BY: INDU SPUGNARDI
Decades of research have shown that improving the social determinants of health — economic stability, physical environment, education, food and social context — has the greatest potential to improve health for the greatest number of people.1 While recent health policy innovations tend to focus on meeting the health-related social needs of individual patients, it is important for health care organizations to advocate for policies that improve the adverse social conditions of their communities. Policies that address issues such as poverty, early childhood education and violence do not directly impact the operations of the health care delivery system, but they have a significant impact on health outcomes. Only by addressing both individual and community-level social needs can there by a transformational impact on health care costs and quality and community well-being.
POLICIES ADDRESSING SOCIAL NEEDS THROUGH THE HEALTH CARE DELIVERY SYSTEM
Tax Exemption Policy — The Affordable Care Act requires tax-exempt hospitals to conduct community health needs assessments (CHNAs) and develop implementation strategies based on assessment findings.2 When hospitals analyze the needs identified in their CHNAs they should understand their causal factors. For example, if the community has higher rates of obesity than neighboring communities, the hospital should examine potential causal factors such as the availability and safety of places to exercise, the availability of healthy foods and income levels. While the hospital cannot address these factors on its own, it can join like-minded community partners to work for policy changes.
Federal Health Policy — Addressing the social determinants of health is seen as a key piece in moving the health care delivery system toward value-based care, care with payment models based on meeting certain performance measures. In a November 2018 speech U.S. Health and Human Services Secretary Alex Azar noted "social determinants are closely integrated into the priority I've laid out to move toward a value-based health care system – one that delivers better outcomes at a lower cost." This recognition has resulted in changes to Medicare and Medicaid that incentivize health care organizations to meet the unmet social needs of beneficiaries, including:
- Medicare Advantage—Starting in 2020, Medicare Advantage plans will be allowed, but not required, to offer chronically ill beneficiaries services that can help meet their health-related social needs. Examples of these services include: home delivered meals, minor home modifications to support mobility and transportation for nonmedical needs.3
- Centers for Medicare and Medicaid Innovation (CMMI) — Starting in 2016 the CMMI has been running the "Accountable Health Communities" model demonstration.4 The model tests whether systematically identifying and addressing health-related social needs of Medicare and Medicaid beneficiaries through screening, referral and community navigation services will affect health care costs and reduce health care utilization.
- Medicaid — Much of the policy innovation around addressing the health-related social needs of patients is happening in the Medicaid program. Reforms such as alternative payment models, waivers and health plan care management can enable states to incentivize or require managed care organizations and other health care organizations to develop systems and processes to address social needs as well as open up new funding streams to advance this work.5
POLICIES ADDRESSING THE ROOT CAUSES OF POOR HEALTH OUTCOMES
While policy to address the health-related social needs of patients is critical to improving health care quality and costs, it is only part of the solution. To achieve sustainable results, the underlying social and economic conditions that impact the health of all people need to be improved. In a recent Health Affairs blog post, Brian Castrucci of the de Beaumont Foundation and John Auerbach of the Trust for America's Health discuss the importance of recognizing these two related policy goals and distinguishing between efforts to address a patient's or beneficiary's social needs and the social determinants of health of a population: "Redefining the meaning of "social determinants" to be mostly or only about the immediate social needs of expensive patients makes it harder to focus on the systemic changes necessary to address root causes of poor health."6
The good news is that there are national initiatives and organizations that have started to identify and implement evidence-based policies to address the root causes of poor health in communities, including:
- The Centers for Disease Control and Prevention has developed the Health Impact in 5 Years (or HI-5) initiative that highlights 14 well-known, already proven community-wide interventions that have seen results in five years or less.7
- Organizations such as PolicyLink and ChangeLab Solutions offer research, model policies and technical assistance aimed at advancing racial and economic equity.
- Cityhealth, an initiative of the de Beaumont Foundation and Kaiser Permanante promotes a set of evidence-based policy solutions to improve community health and regularly assesses the country's 40 largest cities in terms of their progress on nine specific policies.
- The Health Anchor Network brings together more than 40 leading health care systems to share ways their hospitals can use their economic power — hiring, purchasing, investing — to strengthen their local economies. The group also is starting to look at federal policies they can support, such as housing and community investment policy, which will make their local efforts more effective.
