As we emerge from a public health crisis that magnified and exacerbated health disparities, the need to address social determinants of health (SDOH) has reached a pivotal moment. In both social and healthcare, the pressure is mounting to address key drivers of health and amplify value-based care models.
To succeed, these models need to be effective and measurable as we work to build trust with all stakeholders (e.g., at-risk individuals, health plan members, community partners).
A recent report reveals that programs focused on SDOH might reduce unnecessary healthcare use, but may also end up costing health systems more than they save in the long run. While it’s promising to see hospitals spending on programs aimed at helping patients find housing, employment, education, food and other resources ($2.5 billion from 2017 to 2019), it feels like a bit of a gut punch to find any reason to question that investment and commitment.
But it doesn’t have to.
Imagine the impact – on communities, at-risk individuals and budgets – if we proactively provided social care, rather than waiting for patients to present at the emergency department with SDOH-based needs or acute health issues. There are challenges, to be sure, but we have everything we need to shift to a more proactive approach: technology, communication, care navigators and data.
By 2028 U.S. healthcare spending will reach $6.2 trillion and account for almost 20% of the GDP. That coupled with leaders increasingly finding themselves working in a climate of evolving financial uncertainty, means we must identify models that deliver effective, measurable and financially-viable community care. Understanding – and overcoming – the obstacles to pursue proactive approaches to whole-person care will be central to realizing a reimagined future of healthcare that serves all members of our communities.
Business Model Conundrum
The decades-long conundrum for organizations is figuring out how to fit Social Determinants of Health into their existing business and care delivery models. Payers and provider organizations have known about, and understood, the implications of SDOH on their members’ and patients’ health outcomes, but it’s really hard to change a healthcare “business model.”
This poses a problem within our current landscape where traditional organizations are seeking to address SDOH, despite the fact they aren’t established as part of their profit formulas, nor have past efforts led to success.
Incumbent payer business models built to succeed in the Fee for Service (FFS) environment are optimized to resolve acute health issues. FFS organizations contract with vendors who support their processes to deliver care (i.e., electronic health record companies, group purchasing organizations, etc.), and pay experts (i.e., doctors) to solve acute health events.
Payer business models in this ecosystem are set up to reimburse provider organizations for the services and transactions they perform. While some payer and provider organizations are seeking to shift to business models that are optimized to succeed under value-based case (VBC) arrangements, and thus keep people healthy, the attempts have produced mixed results.
This lack of consistent success in SDOH and VBC initiatives demonstrates the problem we face with our current inflexible business models.
A Shift to a New Paradigm: Proactive Community Care
Innovators are flipping these traditional business models on their heads by building their businesses around broader definitions of health delivery. They focus on a whole-person approach to health by addressing social connections, isolation, nutrition, physical activity, mental health, and physical health, as opposed to just the physical health characteristics upon which traditional models focus.
Because the FFS system doesn’t financially incentivize the time and resource-intensive approach required to deliver whole-person care, innovators have developed new payment models and new measures of success that support keeping people healthy instead of simply “fixing” them once something “breaks.” They don’t rely on FFS reimbursements, but instead upon value-based arrangements to fund their SDOH efforts. They also hire new types of resources (community health workers, doulas, health coaches, etc.), and establish new processes to build trust and fully understand the member’s life.
A “Path Assist” Model
As a community, we need to extend our efforts and redefine our business model to incorporate SDOH care with a more whole-person approach.
Care happens in the community, so medical professionals need to find ways to partner with other organizations to augment their current SDOH models of care and fill gaps that have been identified. The best partners will be cohorts who can put boots on the ground to work with and assist unengaged individuals through targeted intervention.
In order to have effective, efficient, and measurable performance, efforts should always be tech-enabled and data-driven. A proactive, omnichannel model with outreach, engagement tools, education and follow-up can guide patients down a better path to improved health and social outcomes.
The goal is to work further upstream to avoid reactive social care events. Proactive social care navigates members away from reactive acute social care events and unnecessary admissions. The job to be done is not only helping the individual find resources but coaching and supporting them to break down the barriers that exist and keep them away from avoidable and costly events.
The Future of Proactive Social Care
The way we address SDOH has traditionally been reactive, but moving forward, we have to find solutions that take a more proactive approach. Change is difficult and uncomfortable, but a mindset shift is the first step to making it a reality. Value-based models, treating individuals as whole-person instead of a collection of symptoms, and strong community partners will be essential in a proactive social care model.
To everyone already doing the work and making efforts to address the social care needs of your community members, thank you. Your efforts are redefining the existing care business models and giving others an example to follow. Working together, we will be able to positively impact the individual lives and communities we serve so that everyone has the same chance at leading healthy lives.
About Tom Quinn
Ted Quinn is the Chief Executive Officer and co-founder of Activate Care. He earned his B.A. from Brigham Young University and his M.B.A. from Harvard Business School. Since graduating, Ted has acquired 25 years of experience working in technology and healthcare.