Getting to the root of the problem

Delores Banks is a 61-year-old diabetic with congestive heart failure who was hospitalized twice last year. She lives alone on the 15th floor of a senior public housing project in one of the poorest sections of Chicago.

A recent two-week elevator outage stopped Banks from leaving her building on three occasions. She decided to simply stay in her apartment until it was fixed.

That's when the Sinai Health System's disease-management team sprang into action. One member called the Chicago Housing Authority to expedite the repair work. “It just makes you feel like you're not alone,” Banks said. “The elevator is working now, and I haven't been stuck.”

The emergency intervention was part of a Sinai program launched in 2011 to help patients better manage the chronic conditions that lead to frequent hospitalizations. But as the care coordination team members quickly discovered, their efforts had to reach well beyond phone calls to make sure Banks took her medicine or to remind her about doctor appointments.

In addition to fixing elevators, they helped her pay for her drugs and assist her with transportation to see her doctor. Team members even guided Banks through the paperwork needed to move to another senior-living facility.

Sinai is one of a growing number of health systems across the country that have begun tackling the social, economic and environmental conditions in the communities they serve as part of their programs to reduce hospital readmissions and improve outcomes. They are responding to the well-documented association between poverty, joblessness, inadequate housing, poor nutrition and chronic stress and poor health outcomes. Only by addressing these social determinants of health, they say, will they be able to get better outcomes and improve the overall health of their local populations.

“Some extremely large studies have shown engaging in health behaviors, like diet and exercise, and even our blood pressure, is affected by conditions in our home, neighborhood and workplace environment,” said Tamara Dubowitz, a senior policy researcher for the RAND Corp. “Ultimately, putting our resources into (improving) these things will give us a better bang for our buck.”

But such efforts pose an immediate financial risk to systems under current payment regimes. At a time when providers remain stuck in a fee-for-service payment model that rewards the quantity of services and not results, programs that address the social determinants of health come right out of a provider's bottom line.

“There is no business case really for quality or improving the social determinants of health at present time,” said Kelly Devers, a senior fellow in the Health Policy Center at the Urban Institute. “We still have a very fragmented healthcare system whose training and mindset has been focused for decades toward acute care and intervening once someone is sick—not necessarily preventing them from getting sick or keeping them well.”

Income is the single largest social factor driving overall health. A recent report from the Robert Wood Johnson Foundation's Commission to Build a Healthier America found that 23% of African-Americans who earned less than 100% of the federal poverty level had a health status that was “poor to fair” compared with 6.8% of blacks with incomes that were more than 400% of the poverty level.

Among whites, the disparity was even greater. Twenty-one percent of whites earning below 100% of poverty reportedly had “poor to fair” health compared with only 4% of whites making more than 400% of poverty. Education level is another indicator of health. According to the report, a 25-year-old college graduate can expect to live up to nine years longer than a 25-year-old who has not completed high school.

At Sinai, where about 15% of the patients are uninsured and 60% are covered through Medicaid, half of the $1.1 million a year that has been budgeted for the disease-management program comes from foundation grants. Without that support, such care would be extremely difficult to provide because Sinai does not receive reimbursement for many of the program's services.

“We let them (patients) see a dietitian (even though) public aid doesn't pay for a patient with bad diabetes and really high blood sugar to see a dietitian,” said Tina Spector, vice president of clinical integration for Sinai Health System. “If I want to arrange transportation for someone, if it's not always reimbursed, we either have to donate it or people don't necessarily get in to see their doctors.”

Despite the lack of financial support from payers, Sinai's program has registered some impressive results. Hospital readmissions among heart failure patients fell by 45% in 2012, according to the Sinai Health's 2013 annual report.

“Without a doubt, addressing the social determinants is a key part of improving health,” said David Williams, a professor of public health at Harvard University. “Imagine a mother bringing a child to the hospital who has asthma, and that asthma is driven by poor housing conditions. All the asthma medication in the world and the latest and best medicine in the world will not solve that child's asthma problem if we treat the child and then send them back to live in the same conditions that made them sick in the first place.”

The evidence is overwhelming that poverty, homelessness, unemployment and hunger have a significant impact on the overall health of a population in communities where such conditions are prevalent. They have disproportionately higher rates of heart disease, diabetes, lung disease and cancer.

