February 15, 2018; American Journal of Managed Care
As NPQ has noted, social determinants of health is a concept that points out that true health has less to do with doctor’s visits, medicine, and health insurance than it does with factors outside the healthcare system, such as poverty, environmental hazards, lack of access to healthy food, and a built environment that makes walking and exercise difficult. This concept is now common, but much can get lost in translation as insurers adopt this finding into their payment models, as a recent HealthCare Executive Group and Change Healthcare survey of insurance leaders illustrates.
Last November, NPQ featured the work of Pritpal Tamber, cofounder and CEO of Bridging Health & Community, a Seattle-based nonprofit. Tamber cautioned, “There is a risk that initiatives resulting from the health sector’s growing enthusiasm for influencing social determinants will be too limited to meet the mark because they leave out the knowledge and power of those most affected by the very challenges they intend to address.”
In short, fully addressing social determinants of health requires a shift in power that enables marginalized communities to co-design their own healthcare solutions. Unfortunately, health insurers, while willing to alter payment models and entertain some changes in what they will pay for, have yet to grasp the more fundamental nature of the need for system change and community empowerment inherent in the idea that health, ultimately, is about much, much more than health care.
In the survey of health insurers and related industry players, writes Allison Inserro of the American Journal of Managed Care, respondents noted that they address social determinants of health in the following ways:
- Integrating community programs and resources: 42 percent
- Integrating medical data with financial, census, and geographical data: 33.7 percent
- Offer a social assessment with the health risk assessment: 33.1 percent
- Incorporating social determinants into the clinical workflow: 26.6 percent
“However,” Inserro adds, “fewer organizations were training physicians to identify social determinants (21.3 percent) or using point-of-care checklists to identify potential social determinants (20.7 percent).”
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In terms of billing, the standard model remains payment per procedure, or “fee for service.” But insurers are increasingly adopting different forms of value-based pricing, based on the idea that medical providers should get paid for keeping people healthy rather than performing procedures.
Payment models that reimburse medical providers based on value include risk-sharing, pay-for-performance, and full capitation. In the risk sharing model (also known as “shared savings”), hospitals benefit financially if the volume of procedures for the relevant patient group is below the benchmark level. Pay-for-performance, as it sounds, is payment based on favorable health outcomes. Full capitation refers to a set payment per patient treated for a given health condition. According to the survey, 45.6 percent used risk sharing, 43 percent used pay-for-performance, and 34.9 percent used full capitation for at least some medical conditions.
In short, the industry is shifting, but, as Inserro points out, many shortfalls remain. These are detailed in a report from the National Quality Forum, titled Framework for Medicaid Programs to Address Social Determinants of Health: Food Insecurity and Housing Instability. The report, which forms part of a multi-year health equity initiative that aims to reduce health disparities, argues that while a systematic approach is needed to coordinate the unmet health needs of patients in the areas of food and housing, the US healthcare system fails to collect relevant “data or coordinate care to address social needs.”
To date, most social factor interventions that insurers have been willing to entertain focus on behavior change, rather than addressing the root or “upstream” causes of those behaviors. For example, insurance might subsidize a gym membership but is less likely to pay for sidewalks, which would make it easier for everyone to walk safely in the neighborhood.
The survey did find that over a quarter (25.4 percent) of respondents offered healthcare premium discounts contingent on patients adopting healthier behaviors (like quitting smoking) and that such measures often were effective. By contrast, high-deductible insurance plans that seek to limit healthcare spending seem to be a bust. Inserro writes that, “just 3.4 percent of respondents said high-deductible health plans were used to achieve behavior change, and the report said such plans may actually deter patients from seeking [necessary] care.” Healthcare, Inserro adds, is “transitioning from negative to positive incentives to influence consumer behavior.”
The steps health insurers are taking will help some, but creating a culture of health, as the Robert Wood Johnson Foundation has put it, requires much more thorough social change that is grounded in community empowerment. “Risk factors,” Tamber points out, “whether personal, environmental, or social—explain less than half of why people are healthy or sick. The rest seems to come down to whether they have a sense of control over their lives, which requires agency. And yet we rarely see fostering agency embedded in work trying to influence health.”—Steve Dubb