– More and more healthcare providers and payers are teaming up with ride-sharing companies, food pantries, and other community-based organizations to address one of the largest drivers of patient outcomes – social determinants of health.
Where a patient lives, what food she can afford, her education level, if she drives, and a host of other socioeconomic, behavioral, and environmental factors drive health outcomes, whereas purely clinical care contributes to just 10 to 20 percent, according to commonly cited statistics.
As healthcare providers strive to reduce costs while improving quality of care, especially under risk-sharing contracts, they have realized the value of addressing these social determinants of health.
But developing, implementing, and notably, generating ROI on programs that target social determinants of health has been a major challenge for both providers and payers, leaving many to wonder if the programs will last long enough to improve care for patients.
“There are little pockets of these things happening, but they’re happening in silos,” explained Jacob Reider, MD, CEO of Alliance for Better Health, a regional network of organizations that provide social services to marginalized communities in New York.
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“I would predict that all of these siloed efforts are not going to demonstrate ROI, and therefore will be written into the history books as failed experiments,” Reider stated.
Like high-quality clinical care, efforts that address social determinants of health need to be coordinated among all the different players touching that part of a patient’s healthcare journey, Reider asserted. For that reason, the Better Health Alliance created a new type of IPA consisting solely of community-based organizations.
According to the American Academy of Family Physicians, an IPA, or independent physician association, is “a business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs).”
Purchasers of healthcare services are more likely to sign contracts with larger groups of physicians who collectively demonstrate high quality, low cost, comprehensive care, the Academy continues. Therefore, IPAs can help independent physicians leverage the scale needed for more favorable contracts with payers, suppliers, and other healthcare entities.
The Alliance for Better Health’s IPA is built on this premise, but with a notable difference: The IPA consists of organizations that provide social care services that are not currently billable to Medicaid, or really any other payer.
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“As far as we know, we’re the only IPA that is explicitly focused on social services nationwide,” Reider said.
The Social IPA, as the Alliance for Better Health calls it, acts as the middleman by bringing community-based organizations together and contracting with health plans to set up sustainable, comprehensive programs that address social determinants of health.
“We sit in the middle and we do our best to speak both languages,” Reider explained. “We speak health plan in a language they understand, so things like ‘PMPM’ or ‘ROI.’ Then, when we speak to the CBOs, we use different languages because these are organizations that are focused on the services that they provide. They are not as business savvy as either the medical providers or the health plans, so we need to use a different language.”
Being fluent in multiple “languages,” the IPA can then “start to insert some of the concepts, like quality,” Reider elaborated.
“What is a high-quality food pantry?” posited Reider. “So, we’ve had to work with them on what high quality is to them and how they participate in an individual’s health overall, rather than just the space that they’re working in.”
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Reider hopes that this coordination, coupled with real payer contracts, can create a more sustainable system for addressing social determinants of health, rather than the patchwork of programs run by payers, providers, and community-based organizations.
While healthcare executives agree that hospitals and health systems are best positioned to run social determinants of health programs, a lack of reimbursement for the services has been a major barrier for providers, a recent survey showed. And that barrier was followed by an inability to generate a return on investment.
“This is very different from, say a hospital that’s doing bundled payments and controlling the whole value stream for total knee replacements,” Reider stated. “That makes a lot of sense because there’s presumably ample supply of orthopedic surgeons, physical therapists, and ambulatory surgical centers, and you can see how if you connect all of that together, you control it and it’s all within your network. But I would argue in this space, there isn’t enough financial margin.”
The Social IPA plans to fix that by identifying potential interventions using community-based organizations and data analytics. For example, the IPA has discovered that providing rides to Narcotics Anonymous for individuals with opioid use disorder correlated to fewer emergency department visits.
“Now, we got to get to the return on investment question,” Reider said. “What’s this worth to a health plan?”
The IPA is currently working with several health plans to implement and scale programs like that, but eventually, Reider hopes to tie successful interventions to a more stable source of revenue, like a per member per month (PMPM) payment.
“What I’d like to get to someday is a PMPM in which in all of the plans in a community will contribute say $3 or $4 per month, and then all of the services that are available in the community will be paid for by our organization,” Reider elaborated.
The PMPM payment structure, according to Reider, solves the problem of individuals only having access to a certain type of social determinants of health program based on what health plan they have. With the Social IPA, patients across health plans would be able to take part in programs involving a wide range of community-based organizations that fit their individual needs.
The payment structure has also recently gained more attention during the COVID-19 pandemic for its stability and predictability. Unlike traditional fee-for-service contracts, providers with PMPM or capitated payments were able to stay open and operational when patients could not come in for elective services.
In a world where healthcare utilization is limited appropriately, PMPM payments can help providers – traditional and non-traditional – offer the services patients truly need for better outcomes.
“Our hope, plan, ambition, all of the above, is to implement a public utility, so this would be a shared infrastructure by region,” Reider explained. “We think it’s important that these kinds of things be available just like streetlights and electric wires, the community shares in the creation and the maintenance of the assets and pays for their use on an ongoing basis.”
The reason why this is so important? “We don’t think it’s practical for any one institution to take on the expense of investing in something like this on their own,” Reider said.