More Dollars for Social Determinants Leaves Less for Delivery Team Members

The movement to have practices or hospitals address social determinants seems like another good idea, but we should examine this closely. What is the most important element of areas such as primary care or mental health delivery?

Social determinant dollars for housing or food appears attractive at initial examination, but can defeat team members and their ability to innovate.

Most important are supportive practice environments that enhance the one on one innovation with each patient. Designers have long ago forgotten that that the only innovation in health care that matters is this one on one interaction. This is disappearing via the financial design.

For decades the policies and payments have been shaping fewer and lesser delivery team members. This is a move away from the heart of health care delivery. See in this geographic rendition how 45% of patient complexity is packed into 40% of the population because of concentrations of poor, elderly, disabled, and worst social determinants. This is made worse with the worst quality health insurance concentrations specific to populations that are poor, elderly, disabled, or packed with worst employers. The payments in 30 states and 2621 counties are lowest across Medicaid, Medicare, and private insurance. High deductibles complicate the problem. Only 25% of primary care, mental health, women's health, and basic surgical workforce is found in these counties.They are supported by less than 20% of spending in each - shaping fewer and lesser. Relatively higher costs hurt these practices that tend to be small and medium size. The result is less than 20% of spending in each area to support just 25% of the workforce. Compromise by design has been present for decades, but with worse to come.

If Medicaid had superior funding and if delivery team members with concentrations of Medicaid patients had great support and billions were added for social determinants - there would not be a problem. But this is not the case.

In fact, dollars going to practices are decreasing. Costs of delivery related to inflation and new technology are going up. Micromanagement focus adds new areas with increases in costs of delivery for each area. Now we have another assumption from far outside of practices that is untested and is a preferred innovation and waiver area (Fire Ready Aim).

Will the Focus on Social Determinant Interventions Actually Sustain Improved Outcomes? Can We Reverse Decades of Different Influences Shaping Differences in Populations?

Medicaid and Dual Eligible patients are commonly most behind in social determinants, workforce access, outcomes, and many other areas. They have been behind for years or decades or generations of life influencing events. Now the focus is on last minute, costly interventions that have yet to demonstrate value. Can one or two areas addressed, reverse a lifetime of influences? There is little logic in such and intervention.

Of course American health care has a major theme of too little, too late, at highest cost, for little change in outcomes - and the social determinant focus appears to be a good fit.

Where Will the Dollars for Social Determinants Come From?

This is obvious. Diversions of Medicaid dollars away from those who deliver the care have continued for decades. This will worsen the diversions.

Medicaid is grossly underfunded. It only pays 70 - 80% of the cost of delivering care in Community Health Centers according to NACHC studies. Medicaid causes fewer and lesser delivery team members in CHCs and where Medicaid populations are concentrated. Medicaid is one of the biggest reasons for limitations of CHCs and similar practices

So now Medicaid dollars are being diverted to pay for housing, food, etc. You cannot divert dollars to another area and not impact dollars going to practices, hospitals, and the delivery team members that are the biggest portion of their budgets

Not Only Lesser Support for Delivery Team Members, but also Added Tasks

And you are asking delivery team members to add new tasks to help arrange contacts for housing, food, etc, despite being fewer and lesser already. Can you see that this will facilitate burnout, turnover, lower productivity and worse? There is little indication that this will change outcomes.

The Inside Out Perspective

You can see this is you see from inside of practices, but CMS has not done this for 40 years. Only 1965 to 1978 did they add new billions initially and annually to build up practices and hospitals where most Americans most lack care

CMS needs to pay attention to the inside and process of care impairments. Miller and Crabtree alerted us that practices had to make very specific choices in order to maintain their primary care missions - which required better funding to support the process of care and delivery team members. Shifting Implementation Science Theory to Empower Primary Care Practices by William L. Miller, Ellen B. Rubinstein, Jenna Howard and Benjamin F. Crabtree in The Annals of Family Medicine May 2019, 17 (3) 250-256; DOI: https://doi.org/10.1370/afm.2353 at https://www.annfammed.org/content/17/3/250.full.pdf+html

