message, both prenatally, at the time of their birth and through the first year of life, and, that is, how to place an infant to sleep in the safest possible environment to minimize the risk of a death by suffocation. We must also strive to understand the reasons why many who hear and understand the message choose not to heed it, which continues to be a vexing part of our ability to promote this public health message. Thank you for your attention.
Thank you very much. Thank you so much for the information and taking the time to come today. This adds to the testimony and the information we will be gathering for 162 6/15/10 - PUBLIC HEALTH - RES. 100260 further action. Thank you.
Good afternoon, Councilwomen Reynolds Brown and Tasco. Thank you very much for this opportunity. I'm Natalie Levkovich, Executive Director of the Health Federation of Philadelphia. The Health Federation is a public health agency that works closely with the City Health Department, as well as community health centers and other organizations in Philadelphia to bring state-of-the-art approaches to bear on ongoing public health challenges, including HIV/AIDS, child abuse and neglect, delivery of primary care, and maternal and child health. The community health centers with whom we work all deliver prenatal and postpartum care and pediatric care to women and families regardless of their insurance status throughout the City, and as Dr. Schwarz mentioned, we are working together to address issues of continuity 163 6/15/10 - PUBLIC HEALTH - RES. 100260 of care for pregnant and postpartum women and to work together on this prenatal registry. So that's been a wonderful collaboration, which hopefully will begin to bear fruit when the registry is designed. In this room, we all understand that the infant mortality rate in Philadelphia, particularly in the African American community, is tragically high. Data on infant mortality, as you've heard, is used worldwide as an indicator of the overall health, well-being and level of development of communities. When too many babies die, it is an indication that something is terribly wrong with the health of the community as a whole, not just the health of individual mother and baby. At the same time, infant mortality is not an easy problem to fix. Because it encompasses so many factors of community health, there is not a clear answer in what intervention is going to 164 6/15/10 - PUBLIC HEALTH - RES. 100260 work to prevent infant mortality. We know that a significant portion of deaths are the result of low birth weight deliveries, but we don't know exactly why and which women will experience preterm labor. We know that early entrance into prenatal care and regular, high-quality care for pregnant and postpartum women is very important, yet study after study has shown that the timing and frequency of such care alone is not sufficient to reduce disparities in the area in the rates of infant mortality. In recent years, many researchers examining these intractable health problems, not just infant mortality but chronic diseases and mental health issues, among others, have begun to look at health through a much broader lens. This approach, which you've heard referred to today as the life course perspective, suggests that a complex interplay of biological, behavioral, psychological and social protective and 165 6/15/10 - PUBLIC HEALTH - RES. 100260 risk factors contribute to health outcomes across the lifespan of a person's life. This life course perspective builds on research that demonstrates that early experiences of adversity, trauma, severe stress can cause changes in the body and the brain that make individuals more vulnerable to poor health outcomes in the future. The life course model posits that when fetuses, infants, young children experience severe and repeated stress or trauma without the protective effects of stable, positive adult support, they are at risk for growing up with increased vulnerability to poor health outcomes, including poor reproductive outcomes, including infant mortality and low birth weight, and chronic diseases such as diabetes, cardiovascular disease and mental illness. The evidence to support this model, this intergenerational life course 166 6/15/10 - PUBLIC HEALTH - RES. 100260 model is strong. There is increasing body of research using both animal and human subjects that demonstrates how stress and trauma affect changes in the brain and body chemistry. In addition, research has shown strong correlations between stress and trauma in early childhood and a number of poor health outcomes in adults.
