Social determinants of health: Can we reach for the stars?

I always liked the idiom, "reach for the stars." But, as the young child demonstrates, as we reach for the stars, we need to remember to keep our "toes" on the ground. This caveat is especially relevant in our goal to address social determinants of health in a sustainable manner.

--- Tom

As discussed in my last blog to effectively address the social determinants of health in a financially sustainable manner the following needs to occur:

• A targeted population (Medicaid recipients)
• A primary care medical home hub (i.e., community health centers)
• A seamless collaborative support network ( Accountable Health Communities ; Accountable Care Communities; The Pathway Community Hub)
• Sustainable funding sources that incent stakeholders to focus on a healthy community (No shortcuts, you need to read this blog to get this answer)

Effectively addressing social determinants of health will require unprecidented community collaboration and teamwork

 As we have discussed in my first and second blog on social determinants of health, effectively addressing the social determinants of health will require seamless collaboration between multiple stakeholders at the community level.

As stated in my second blog, this collaboration becomes even more difficult since each of these stakeholders has its own primary mission as well as its own challenges in achieving success and survivability of its organization or entity, especially in these disruptive times of healthcare.

How, then, can we harness these multiple stakeholders, which has its own focused mission, to be part of a comprehensive and coordinated strategy to address the social determinants of health at a community level in a sustainable manner?

In today's blog, we will first look at various models of collaboration that are currently being utilized in communities around the country. What can we learn from these models and what "ideas" would make sense for your community?

CASE STUDIES AND MORE: What "ideas" would make sense for your community?

MINNESOTA's Accountable Communities for Health :

"The Minnesota Accountable Health model, and the structure of an ACH, is built on the work of community care teams. These are locally based teams that partner with primary care practices, hospitals, behavioral health, public health, social services, and community organizations to ensure strong, coordinated support for the whole patient. In 2011, Minnesota competitively funded three community care teams—Ely, Mayo, and HCMC—to learn how communities and a broad group of providers could work together effectively. A video from Ely shows how community partnerships created healthy futures. The three original community care teams received sole-source ACH funding in late 2014."

Additional information relating to Minnesota's Accountable Health Model:

• Accountable Communities for Health: Perspectives on Grant Projects and Future Considerations’ Report (October 2016)
• SHADAC Brief Examines Minnesota's Accountable Communities for Health
• Access the SHADAC issue brief, "Minnesota's Accountable Communities for Health: Context and Core Components."

MASSACHUSETS

This article explores a pilot initiative delivering nutritious, “medically tailored” meals to Massachusetts residents who are dually eligible for Medicare and Medicaid. The researchers found that beneficiaries who received the meals experienced fewer trips to the emergency department (ED) than their counterparts in a control group did.

COLORADO

"The Accountable Health Communities Model (AHCM) is an opportunity to test, over five years, if systemically identifying and attempting to address the health-related social needs (housing, food, utilities, safety, transportation) through referral and community navigation can reduce healthcare costs, inpatient and outpatient utilization, and improve healthcare quality and delivery. This PowerPoint presentation provides a brief overview of the project.

Western Colorado was selected as one of thirty-two sites across the country to participate in this Center for Medicare and Medicaid Innovation initiative from May 1, 2017 to April 30, 2022."

CINCINNATI

"Cradle Cincinnati has worked to reduce infant mortality through the work of a cross-sector collaboration of hospitals, government agencies, social service organizations, philanthropy, and community advocates. The Pathway HUB model, launched in Cincinnati seven years ago by HCAN (a community social service organization, Health Care Access Now) will be the platform for referrals, training and data collection for the community health workers (CHWs). CHWs will work out of four care coordinating agencies."

A REVIEW OF LITERATURE:

• "Elements of Accountable Communities for Health: A Review of the Literature"

ROBERT WOOD JOHNSON FOUNDATION - Leading the fight to address the social determinants of health:

• Robert Wood Johnson Foundation Policies for Action
• 2018 Call for Proposals: Robert Wood Johnson Foundation

POTENTIAL FUNDING SOURCES (FINANCIAL & IN-KIND) TO ENSURE SUSTAINABILITY:

Stakeholders identified below all have the ability to contribute funding (financial and in-kind) to support the sustainability of community efforts to address the social determinants of health. Also, as noted below, each of these stakeholders, using the health economics concept of self-interest, have a vested interest in addressing the social determinants of health (even if they may not currently recognize it).

