The following is an interview with Lisa Simpson, MB, BCh, MPH, FAAP, President and CEO of AcademyHealth, with input from several senior staff at AcademyHealth. Follow her on Twitter @DrSimpsonHSR
Among health care systems, plans, and programs, there has been increasing discussion of, if not investment in, approaches to addressing social needs. What is driving this phenomenon? Why is it happening now (as opposed to, say, 10 years ago)?
There are several changes in our current context that are driving this new focus on social needs. First, passage of the ACA opened up a space to look beyond coverage and direct access to focus on health care outcomes, and this naturally and quickly leads to a focus on the true drivers of health – social needs and behavioral issues. Second, various value-focused CMS initiatives that stumbled or failed shone a light on underlying factors that affect health and brought increasing awareness of social determinants of health. For example, when CMS started looking at 30-day readmission rates for Medicare patients as an indicator of quality of care, it became clear that many patients were being discharged with no social support, no food in the house, no one to shop for them, etc. Third, the inexorable growth in health care costs despite repeated attempts and various policy fads, together with a reluctance to tackle actual health care prices, makes a focus on social needs a natural diversion (as demonstrated in a Policy Insight by Len Nichols and Lauren Taylor).
Another way that health care costs are driving this focus is at the state level where pressure on state budgets has Medicaid officials increasingly realizing that if they are to rein in costs and improve health, they need to do something to address enrollees’ social needs, which are often intertwined with complex health care needs. (AcademyHealth is currently supporting a Robert Wood Johnson Foundation (RWJF) research funding opportunity to investigate how state Medicaid programs are using their contracts with Medicaid managed care organizations (MCOs) to incentivize or require MCOs to undertake activities that identify and respond to enrollees’ social needs. Funded studies will be announced early next year.)
Finally, there is inescapable, mounting evidence that, despite a focus on improving access to health care over the last 40 years, and at least 20 years of a focus on quality and safety, many health indicators are stagnant or worsening, and pervasive disparities have not abated. The final factor driving this focus is the RWJF shift to a culture of health which has given recognition and resources to those who were studying and acting on social needs, and drew many more into addressing these issues through research, practice, and policy. Thus, the Foundation has served to catalyze and amplify a national movement for the health care sector to consider the social needs of patients.
To what extent should the health system be involved in addressing social needs? After all, these are not traditionally in the purview of health care. Are the boundaries of health care shifting? Should they?
For those earlier in their career than me, let me just remind us that some health care organizations have been working to address social needs for a very long time! As a pediatrician, addressing the social needs of children and their families has always been a part of our culture and training, even if addressing them has not been as widespread or effective in practice. Child abuse and neglect came out into the open in the 1960s thanks to Henry Kempe’s description of the “battered baby syndrome.” Bob Haggerty challenged the field of pediatrics in the 1970s to address the “new morbidities” of childhood driven by psychosocial needs, and programs such as Reach Out and Read, the Medical-Legal Partnership, and DULCE are examples of pediatric innovations to address various social needs. You can also reach further back to seminal reports in the 1920s on the role of income and paternal occupation to infant mortality which contributed to the passage of the Sheppard-Towner Act in 1921 and later Title V of the Social Security Act, which authorizes the Maternal and Child Health Block Grant.
In addition, efforts to connect “medicine and public health” have existed for many decades (I remember Jo Ivey Boufford led a big one in the Clinton administration when Phil Lee was Assistant Secretary for Health), but have been met with only limited success due to the misaligned goals, priorities, and financing of medical care versus public health. The shift to value and outcomes noted above has opened up a new incentive for health systems to now focus on root causes. However, breaking down the boundaries of health care (institutional, professional, and financial) to spur efforts to address social determinants isn’t happening fast enough. The key issues include: How far should care systems go? Given the fragmented financing of health and social care in this country, which funding stream should pay for which aspects of an individual’s needs? Certainly, screening for social needs would seem to be a natural step for care systems, but if there are no resources to refer individuals/families to, what further responsibility does the health care professional have? I think the answer to these questions will vary to some extent by geography based on a community’s assets, history, and culture. These issues are also the subject of active debate in the Adverse Childhood Experiences research community (see also here and here)
Finally, there is the question of whether the health system should be held “accountable” for addressing social needs. The Medicaid clinical leaders engaged with AcademyHealth in the Medicaid Medical Directors Network embrace the importance of addressing social needs, but consistently question the value of building measures that aren’t truly measuring the solution (e.g., measuring homelessness by flagging a person as homeless or providing referrals to case managers as opposed to measuring patients receiving permanent supportive housing) or aren’t actionable (e.g., state may not have the adequate housing supply/capacity to meet the need).
Are we making progress in addressing social needs and/or social determinants of health? How would we know if we are? What would constitute “success”? How should we measure it?
In general, we are making more progress than ever before in getting health care leaders and systems to understand that they need to address social needs. Most of that progress to date has focused on how to screen people for social needs in clinical settings, yet recent estimates put screening rates at just 24 percent in hospitals and just 16 percent in physician practices. While increasing these rates is a critical first step, it must go hand in hand with addressing the need to make meaningful and seamless connections between patients and resources in the community (if they exist) after screening has occurred. More recently, a number of technology solutions are being deployed to help health care providers establish effective referral systems.
Where we are seeing slower progress is in the documentation of successful and sustainable (i.e., with clear return on investment) health system strategies and the development and deployment of effective payment models at scale.
A final aspect of accelerating progress rests on effective health care leadership as demonstrated by the work of Bernard Tyson at Kaiser Permanente whose commitment to social justice was evident decades before today’s conversation on social needs. We need more leaders like him.