The healthcare reform movement in the U.S. has very appropriately put the spotlight on keeping people well and eliminating the need for much of the sick-care that doctors and hospitals have traditionally provided.
But it has quickly become clear that, as important as value-based care and population health management strategies are, they leave a gap that needs to be filled: supporting health on a community level.
Someone needs to go beyond just managing lives and actually invest in the things that will change the health status of the community—eliminating food deserts, promoting clean air in public housing, providing health education in schools to change the trajectory for the next generation. Someone needs to partner with the community and philanthropic organizations that do such important work in vulnerable neighborhoods, integrating their community-oriented programs into traditional health services while also infusing them with an evidence-based approach to health and wellness.
Large urban academic medical centers and health systems can help. These institutions—including my own—have a long history of involvement with their communities. We, and a group of other not-for-profit urban health systems, are already the healthcare provider of last resort for East Harlem in New York City, the South Side of Chicago and West Philadelphia.
But we cannot do it alone. In part, this is because the shift from fee-for-service to fee-for-value healthcare, while it potentially cures many of the perverse incentives that have made U.S. healthcare expensive and uneven in quality, is not designed to deal with community health. Even under the most advanced population health models, there is no way to get paid for improving the long-term health status of the community. Annual enrollment cycles for insurance, single-year risk adjustment and 12-month total cost-of-care metrics are all aligned to managing attributed lives, not supporting communities.
For example, if a patient attributed to us has diabetes and we keep that person out of the hospital, we are financially rewarded in a population health model. But if we invest in preventing community residents from ever getting diabetes in the first place, we're paid nothing extra: They never carry the diabetes risk-adjustment code that enhances our revenue for caring for them under standard population health reimbursement models.
To align incentives to promote community health, we need to explore multiyear risk models, accountability for everyone living in a geographic region—not only patients attributed to a particular hospital—and the next evolution of payment reform even while this one is still underway.
Even if payment models were changed to address this challenge, not all vulnerable neighborhoods have an academic medical center or other not-for-profit health system close by in a position to help. Increased government support for social services needs to be part of the solution as well. The U.S. spends far less than many other industrialized nations on social services—about 55 cents per dollar spent on healthcare, compared with the average $2 on social services for every dollar of healthcare spending according to the Organisation for Economic Co-operation and Development—yet social workers have a significant effect on care in their communities.
Social services focus on the basic necessities of life. When these needs—such as adequate nutrition, proper shelter and a subsistence income—are unmet, disease and illness often follow. Social workers are also essential to preventing readmissions. When an emphysema patient returns from the hospital to a moldy apartment, or a patient with heart failure to a high-rise building without a working elevator, the social worker can press the landlord to make repairs.
In the end, whether social services are funded via new payment models for hospitals or directly by the government is less important than that they be funded, somehow. Academic medical centers and not-for-profit health systems can then lend our expertise to help address the challenges. Yes, we are leaders in specialty care and groundbreaking research, but we are deeply immersed in our communities, proud of the work we already do there, and ready to take on an array of new responsibilities.
