Two health care “megatrends” have put a new spotlight on the social determinants of health. First, there is the Patient Protection and Affordable Care Act of 2010 (PPACA) rule changes that eliminate pre-existing condition clauses and lifetime limits in health plan coverage. Second, there is the move from reimbursing provider organizations from pay-for-volume and pay-for-value. Why the new spotlight? Because, the focus of health care has shifted away from both moving consumers from plan to plan, and providing lots of services for conditions that were most likely preventable.
The concept of social determinants of health is that there are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (for more, see Social Determinants of Health). There are five key categories on a “social determinants of health” continuum, including economic stability, education, social and community context, health and health care, and neighborhood and built environment.
Typically, the U.S. health care system has focused just on the single health care category – and not the other four factors. But, as Arthur C. Evans pointed out in his keynote at 2015 OPEN MINDS Performance Management Institute, most of health care costs are due to non-health care factors (see Improving Population Health Management With Public Health Approaches). Of the factors that influence health status (and by extension health spending) only 10% are within the control of the health care system. By far, the largest factor that effects an individual’s health is lifestyle (51%), followed by genetics (20%), and the environment (19%) (see Moving Beyond The 10% To Be A ‘High Value’ Organization). Despite these statistics, the U.S. spent $2.9 trillion on health care in 2012 – but only $318.2 billion on social services in 2012 (see Health Care Spending Vs. Social Service Spending).
But innovative health care organizations are developing models to address the social determinant of health in conjunction with managing health care. Three examples of these types of programs include:
Health Leads – The Health Leads program, sponsored by Health Leads, attempts to address the social determinants of health by allowing doctors to write “prescriptions” for social services – such as heat, food, or housing. Prescriptions are filled by consumers at the Health Leads desk located within the office. Health Leads Advocates help consumers “fill” those prescriptions by locating services in the community, helping to complete applications for those services, and securing transportation to services.
Funding for the program largely comes from grants and donations, which are used to get the program up and running in new clinics. Because Health Leads is not providing social services, but acting as a referral agency, the cost of social services for the consumer is entirely the responsibility of the organization providing the service. Additionally, the program relies on college students who volunteer their time to act as Health Leads advocates and clinics with a Health Leads program must finance the cost of a program manager. The program is active in seven cities across the country.
Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP) – The NeighborhoodHELP program, managed by Florida International University (FIU), sends teams of FIU graduate students from a variety of backgrounds (including medical, social work, nursing) out into the community to provide primary care, legal advice, Medicaid/Medicare enrollment, and utility bill help to families. Students generally provide services and supports to the same one or two families for the duration of their time at FIU. For services that cannot be provided by the students, the program has linkages to over 120 organizations in the community that can provide those services.
Funding for the program is largely provided through grants and services are provided by FIU students who are required to participate in the program as part of their education. Additional social services are provided by government agencies and non-profit organizations. The program is based in Miami-Dade County.
HealtheRx – The HealtheRx program, developed by University of Chicago South Side Health and Vitality Studies, uses a database integrated with EHRs to link individuals with social services. Like the Health Leads program, doctors are able to prescribe services, such as fitness programs and healthy eating, to individuals who visit the clinic. At the end of the appointment, a list of provider organizations and services close to the patient’s home is generated based on the doctor’s prescriptions. The prescriptions also contain a code that individuals can use to view relevant services on the HealtheRx website. Additionally, individuals are given contact information for a community health specialist that can help link them to services if they are interested.
The program is funded completely by grants and donations, including a $5.8 million Health Care Innovation Award from the Centers for Medicare and Medicaid Services (CMS). According to the Health Care Innovation Award description, the program is projected to save $6.4 million over three years due to better population health, increased compliance with care, and fewer visits to the emergency room. HealtheRx is a non-profit organization located in the South Side of Chicago.
Are these the programs of the future? I believe the answer is yes – with one big caveat: funding. These three programs are being funded primarily through grants and donations, which isn’t sustainable on a large scale. However, with better “big data” and the use of practice-based evidence analysis, these programs will become the living laboratories for sorting out which investments in social determinants of health make clinical and financial sense for health plans and provider organizations in this new reimbursement environment (see Social Determinants Of Health & Medical Homes).
As we continue to have a national discussion on lowering health care costs and improving health care quality, how we address the non-health care needs of consumers is sure to be important, and health and human service organizations must consider how to better coordinate the social service needs of consumers into their models. For little proactive reading on this topic, check out TACOs, Anyone?, and Transformation Practice Guidelines for Recovery and Resilience Oriented Treatment, published by Philadelphia Behavioral Health Services.