Clearly, this is a very different way of looking at a problem like infant mortality and calls for a sea change in how we think about efforts to address this and other health problems. It does not mean that we should stop or reduce programs that encourage pregnant women to get prenatal care, that foster safe environments for infants or that promote the best possible care for high-risk pregnancies and low birth weight babies. These programs absolutely need to continue or we will go backward. However, these are not enough. It means that we need to widen the lens 167 6/15/10 - PUBLIC HEALTH - RES. 100260 through which we look at health problems like infant mortality. We cannot start to prevent infant mortality when a woman becomes pregnant. We need to start when that woman is herself an infant to surround her with a supportive environment that makes it possible for her to grow up healthy and, by extension, to then bear healthy children. We need to look at each and every system that touches the lives of infants, young children and their families and realize that by reducing stress and trauma in these young lives and improving opportunities for supportive, protective relationships with adults, we are making an essential investment in the health of our communities and future generations. Therefore, as we think about funding and policy decisions related not just to health but to child welfare, education, law enforcement, food and nutrition, transportation, economic development, 168 6/15/10 - PUBLIC HEALTH - RES. 100260 housing, we must realize that these decisions all have an enormous impact on the future health of our communities. This is not an easy shift in our thinking about infant mortality and other health problems. The issues that we need to confront to improve the health of our communities using this perspective are big and daunting. Nonetheless, the City of Philadelphia is beginning to take up this challenge. The Department of Health has embraced this life course perspective and is seeking ways to use this model to inform future policies, planning and funding decisions and cross-system strategies. You've already heard mention that on June 29th the Department will be sponsoring a day-long symposium featuring national experts on the research behind the life course perspective model and how it can be put into practice. The Health Federation commends the Health Department for their willingness to take up this 169 6/15/10 - PUBLIC HEALTH - RES. 100260 challenge and commits to being a partner in moving this initiative forward. I would encourage members of Council to join us on the 29th to learn more about this approach, to have an opportunity to interact with national experts and to contribute your own knowledge of the needs of Philadelphia's communities to the dialogue. Thank you very much.
Thank you very much. We appreciate your testimony. Letty Thall and Rorng Sorn.
I'm Letty Thall, the Public Policy Director at the Maternity Care Coalition, which has been delivering home-based visiting services that are evidence based -- I have to put in for HRSA -- in the form of the MOMobile and Early Head Start, and we also have a Healthy Start contract to serve parts of West Philadelphia from the City. And I want to -- I'm not going 170 6/15/10 - PUBLIC HEALTH - RES. 100260 to read. This is -- we're all hungry, but I want to just point out some of what has been said here today and make some suggestions. We have six hospitals who deliver wonderful services for maternity and birthing, but I want us to recognize that when I'm pregnant or any of us who are women are pregnant, we're only in the hospital for 48 hours. We're pregnant for nine months, plus we need postpartum care. So I look to say, so who is delivering prenatal care and what is the relationship, and as Natalie pointed out, we do have some wonderful community health centers here that do do prenatal care. But it's also we recognize -- in 2007, we had done a study that revealed there were 139 individual practitioners at 61 prenatal care sites through the City, which was very different than what the managed care contractors and the Department of Public 171 6/15/10 - PUBLIC HEALTH - RES. 100260 Welfare had cited they had over 1,500. So I think as Dr. Montgomery had pointed out, when the hospitals close, who are the physicians, the medical students, the residents, the nurse midwives who may be delivering service and where. So I think that we really need to recognize. The other issue I want to point out is what I might call the elephant in the room, the insurers, the funders. Women do not automatically have healthcare and do not automatically get maternity coverage. And so when we're looking to our colleagues in Harrisburg and how they can help and what they can do, we need to recognize that many women do not have health insurance, and I think the researcher from North Carolina pointed that out. African American women don't have access to preventive care if they don't have health insurance. Why? Commercial insurers in Pennsylvania do not need to cover pregnancy and health benefits. Plus, 172 6/15/10 - PUBLIC HEALTH - RES. 100260 they can charge us more in higher premiums because we're at risk of getting pregnant. And pregnancy is also a pre-existing condition. So if we have women who are earning over $25,000, a single woman, probably working somewhere where they don't get health insurance, they do not have healthcare. Twenty-five thousand is the cutoff for our Medicaid eligibility. So let's just say I do have MA. I ask my employer to please reduce my income to 24,000. I can sign up for Medical Assistance. But then I have to find a contractor, some managed care organization. If I sign up for one right now, there are only four in the City that I could sign up for, managed care organizations. And let's say I might want to go to Jefferson, because they've got some great -- we've heard, seen. Jefferson Hospital may not have a contract with the managed care plan that I've signed up for, because they only had 173 6/15/10 - PUBLIC HEALTH - RES. 100260 one, and the Jefferson physicians may not also be part of that health plan. So this is an incredibly complex system, that we have to look at the funding, we have to look at the State Department of Public Welfare. I think it's wonderful we've had the State Health Department and the City Health Department here, but the funder for low-income women and healthcare insurance is the Department of Public Welfare. So that's my remarks, and I just want to say we need to look at that, and then we need to look at the populations and develop the services needed by the families, not the services dictated by the funding stream. As much as we can love the feds and everybody who funds us, we know in our neighborhoods what works, and if it's HIV in this neighborhood, let's do something about HIV.
