The search for the best ways to tackle the social determinants of health is turning up more questions than answers. How should interventions for homelessness or food insecurity be managed and funded? Can healthcare organizations do it successfully and sustainably?
Two studies published Wednesday in the November issue of Health Affairs drove those questions home. One examined the different ways accountable care organizations tried to improve population health. Another looked at an innovative way of financing interventions using a model called pay-for-success.
Both studies determined that these models had potential but were nonetheless beset with challenges.
“It's so new right now,” said Paula Lantz, a professor of public policy at the University of Michigan in Ann Arbor, who led the study on how pay-for-success models might be used to improve population health. “People are just trying to figure out, What's going to work here?”
The study that examined accountable care organizations trying to tackle social determinants of health found that while their methods were innovative, the organizations struggled to develop scalable solutions.
“These are some pretty innovative ACOs that are willing to address these needs that are huge and complex and challenging in so many ways,” said Taressa Fraze, a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, who led the study. “That doesn't necessarily mean that they're the best one to address those needs in the long term.”
Meanwhile, pressure on healthcare providers and systems to improve quality of care and lower costs is rising. The CMS has said it will tie 90% of Medicare payments to quality or value by 2018. Commercial payers are moving in the same direction.
As much as 90% of an individual's health can be attributed to non-medical factors like the environment and education, and healthcare providers are scrambling to find ways to alleviate the challenges their patients encounter outside the hospitals that damage their health. But sustainable, systemic solutions remain elusive, for financial, logistical and a myriad of other reasons.
That's one reason Lantz sees pay-for-success models as promising: They offer “more creative financing opportunities to focus on the social determinants of health,” she said. “Local governments don't have the bandwidth to invest in things right now that'll only have a payoff in the future.”
Pay-for-success is a financing strategy where the private sector invests in a program and receives returns, from the public sector, only when that program produces positive results.
Lantz's study analyzed the first 11 pay-for-success programs in the U.S., carried out from the city to the state level. They focused on issues that directly or indirectly affect health, such as homelessness, foster care, maternal and child health, and family instability. Investors included banks, philanthropies, individuals, and others.
One major problem was unrelated to the pay-for-success model, stemming instead from a dearth of proof that the intervention itself would work.
“One of our major concerns is that some of the interventions that are being used aren't fully tested and don't have a strong evidence base behind them,” Lantz said.
In 2012, Goldman Sachs and Bloomberg Philanthropies poured $9.6 million into a project aimed at reducing criminal recidivism in New York City.
Dubbed ABLE, for the Adolescent Behavioral Learning Experience, it had no clear impact, so it ended in 2015 without a payout to Goldman and Bloomberg. The study called the outcome “not surprising,” given the lack of evidence for ABLE's approach.
So what about tackling social issues from within the healthcare system? Fraze's study looked at how 32 different ACOs, a model where a group of providers are collectively responsible for the care and costs of a group of patients, tried to address their patients' non-medical needs.
Of the 32 ACOs Fraze's study examined, 16 attempted to address patients' needs such as housing, transport or food. Most did not significantly integrate services or organizations, although they were moving in that direction, the study found.
To solve transportation needs, for instance, ACOs worked with transit companies or gave patients passes for public transportation. One considered developing an app for its local area through which patients could hail drivers, who were paid by the ACO.
Others helped patients with food insecurity, partnering with food banks to offer healthy food, or assisting patients who qualified for food stamps.
Fraze was encouraged by the results and the proof of what medical providers could do for population health, even in their limited roles as medical providers. But, she said, the study's broader implications are daunting.
Although medical providers and ACOs can make a difference in community and population health, “they can't be the solution,” Fraze said. “We have to decide whose responsibility is population health,” she said.