1. Medicaid Managed Care Plans:

• Medicaid Managed Care Plans can play a primary role in addressing the social determinants of health in a financially sustainable manner. Their ability to help financial support initiatives that focus on the social determinants of health was discussed in my last blog.
• As noted in my blog on long-term care and the elderly, seniors are especially vulnerable and it is critical that we address their social determinants of health in a focused and sensitive manner.
• Self-interest: The key to Medicaid Managed Care Plans proactively addressing the social determinants of health starts with their contract with the state. The contract is based on some form of capitation which provides the needed financial incentive to Medicaid Managed Care Plans to look at innovative ways to keep their members healthy. The healthier their assigned Medicaid members, the more profit for the Plan. There will also be contractual incentives and terms that will require Plans to address the social determinants of health in an effective manner as part of their relationship with the state.

2. State government:

• Most states have a constitutional requirement for a balanced budget.
• Self-interest: In Ohio, for example, Medicaid represents approximately 20% of the state budget and, from an opportunity cost perspective, what better way to address these costs than to enter into risk arrangements with Medicaid Managed Care Plans! States from a self-interest perspective, want Medicaid Managed Care Plans to succeed and they are very willing to provide them with additional tools to assist in that goal. One of those tools is the ability to address the social determinants of health which, in turn will keep the Plan's Medicaid members healthier and less costly.

2. Medicare Advantage Plans:

• Medicare Advantage Plans now have the ability to expand their reach to address social determinants of health.
• Currently 33% of seniors are enrolled in Medicare Advantage Plans, and many predict that enrollment could increase to the 50% range within the next five years as a result of demand for this option by the baby boomers.
• Self-interest: Similarly to the Medicaid Managed Care Plan arrangement with the state, Medicare Advantage Plans enter into a capitated arrangement with the Center for Medicare and Medicaid Services (CMS). As noted above, Medicare Advantage Plans now have the ability to address the social determinants of health from a payment perspective. There will also be contractual incentives and terms that will require Plans to address the social determinants of health in an effective manner as part of their relationship with CMS.

3. Center for Medicare and Medicaid Services (CMS) :

• CMS has been a catalyst in providing partial funding for innovative initiatives such as Accountable Health Communities (AHCs) , Accountable Care Communities (ACCs) and The Pathway Community Hub
• Self-interest: The combination of the extension of life of our seniors and the onslaught of baby boomers into the Medicare ranks have created a financial necessity for CMS to address the short- and long-term costs of the program. What better way to address these costs than to enter into risk arrangements with Medicare Advantage Plans! CMS from a self-interest perspective, wants Medicare Advantage Plans to succeed and it is very willing to provide them with additional tools to assist in that goal. One of those tools is the ability to address the social determinants as part of their contractual relationship with CMS.

4. Health Insurance Plans:

• Health plans use the National Committee for Quality Assurance (NCQA) and their Health Effectiveness Data and Information Set (HEDIS) tool to evaluate their performance on a variety of different aspects of services.
• NCQA has updated current HEDIS performance measures for plan year 2019 and added new technical specifications for population health metrics
• Self-interest: CMS applies its star rating system to distribute bonuses to health plans that achieve 4- or 5-star ratings. Effectively addressing the social determinants of health as part of the population health metrics will help the plan achieve its 4- or 5-star ratings as well as the resulting bonuses.

Local governments:

• Local governments (city and county) have the ability to provide funding and in-kind services through local agencies such as health and social services departments.
• Self-interest: Local governments (city and county) have a vested interest in maintaining a healthier community. Cities and counties have services and people (social services, health departments, etc.) under their control that could play a major role in achieving a healthier community. They also have the ability to assist in funding initiatives that would support a healthier community.

