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Bridging the Health Care Gap

Dr. Jose Francisco Figueroa fights to improve the system for those with less means.

He grew up in a small Texas town called Eagle Pass, on the eastern bank of the Rio Grande.

Many days in those late-1980s and early-90s were spent across the river in Piedras Negras, Coahuila, Mexico, playing with friends before crossing back in time for dinner.

“Where do you live?” a border patrol agent might ask, to which young Jose Figueroa would answer earnestly with his address.

“What’s your favorite food?”


“Go ahead, then.”

The border was safer, life was simpler, and the only thing Jose knew about doctors in those formative years is that’s who you saw when something went wrong. The people in his circles were not of great means, and his own home was made up of a single mom of six siblings. Hospitals were almost exclusively meant for emergency services, certainly not a place to go for routine primary care.

In fact, it wasn’t until his early high school days, when the family moved to a Houston suburb and were living among people of slightly greater wealth, that Jose began to understand such a thing as preventative medicine even existed.

It just hadn’t for him.

And it hadn’t for many others in similar economic circumstances.

“My first real experience with this work was through the Rappaport Foundation, and now I’m looking at it every day. That project served as the foundation for a lot of the work I do now.”

Dr. Jose Francisco Figueroa

“I started seeing that people interacted with the health care system much differently than I was used to seeing,” he said. “That’s when I learned there are two different health care systems: one for people of means, who have good insurance and who can see doctors when they need to; and a second health care system for people of low-income populations, which is often emergency rooms, and late and delayed care.

“I became very interested in health care, in discovering how to improve care for people that don’t necessarily have access to it.”

It is the issue that has driven Dr. Jose Figueroa ever since. In addition to being an instructor at Harvard Medical School and associate physician at Brigham and Women’s Hospital, his primary work is to study the impacts of state and federal health care policies, particularly on vulnerable populations, as assistant professor of health policy and management at the Harvard Chan School of Public Health.

And a formative piece of his journey was as the first recipient, in 2013, of the Rappaport Award in Clinical Innovation at Brigham and Women’s – a prize specifically designed to inspire new ways of thinking about value in health care.

“My first real experience with this work was through the Rappaport Foundation, and now I’m looking at it every day,” he said. “That project served as the foundation for a lot of the work I do now.”

The project was entitled, “Educating and Incentivizing Housestaff on Early Discharges: An Intervention at Cost Containment.” For an award that was specifically designed by the Rappaport Foundation to utilize the unique perspective of residents at Brigham and Women’s to shine a light on areas in need of value-improvement, and attempt to find a remedy, it was an ideal first recipient.

What Dr. Figueroa and his colleague, Dr. Bram Geller, were noticing was that for all the attention necessarily paid to the medical interventions needed to make sick patients better, there wasn’t enough time dedicated to the logistics of discharge.

“There’s all this stuff that hasn’t been done, because in some ways you haven’t thought about it yet as a team in the hospital,” Dr. Figueroa said. “Then there’s this huge delay in patients going home.”

Not only do the delays bring the obvious frustrations of patients and family members, the doctors reasoned, but a bed being used unnecessarily causes a downstream roadblock in the emergency rooms, creating both anxiety and potential safety concerns for those who need care sooner than later.

And then there’s the financial component. Add up a couple wasted hours here and a couple more there over the course of weeks, months and years, and the cumulative inefficiencies can create legitimate budgetary deficits.

So, how to combat such delays? In this case, the remedy for a complex problem boiled down to a very ordinary solution: Amazon gift cards.

It’s true. For their winning Rappaport project, Drs. Figueroa and Geller theorized that offering $50 bonuses to residents whose patients were released on time would mean greater discharge efficiency.

And … “We got the answer,” Dr. Figueroa said. “It worked.”

It worked so well, in fact, that it was later modified and re-adopted by the hospital, led by Dr. Robert Boxer, one of the faculty members who had initially worked on the project as part of the Rappaport team.

Naturally, Dr. Figueroa said, any such program runs the risk of unintended consequences – most notably in this case the possibility for patients to be rushed out of the hospital for the sake of financial gain – but he said even hearing whispers of potentially bad behavior was rare, and far outweighed by the added efficiencies.

He considers the program a huge success, not only in terms of the immediate and long-term value it provided the hospital, but also in serving as a springboard to his own career.

“It can light a fire into someone’s career and serve as a catalyst,” he said. “It certainly was a catalyst in my career, and now I’m doing things where the approach is very similar but the scale is much different and much bigger.”

He said the Rappaport Award is particularly important in that it provides a form of validation during a relatively vulnerable time in a doctor’s career. Residents are not yet well-paid despite their long, arduous shifts, and they are physically at the front and center of everything. It is that particular insight that makes them perfect candidates for a prize focused on value.

“They have a great vantage point,” Dr. Figueroa said. “They can see all of the different problems in the health care system.”

And although his lens has broadened, those problems are still the ones that come into focus for him during his research work today.

“I’m interested in trying to increase the value of health care to provide a better patient experience, while at the same time trying to do something about our really expensive costs,” he said. “We pay a lot of money in this country relative to other countries, but yet we’re not achieving the same outcomes that other countries are doing with fewer dollars.

“I’m applying the same principles I used during that project at a national and international level.”

Dr. Figueroa is a busier man today, certainly, than he was in those care-free days crossing the border between Eagle Pass and Mexico, and his responsibilities have recently expanded to include his first child, complementing a family that includes nine nieces and nephews in the Houston area.

He wants his family’s children, and all children, to grow up in an environment that eventually levels the playing field when it comes to the way families of different means interact with the health care system. It’s what he discovered in Texas, it’s what was reinforced with his Rappaport Award, and it’s what he spends a majority of his days working on now.

“That’s been my main motivation,” he said, “to try to improve care for a lot of people who grew up like I did.”