If Clark Kent were a woman, she’d probably wear stylish, black, thick-framed glasses much like Elizabeth Majestic’s, Cottage Health’s new, first, and to date only vice president for Population Health. The hue of Majestic’s blue suit when we met vibrated on much the same frequency as the Man of Steel’s superhero leotards. A recent arrival to Santa Barbara, though a longtime visitor, Majestic is leading Cottage Health’s recently launched foray into as-yet uncharted territory — “population health” for medically underserved neighborhoods throughout the South Coast. A few superpowers would no doubt come in handy, but Majestic will have to rely on her 24 years of experience with the Centers for Disease Control (CDC), where she took on a variety of chronic diseases as a high-octane, number-crunching, public-health-policy wonk.
“The basic idea is that we have a very fragmented health system,” she said in a recent interview. “We have to piece it together. That’s why we need to get outside the walls of the hospital.”
Majestic began work for Cottage Health on October 1. In short order, she and a translator were pounding the pavement of Santa Barbara’s Westside, radiating out from Micheltorena and San Andres streets — the epicenter of a neighborhood defined by high poverty rates and dramatically higher death rates. Majestic went from store to store, taking a detailed inventory of what foods were available and what foods were not. The neighborhood didn’t qualify as a “food desert,” she said, thanks to Foodland’s looming presence. But she didn’t find an abundance of fresh produce, either. In one establishment, Majestic noted sprigs of wilted cilantro marinating in murky green water. Mostly, she found lots of corner stores selling foods high in fats, sugar, salt, and alcohol. “The urban wallpaper of the neighborhood was alcohol ads,” she commented.
Majestic didn’t merely take copious notes and retreat to the comfortable confines of her Cottage Health digs. “If you want to improve people’s health, it’s important that you talk to them,” she said. “You don’t just do things to them.” So what did she hear? “They want to learn how to cook healthy dishes but within the confines of the culture,” she said. While Majestic has yet to prescribe any solutions — she’s still in the early stages of her listening tour — she pointed out how proto-population-health gurus in Detroit addressed the same issue by organizing cooking classes in social settings.
As both concept and buzzword, “population health” has only been around a few years, secondhand policy smoke generated by the Affordable Care Act. What exactly it is and what it can become, Majestic acknowledged, remains very much a work in progress. Countless experiments are now springing up across the United States, she said, as medical care providers find themselves forced to shift away from a fee-for-service business model into something new. Under the Affordable Care Act, hospitals are now being held accountable for the health of patients after they’ve been discharged. Hospitals with high readmission rates are penalized with lower Medicare reimbursements. As of 2018, such penalties will range between 4 and 8 percent. That can add up quickly. Cottage ranks in the top 7 percent of all hospitals nationally when it comes to readmission rates, said spokesperson Maria Zate, and the highest-performing 5 percent in the state. Zate noted that 75 percent of all hospitals were dinged for excessive readmission rates last year; Cottage was dinged only 0.11 percent, she said, for going over the readmission rate by less than one percent for only one of seven procedures monitored by Medicare.
In this context, treatment for lifelong diseases such as diabetes clearly needs to begin before patients ever check themselves in. Seventy percent of overweight and obese kids, Majestic said, grow up to be overweight, obese adults with a lifetime of chronic diseases ahead of them. The trick is to teach them healthy eating and exercise habits when they’re still young. Under a population health approach, she suggested, a doctor could write a prescription for exercise. But that presumes there’s some agency — a community nonprofit perhaps — to help make it happen. For the exercise-averse, Majestic said, “it could be something like a dance class.” The key challenge, she added, is getting people to take the first step.
The United States spends the most among 17 industrially advanced nations on health care but boasts the lowest life expectancies. The single best predictor of health outcomes, Majestic said, is education and income. Those on the high end of that equation, on average, live nine years longer than those on the short end of the stick. As 78 million baby boomers and 35 million Gen Xers hit their golden years — when medical challenges become more numerous and treatment more expensive — such disparities will bear more dire results.
As lore has it, Cottage CEO Ron Werft received an unsolicited email one day with a link to Majestic’s résumé attached. They talked. He was impressed. She, likewise, found herself impressed by Werft. Majestic’s husband had just retired from his post with the CDC, and the couple was thinking of moving to Santa Barbara, which she discovered 10 years ago while attending a conference on childhood obesity at the Bacara hotel. On that trip, Majestic was struck by the sometimes fractious vitality of Santa Barbara’s sprawling community of nonprofit organizations. These, she explained, are indispensable partners for any entity seeking to address imbalances in access to health care. With an enthusiastic CEO, one nonprofit for every 200 people, and a geographically distinct population in a very defined medical universe, Majestic could hardly say no when Werft offered to create a new post just for her. Two weeks into the job, Majestic was the star attraction for a two-day retreat held by the Cottage Board of Directors, focused exclusively on population health. At the end of the retreat, the board voted to change Cottage Health’s mission and vision statements to embrace population health.
One partner whose mind Majestic has clearly blown is Dr. Fred Kass, the noted oncologist and head of the Cancer Center of Santa Barbara. In the past year, Kass has independently taken a keen interest in the health-care needs of the Westside; his wife is a volunteer tutor at the Westside United Boys & Girls Club. Known for his expansive enthusiasm, Kass watched Majestic in action at several neighborhood meetings and couldn’t have been more impressed. “I don’t know if you believe in God or happenstance, but her arrival in Santa Barbara at this particular time makes you believe in one or the other,” he exclaimed. Majestic, Kass said, won’t merely make a major contribution to Santa Barbara. “She could create a national model.”
To an exceptional degree, Kass said, Majestic knows how to crunch the numbers to achieve a tellingly detailed diagnosis of Santa Barbara’s diverse and disparate health-care profiles. Armed with such baseline data, Majestic can better gauge what gaps in care need to be prioritized and what interventions are called for. That same information, Kass said, will prove indispensable in determining just how successful — or not — those interventions have been. By sharing this information, Kass suggested, Majestic and Cottage can help nonprofit partners better compete for limited grant funds. And, he added, it will help them better determine what strategies will be most effective. “It won’t be a matter of gut feelings or good intentions,” Kass said. “There will be actual evidence available now that can indicate what strategies work and which ones don’t.”
Kass was equally bullish on Majestic’s political skills. He recalled attending a meeting where Majestic described in great detail, without notes, all the shops she visited on the Westside and which ones — such as the Botanica, a traditional Mexican apothecary — might make good partners. “Let me tell you: That’s not our image of a hospital vice president, someone who goes door-to-door and spots a shop like Botanica as a possible partner,” he said.
For the next 10 months, Majestic and a small staff will be strip-mining data from census tracts, readmission records, and state, local, and federal health reports. From that, various plans of attack will emerge. “It’s all about making a difference,” she said.