If it's cocaine, let's do something about cocaine, but let's look at what's needed, not the funding stream. 174 6/15/10 - PUBLIC HEALTH - RES. 100260 And that's, I think, my summary.
Thank you so much, Letty. We know you work so very hard for this issue and dealing with -- advocating to keep the hospitals, birthing centers open, the obstetricians there.
Maternity and birthing services. You've really been a strong advocate for women and for mothers. Rorng Sorn. Hello.
Councilwoman Tasco, Councilwoman Reynolds Brown, thank you for the opportunity and thank you, Letty. It's nice to see you again. I used to work with the Maternity Care Coalition, what a wonderful organization, advocating 175 6/15/10 - PUBLIC HEALTH - RES. 100260 strongly on behalf of women and children. So thank you. My name is Rorng Sorn and I am the Executive Director of the Cambodian Association of Greater Philadelphia, a community-based organization serving over a thousand clients, majority of them from refugee and immigrant from Cambodia, Lao and Vietnam. I'm here today to share some of my concern on the infant mortality rate among Asian, especially among the poor and limited-English proficiency. Majority of these population again came as refugee because the result of the Vietnam War. Many of you may already know. So many of these population came here without any resources or the educational and marketable skill that can strive and succeed in this wonderful land of opportunity. We know that most of -- the common cause of infant mortality is 176 6/15/10 - PUBLIC HEALTH - RES. 100260 preterm birth, and that may be due to educational attainment. While Asian, if you look at the Asian statistic, the education attainment is a lot higher than not just white but all the races, but if you break down into the different ethnic group among Cambodian, Lao and Hmong, it's less than ten percent graduated from college and more than 50 percent drop out from high school. And majority live in poverty, with poor housing and in depressed socioeconomic area. So our cause may be due to stress from working long hours, and many of these women do work until they go to labor, delivery, and many of them also live in crowded and poor housing environment as well. So as Dr. Montgomery stated earlier, every baby die is a tragedy. And although among Asian is low, but like Ms. Jordan was mention, among the Asian, infant mortality rate has been increased. So there must be something going on 177 6/15/10 - PUBLIC HEALTH - RES. 100260 within our community. Maybe there's still lack of education, lack of case management, lack of services provided to these hard-to-reach population. Lack of education is really one of a major factor to limited -- I mean, not accessing to care. Majority of these population came from country that healthcare system is really poor, and they didn't -- majority of them had no 12 access to healthcare where they came from. So coming here, although healthcare is accessible, but they don't know that early, regular and ongoing care is important. And one of the issue among these population, although majority of women do not smoke, but men do smoke and they smoke around their family, especially -- and we know that secondhand smoke can affect the family member within the household. So that's also the lack of education. And there's many other barrier 178 6/15/10 - PUBLIC HEALTH - RES. 100260 to healthcare. The language barrier, not many provider within the City of Philadelphia are linguistically, causally appropriate or competent to serve these population. So there has been a challenge for these women to seek care. The lack of insurance for the women or family, small businesses or those who can't afford really the insurance and, again, the health plan that is the challenge and the lack of understanding, how it work and what can they do to really make access to those quality healthcare. I share with Ms. Jordan in April that in the City of Philadelphia, there's no medical doctor who can speak either Cambodian, Laoshen or Hmong, none whatsoever. We don't have any. And there's a few, like a handful, of nurses, but they all work in different institution that can't really benefit directly to these population who really need. So that is a huge issue in term of 179 6/15/10 - PUBLIC HEALTH - RES. 100260 really accessible to care and quality healthcare.