Not surprisingly, rates of hospitalization are higher, too. Near Sinai, the rate of hospitalization for those diagnosed with diabetes in 2010 was 35 for every 100,000, compared with 25 for every 100,000 in Chicago as a whole and 19 for every 100,000 nationally. In Banks' neighborhood of East Garfield Park, the rate was nearly double the city average, where 50 out of every 100,000 residents are hospitalized because of the disease.

Providers seeking to address the social conditions of their most impoverished patients face a fiscal environment in Washington that is making their jobs more difficult. The Supplemental Nutrition Assistance Program, for instance, was slashed by another $8.6 billion over 10 years last week in the latest version of the Farm Bill (See editorial, p. 22). Advocates estimate that will result in a loss of about $90 a month in food stamps for as many as 850,000 recipients.

That measure came just a few months after the $17 billion in cuts over the next decade that went into effect as a result of a deal made in 2010 between President Barack Obama and Congress to reauthorize child nutrition programs such as the National School Lunch and School Breakfast programs.

Such cuts have a direct impact on the health of the people who rely on food stamps. A recent study in Health Affairs found the risk for hospital admission for hypoglycemia in low-income patients with diabetes increased by 27% during the last week of the month—when food budgets are strapped and food stamps run out—compared with the first week of the month. The study found no such occurrence among populations with higher incomes.

“It is not reasonable to think that every healthcare provider has to become a social worker and solve all of these problems,” Williams said. “But we can put in place complementary resources where the provider simply has to refer that patient to someone who could connect them with resources to help solve the problem that is driving their underlining health conditions.”

Some health systems have begun addressing social issues with the help of third-party coordinators who focus on providing for a patient's nonmedical needs. Health Leads of Boston, funded by the Robert Wood Johnson Foundation, helps healthcare providers obtain basic resources such as food, heat, electricity or housing for their patients.

When a physician identifies patients struggling with basic needs, they'll refer them to a Health Leads “clinic” in the healthcare facility. The advocate then helps the patients gain access to community resources that can help provide those services. “A patient can take a prescription for heat in the winter or to have their lights turned back on to a Health Leads desk to get it filled,” said Rebecca Onie, Health Leads CEO and co-founder.

But foundation-supported efforts such as Health Leads are far from ubiquitous in communities with the greatest needs. That forces providers such as Sinai to use their own dollars to help patients address the social conditions that may worsen their illnesses and make recovery from hospitalization more difficult. Even though such work can lower readmissions, no payer compensates them for paying to get a patient's electricity turned back on or steady access to food.

Sinai is betting that participation in the CMS' bundled-payment demonstration program may generate enough savings to help them finance such efforts. The program gives a set payment for care over a 90-day period for inpatients with either chronic obstructive pulmonary disease or congestive heart failure. If the cost of treating those patients comes under the target price, Sinai keeps the savings. If they go over the target amount, however, the difference must be paid back to Medicare.

“At some point, it is anticipated that we'll get paid to keep patients well and out of the hospital, but the business model hasn't really fully evolved yet,” said Dr. Mark Mackey, vice chair of emergency medicine at the University of Illinois Hospital & Health Sciences System. “It's a difficult proposition, but I think if you have people who are a little bit forward-thinking, they recognize that we have to get better at this, the way of approaching patient care, because financially, it will be in your best interest in the future.”

Some advocates contend addressing the social determinants of health is the only economically viable solution for a system that spends more than $2.8 trillion annually on healthcare without producing the best outcomes. The U.S. ranked 22 out of 27 of the world's wealthiest nations when it came to the efficiency of its health system, according to an analysis published last December in the Journal of Public Health.

Clearly, investing solely in sick care isn't getting results. The study found that every $100 spent on healthcare in the U.S. increased a patient's life expectancy by two weeks. In Germany, the same amount spent on healthcare increased life expectancy more than four months. “On a population level, investing in social conditions as they pertain to patient health is certainly the most economically sound approach,” said the RAND Corp.'s Dubowitz.

According to Randy Oostra, president and CEO of Toledo, Ohio-based ProMedica, not-for-profit health systems are ideally suited to addressing the social determinants of ill-health. In the past few years, the provider has embarked on a national campaign to raise awareness about the link between health and social issues such as poverty, hunger and homelessness.

ProMedica's interventions include food drives and obesity education. It has also invested in community organizations that are creating affordable housing and a grocery store in an underserved part of the city. Devoting resources to these “fundamental areas of life can have a huge impact on a person's overall health,” Oostra said.

Follow Steven Ross Johnson on Twitter: @MHsjohnson