5. Hospital systems:

• Historically, hospitals have thrived as a result of our "sick care" system. As a society, we recognize that not only can we not continue to financially support a "sick care" system, we also recognize that a healthier community is a less costly community. Hospitals are beginning to recognize that they need to look outside their historical walls and silos and begin to focus on the health of their surrounding community.
• As a tax-exempt non-profit entity, hospitals are also required to provide "Community Benefits" Historically, much of the support for the Community Benefit requirments was achieved by providing care for the uninsured. There is now a recognition by many that a core objective of the Community Benefit requirements should be redirected to outside of the walls of the hospitals, specifically to the community.
• Hospitals are beginning to embrace this external role, but more can be done, especially with regard to collaborations with other community hospitals as well as regional initiatives directed at the social determinants of health.
• Self-interest: As noted above, there is a societal recognition that we need to evolve from a "sick care" system to one that is a true "health system." A key component of this evolution will be the transition from a fee-for-service payment system to one that is risk/value-based. Given this transition, hospitals have a vested interest in playing a proactive role with other stakeholders to achieve a healthier community. A healthier community will not only expand the hospital's focus outside of its walls, but will also allow it to better achieve financial success in a risk/value-based world.

6. United Way Plans:

• United Way Plans play a critical role in our communities by addressing the needs of our vulnerable populations.
• United Ways Plans, as a result of their trusted position in the community, are increasingly playing a leadership role in facilitating collaborations. An example of local United Way leadership is "United Way of Greater Cleveland"
• Self-interest: United Way Plans have a vested interest in leveraging their existing role and funding to better serve the vulnerable population within their community.

7. Health Foundations/Community Foundations:

• Findings from a recent study (Health Affairs Blog post) show that thirty-three health foundations are addressing SDOH with their grant-making and through additional strategies such as capacity building, convening, policy research, and agenda setting. The study focused specifically on health conversion foundations, which are formed with the proceeds that arise from the sale or acquisition of a nonprofit health organization.
• Community Foundations can also play a critical role in both funding and fostering collaborations between the critical local stakeholders.
• Self-interest: Foundations have a vested interest in leveraging their existing role and funding to better serve the vulnerable population within their community.

8. Academic Institutions:

• Universities can bring in expertise and skills as well as other resources to strengthen the work of community collaborative hubs within our communities.
• Additionally, universities and community college can foster training opportunities for their students in health care and social services agencies within their communities.
• Self-interest: Just as hospitals need to focus outside their walls, so too do academic institutions. Going outside their walls will not only increase the stature of academic institutions within a community, but will also provide their students with real-world experiences that would not be duplicated in a classroom setting.

9. Chambers of Commerce & Economic Development Corporations:

• Chamber of Commerces promote the interests of businesses in a particular geographic area and Economic Development Corporations focus on longer term economic growth by attracting new businesses.
• Self-interest: Both of these organizations have a vested interest in a healthier community. There is a clear linkage between the health and economic stability of a community both on a short- and long-term basis. Also, a key factor in addressing the social determinants of health are jobs. Especially helpful would be the facilitation of job training opportunties.

How can we incent the stakeholders to "reach for the same star" vs. their own star?

As you can conclude from the brief overview of stakeholders above, finding the needed resources (financial and in-kind) is probably less of a concern than one would expect. The real challenge is effectively using those resources in a sustainable manner to address the social determinants of health.

As stated previously in this blog, each of the above stakeholders has its own primary mission as well as its own challenges in achieving success and survivability of its organization or governmental or non-governmental entity, especially in these disruptive times of healthcare.

Given this, the stakeholders noted above would not continue to support initiatives to address the social determinants of health unless it can be demonstrated that they are working to address the societal health needs of their population. These stakeholders would also need to know that their funding (financial & in-kind) is being used in an optimal manner to address this goal of a healthier community.

Each of the above stakeholders already addresses social determinants of health to some degree. The problem is that most of them do it in a silo as well as with various levels of commitment. Addressing the social determinants of health in a silo is not only not effective, it is not an optimal use of organizational and community resources.

We have previously discussed in this blog and a prior blog how Accountable Health Communities (AHCs) , Accountable Care Communities (ACCs) and The Pathways Community HUB model could potentially play key roles in facilitating collaboration and focus between the local stakeholders.

But, even if there are multiple sources of financial and in-kind funding for AHCs, ACCs, and Pathways HUBS, what can be done to ensure this collaboration will be sustainable in the long-term and that it is done in a cost-effective manner?