There's a few doctor, practitioner who are Asian descent, but they don't speak the language, and also many of them are at the retiring age who really about to retire, and there has been no upcoming medical doctor who can provide the services to these hard-to-reach within the community where they can access to care. So that is a huge barrier within these population. The lack of funding and support to community-based organizations such as our organization that do the direct work and have the direct contact with the community where they can really educate, outreach and also make appropriate referral to healthcare, that is also a huge barrier for our community to access quality healthcare. So my few recommendation would be to ask you, Councilwomen and the Committee, to really help ensure that provider hire linguistically, causally 180 6/15/10 - PUBLIC HEALTH - RES. 100260 appropriate staff to work within the limited proficiency and these hard-to-reach population to really reach out and get them to access to quality healthcare. Support community organization servicing the population and who work directly with the community member to provide outreach, education and support, referral or case management to the population. And provide adequate resources to these organization so that they can be effective and efficient in providing the services. Let me say this: A lot of time they ask from health institution, hospital and many other provider to provide services without proper compensation or no compensation at all. We have very limited resource, limited staff. We being called in different direction every day. So that is the difficulty and the challenges we have 181 6/15/10 - PUBLIC HEALTH - RES. 100260 trying to meet the need of our community, yet we don't have enough resources to support the work that we do, and we all drained and burdened. So that can be a huge stress on our staff, who are really trying to do the best we can. Last, but not least, is to ask you to ensure that every woman and child receive the quality healthcare, early, regular and ongoing healthcare that is to prevent -- to really prevent infant mortality, from my opinion. And thank you so much for your attention and your consideration.
Thank you very much. A lot of thoughts are going through my head as I listen to your testimony. We're lacking in many ways, not only in the healthcare field but in many other ways and having a diverse community to deal with the problems of the various groups that have come to the United States, and it's my ongoing concern about that. 182 6/15/10 - PUBLIC HEALTH - RES. 100260 Do any members of your community use any of the health centers, particularly I know South Philadelphia and then we have one in the Northeast?
Yes. Matter of fact, the two places on our populus where we refer our community member to, we usually refer women who are pregnant to Health Center 2, although they live all the way in the Olney, Logan area, because that health center provide interpretation services.
Yes, because that center have ongoing interpretation services, but not at the Northeast, which is at Health Center 10. So our women have to travel from up there all the way to South Philly to get prenatal care, and when they are eight, nine month pregnant, it is hard and some of them have to take the subway or on a bus. So that can be challenging. 183 6/15/10 - PUBLIC HEALTH - RES. 100260
Okay. I hear you. I certainly appreciate the work you do in the community, and we will share this information with Dr. Schwarz as we look further to how we can make our health centers much more accessible and friendly.
May I ask one more thing? I'm not sure if you can come up with a solution where you can help promote or train emerging healthcare provider, especially those with language capability, who is in the nursing position or from the community to become the next provider who have the language capacity to be able to serve. This is a long-term investment, but it can address the issue in the long run. That's really important.
Maybe hospitals, if they're getting additional dollars in terms of the obstetric, might be able to 184 6/15/10 - PUBLIC HEALTH - RES. 100260 say and to look that you need the cultural competent and you need the staff or at least the staff in training to help your community.
