NEW YORK CITY—Health systems are increasingly investing in programs to address "social determinants" in healthcare like food and housing insecurity. But too often those efforts are still too fragmented to make the intended impact.
That was the message from executives from Kaiser Permanente, Dignity Health and Centene, who said their own organizations have put money into these traditionally nonclinical areas of patients' lives but see a wider industry struggle to properly scale these efforts.
There needs to be a strategic shift in thinking in order to leverage the full impact of these programs, they said during a recent conference in New York City hosted by Unite Us, a technology company that provides social determinants of health software.
“We’ve done some really good work, but it was really random acts of kindness,” said Rich Roth, chief strategic innovation officer at Dignity Health. “We have now become more focused and directed and shifted that community benefit model to one of community health.”
As the healthcare industry transitions to value-based care, inclusive of risk-based payment and population health models, health systems are taking on more accountability for the health of local communities. Healthcare organizations like Kaiser Permanente, Dignity Health and Centene have a number of social determinants of health initiatives, but the long-term goal is to address the root causes of hardship and poor health in their communities, the executives said.
A strategic challenge most health systems encounter is trying to build a business case showing a return on investment based on reduced cost or improved health outcomes, they said.
A Deloitte survey examining social determinants initiatives at hospitals and health systems found that most activities were fragmented and only reaching some targeted populations. Hospitals cited a lack of sustainable funding as a key barrier, according to the survey. When asked which data would spur additional investment in these initiatives, 51% of hospitals said evidence of cost reductions and 48% selected evidence of improved outcomes.
“I’m being asked, with regard to the business case, are you going to reduce total cost of care in your organization? And there’s not a lot of literature, so what do you base that on?” said Sarita Mohanty, M.D., vice president of care coordination for Medicaid and vulnerable populations, national Medicaid at Kaiser Permanente. Recounting conversations she had with Kaiser Permanente's eight CFOs, Mohanty said, “They said, what about customer retention? We’re a health plan, do you think this will change member or patient experience and lead to customer retention? So, let’s monitor that, I said. Let’s think about the different aspects that could be looked at and how we can use informed data to make some critical decisions.”
"We’re still learning, we’re going to iterate and that’s going to inform our strategy. We’re going to share those learnings and partner with other agencies and entities in the community as we learn," Mohanty said.
Changing payment models can support social determinants work
Evolving payment models and the ongoing transition from fee-for-service models to value-based payment models represent an opportunity to help move these initiatives forward, the executives said. Speaking to how social determinants projects are funded now, Roth said, “It’s a smattering right now—it’s grants, it’s loans, it’s occasionally one of the several health plans in the market might pay for it.”
“What I’m excited and hopeful about is that as health systems move to more value-based care, whether that’s managed Medicare, Medicaid, or even commercial products, that the more risk that is allocated to the system, amongst the providers, the better outcomes will be,” he said. He pointed to the Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement initiative as an example of a payment model in which providers are incented to work with post-acute care facilities to better coordinate care.
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Addressing social determinants of health is not just a Medicaid or low-income Medicare problem, Mohanty said. “Kaiser found that 30% of its commercial members fall at or below the 200% federal poverty levels. Organizationally, when that was recognized, people took a pause,” she said. “Employers are going to have expectations as well, about how are we helping our members and patients become more self-sufficient and how do we support them.”
The broader goal, many healthcare executives say, is to address the root causes of social issues, such as unemployment and inequity in communities. Centene, a managed care organization with 14 million members, is trying to make headway in that area.
After protests broke out in Ferguson, Missouri, five years ago, triggered by community anger over police shootings, Centene built a new claims center in the city with the purpose of creating up to 200 new local jobs with healthcare benefits, said Laura Sankey, VP of product strategy and social determinants of health at Centene.
“Jobs was one of the drivers of that. We’re looking at innovative solutions,” she said, also pointing to Centene’s partnerships with correctional facilities with the aim of reducing recidivism.
Mohanty said, “At Kaiser Permanente, we’re screening for food insecurity and connecting people to food banks, and that’s addressing the social need, but that’s not really tackling the larger, pervasive issues around poverty and unemployment. It’s about recognizing that and thinking not only about our delivery system investments, but how does it impact communities as a whole? That’s going to be our road map."
“It is about integration with the clinical, mental and social; that is the essence of what we’re trying to achieve," Mohanty said.