By: Andrew Snyder, Chief Medical Officer, and Anita Cattrell, Chief Innovation Officer, Evolent Health
Years of research and data have shown that social determinants of health have a significant impact on the profitability and sustainability of the health care industry. In fact, when considered broadly across racial disparities, education, social support, transportation, healthy food and poverty, social determinants of health have been shown to account for more than a third of total deaths annually in the United States, and up to 60 percent of health care costs, eclipsing actual direct medical expense. This is most likely attributed to the imbalance of medical and social spending in the U.S. On average, nations that are members of the Organization for Economic Cooperation and Development (OECD) spend about $1.70 on social services for every $1 on health services; the U.S. spends just 56 cents.
To correct this imbalance, we need to shift a portion of our current health care expenditures to investments that address upstream social factors that heavily influence downstream outcomes. Evidence suggests that addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages. For example, in addition to lower body mass index and fewer risk factors for chronic disease, early childhood education has been associated with higher levels of education attainment and income and lower rates of violent crime and incarceration.
Given the far-reaching impact of these efforts, the return on investments addressing social determinants accrues not only to the health system in the form of reduced health care expense, but also to the broader community. However, current financing structures make it challenging for public sectors to pool resources together and measure the “full” return of these investments, which consist of capital infusion, tools and community-level mechanisms to deliver services. Most provider organizations don’t have the means to make these investments on their own, and those that have the means will likely find it difficult to see a near-term monetary ROI, as downstream efforts take time to take effect and may be extended beyond the health care system.
Pushing Forward by Working Backward
Until broader community impact can be measured, such that other sectors are helping fund these services, health systems will need to be thoughtful and targeted on where and how they invest in social determinants of health to ensure a positive ROI. By developing approaches that work backward from the outcome they’re trying to change, health systems can take progressive steps toward targeting the underlying causes of these issues, rather than siloed steps that treat only symptoms.
Some of the cursory discussions of social determinants of health suggest that addressing single factors can have a large impact on outcomes. Analysis shows this not to be true, yet most organizations are still tackling these issues in a silo. For example, we’ve seen evidence that providing free transportation services to Medicaid patients does not decrease missed primary care visits, and that building grocery stores in food deserts does not alter dietary habits.
One big reason why these interventions are not showing impact is because they are not targeted at those who would benefit most, and another is that they frequently lack an agreed-upon point of accountability for integrating these social services into the broader health care planning for these individuals. For example, through our own analysis, we know that for a specific set of individuals, having a transportation barrier is associated with a 63 percent increase in risk of readmission. However, providing just a ride for those patients isn’t enough. This needs to be coordinated with a medical professional visiting the home and ensuring that the conditions are conducive to a successful recovery. This includes making sure the patient has a follow-up visit with his or her physician; conducting a comprehensive medication review; and ensuring the individual has the support they need to obtain and adhere to the prescribed regimen to avoid a readmission.
But without someone taking accountability for coordinating this transportation service with all the other services needed, the chances of avoiding that readmission are low. It’s the diffuse responsibility that’s led to symptom-focused and ineffective solutions, and that’s what needs to change to see widespread impact and an actual ROI on these types of investments.
When accountability is present, however, a chain of connections answering to one another can help identify overall goals that can be approached in a concerted way. The team can work backward from there to drive forward progressive steps toward bigger goals and address social determinants of health in ways that show marked impact on health outcomes. To help ensure that social determinants of health efforts are accountable and productive, health care organizations can use these three action steps as a guide:
- Define accountability. As a care team comes online, they’ll need a leader—one who is not necessarily responsible for addressing individual social determinants, but who is accountable to the patient for the results. Primary care physicians—already the “quarterbacks” for their patients’ care and accountable for total cost of care in new payment models—are perfectly positioned for this role. To succeed, though, these quarterbacks must have a strong team behind them, consisting of dedicated clinicians who are integrated into a care delivery team and who themselves are empowered to advocate for change, act on data-informed recommendations and coordinate or monitor interventions within and without the health care provider.
