The power of calling us back to ourselves

Dr. Saha began her medical career in the Berkeley/UCSF Joint Medical Program, which is a 5 year program combining an MD from UCSF with an MS from the Berkeley School of Public Health. In her conversation with Judson, Soma mentions several times the formative experiences she had during her master's degree work with a Baha'i community in Guyana. A Caribbean country located on the north coast of South America, Guyana is a former British colony that gained independence in 1966. The economy of the country was primarily agrarian and characterized by high levels of poverty at the time of Soma's work there, but Guyana has since been transformed by the discovery of offshore oil reserves in 2015 and has become the world's fastest growing economy. National health outcomes remain poor, however, and only 76% of the population had access to essential healthcare services as of 2021.

The Baha'i faith originated in Persia (Iran) in the mid 1800s and was first introduced into Guyana in the 1920s. While Baha'i followers remain a small religious minority, the group has been influential in Guyanian community affairs at least in part due to their focus on unity. A key principle of Baha'i is the Oneness of Humanity, meaning that "every human being has a unique purpose to help bring about a unified world, that justice enables each of us to fulfill this potential, and that the inequalities between women and men, black and white, rich and poor, East and West must dissolve." Along with the Baha'i belief that "lasting social change starts at the neighborhood level when we build relationships based on love and mutual respect", these ideas echo throughout Soma's work on equity, justice, and community as key pillars of health.

When Dr. Saha finished her medical residency training in 2004, she took a job at the Cambridge Health Alliance (CHA) as a primary care doctor. CHA is a storied institution in Boston, tracing its roots back to the founding of the original Cambridge City Hospital in 1918 as a charitable institution dedicated to the care of the poor. The modern CHA was created in 1996 by the merger of Cambridge Hospital and Somerville Hospital. Today, the organization serves 150,000 patients, is comprised of 2 acute care hospitals with primary care sites in 5 locations around the Boston area, is affiliated with Harvard and Tufts Schools of Medicine as well as the Beth Israel Deaconess Medical Center, and remains committed to providing "outstanding health care to our communities and to improving access to care while pursuing health equity and social justice."

The background context for this early part of Soma's career was an important era in the story of efforts to reform American healthcare. In 2006, the state of Massachusetts, led by Governor Mitt Romney, enacted healthcare reform legislation that attempted to improve access to care by providing universal health insurance coverage for the citizens of the state. The essence of the law was to provide coverage through the combination of a mandate for individuals to purchase health insurance, state subsidies to help residents purchase insurance on a state exchange, and Medicaid expansion. The law was successful in reducing the percentage of uninsured people in the state to roughly one third of the national average. Despite hopes that improved access to preventive and primary care services would reduce the use of more expensive specialty and hospital care, health care costs continued to rise - at least in part because the increase in insurance coverage led to increases in the number of people financially able to seek care. In 2009, to address the ongoing cost increases, a Massachusetts state commission formally recommended moving away from fee-for-service payments and to a global payment system based around accountable care organizations.

The definition of a "global payment" system deserves a brief explanation, as this topic comes up repeatedly in these podcasts. In over-simplified terms, the general idea is that in a fee-for-service system, such as a grocery store, where items are purchased one by one at prices (fees) set for each item (services), the grocer has an incentive to sell the customer as many items as possible in order to maximize their profit. If instead of a grocer, the seller is a physician or a hospital, their incentive is to sell as much medical care as they can to their patients, with the result that patients sometimes end up buying more care than they actually need.

In contrast, a global payment model is more like a subscription. This approach creates an agreement that the customer will pay the grocer a single subscription fee for one year's worth of groceries, regardless of how much the customer actually takes home. If the customer takes less than their payment covers, the grocer keeps the profit; if the patient takes more than their payment covers, the grocer loses money. In this type of model, the grocer has an incentive to provide enough food to keep their customer happy and healthy but not to provide excessive or unnecessary food. At least in theory, global payment models in healthcare better align the incentives of the healthcare providers with the needs of their patients.

In the healthcare system, who plays the role of the grocer in this analogy? Someone needs to be responsible for accepting a payment in exchange for providing all of the healthcare that a person might be reasonably expected to need in the next year. That someone is often an accountable care organization, or ACO. In the words of the Center for Medicare and Medicaid Services, "ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to the patients they serve." It is also worth noting that global payment models come in many different forms, with variations ("shared risk models") in who exactly benefits if the patient uses less healthcare than they have paid for and who exactly is on the hook if the patient needs more healthcare than their fee covers.

These basic concepts remain a focal point of healthcare reform today, and they recur in our podcasts. In particular, check out our upcoming conversation with Dartmouth professor Elliott Fisher, one of the original architects of the ACO idea and its implementation in the Affordable Care Act.

One of the keys in implementing any reform is how to measure progress towards your goals. Soma Saha mentions Cantril's Ladder as an example of a simple but reliable and human-centered metric to guide resource allocation. Hadley Cantril (1906 – 1969) was an American social psychologist best known for probing how people perceive and interpret large-scale events. A long-time professor at Princeton University, he co-founded Princeton’s Office of Public Opinion Research and advised U.S. presidents on wartime morale and propaganda. Cantril’s scholarship ranged from a famous study of listeners’ reactions to Orson Welles’ War of the Worlds broadcast to pioneering methods for cross-cultural opinion polling.

In his 1965 book The Pattern of Human Concerns, Cantril introduced the "Self-Anchoring Striving Scale" — now widely known as Cantril’s Ladder. He asked respondents to imagine a ladder with ten rungs: the top (a score of 10) representing their “best possible life” and the bottom (a score of 0) their “worst possible life.” By rating where they stand today and where they expect to stand in five years, individuals supply a simple yet powerful snapshot of subjective well-being. The scale has proved remarkably robust across cultures and demographics, and it has become a staple of the Gallup World Poll and the World Happiness Report. In addition, the ladder has been used as an outcome metric in numerous studies linking higher ladder scores to longer life expectancy, lower hospitalization rates, and reduced public-health costs.

The choice of appropriate, reliable, feasible metrics is of crucial importance not only in medical research but also in healthcare delivery. Recent thinking has increasingly embraced the idea of "patient-centered care" guided by metrics that focus less on the performance of health system personnel ("how did we do?") and more on the patient's perception of their own wellbeing ("how are you doing?").

As part of the 100 Million Healthier Lives campaign, which Saha helped lead, a team at IHI created a Health and Well-being Measurement Approach and Assessment Guide, which frames health and wellbeing as the integrated way people think, feel, and function, and which outlines a practical method based around an expanded and updated version of the ladder for tracking those domains at individual and community levels. Of note, the potential complexities of using even simple tools like this one were highlighted by a recent study suggesting that for many people the ladder imagery emphasizes power and wealth, and that the hierarchical structure of a ladder may not represent an ideal life to people of cultures with a greater emphasis on harmony and community.