Bending the Trends

ADDRESSING THE SOCIAL NEEDS

As delivery system reform has progressed, payers and health systems are assuming greater financial risk for health outcomes. Even the highest performing health systems are finding the medical model insufficient to adequately constrain costs and improve health outcomes due to the social needs of their patients. Failure to appropriately contextualize the health care plan can have significant consequences.⁷ Providing the best quality care for a patient with COPD in the clinical setting is an important goal. But if that patient cannot afford the medication or does not have access to transportation for their follow up care, their disease will quickly become uncontrolled, leading to worse health outcomes and higher utilization-related costs.

In response, public and private payers are piloting payment models that encourage the health care system to address social needs. For example, the Centers for Medicare and Medicaid Services recently announced the Accountable Health Communities demonstration model that encourages health care providers to build linkages with community organizations, such as Meals on Wheels, that can address their patients’ social needs such as hunger or poor nutrition.⁸ Pay-for-success models, such as the South Carolina Nurse Family Partnership, are a version of social impact bonds that go a step further by encouraging community linkages and providing resources to support them.⁹

Community-oriented primary care providers are especially likely to welcome these types of payment models and the new technologies that support them because addressing the social factors of health is fundamental yet complex and rarely compensated. Encouragingly, evidence is building that addressing social factors improves health outcomes at a lower cost^10,11; investing in coordinators who connect patients to social services can save between $15 and $72 billion annually.¹²

ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH

Though integrating health care with social care is critical for improving health at a lower cost, reforming payment models alone is insufficient.¹³ Leaders must work to create healthy communities by addressing factors further upstream such as the environment, housing, transportation, and access to healthy food and safe spaces. By moving to a public health model, rather than a purely medical model, communities can create the conditions where everyone can be healthy and reverse health disparities.^14–16

This undertaking requires collaboration and resources from many community sectors, and cannot be the sole responsibility of the health care system. The promising news is that communities across the country are pioneering a new approach to improving the health of their communities by addressing all the determinants of health.^17,18 These “Public Health 3.0” communities are coming together to create new umbrella organizations to set a shared vision and shared goals about the health of their communities, to share data and funding, and to coordinate activities aimed at improving health. Their efforts are showing promise, including improvements in health outcomes and reductions in mortality.^19,20 For patients with COPD, this would mean not only that their community’s health care system can link them to support services for their social needs, but also that they can live in smoke-free housing.

DISRUPTION NEEDED TO CREATE AFFORDABLE, EQUITABLE HEALTH FOR ALL

These collaborations will only be successful if we address the social needs of our patients and make structural changes to funding and accountability for individual and community health. First, clinical teams should identify and support the social needs of our patients with the rigor they would apply to avoiding other medical errors. Second, health systems should show leadership by holding their executives accountable not only for outcomes for their patient population, but also for the health outcomes of their communities. Third, communities can only advance health if they have access to timely, specific data. Data availability will require continued focus on creating a culture of data sharing for public health advancement. Fourth, federal and state policy makers should work with states to maximize funding flexibility to accommodate local innovations aimed at investing in upstream social determinants of health. Fifth, education of the clinical and public health workforce should encourage an understanding of the social determinants of health and provide training in working across sectors. Sixth, it will require an increase in investment in the social determinants of health. Currently, US spending on social services is on par with other Organisation for Economic Co-operation and Development countries, but we spend a significantly greater proportion on health care. This spending pattern may need to change if we seek to improve health outcomes.²¹