A frequently cited statistic in the health equity arena is that 60 percent of health care spending is driven by social factors. During the American Hospital Association Leadership Summit July 27-29 in San Diego, RISHI MANCHANDA,M.D., president of HealthBegins, an organization dedicated to achieving health equity, and the former chief medical officer for a large self-insured employer based in California, will deliver a keynote speech depicting a health care system that addresses.

When leaders at Parkland Health & Hospital System in Dallas launched a novel program for administering long-term antibiotics to Parkland Memorial Hospital patients, they were seeking to address two problems that vex many provider organizations: disparities in the delivery of health care services and the inappropriate use of health care resources. Kavita Bhavan, M.D., medical director of the Infectious Diseases Outpatient Parenteral Antimicrobial Therapy [OPAT] Clinic at Parkland, says the clinic treats many patients who need intravenous antimicrobial therapy for several weeks to recover from serious infections stemming from illness or injury. Providers can administer long-term IV antimicrobial therapy to insured patients within a number of locations: an infusion center, a physician's office, a skilled nursing facility or, most frequently, at home with support from home health services. Uninsured patients, however, have no access to home health nurses or other options, so they traditionally have been treated as inpatients at Parkland, the only provider organization that provides free care. "It wasn't unheard of to be here 42 days getting IV antibiotics," says Bhavan, who also serves as associate professor of internal medicine at the University of Texas Southwestern Medical Center. "And they were doing fine - the only reason they were there was to get the antibiotics." That meant inpatient beds were being tied up by patients who could be treated at home, while Parkland struggled to find beds for acutely ill patients coming through the emergency department. At the same time, the patients receiving long-term antibiotics did not want to be in the hospital unnecessarily. "Many of our patients are the working poor," Bhavan says. "They would like to get home to be able to pay their bills on time, and take care of their loved ones. It's burdensome for them to be tied up in a hospital." Furthermore, spending weeks as a hospital inpatient comes with the risk of nosocomial infections, so Bhavan recognized a disparity in the quality of care being provided to uninsured patients versus their insured peers who were being treated at home.

Chicago has made national headlines for the more than 780 murders last year and the dozens ofhomicides committed already this year. University of Chicago Medicine is now building the only adult Level I trauma center located on the South Side, one of the city's most violence-plagued communities. Spearheading the effort is SELWYN ROGERS JR.,M.D., a Harvard-trained surgeon and public health expert who previously served as chief medical officer with the University of Texas Medical Branch in Galveston.

Ladysmith and the surrounding community - Rusk's service area is about 18,000 people - traditionally had good primary care access provided by 10 to 12 physicians in an independent medical group. A few years ago, the group began struggling to recruit physicians to Ladysmith. They said, 'We cannot recruit anybody because of the call burden, you need to have a hospitalist program.' "Oland says. The impact on the hospital was profound. By 2013, six physicians had left the medical group's clinic in the previous two years, forcing Rusk to suspend its obstetrical services. The remaining physicians increasingly referred patients to a hospital 45 miles away. Rusk's acute care inpatient days fell to roughly half the volume it had in 2010. To address the crisis, Rusk started its own primary care clinic. But Oland knew that she would face the same recruitment and retention challenges as the independent group. More and more, primary care physicians do not want to take call duty at the hospital, and many are no longer willing to round on their patients at the hospital. The key to our own success in keeping the hospital open was starting the hospitalist program so that we could recruit younger physicians that wanted a lifestyle balance," she says. The vast majority of American hospitals have launched hospital medicine programs in the past decade for just that reason. But Rusk and other small, rural hospitals have been slower to add hospitalists, mostly because of the cost. Although hospital physicians bill for their services, hospitals typically have to subsidize the program by at least $150,000 a year for each full-time hospitalist - and that's when the hospitalist has responsibility for 15 or more patients a day. In Rusk's case, the average daily census is just six to eight patients, meaning the hospitalists have less billing opportunity and require a larger subsidy from the hospitals.