Kaiser Permanente said it would put $200 million toward initiatives targeting housing insecurity and homelessness.
Geisinger is scaling up what it calls its Fresh Food Farmacy program—set up to help patients get healthy foods—with a digital app. And last year, RWJBarnabas Health partnered with Horizon Blue Cross Blue Shield of New Jersey to address social factors of health such as maternal mortality.
According to researchers, SDOH programs accounted for at least $2.5 billion of spending, the bulk of which focused on housing insecurity ($1.6 billion) and employment ($1.1 billion). The remainder was spread across areas including education, food security, social and community context and transportation.
While those numbers are substantial, it’s hard to put them into context, acknowledged study author Leora Horwitz, M.D., an associate professor in the Department of Population Health at New York University Grossman School of Medicine.
“The optimist in me—and I am an optimist—says that 10 years ago this number would have been zero probably, or close to it. So the fact that we see many health systems, not just a couple high-profile ones, investing their own funds in upstream social determinants of health work that has nothing to do with healthcare—that’s about jobs or housing or food—is really new and encouraging,” she says.
On the other hand, the industry reports more than $60 billion a year in overall community benefit spending, which historically has included subsidized care, subsidized teaching, health fairs and screening and referral programs. Although the study identified 78 distinct programs involving 917 hospitals, only 57 of the country’s 626 health systems committed funds to address social determinants directly.
No for-profit health systems participated.
In that light, $2.5 billion may look like a drop in the bucket. But Horwitz points out that the entire concept of health systems getting directly involved with community programs somewhat outside their core competency covers relatively new and uncharted territory. In addition, the effects of such programs could be difficult to measure via traditional healthcare metrics and may not even become noticeable until decades after their implementation.
“We know surprisingly little about the impact these programs have on outcomes or health spending or on collective return on investment, in large part because they’re so far upstream,” says Horwitz.
That lack of information on return on investment may explain for-profit systems’ reticence to get involved to date. The study notes that, while the absence of those institutions suggests health systems don’t see a clear path to direct financial return, most of the systems making these investments are in Medicaid expansion states, the Centers for Medicare and Medicaid Services' Bundled Payments for Care Improvement initiative or accountable care organizations—meaning they would stand to benefit from reductions in healthcare expenses.
“On balance, it seems to me that people are largely not doing this for anticipated substantial ROI,” Horwitz said. “I think they’re more often doing it for a sense that it’s the right thing to do and that they hope it will be beneficial in the long run.”
The long-term amount and viability of direct spending on SDOH will require further study to determine what works, how it works and where the benefits accrue. That process may require some additional work to establish a baseline as well. Horwitz points out that before this study, no data set existed at all—the numbers in the study itself came from monthly searches of local newspapers. Further complicating matters, health systems only have to report overall community benefits as a global number, without breaking out spending on specific programs. As a result, even small, simple policy tweaks could be enough to keep the ball rolling in the near term.
“It was striking to us how hard it was to find the information—a simple policy fix or intervention could be just some mechanism of reporting and tracking,” Horwitz suggests.