Targeting Patients' Social Needs Helps Quality, Costs: Study

Marcia Frellick

June 13, 2014

Before physicians can substantially cut costs and improve outcomes, they must first address patients' social needs, including whether a patient has a home or heat or access to healthy food, according to findings from a new report.

In the report, prepared by Manatt Health Solutions for The Commonwealth Fund, The Skoll Foundation, and The Pershing Square Foundation, the authors explore the effect of social needs on health outcomes and costs of care and identify evidence-based strategies for targeting social needs, improving health, and reducing spending.

Lead author Deborah Bachrach, JD, is special counsel at Manatt, Phelps & Phillips, New York, New York, where she advises states and policymakers on strategies for healthcare reform.

"If you have a low-income patient who can't access the care they need because they don't have heat or they don't have a home, it becomes part of the physician's or the clinic's responsibility when it's looking to improve health and contain costs," she told Medscape Medical News.

Those problems are coming to the forefront as the Affordable Care Act (ACA) expands coverage to millions more low- and modest-income people. At the same time, pressures are increasing to cut readmissions and contain costs.

The report lists examples of programs with successes, among them Health Leads, which operates in clinics and community health centers in 6 cities and enables physicians to write prescriptions for patients to get food and heat. Trained volunteer university students who work out of the hospitals and clinics connect patients to local resources. Nationwide through the program, volunteers have been able to address at least 1 need for 90% of patients, the report says.

Another example is the Healthy Homes Project in the Seattle-King County area of Washington, where community health workers visit low-income families of children with uncontrolled asthma. The share of people using urgent care services fell by almost two thirds during the intervention, and costs were estimated to be $334 lower per child, the report shows.

Paying for It

The authors list possible funding sources for evaluating patients' social needs, including public and private financial incentives for patient-centered medical homes (PCMHs), which require that providers integrate social supports into their care models. "These certifications almost always trigger higher levels of reimbursement," the report notes.

Also, nonprofit hospitals must provide a community benefit (usually equal to their tax benefit) to keep their tax-exempt status. In total, this makes about $13 billion available annually, and because these funds have typically gone to the underinsured or uninsured, now greatly reduced by the ACA, more funds may be available for targeting social needs, authors say.

Does Theory Work in Practice?

Leslie Greenwald, PhD, chief scientist in the Division for Health Services and Social Policy Research with nonprofit, independent research institute RTI International, Research Triangle Park, North Carolina, told Medscape Medical News that Bachrach's theory is sound and there's good logic in linking social services and medical care, which makes the concept ripe for more investigation. But she said she is less certain about whether trying to address social needs from a medical care practice level will necessarily improve quality and reduce costs.

"It may do one — improve quality — but not the other — reduce costs.  There is some evidence that greater care management and coordination is as likely to identify unmet social and medical needs that, particularly in the short run, increase costs because most needs are identified and met," she said.

She also said that despite physicians' best efforts, some populations may simply not use services even if a physician gets patients access. She added that even if physicians make referrals, the question becomes whether there are sufficient resources in a community to solve social problems, such as lack of access to healthy food and homelessness.

Incentives for Investing in Services

That's precisely what the report is making a case for, Bachrach says: that physicians will see the medical and economic benefits of investing in the services so that the services exist and are able to complete that component of patient care.

The authors acknowledge that more data on how interventions work are important and also that getting funding for collecting those data is difficult.

"We lay out the business case for providers to include these interventions at their sites in their clinical models…so that providers have a reason for investing, paying for, underwriting the cost of the social intervention."

This isn't about adding more requirements to the primary care visit, Bachrach said, but rather being the person who links patients to outside services, so that physicians can concentrate on medicine.

She said especially under a model such as a PCMH, the link to services might play out in physicians asking a community organization to come onsite and then pay for them to be onsite a few days a week. By having an outside entity focusing on follow-through with a patient's social needs, the physician can focus more directly on medical care, she said.

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