- Use AI and machine learning to create and follow a comprehensive map. To change a patient’s health status and trajectory, one needs a clear understanding of where the patient is headed, what’s pushing them in that direction and any roadblocks to better paths. Can they easily access a store that sells food appropriate to their recommended diet? If told to come in for a follow-up, can they make time during the day, or are they a sole caregiver to a disabled relative?
Disparate data sets can shed light on neighborhood food and public transit access, household type, education and financial history, clinical notes from the electronic medical record and other variables. When these data sets are aggregated, artificial intelligence and machine learning can flag variables that, when viewed together, can pinpoint both clinical and social risk factors and flag opportunities for either physician or community intervention. Such machine-learning resources can be designed to provide push-notifications and other interactive support tools that convert data sets into actionable insights while minimizing any additions to administrative time.
- Redefine your measurement strategy by collaborating across stakeholders on shared goals. Realizing an ROI is muddy business when the investments made affect patients from multiple touchpoints. Metric definition and metric measurement, like interventions themselves, need to extend beyond a care provider’s four walls. Work that has traditionally been done purely at the social level should now be married with health and outcomes data to more robustly predict areas of need and define success. Considerable barriers remain, as clinicians who answer to their own facility’s balance sheets must answer to financial overseers who may not be willing to count a community benefit as a realized return. We may need to see new public discussion on tax exemption and definitions of community benefit here, but there’s strong potential, if we get it right, to truly redefine managed care and community health if we can redefine the metrics of care outcomes.
Andrew Snyder is the Chief Medical Officer and Anita Cattrell is the Chief Innovation Officer at Evolent Health. They can be reached at AMSnyder@evolenthealth.com and ACattrell@evolenthealth.com.
My Interview with the President… Jeff Buehrle
By Kelly Ryan
Regional Director of Business Development
Healthcare Resource Group
Recently I had the privilege of meeting with Jeff Buehrle, the 2018- 2019 President for the Arizona HFMA Chapter. Chapter success requires a strong leader with vision to inspire and guide a volunteer board, creativity to maintain and grow membership and, focus to ensure the HFMA mission is adhered to. Jeff has the mad skills to do just that. He brings a wealth of experience to the position both with his 32 years in Healthcare Finance and, participating with Arizona HFMA in various roles for more than 30 years. We are looking forward to the continuation of his term as President and the difference we know he will make.
KR: Jeff, thanks for taking time to talk about your current term as President of Arizona HFMA. You’ve been on the job for almost four (4) months and we’re just coming off a successful Fall Conference. The conference was not only well attended, but the education was amazing and the networking opportunities were well planned and fun. What were your three favorite takeaways from the conference?
JB: Yes, thank you Kelly. My three take ways from the fall conference were: first, our chapter has amazing leadership, especially on our Program Committee. This team pulled together a great conference. Second, a diverse agenda combining technical education and leadership skill training makes sure that interested people attend and participate but also resulted in our members feeling that they got more out of the conference than maybe they even considered they would. Lastly, I heard in several presentations that we as leaders need to think differently. Stop using the B solution because it is safe and maybe easier to do, but pull out the A card and try something completely new and turn the project on its head. That is how you disrupt and find solutions that most would not have looked at otherwise.
KR: During your short tenure as President there have already been some significant enhancements, specifically in member communication. The webpage has a beautiful new makeover that is so much easier to maneuver and Cvent online registration is now available streamlining the process and eliminating the need for paper invoicing. Both were a long time coming and took a team to accomplish the final products but these are great improvements early in your Presidency. What do you see as your priorities for the remainder of your term?
JB: Kelly, again I am so proud of the leadership team, especially our Communication Committee and our chapter administration support team, KCA. Together the team designed and replaced an archaic web site with a user friendly platform. In addition they moved us on to an easy to use registration application, Cvent, which is standardized to the HFMA National Platform making data sharing easy. Finally, our leadership team is expanding our membership campaigns to target markets including payers and national health plans, physician groups, early careerists, and, in Arizona we added our Native American members. Part of this outreach includes looking at expanding our educational programs to include topics of interest to our target groups
KR: Like most chapters, maintaining and growing membership is always a key priority for HFMA Chapter leadership. What is your vision for improving the member experience and continuing to expand and grow membership?
