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Perspectives on a selected key
topic
April/May 2019 |
 hat
are the challenges and issues involved in estimating any ROI on
Social Determinants of Health (SDOH) initiatives, and to what
degree do you see ROI pressures being applied now or ultimately
to SDOH investments?
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'Peter R. Kongstvedt
President
P.R Kongstvedt Company, LLC |
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Consistent with how I think of anything, I will start with
why it’s hopeless, and finish with why it isn’t.
The
greatest challenges involved in estimating any ROI on SDOH
initiatives are related: there are so many of them and we
know so little about how each interacts with another, and
how, in combination(s) they affect health outcomes
independent of other factors. On top of that, how many known
determinants affecting health – smoking and diet, for
example – are themselves affected by social determinants and
vice versa, and how are they affected? With apologies to
Jonathan Swift (1733):
“Social Factors have littler
Factors,
Upon their backs to bite 'em;
And littler
Factors have littler Factors,
And on ad infinitum.”
This is the hopeless part: an overwhelming amount of
complexity in variations, numbers, and recursive impacts.
This can be illustrated with this highly simplified, easy to
read graphic depicting only a few potential SDOHs and other
types of factors:
And this is not hopeless how? By putting in the time and
effort necessary to identify which SDOHs have the most
impact and that are also factors that we can, realistically,
change on a population basis. By now we should have learned
that no matter how current a topic is in the lede to an
article or a speech by a pundit <ahem>, making broad and
inspiring statements about massive topics affects only the
readers’ or listeners’ sensibilities, and even then only for
a few hours or days. After which we go about our day jobs.
But trying to take ‘em all on leads back to hopeless, and
that’s not the place to go.
Better to do what we’ve (sorta)
successfully done already when we collectively identified
smoking as a serious problem and undertook a societal effort
through new regulations, taxes, billboards and other types
of media, and even lawsuits, all resulting in reduced
smoking. And leading to the rise in vaping, but that’s
another campaign. This type of approach is not simple, cheap
or fast, but it does have the virtue of having a potential
impact. It also does not affect the other factors that lead
to a particular factor, such as social settings that
encourage smoking, but perhaps one can still have an impact
without trying to solve all factors. It is slow and
incremental work, but the alternative is more speeches and a
jigger of pixie dust.
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Patrick Horine
President
DNC GL Healthcare USA, Inc |
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As you will read among other articles on this topic, it is
competing priorities which presents the biggest challenges
for the C-Suite. While process improvement, efficiency gains
and better care can be derived from such an investment on
SDOH, it is often the “soft” costs used as the measure. When
looking at ROI, most want it to be more tangible for the
result. Investing in technology or a new business line, you
are looking at revenue growth. Investing in SDOH one is
measuring resulting savings and reduced loss. Where we are
with value-based reimbursement, it is imperative that
healthcare organizations not only streamline but also
maintain the quality of care. It is managing the patients
from the vulnerable populations that is the real challenge.
Organizations with sound quality management systems
that look at both the operational and clinical aspects of
care can impact the savings to be realized. Whether it be
increased costs from a patient population using the
Emergency Department as their care provider or the costs of
readmissions, making investments in technology, process
change, projects focused on specific needs, these can make a
considerable impact that will be realized with maintaining
reimbursement and not being penalized.
As we look to
the future of precision medicine and advancements in
technology, this will enable providers to provide a means
for better assessment models to identify those more at-risk.
The resulting affect is that processes change by introducing
new protocols or other means to better manage patients. The
more consistent, the more to be gained. Lack of data is a
shortcoming because most of the systems do not have a robust
method in place for identifying social and behavioral
concerns that should be considered in preparing a treatment
plan for the patient.
There is objective evidence
from success stories that have proven to be effective, but
they made an investment to make this happen. Is it
worthwhile for investment in SDOH, of course, but how to
prioritize this among the other needs that are part of
capital and operating budgets. If hospitals are not
effective in how they are delivering care in the value-based
reimbursement model that will likely continue, they will
feel the pinch of this. Use a little now to save a lot more
later.
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David Fairchild, MD,
MPH
Director
BDC
Advisors |
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The World Health Organization has defined the Social
Determinants of Health (SDOH) as, “The conditions in which
people are born, live, work, and age.” The WHO goes on to
say that “these circumstances are shaped by the distribution
of money, power, and resources at global, national, and
local, levels.” Social determinants are a cause of a number
of major health inequities including heart disease, obesity,
diabetes, drug addiction, alcoholism, and a variety of
mental health issues. The growing inequalities of health and
wellness in many communities in the midst of economic growth
and concentrated wealth has helped to direct attention to
SDOH.
Further, the advent of value-based contracting
and population health programs has required clinicians like
me to take a more holistic view of the circumstances in
which our patients work and live.