Inside out is also seen in other articles. Small and medium size practices are more likely to be disrupted by changes in key personnel, EHR, billing, location, ownership, and other changes. These can be costly and can contribute to inability to adapt to any number of changes. In The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma by James W. Mold, Margaret Walsh, Ann F. Chou and Juell B. Homco in The Annals of Family Medicine April 2018, 16 (Suppl 1) S52-S57; DOI: https://doi.org/10.1370/afm.2201

What is the Evidence Basis? How Do Housing or Food Variables Relate to Better Outcomes? Is this a Dichotomous, Continuous, Threshold, or other Variable Relationship?

The fact of the matter is that this has not been well studied. Once again the Fire, Ready, Aim designs of CMS dominate as with DRG, RBRVS, value based, and other implementations made before ready for prime time. And the differences in outcomes seen in studies fail to explain away the alternative that they were about population differences being compared instead of some intervention.

Quality is indeed found in the matrix of relationships as Deming noted. But outcomes are more about complicated matricies of relationships that interact at the patient, family, neighborhood, employer, practice, and population levels. Humans individually are complex, but with multiple humans, groups, and numerous variable differences - a huge problem.

What seems to be consistent is that humans most behind have worst outcomes - and they have numerous other social and non-clinical factors stacked against. Changing numerous variables is likely required.

For example, when you choose housing as an intervention, this may not be the best for the individual involved. And over a 2 year period, the impacts of an intervention may not be sustained as with so many clinical interventions.

When you look at the US population as a whole, there are even more complications when pushing social determinant interventions.

Social determinant focus also exposes value based designs. It appears that social determinant, genetic, and non-clinical factors dominate. So why would you want value based designs. Why should practices and hospitals be punished because they served populations most behind?

And why try to adjust for dozens of social determinant and other variables when the basics are not even well understood.

Massive Deficits of Social Determinants Exist

There is an assumption that small portions of Medicaid budgets can go for social determinants. This ignores the magnitude of disparities that exist in the US, and have been worsening since the 1980s across health care, housing, economics, nutrition, trade policies, and other designs.

The focus on rural or minority has hidden the fact of most Americans most behind while fewer get farther ahead. The social determinant differences are massive, and getting worse.

More studies demonstrate worsening of the American population as they age, get poorer, or get sicker or have family members who get sicker.

More studies demonstrate the inability of Americans to pay for basic costs of housing and living. (This forces them to leave places with concentrations of workforce and social support to go to 2621 counties lowest in both, the fastest growing counties where practices and hospitals are most being closed and compromised.)

Counties most behind depend upon just a few economic contributors for jobs, social determinants, and supports. Health care, education, government jobs, and social supports are more important for them due to weaker local employers. Health care funding discriminates against them via DRG, RBRVS, other CMS designs, state designs, and private payer policies. Counties with lower property value or less taxable land lose out in education based on property taxes. Government jobs are being cut or centralized away from these counties. Social supports are not keeping up and are constantly under attack at the state and federal levels.

As health care, prison, military, and debt overspending increase, the ability to invest in Americans and their social determinants and supports decreases at all levels - federal, state, local, employer, family, and personal.

In fact, as Medicaid Has Increased in Costs, it has actually been compromising the basic investments in social determinants and other investments in people.

Will We Ever Address Basic Health Access for Most Americans Most Behind?

See how the 2621 counties lowest in health care workforce have been increasing the fastest in population numbers, demand, and complexity (blue line) - given the characteristics of these counties. They also have 40 million rural people (75%) (light blue) that are slowest growing plus 90 million urban people (in red line or 32% of the urban pop) that are the fastest growing US population.

The hospitals and practices have been most closed and compromised where America is growing fastest and already has lowest levels of workforce, economics from health care, and local health care leadership.

You might want to address this long term chronic problem made much worse across 40 years of CMS policies, assumptions, and innovations.

File this New Social Determinant Innovation Away for Retirement. Stop Diverting Health Care Dollars Away from Those Who Deliver the Care!