It has been about six years since Atul Gawande, MD – a surgeon, writer, and public health researcher – profiled Jeffrey Brenner, MD, in an article in The New Yorker. Dr. Brenner used advanced analytics to identify patterns underlying health care utilization data, which he dubbed “hotspotting” It’s a term used by some police departments to identify high-crime areas. Dr. Brenner used it to pinpoint neighborhoods within a community that had unusually high health care costs.
Many of the factors that drive high health care costs, he determined, are non-health issues such as unstable housing, violence in the community and at home, loneliness, and other issues. Dr. Brenner’s work complements more recent research that ties some health care costs to social determinants. Outside of the US, other research has shown that countries that spend more on social programs tend to spend less on health care.
Together, this research can make a compelling case for widening our perspective on managing health care costs by considering how we can meet a broader set of needs that people may have – for housing, social services, transportation, employment, education, and nutrition, among others.
Private and public initiatives address social determinants
The Robert Wood Johnson Foundation, The Commonwealth Fund, and others organizations at the forefront of this issue in the US, provide financial support for a wide variety of community and health-system based initiatives. Organizations such as Health Leads were created to assist hospitals and other caregivers connect patients to community-based programs.
Dr. Brenner has an accountable care organization (ACO) in New Jersey that focuses on bringing the insights from hotspotting into practice, and it offers a toolkit to others interested in replicating his work in their own communities.
Some states are incorporating directives to address social determinants in ACOs. In June, for example, Massachusetts Gov. Charlie Baker announced that 18 ACOs from across the state had been selected to participate in a restructured ACO program that will integrate providers with community-based health and social service organizations. The state secured more than $50 billion in federal funding through a Medicaid waiver. The program represents the first major overhaul of MassHealth in 20 years, and is expected to cover more than 900,000 MassHealth members.
In many countries, local and national governments are working to build more connections between social and health programs. Our colleagues in the Centre for Health Solutions based in the United Kingdom have provided a wealth of examples in their recent report, Breaking the dependency cycle.
Many hospitals are trying to address social needs, but need more information on what works
According to our new Deloitte Center for Health Solutions research, many hospitals in this country are devoting some resources to help direct patients to social programs that can help address a broad set of needs. Not surprisingly, many hospitals tend to focus on populations that have the greatest health care spending – inpatients and those with high risk scores according to predictive modeling.
The finding that really struck me most is that several hospital executives told us that they are seeing limited short-term return-on-investment (ROI) from such programs. Health systems that invest in improving the health of their communities generally would like to see ROI in terms of improved health outcomes, reduced costs, or both. Indeed, about half of our respondents say evidence of ROI would encourage their organization to increase its investments in health-related social needs activities.
I think this points to an important gap. Even though research has shown a strong relationship between social determinants and health care spending, directing high-cost populations to social programs probably won’t reduce health care spending immediately. Such investments might be effective for certain groups of people, and some social-program investments might have a more substantial influence than others. Over the long term, some of the more impactful programs might be those that target children, who might not show up in the health care system until they reach adulthood.
We clearly need to invest more in research that can find the most efficient use of health system resources to get to the goal of lower health care spending – both in the short and the long term. It is probably unrealistic to expect hospitals themselves to figure this out. Sustainable funding is already a challenge for some hospitals and for the programs they have. They might not be able to devote additional resources to research and evaluation. Before we can understand how to target programs and people most effectively, we likely need data from many different initiatives and populations.
Social programs are not the only answer to better care
Figuring out what works, along with determining the health outcomes and cost impact, is especially important if these investments are to help us get to better outcomes at lower cost – the goal of many value-based care initiatives. Indeed, our study did find that hospitals with greater involvement in value-based care were generally more committed to referring patients to social programs, and measuring outcomes related to health, patient experience, and costs. Many interviewees also said that, regardless of the direction federal and state funding takes in the years ahead, the move toward value-based care is expected to advance the health care system’s ability to address social needs.
Many hospitals and clinicians continue to adopt value-based care payment models, and are turning their attention to the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). Our research indicates that many hospital system executives want to advance their collaborations with community-based organizations outside the health care system to strengthen their understanding of the gaps patients face, and to help them engage more effectively with patients. As described in our recent report on MACRA, many senior leaders across health care organizations are also interested in hiring patient advocates, navigators, social workers, and/or home health workers to assist with patient coordination, and to help patients navigate the system.
Coming back to hotspotting, Dr. Brenner’s work also showed that some high-cost patients benefited from different models of health care that is supported by richer data and a change in perspective among clinicians. These models include improved care coordination and monitoring between visits, and better alignment between behavioral health and physical health care.
So, not only do we need to have better information about the ROI of social needs programs, we need to be able to combine this information with what health care clinicians and hospitals can do better under new incentives that are aimed at the people where it will have the greatest impact on outcomes and costs.