There is a long
list of social determinants of health including
transportation availability, safe housing, physical
environment, racial segregation, access to safe drinking
water, food insecurity, that impact community health. Recent
research has shown social determinants, in fact, have a
higher impact on population health than healthcare services;
and that states that allocate more resources to social
services than to medical spending have improved health
outcomes over states that do not. Data availability, of
course can be challenging. But the rapidly emerging field of
data analytics has opened the door for companies such as
LexisNexis Health Care which gathers SDOH data from public
sources to help predict which patients may be facing serious
health issues, and the National Association of Community
Health Centers which has developed a risk-based SDOH tool
for interviewing patients.
Previously viewed as
simply beyond the scope of provider systems, SDOH have
historically been overlooked in clinical practice. However,
the move from volume to value-based contracting has opened
the eyes of providers to the financial impact of SDOH and
has prompted an increasing number of provider systems to
address SDOH as an element of their population health
strategy. A new set of SDOH standards identified by the
Institute of Medicine in 2012 identified 12 different SDOH
measures that are only recently becoming used in clinical
practice. SDOH initiatives focus on community partnerships
that may offer food, temporary housing, and transportation.
Organizations such as Montefiore Health System in the Bronx
have reported a well-publicized “300% ROI” on their
community housing program which has reportedly reduced ER
visits and readmissions among high risk and chronically ill
patients. Other providers are partnering with community
organizations and are using data to identify frequent users
of ER services and link them to primary care providers.
The good news is that the move toward population health
management will fuel local SDOH initiatives that can
generate a ROI in a value-based reimbursement environment.
But it should be clear that these SDOH efforts are not
focused on improving the underlying social and economic
conditions of these communities to foster improved health
for all---they are primarily about ameliorating the social
service needs of individual patients, and by doing so
securing better outcomes for the provider’s value-based
contracts. Our own experience is that the most successful
population health program will have an SDOH focus as part
its efforts. These investments in social and community
services are essential, especially for any providers dealing
with high risk dual eligible and Medicaid patients.
As we start to normalize the tracking of SDOH metrics, the
next question will be should we hold providers accountable
for performance on these metrics-as we do now for quality?
Based on a decidedly unscientific “biopsy” of medical
institution hallway conversations, being accountable for
social factors makes providers very nervous. Nevertheless,
holding provider systems accountable for performance in this
area is a potentially powerful tool, even more so if in
doing good, provider systems can also do well.
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Vince Kuraitis, JD,
MBA
President
E-Caremanagement |
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During the disease management (DM) era of the 1990s and 00s,
we learned a lot about ROI on interventions to improve
health and/or avoid healthcare costs. Let's revisit some of
those lessons.
For typical health plans, the average
member tenure is about 3 years and about 20% of patients
turn over in a given year. Thus, health plans were only
inclined to make DM investments with a very short ROI
horizon (1-3 years) and a clearly attributable payback.
For example, congestive heart failure (CHF) was
considered one of the strongest cases for positive ROI. For
CHF patients rapid weight gain is one leading indicator of
imminent need for hospitalization. A patient who
inadvertently ate a can of high sodium soup is likely to
gain several pounds overnight. The DM program flagged the
weight gain through an electronic scale provided to the
patient; this might trigger a visit from a home health nurse
who would give the patient a shot of lasix, thereby avoiding
a $15 K hospitalization. Even here many health plans were
skeptical about ROI because investments and payback need to
be measured and attributed across an entire population of
patients.
Most potential DM interventions failed to
meet health plans' ROI thresholds. Reducing a diabetic
patient's A1C levels today might prevent the need for foot
surgery 15 years down the road, but the economic benefit
would almost certainly NOT accrue to the health plan that
made that investment today.
Measuring ROI for some
SDOH interventions might be straightforward. For example, a
provider's population health program might subsidize or
provide a patient with an Uber ride to a medical
appointment. Here you can weigh the costs of rides against
the probability of missed appointments to calculate ROI.
But...measuring ROI for most SDOH
interventions/investments won't be this straightforward. The
term SDOH is an umbrella term for a wide range of potential
social, economic, psychological, behavioral, etc. issues
affecting patients. Many patient social determinants of
health occur or build up over a long period or even a
lifetime; they're not necessarily easy to detect, change,
and monitor...AND creating positive patient change can be
difficult, time consuming, and a lengthy process. Or in
plain English, this stuff is really complex and we are just
beginning to scratch the surface.
Measuring and
establishing ROI will be challenging for most SDOH
investments. How soon will the payback occur? Can the
payback be accurately attributed to a specific investment?
Which patients should be considered "members" of a
population health program -- unlike a health plan population
the beginning and end dates for "membership" might not
clearly definable. What's the time period over which ROI
should be calculated?
It would be irresponsible for
health care organizations NOT to understand ROI aspects of
SDOH investments. That doesn't mean that ROI is the sole
decision criteria, particularly for organizations driven by
a strong sense of mission.
The economic logic for
success will require focus on a limited set of SDOH
investments, where an intervention (investment) can be made
under clearly definable circumstances, where payback can be
attributed and measured accurately, and where ROI can accrue
quickly. It will take many years -- if not decades -- to
establish best practices.
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