The quest to contain Health costs while improving the quality of care typically focuses on service delivery, such as reducing unnecessary or harmful medical procedures. But changes in health care financing are pushing some health systems to take a more holistic approach and address social factors that directly impact patients’ health. Think of it as the “community cure” for health care.
The rationale for thinking outside the clinical setting is compelling. According to a recent Robert Wood Johnson Foundation study, only 20 percent of the factors that influence a person’s health are related to access and quality of health care. The other 80 percent are due to socioeconomic, environmental, or behavioral factors –including unhealthy housing, poor diet, inadequate exercise, and drug and alcohol use. As federal and state reforms prod payers to move away from traditional fee-for-service—which pays for volume, not outcomes—and toward a pay-for-performance model that rewards keeping people healthy, the economic argument for addressing social determinants of health becomes clear.
Poverty, for example, is associated with an increased prevalence of asthma; homelessness drives up emergency-room visits; and urban “fresh-food deserts” where it’s hard to find affordable, nutritious foods stoke the incidence of type 2 diabetes.
Doctors are adept at treating us when we’re sick, but not at keeping us well. But the U.S. health care system has been slow to move beyond pills and procedures. Only a handful of pioneers have begun to address patients’ “upstream” social needs to improve their health and reduce costs.
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Kaiser Permante Southern California is one such organization. Kaiser, one of the nation’s largest managed-care organizations, has found that just 1 percent of its patient population accounts for approximately 25 percent of its annual medical costs and that these costs are often related to social and behavioral issues that drive the need for care.
To address those factors—challenges around diet, housing, hygiene, and other issues—KP Southern California has teamed up with Health Leads, a national nonprofit that places volunteers at “family help desks” in outpatient clinics, emergency rooms, newborn nurseries, and health centers, where they collaborate with physicians, social workers, and other care providers to screen patients for a range of needs and connect them to community resources and social services. One of Health Leads’ first assignments from Kaiser was to work with high-cost diabetes patients, more than half of whom had two or more social needs—such as for better housing or counseling—a prevalence much higher than Kaiser expected. While it’s too soon for conclusive results from this effort, Health Leads’ program at Massachusetts General Hospital in Boston has contributed to improved cholesterol and blood pressure levels among adult patients.
While Health Leads helps patients cope with a variety of health-related social issues, ProMedica in northwest Ohio and southeast Michigan has chosen to focus its attention on the health effects of hunger and poor nutrition. ProMedica, which serves 1.5 million people, decided to act after a study showed that a large proportion of patients subsisted on low-cost junk food diets—things like pizza, tacos, chips, and soda. As a result, they suffered higher-than-average rates of obesity, diabetes, heart disease, and back issues.
ProMedica now screens all patients for hunger and poor nutrition. “When you look at poverty, there are so many [overwhelming] issues—education, crime, underemployment, and so on,” said Randy Oostra, ProMedica’s president and CEO. “But hunger [and malnutrition] was something we could get our arms around. We can screen every single patient we touch for hunger.”
In the program’s first nine months, the organization screened nearly 36,500 patients and found 1,500 (4.1 percent) suffered from chronic hunger. To address this problem, ProMedica is setting up a number of food “pharmacies” (essentially on-site food pantries) for low-income patients, offering nutrition counseling, and opening a supermarket in a low-income area that previously had none.
For others to follow, pioneers pursuing the “community cure” for lower costs and better care know they shoulder the burden of proof. For its part, Kaiser is measuring results by looking at factors like use of health care services, total cost of care, health outcomes, and patient satisfaction. Since its effort focuses on the highest users of care—the top 1 percent—there is some hope that it can demonstrate cost savings reasonably quickly. With its food and nutrition initiative, ProMedica is not counting on short-term cost impact. Rather, it is laying the groundwork for estimating return on investment by doing research to establish patients’ current experience with hunger, quality of life indicators, and medical care, as well as the cost of that care for a sample of patients.
Optimism about what the evidence will show led Kaiser and Health Leads to convene leaders from a dozen US health systems last year to explore what role their organizations should play in addressing social needs. And ProMedica—working with the AARP Foundation, the American Hospital Association, and others—has started the national Root Cause Coalition to engage health care systems, businesses, nonprofits, and government in tackling hunger and food insecurity.
The health care leaders we talked to believe their efforts will have an impact on the bottom line, both in terms of cost and patient health. “At the end of the day, health care executives have to run the business,” said Dr. Ross Wilson, chief medical officer of NYC Health + Hospitals, a public system that serves roughly 1.4 million people. “If the work on social needs reduces utilization and emergency department visits, you start to find a business model that is effective.”