The health care industry’s shift in focus to truly address the social determinants of health is a make it or break it opportunity, according to Jamo Rubin, M.D., founder and CEO of TAVHealth, who served as the chair of last month’s RISE Symposium on Partnering to Address the Social Determinants of Health in Fort Lauderdale. Social determinants left unaddressed or unresolved flow into the health care system as unintended consequences and become health care claims, he said. The two-day symposium highlighted the challenges and successes of organizations that have made progress tackling social determinants, including behavioral health, opioid addiction, housing, and transportation. Here are five takeaways from the conference:
ZIP codes matter more than a person’s genetic code, said Garth Graham, M.D., MPH, president of the Aetna Foundation, an independent philanthropic arm of CVS Health. People who live minutes or a few miles away from one another lead dramatically different lives just based on where they live. And the industry must better understand and manage the most vulnerable populations to bend the cost curve, according to Graham, who was the keynote speaker at the symposium. It’s important to stand back and think about what their lives are like, he said. For example, they may face food insecurity every day. And if they do, it’s difficult to engage with that population about efforts to reduce readmission rates when they are worried about where their next meal is coming from, Graham said.
Furthermore, he noted, even if some people find a better job opportunity and earn more money, they often stay in their same neighborhoods. In those cases, the same social dynamics are in play although they may have higher incomes than their neighbors.
Despite the increased focus on social determinants, the United States has been grappling with this issue for decades. Graham said that health care policy has been on the legislative agenda perennially beginning with the passage of Medicaid in 1965, and efforts to eliminate health disparities in the country date back to the 1980s. “Politics will change, things will change, but social conditions and the kinds of challenges we’ve been tackling for 100 years are still happening now,” he said.
Metrics for social determinants may soon be a reality. Most interventions that are conducted by health plans, the federal government, and academic and hospital settings look at utilization metrics and program costs, Graham said. Instead, they need to look at clinical outcomes and public health metrics.
Last month the National Quality Forum and Aetna announced an initiative to identify quality and payment innovations that address social determinants of health and reduce health disparities. Graham said the organizations will work on the project for nine months and aim to publish standards and quality metrics based on data-driven strategies to measure for social determinants of health.
Medicaid can offer lessons to Medicare Advantage (MA) health plans on what to do and not do when adding programs that address social determinants, according to Barbara Otto, chief executive officer, Smart Policy Works, a non-profit organization based in Chicago. New guidance under MA plans allows for supplemental benefits and has shifted the notion of Medicare being an acute care program to more of a health care program, which may lead to more in-home services and support.
This is where MA plans could learn from challenges that have emerged under the Medicaid program, she said. For example, Medicaid doesn’t credential personal care assistance workers because there are no federal training or licensure requirements. But lack of credentialing means there is no consistent training, said Otto. And workforce recruitment and retention are difficult because of low pay. Indeed, Otto said home care service providers are the “worst paid fastest growing job in America.” But MA plans could provide specific training or partner with larger agencies or community-based providers that will train in-home service providers. The training, she said, could translate into higher wages and better workforce retention.
Community involvement and partnerships are critical for success. That theme was underscored in nearly every session of the two-day symposium. It requires the establishment of sustainable models that allow health plans, providers, and community organizations to come together to create programs that drive innovation.
One example of such an accountable community model is “Be Well Orange County,” which addresses social determinants to improve behavioral health for the 3 million residents who live in the Southern California region. Among the issues facing the county: Disparities and inequities in geographic service availability; people can’t connect to the right care in the right place when they need it; and gaps in services, access, and funding exacerbated by organizations that work in health care silos.
Clayton Chau, M.D., Ph.D., regional executive medical director, Institute for Mental Health & Wellness, Providence St. Joseph Health, said that began to change in April 2017 when the system began its mission to create a better mental health system of care in the community. However, the organization quickly realized that it wouldn’t accomplish its goal on its own and it reached out to others in the community.
The integrated, community-based movement now includes representatives from the county government, social services, public health, law enforcement, several health systems, all major health plans, including Medicaid health plans, local mental health advocates, the National Alliance on Mental Illness, United Way, the county’s housing authority, the department of education, businesses, and philanthropists. Chau said that all participants agree to solve the problem through collaborative, coordinated actionsalign activities to achieve shared outcomes, use a set of common measures to track progress, continuous communication, and provide support to sustain the collective impact initiative.
Over the past 18 months the “Be Well Orange County” initiative has created a blueprint to provide mental health services to the community and to all vulnerable individuals regardless of the payer source. And late last month the collaborative made significant progress in the first step of building one of three wellness hubs in the area. Chau said the county just approved $16 million in funding to help build a $40 million mental health center that will provide short-term and long-term mental health services as well as drug abuse and psychiatric crisis units, residential programs, and substance-addiction recovery. CalOptima, the county’s health care system, and hospital systems Kaiser Permanente and St. Joseph Hoag Health will contribute the remaining funds to build the 60000 square foot center. They envision the hub will close gaps in services by providing under one roof mental health treatment services to those in crisis, decline or on the road to recovery, regardless of whether patients have insurance.