Thank you. We can talk about that. Councilwoman Brown.
Yes. Could I please ask the Executive Director, Ms. Levkovich, from the Federation to come back to the witness table. (Witness approached witness table.)
Please tell us first how your organization is funded.
We're funded through a variety of grants and contracts, both through the federal government directly and through the City 185 6/15/10 - PUBLIC HEALTH - RES. 100260 through various grants and contracts, some foundation funding. Our community health centers pay membership dues.
Does any of those contracts come with stipulations or criteria that for this contract, you must do X, Y, Z?
You spoke about how you are working with Dr. Schwarz around the issue of the uniform registrar system.
So what does that mean? What role is your Federation playing?
The role that the Federation plays with respect to community health centers, who are members of the Health Federation, is a representational one. In other words, through the Federation, I'm able to help organize the community health centers to 186 6/15/10 - PUBLIC HEALTH - RES. 100260 give their input, to share their information and concerns, to build the bridges between prenatal providers and the hospital delivery sites, and to represent those health centers then when Dr. Schwarz convenes the hospitals that he mentioned, the six delivery sites, and the community health centers to plan together how to make this registry work. It is I who come to that.
That's helpful. We've just heard from Ms. Sorn who has made it very clear what the challenges are, and she's actually done better than that. She's offered a couple of recommendations on what we as a city can do to create better access for the Cambodian community and our Philadelphia health system. So what role is there in a recommendation like that for the Federation?
Well, there's several. One is that from an insurance standpoint, all of the community health 187 6/15/10 - PUBLIC HEALTH - RES. 100260 centers provide care to whoever shows up, without regard to immigration status, insurance status or ability to pay. They all provide services on a sliding fee scale. With respect specifically to the language and cultural issues, the Health Federation holds a contract with the City of Philadelphia to provide language access support to various City departments, including City health centers. So we have done extensive training of bilingual staff within the health centers, for instance, in skills as medical interpreters. We also subcontract with two other firms that provide in-person interpreters and telephonic interpreters and document translation for City departments. And so while that's not as good as having a doctor or a nurse practitioner or a social worker who speaks your native language, the next best thing is to provide interpretation services. 188 6/15/10 - PUBLIC HEALTH - RES. 100260
It surely is a short-term solution. So I will challenge your organization to consider her broader recommendation, and, that is, to actually speak with the six hospitals that we have here who have nursing programs where you might have a young aspiring nurse of Cambodian descent or some other and link them when they're in college, link them with healthcare centers and the City so that there really is a continuum in terms of a career path as well.
Yeah. There certainly could and should be incentive programs for professionals who are particularly in high demand, incentives not only to enter into health professions, but then to come back and serve in medically underserved communities rather than going into a suburban practice or into academia or research or something else. I might mention that one of the 189 6/15/10 - PUBLIC HEALTH - RES. 100260 things we've done with respect to training interpreters is that for the last three years, we have been working with medical students at Jefferson. They have organized all of the interested bilingual, bicultural medical students and we've provided them with interpreter training and certification, and in turn, as payback for that, they volunteer at district health centers as interpreters so that they are now not only proficient in an understanding of medical issues, but also as certified interpreters.
Thank you very much. Is there anyone else here to testify on this resolution? (No response.)
We'd like to ask Ms. Jordan to come back to the table, please. 190 6/15/10 - PUBLIC HEALTH - RES. 100260 (Witness approached witness table.)
I just have two questions, and then I guess we'll sum up as to where we go from here. As a follow-up to your earlier comment, how much money comes to Philadelphia from the State for home visits, and how does this compare to other areas of the Commonwealth?
Let me answer that in twofold. One is, Philadelphia receives an appropriation from the State to the City in the figure of 3.25 -- $3.2 million. However, they use their funding around home visiting to -- they can use a portion of those funds, of course, in many ways, so I can't tell you exactly how much of that that they allocate for the home visiting program.
