Study: Health system's social needs program reduced utilization, but not enough to cover its high costs

An integrated county health system that spent more than $22 million on a social needs case management program for its adult Medicaid patients was rewarded with significant reductions in hospital admissions and a minor dip in emergency department visits, according to a new study published this week in Annals of Internal Medicine.

However, reduced utilization during the first year of Contra Costa Health Services’ (CCHS') case management program translated to roughly $3.4 million in hospitalization and ED cost savings—just 17% of the program’s one-year cost—casting doubts on whether the intervention is economically feasible even when considering its other potentially avoided downstream healthcare costs.

“Although social needs case management programs may reduce health care use, these savings may not cover full program costs,” researchers wrote in the journal.

San Francisco Bay Area’s CCHS, which operates a 166-bed regional medical center, a public health program, a health plan and other services for the county, developed a case management program in which its highest-risk Medicaid beneficiaries were supported by in-person, clinically licensed case managers and other community health workers. The program focused on social needs such as food or housing, developing and coaching patients through a care plan, and assisting with applications or referrals to care or other services.

CCHS enrolled 57,972 patients who were in the top 15% of risk for healthcare use into the intervention or control group. Only 40% of those in the intervention group engaged with the program, which the researchers said was typical for such social needs assistance programs but, due to study design, did not allow the researchers to measure the intervention’s impact specifically on those who engaged.

Rather, among the full intervention population, the researchers reported an 11% reduction in total inpatient admissions over the 12-month study period.

Greater reductions were seen in “avoidable” admissions (those for diagnoses such as hypertension that can be addressed with earlier intervention) and admissions among beneficiaries who self-identified as Black or African American, indicating that the program “may have had a more pronounced effect for this group, possibly by overcoming barriers to care, such as prior experiences of racism in healthcare settings,” the researchers wrote.

Reductions in the intervention group’s ED visits and avoidable ED visits were smaller and not statistically significant, according to the study.

Qualitative input from the program’s case managers suggested the intervention drove additional health and well-being benefits among the patients “and a possibility of outpatient care and efficiency gains, which would have implications for the program’s financial impact,” the researchers noted.

However, researchers noted that the $1,880 per patient (including the 60% non-engagers), per-year price tag and limited inpatient and ED return could limit the program’s reproducibility for other health systems.

“More work is needed to identify ways to increase patient uptake and define characteristics of successful programs,” they wrote.

Health systems’ interest in programs addressing the social determinants of health among their patient populations has grown in recent years. A 2020 Health Affairs study estimated these programs accounted for at least $2.5 billion in spending nationwide, with the majority of that spending ($1.6 billion) going toward addressing housing insecurity alone.

That number has likely increased since with major names like Kaiser Permanente recently ramping up their social impact investments in affordable housing and other social risk factors. Executive leadership from Cleveland Clinic, UMass Memorial Health and Boston Medical Center have also gone on the record arguing that community investments should be a key piece of a health system’s investment portfolio.