Can Payment Reform Move Healthcare Outside the Clinic?
We hear a lot today in healthcare about thinking “outside the box,” but just what box do we mean? Sometimes we are talking about tired workflow routines, or the strictures of bureaucracy. Sometimes, however, it is the clinic itself that confines our thinking, for too often the view we get in the exam room misses the full scope of what makes some patients healthy and some patients sick.
Social determinants of health (or SDOH, because everything in healthcare needs a good acronym) is healthcare shorthand for the web of factors—cultural, economic, environmental—that can have an even more profound impact on a person’s health as the germs they are exposed to, the genetics they carry, and the medical care they receive. We’ve known for a long time that the underprivileged have worse health outcomes than those who are financially stable. Study after study has shown that if we are to fully understand a patient’s health prospects, we have to account for their income, level of education, employment, neighborhood and so forth. This is because these factors may influence whether patients’ local grocery stores have healthy food options; whether patients have access to the transportation they need to make their medical appointments; whether they have a safe place to live free from environmental contaminants; how much stress they are under; even how much sleep they get each night.
Addressing social determinants of health requires thinking outside the box for traditional healthcare providers. First, it means breaking the routines of seeing patients primarily when they are sick, moving from treatment to prevention and from prevention to tackling deep-rooted issues like poverty. It also means getting out of the exam room and into the neighborhoods to build better housing conditions, participate in city planning, and expand access to healthy food. If we are to influence health (not just health care), it requires working with the community to understand needs and advocate for changes to improve conditions for the underserved. It’s about forming coalitions and influencing policy to create the kind of prosperity and equity that allows people to be healthy.
Social determinants work happens what we call “upstream,” with treating specific symptoms taking place “downstream.” In fact, this work goes farther upstream than normal prevention, beyond cancer screenings and beyond even teaching patients healthy behaviors. It’s about changing the conditions people live in.
When we start creating the social and physical environments that promote good health for all, it can make a big difference, for both patients and the healthcare system as a whole. Patients will get help with the conditions that are at the root of many health problems, and can remain healthier, while at the same time sparing the health systems from costly preventable emergency room visits.
Along with adopting digital health tech like electronic health records, interventions that tackle social determinants is an important trend in our industry right now. At a recent gathering of community health centers in New Jersey, which we hosted in partnership with The Nicholson Foundation, leaders named SDOH as one of their top three priorities for innovation. But if we’ve known for so long what a huge impact social determinants of health have on the outcomes of patients, why is it only now becoming a priority?
The answer is that healthcare is changing, and fast. You may have followed the rollout of new insurance coverage options through the Affordable Care Act, but for healthcare organizations there is a lot shifting beyond just who has insurance. For example, many payers are moving to change how they reimburse providers. In this new payment model providers are paid a flat rate for each patient assigned to them, and it’s up to the providers to keep these patients healthy and their care costs low. This shift from what’s called “fee for service” (where providers bill insurance for each visit), to a per-member, per-month system requires changing much about how care is delivered.
The idea behind payment reform is in part to make it possible for providers to address the most critical social determinants of health in their community. Under fee for service models, clinics and doctors often can’t take on this work because they aren’t able to bill insurers to spend the time to improve a community’s access to healthy food, even when doing so is likely to do more to promote better health outcomes for their patients than sitting in an exam room writing prescriptions all day. With a different payment model, providers can reprioritize, focusing on what will most improve their patients’ health, instead of only what can be reimbursed.
Earlier this month Alicia Wilson, executive director of La Clínica del Pueblo, wrote a 1776 Insights article “Health Innovation for the 99 Percent” urging health innovators and entrepreneurs to create interventions that work for low-income people, immigrants, and other vulnerable and underserved patients—in other words the patients most negatively impacted by social determinants of health—as well as the budget-strapped providers that treat them. “Often, the latest, greatest idea, with lots of bells and whistles, will not be remotely practical for us to implement,” she wrote. “We’re too busy hustling for grant funding, serving low-income patients and trying to stretch $1.25 of value out of every dollar we receive.”
At the Center for Care Innovations, this is a point we’ve echoed a number of times over the last year. With payment reform set to change the game, we need health innovation that works for the people with the biggest needs. And we need partners willing to try new ideas and think beyond the walls of the clinic if we are going to transform the health of our communities.
At CCI we also believe that the organizations that serve vulnerable people have a vital role to play in imagining and developing these innovations that will transform care. We call it the safety net—those providers that will treat patients regardless of their ability to pay. Many safety net clinics were founded as community organizations that provided an array of social services— however due to the current payment models, many of these organizations have had to prioritize a focus on purely medical needs. Tackling SDOH means renewing focus on those services that go beyond the four walls of the clinic. That history of serving the community, along with the expertise these organizations have working with vulnerable patients every day, means safety net providers are in a prime position to create and test innovations that can make our healthcare system work for the 99%.
That’s why our strategy focuses on driving innovation within the safety net. We take a three-pronged approach: Spark, Seed, Spread. Spark trains safety net leaders and providers in skills like human-centered design thinking that help them see problems in new ways and invent new approaches. Seed is about nurturing promising ideas by providing support for clinics to take risks piloting innovative projects. Once we’ve found interventions that work, Spread is a strategy to get the word out, so other organizations can more easily put the best ideas into practice without reinventing the wheel.
In social determinants work, the best ideas often come down to forming partnerships outside of traditional healthcare systems. Not every community clinic can have a housing advocate on staff, or can set up their own food bank. But every clinic can connect their patients with those organizations that already exist in their communities. In our networked world, startups lead the way in connecting people with local resources. Healthcare could use that expertise to build innovations that help patients get access to the services they need beyond tests and prescriptions.
CCI has been bringing entrepreneurs together with health centers through our Innovations Centers for the Safety Net program, which we affectionately refer to as “the Hubs.” Each of our innovation hubs has built a team passionate about piloting technology solutions that work for vulnerable populations. We believe this model can also be used to help startups test ideas that address social determinants of health. If you have such an idea, we’d love to hear about it. Together we can take down the constricting walls of the exam room, expand the scope of what providers can accomplish, and transform care to keep all patients healthy.