That's an appropriation that comes into the City 191 6/15/10 - PUBLIC HEALTH - RES. 100260 from the Title V, as well as from the State appropriation here to Philadelphia for maternal/child health services.
So this is the total budget that comes from your department?
That's correct. I have to look to my Director to make sure I got that correct.
Okay. And a portion of that is up to the discretion of the department to --
The department has the discretion to use those funds and support home visiting, to support prenatal services, to support infant healthcare services, preventative healthcare services. So that's their preparation. I was also going to add, a few minutes ago we talked about the 192 6/15/10 - PUBLIC HEALTH - RES. 100260 additional funds that would be coming out that was recently released around a new home visiting program. The President has released $90 million -- and let me look to my federal colleague to make sure I got that correct. Ninety million dollars was just released by the federal government for a home-based visiting program. Philadelphia -- I'm sorry. Pennsylvania stands to receive approximately -- this is approximate funding from the feds -- $2,070,398, and that's an approximate amount of money that will be coming into Pennsylvania for home visiting.
And how much do you think would come to Philadelphia?
Well, I can't answer that at this time. 193 6/15/10 - PUBLIC HEALTH - RES. 100260
But your department will be administering those dollars?
My department will be providing the -- in the guidance, it does require the Title V officer and State to provide the statewide needs assessment for it. However, the Governor has the discretion to determine if the Department of Health or the Department of Public Welfare will be the entity that will implement this particular program, and at this time, the Governor's Office has designated the Department of Public Welfare to be the entity that will move forth. And so we will be working very closely with the Department of Public Welfare in implementing the home-based visiting program.
Why would the money go to the Department of Public Welfare?
It is the Governor's discretion to allocate who 194 6/15/10 - PUBLIC HEALTH - RES. 100260 will be the lead on this particular entity. So at this point, the Governor's Office has decided that this is the way that it will be implemented. However, we are working very closely together with the Department of Public Welfare in putting together the guidance that will eventually go out.
What department in the Department of Public Welfare? What subdepartment? I mean, if you know, you have to answer the question.
Secretary Harriet Dichter is overseeing this particular implementation, and I am not familiar at this time who Secretary Dichter has designated within her purview to lead this particular effort. However, the Department of Health and I will be working very closely with Secretary Dichter.
Yeah, you said that, but who in the Department of 195 6/15/10 - PUBLIC HEALTH - RES. 100260 Public Welfare has the experience? Is this a new role for them to play?
No, it's not. No, it's not. The Department of Public Welfare has implemented and have moved forth with the Nurse-Family Partnership program that provides home visiting programs in the State, and they have taken the lead on this and have been doing so for over ten years now.
So this is not a new entity. They have expertise in doing this, and, again, they will draw upon the Pennsylvania Department of Health to assist in this effort. However, the Pennsylvania Department of Health will move forth with the statewide needs assessment that is required by the federal government to implement this program, and there will be also other department or statewide agencies that will participate in this, such as the Department of Substance Abuse -- Alcohol 196 6/15/10 - PUBLIC HEALTH - RES. 100260 and Substance Abuse will also be a part of this, in addition to the Department of Education at the State level.
Well, as of today, we've -- not learned. I guess it was reinforced that it's just not -- the whole issue that we're talking about today is not just about prenatal care. It's a holistic approach to health and how do we treat the health of the individual and particularly the mother. So what we have to begin is a holistic dialogue about how we provide health services so that -- we start when you're an infant so that you grow up to be a healthy adult and then you can produce healthy babies. So the cycle goes around. But I do, after listening to this dialogue today, know that we just can't have the discussion around prenatal care and maternal and infant care, but it's the holistic approach to health, which has sort of triggered a lot of 197 6/15/10 - PUBLIC HEALTH - RES. 100260 ideas and thoughts in my mind about what as a city we might do, but we have a lot of work to do.