As I have repeatedly addressed in prior blogs, the historical lesson learned is a "healthcare system is shaped by what you pay for and how you pay for it."

The "what and how" of these payments, from a self-interest perspective, will act as the glue to ensure sustainability of the community initiatives that are focused on addressing the social determinants of health in a cost-effective manner as well as provide incentives to break down the silos within and outside the walls of healthcare.

Time to look at Capitation, not Decapitation, ... Sorry!

As I have discussed in prior blogs, I am a big believer in risk/value-based reimbursement to both incent cost-efficiencies and achieve positive outcomes. Ultimately, we need to realign the self-interest of the key stakeholders identified above so that they all benefit from reaching for the "same star," that is, a healthier community. And capitation in different forms may provide the necessary financial incentives to achieve both of these goals.

A number of research initiatives have tracked the potential success of payment strategies in addressing upstream prevention and population health. One such research initiative ("Implementing Social Determinants of Health Interventions in Medicaid Managed Care: How to leverage existing authorities and shift to value-based purchasing") was done through a collaboration between AcademyHealth, Robert Wood Johnson Foundation and Nemours Children's Health System. These three organizations have collaborated on some ground-breaking work in the area of social determinants of health.

What I particularly like about this research study was the tie-in between value-based purchasing which is impacting all sectors of healthcare and social determinants of health. Of particular note for me was their recognition that capitated or bundled payments to cover a portion of a social determination of health intervention was an appropriate step to ensure both better cost-efficiencies and quality of service delivered.

Per the report, "Medicaid Managed Care Plans could pay an upfront per-member, per month lump sum payment (capitation) to a Community Based Organization (CBO) partnership to cover community care coordination activities along with a fee-for-service reimbursement for delivered value-added services, subject to prior authorization. The partner would be financially accountable if costs exceeded the payment. However, this payment model should also be linked to quality of service delivery or outcomes achieved, in line with the principles of VBP wherein payment is connected to quality or outcomes."

"There are a couple of additional considerations for Medicaid Managed Care Plans in determining the most effective approach. First, Medicaid Managed Care Plans should consider ways to structure payments so that they cover the associated service delivery costs (e.g. delivering asthma remediation services) with the goal to reward partners for delivering services that lead to specific outcomes (e.g. reducing uncontrollable asthma). This is particularly important to consider if partnering with non-profit Community Based Organizations (CBOs), which may not be capable of assuming financial risk for expenses associated with service delivery."

While I agree that a non-profit CBO may not be capable of assuming financial risk, there must still clear accountabilities on the part of the CBO related to both outcomes and cost-efficiencies that would be tied to financial incentives.

Concluding Comments:

As noted in the above collaborative research there needs to be a tie-in between value-based purchasing and social determinants of health, but we cannot stop there. Ultimately, to achieve a sustainable healthier community, we cannot just narrowly focus on the social determinants of health, we also need to focus on the broader community.

The transition from fee-for-service to risk/value-based reimbursement needs to impact all sectors of healthcare. Payers (both government and non-governmental) recognized this and are moving in this direction, but they need to do it at a faster pace.

As I stated in my second blog on social determinants of health, we need to unleash the power of "self-interest" through payment systems that are risk/value-based. As long as providers are mostly paid under a fee-for-service system, we will continue to have a "sick care" system.

The power of "self-interest" takes over when Medicare (through Medicare Advantage) and Medicaid (through Medicaid Managed Care) primarily reimburse providers of care with a risk/value-based payment methodology (ideally capitation) which redirects the providers focus to health.

When you then add employers to the mix with both risk/value-based payment methodologies, value-based benefit designs and increased utilizations of cost and quality transparency tools, you now have the necessary ingredients for a healthier community for all.

Thomas Campanella is the director of the Health Care MBA and an associate professor of health economics at Baldwin Wallace University near Cleveland, Ohio.

If you are interested in receiving a monthly summary of all of my healthcare blogs, you can respond to me on LinkedIn or e-mail Tom Campanella ([email protected]) with your contact information.

Source of pictures: pixabay.com & pexels.com