JB: First and foremost is to listen to our members, both directly and through our Membership Survey. Both avenues provide valuable information to the chapter leadership team on how to affect change and, how to be responsive to our member’s shifting needs. Adding in our target markets to our growth formula has required greater flexibility and agility to align with our members needs.
KR: Providers have more and more options for education, CEUs and information online. How does HFMA provide better value for our provider organizations? How do we enhance the member experience?
JB: Kelly as I stated earlier, the dynamics of our chapter is changing, and we must find ways to adapt. We earned two Yerger Awards for our Chapter with our participation and vision for both the Western Symposium and, the HERe conference, held this year on November 2nd and designed to address specific needs of women in the health industry. The HERe conference has been a huge hit and continues to grow each year. Men, if the agenda looks interesting please to attend. You won’t be bounced at the door.
The Western Symposium, held this year on January 13-16 in Las Vegas, combines the effort of program planning for both Region 10 and 11, the 13 most western state chapters, into a single event. By consolidating planning and delivery resources into a “Mini Annual Conference” we have been able to contract speakers that an individual chapter or single region could not afford. Through this consolidation we have been able to enhance the programing for our members at a very affordable price.
Lastly we are using scholarships and hosted provider slots to provide opportunities to members to get to any or all of the conferences. We know not every provider representative can afford the travel and the registration: therefore, we are coming up with unique ways to open some slots at our conferences for scholarship and hosted providers.
KR: You’ve been in healthcare for the last 32 years and see the evolution and changes that have taken place. What do think that healthcare will look like in 5 years?
JB: Wow. If I had that crystal ball I would start consulting, after I share with my current employer Banner Health, of course. I think we are going to see a “Medicare for all” program passed. We cannot continue to slice and dice healthcare to meet whatever direction the House, Senate or current President wants to take it. Hospitals cannot continue to bear the cost of a very broken system through Bad Debt and Charity. We are the only industry that expects the patient to be fixed in an emergency and then expect payment. Then we fight to get payment and hope it won’t be denied by the insurance company or, that the co-payment or deductibles won’t be too much for individual to pay. I also think we will see and have to expect decisions on end of life and expensive procedure authorizations. Finally, and probably more futuristic, the most transformative change we’ll see will be in the Pharmaceutical market with Bio-designed drugs to address the illness through genomics and genetics. This will be amazing discoveries but will then beg the question who will pay for it? Lots to consider and lots to do as leaders in Healthcare in the next five years and further out.
KR: Jeff, during your presentation at the Fall Conference you stressed not only your personal commitment to participating and volunteering with the chapter, you also challenged our membership to step up and volunteer. As a long-standing volunteer, what value has this provided you?
JB: Kelly thank you for asking. At first, 30 years ago, I think I saw it as extra work not unlike most people think of volunteering. I thought, where will I find the time and how will I be able to add any value? What I found out is the board and committees review and leverage skills and talents of each volunteer leader. Once volunteering I was able to validate the results of my work through review of attendee conference surveys, Membership Satisfaction Surveys, and through one on one time with members and sponsors. It is the time I spent with people that created the bonds and life-long network of colleagues and professionals that have helped guide me throughout my career and ultimately as the President of the AZ Chapter. Now, it is not work to me, it is giving back and helping shape our members, volunteers and board members to lead in the future.
KR: Jeff, thanks so much for taking time to share your thoughts, experience and vision. One last easy question to wrap this up. It’s always fun to watch people struggle with the pronunciation of your last name when they go to introduce you at conferences. For the record, how is your last name pronounced? J
JB: Funny, thank you for asking. The easiest way to spell it phonically is Burley (Buehrle) Thank you Kelly!