Absolutely. I also wanted just to add a couple of comments that was made again around preconceptional healthcare. Again, I want to bring to the attention of the Council that, again, from the State level and from Title V dollars, we provide four of your hospitals here in the City of Philadelphia with funding for preconceptual healthcare, and that is counseling and healthcare prior to a woman becoming pregnant. And, again, a number of those individuals were here today, but the University of Pennsylvania, Thomas Jefferson Hospital, Temple University and also Drexel University. All of these entities do receive funding from the Department of Health for preconceptual care. I want to also add approximately $7.5 million comes into 198 6/15/10 - PUBLIC HEALTH - RES. 100260 Philadelphia also for maternal/child health at these institutions, as well as into the City of Philadelphia through its Health Department. And so there's a tremendous amount of resources that do come into the City to address a number of the recommendations that people have made here. And so I ask you to take that into consideration as you look at restructuring and as you look at moving forth. And I again applaud the City of Philadelphia for moving forth with the life course perspective, but I also want to caution that is a one-day activity. I hope that we will move forth with a very strong strategic plan to address these issues and to figure out with all of the non-profit organizations, working with our WIC office as well -- as I mentioned a few minutes ago, we have over how many agencies in Philadelphia? We have about 600 stores in Philadelphia that provide services and, as I mentioned, $50 million that also provides services in food and 199 6/15/10 - PUBLIC HEALTH - RES. 100260 $11 million to our north organization that provides outreach, breastfeeding services and so forth to the communities. But this is an opportunity, I think, for the City also to bring together the various organizations to work not only with your hospitals, but work with all of the organizations that deal with women, infant and children and find strategies that can address these issues in a more comprehensive and strategic manner.
So you've mentioned -- you've given us several challenges. Put them in priority order, one, two and three, in terms of what you view the next steps to be.
Well, again, I think you need -- I would suggest, one, again, looking at your available 200 6/15/10 - PUBLIC HEALTH - RES. 100260 allocations, looking at what your current priorities are in your city and addressing your healthcare needs, where you can work in a collaborative manner with your hospitals. You had a number of your institutions here today, all very supportive of your Health Commissioner, and he's done an excellent job in working also with the State. And so, again, bring the entities together to work towards, one, how you can maximize the funding that comes into Philadelphia to address, again, some of the core issues, your core public health issues, and so you can then probably gain more efficiencies that way by working across all of your, like I said, all of your agencies. In addition to that is to work with the community at the community level, identify those organizations that are in the community and move forward with, again, a plan -- and I know the City of Philadelphia is working on a 201 6/15/10 - PUBLIC HEALTH - RES. 100260 plan -- to address the core issues, the core public health issues here, and they need to be a part of that, need to be a part of that strategy, need to be part of the conversation to move those things forward. And then three is to be able to put together how you plan to evaluate the success of those programs, how do you plan to measure your success, identifying some of those areas, your key areas, where you have high infant mortality rates, again, what are the key measures that you will put in place to be able to determine some progress.
Thank you 202 6/15/10 - PUBLIC HEALTH - RES. 100260 very much. Is there anyone else to testify? (No response.)
There being none, let me say that we will recess this Committee to the call of the Chair so that if we want to come back, we can just do so without having to go through a long process of reintroducing a resolution. We thank you all for coming out today. We thank you for your testimony, and thank you to the lady from North Carolina for coming to Philadelphia. Thank you. This meeting is recessed until the call of the Chair. (Committee on Public Health and Human Services recessed at 1:40 p.m.) - - - 203 CERTIFICATE I HEREBY CERTIFY that the proceedings, evidence and objections are contained fully and accurately in the stenographic notes taken by me upon the foregoing matter on June 15, 2010, and that this is a true and correct transcript of same. -------------------- MICHELE L. MURPHY RPR-Notary Public (The foregoing certification of this transcript does not apply to any reproduction of the same by any means, unless under the direct control and/or supervision of the certifying reporter.)