It’s funny what eliminating silos in health care spending will do. The Patient Protection and Affordable Care Act (PPACA) ushered in an era of health care spending that prohibited preexisting condition clauses, eliminated annual and lifetime limits, institutionalized parity for behavioral health conditions in more coverage, brought population health to hospital systems via accountable care organizations (ACOs), and created a path to reducing the number of Americans without insurance. And, suddenly, we have more attention to the social determinants of health and the importance of funding social services to reduce health care costs (see Social Determinants Of Health & Medical Homes).
But there has been more talk than action on this issue. With health homes we’ve seen some movement for health care organizations to coordinate with social service agencies – both health homes (see How Are Medicaid Health Homes Reimbursed For Services?) and ACOs are doing more to coordinate consumers’ social service needs (see What Are The Different Medicaid Performance & Reimbursement Models For ACOs?: An OPEN MINDS Market Intelligence Report). And some health insuring organizations are giving grants to social service agencies to support social services (see The Health Care/Social Service Seesaw and Making The Connection Between Health Care Costs & Social Support Services).
But payment by health plans for social services has been off the table with “medical necessity and clinical appropriateness” as the fundamental definition of what to pay for. A couple years ago, we had several states try (and fail) to get CMS to pay for housing (see Is Housing Health Care? and Health Care Spending Vs. Social Service Spending).
But are we seeing a crack in the wall between health care and social services? You might think so if you listened to former Oregon Governor John Kitzhaber’s recent speech on September 29 at the annual State of Reform conference in Portland. Governor Kitzhaber called for a shift in Oregon Medicaid’s waiver spending to focus more on social support service. The proposal he supports calls for earmarking 5% of the state’s Coordinated Care Organization (CCO) spending for social services, with the percent of spending on social services gradually increasing to 25% over time (see Kitzhaber Returns from Exile to Target Social Determinants of Health). This plan and others like it may or may not be adopted, but it points to a trend we’re seeing across the country — states, managed care organizations (MCOs), and provider organizations are coming to recognize the importance of social determinants of health.
An early proponent of addressing the social determinants of health has been Arthur C. Evans Jr., Ph.D., commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS). In his keynote address at The 2015 OPEN MINDS Performance Management Institute (see Tending To The Social Determinants Of Health – Or Not) he spoke of Philadelphia’s approach to addressing social determinants of health and their success.
Dr. Evans recently noted that the Philadelphia DBHIDS “literally saved millions of dollars” through reinvesting in a broad range of services and programs that address social determinants of health, like homelessness and housing. Moreover, the savings generated allowed the organization to increase its investment in population health strategies, like Mental Health First Aid training — and deliver it free of charge to people who live, work and study in the city of Philadelphia. He said:
It’s much more cost-effective, we have better outcomes, and we get people off the street. It’s a win-win-win for us, because we’ve gotten efficiencies through addressing social determinants of health, resources were freed up that otherwise would have historically gone into treatment.
Traditionally, mental health systems have only focused on people once they have a diagnosis. The problem with that is we spend little of our resources intervening earlier. For the person who’s experienced a traumatic event, there’s literally no intervention until the person develops PTSD, and then they can be treated. Too often, those are things we don’t pay attention to in health care. We spend a lot of time thinking about biology, genetics, and viruses, but we don’t think as much about stress, poverty, or any other social or economic factors that influence our health.
The more of those events you have in early life, the more likely it is you’ll have health problems like diabetes, cardiovascular disease and those kinds of conditions, but also mental health disorders and social problems like homelessness. This is probably some of the clearest evidence that what’s happening in our social environment can have a direct impact on our health later on in life. What we’re saying is that we ought to be going upstream to lessen the likelihood that someone is going to develop a mental health and/or a substance use challenge, and educate people so they’re seeking out and getting help at an earlier point in time.
For more on how payers and health plans are addressing social determinants of health – like access to housing, nutrition, and adequate social supports – check out these OPEN MINDS resources: What Services Are Available For Nutrition Assistance & What Is U.S. Spending On Those Programs?: An OPEN MINDS Market Intelligence Report and What Income Assistance Is Available To Consumers Through TANF & How Does It Vary By State?: An OPEN MINDS Market Intelligence Report.
And to get an update on Philadelphia’s cutting-edge program for addressing health with an integrated approach to social determinants, don’t miss Dr. Evans in Understanding The Role Of Social Determinants In Population Health Management, a free PsychU virtual forum on November 17 at 12:00 p.m. EST. You can also follow Dr. Evans on Twitter @.