CATHOLIC HEALTH CARE'S COMMITMENT TO ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH
Driven by its mission to serve the poor and vulnerable and the need to prepare for value-based care, Catholic health care is embracing this work. Examples include:
- Catholic health systems AMITA Health, CHRISTUS Health, Trinity Health and Dignity Health have hospitals participating in the CMMI Accountable Health Communities demonstration.8
- Mercy Care, a nonprofit health plan owned by Dignity Health and Ascension, provides Medicaid and Medicare managed care coverage in Maricopa County, Ariz., and has improved and expanded housing options for its members enrolled in Medicaid.9 (Dignity Health combined with Catholic Health Initiatives in February to create CommonSpirit Health.)
- Providence Health and Services in Oregon, part of Providence St. Joseph Health, has set up community resource desks at five facilities where anyone in the community can receive help enrolling in health insurance and obtaining food, employment and housing assistance. This aligns with the state's recent direction to Medicaid managed care plans to address social determinants of health and health equity.10
Catholic health care's experience with early policy reforms to address patient social needs positions the ministry to inform and guide future policy development. It will be important to emphasize the need to make it easier for vulnerable patients to access these social services and to point out any unintended consequences that might impact policy goals. It is also necessary to advocate for and build the will for broader policy changes that will fundamentally change the way people live in our communities. As health care providers we see firsthand the failure of our society to enact policies and programs that support all people. This work will not be easy, but these words of Pope Francis should inspire and guide our efforts, "Jesus tells us what the 'protocol' is, on which we will be judged. It is the one we read in Chapter 25 of Matthew's Gospel; I was hungry, I was thirsty, I was in prison, I was sick, I was naked and you helped me, clothed me, visited me, took care of me. Whenever we do this to one of our brothers, we do this to Jesus. Caring for our neighbor; for those who are poor, who suffer in body and in soul, for those who are in need."
INDU SPUGNARDI is director, advocacy and resource development, the Catholic Health Assocation, Washington, D.C.
Community Benefit: www.chausa.org/community benefit/community-benefit
Policy Briefs: www.chausa.org/advocacy/policy-briefs/social-determinants-of-health and www.chausa.org/advocacy/policy-briefs/commitment-to-community-benefit.
- Thomas R. Frieden, "A Framework for Public Health Action: The Health Impact Pyramid," American Journal of Public Health 100, no. 4 (April 2010): 590-95, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836340/.
- "Additional Requirements for Charitable Hospitals; Community Health Needs Assessments for Charitable Hospitals; Requirement of a Section 4959 Excise Tax Return and Time for Filing the Return," 79 FR 78953, Federal Register (December 29, 2014).
- Melinda K. Abrams and Shawn M. Bishop, "New Medicare Advantage Benefits Offer Social Services to People with Chronic Illness," To The Point (blog), The Commonwealth Fund, April 8, 2019, https://doi.org/10.26099/pm2a-gt42.
- Centers for Medicare and Medicaid Services, "Accountable Health Communities Model," https://innovation.cms.gov/initiatives/ahcm.
- Samantha Artiga and Elizabeth Hinton, "Beyond HealthCare: The Role of Social Determinants in Promoting Health and Health Equity," The Henry J. Kaiser Family Foundation, May 2018. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.
- Brian Castrucci and John Auerbach, "Meeting Individual Social Needs Falls Short of Addressing Social Determinants of Health," Health Affairs Blog, January 16, 2019, doi: 10.1377/hblog20190115.234942.
- Centers for Disease Control and Prevention, "The HI-5 Interventions," Office of the Associate Director for Policy and Strategy webpage, https://www.cdc.gov/policy/hst/hi5/interventions/index.html.
- Centers for Medicare and Medicaid Services, "Accountable Health Communities," Data.CMS.gov, https://data.cms.gov/Special-Programs-Initiatives-Speed-Adoption-of-Bes/Accountable-Health-Communities-Filtered-View/xjfx-cdeh.
- Ken Leiser, "Arizona Medicaid Insurers Combat Homelessness," Catholic Health World, March 15, 2019, www.chausa.org/publications/catholic-health-world/archives/issues/march-15-2019/arizona-medicaid-insurers-combat-homelessness.
- David Tuller, "To Improve Outcomes, Health Systems Invest in Affordable Housing," Health Affairs 38, no. 7 (July 2019), https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00676?utm_source=Newsletter&utm_medium=email&utm_content=All-Payer+Claims+Databases%3B+Health+Systems+Invest+In+Affordable+Housing&utm_campaign=HAT+7-12-19.
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