One of the most vexing issues in the U.S. health care system is the “value” equation. As a nation we spend far more on health care than any other country—on average, more than 50 percent higher than other industrialized countries. Yet despite having some of the best health care institutions in the world, on most broad measures of health we rank well below average compared to our peers—26th on life expectancy among the 35 OECD member countries and, even worse, 29th on infant mortality.
KEEPING HEALTH CARE IN CONTEXT
High health care costs and mediocre health outcomes translate to poor value—but this is a somewhat simplistic view of the problem, because health care, we know, accounts for just 15-20 percent of health status. Outside of genetics, nothing has more impact than the social determinants of health—the conditions in which we live, work, and play.
That's a powerful argument for both a broader view of costs—including spending on social services too—and attention to health care's role in ensuring that those factors are recognized and addressed.
Researchers have demonstrated that countries—and, within the U.S., states—with higher proportions of spending on social services relative to health care have generally better health outcomes. But simply increasing spending on social services, particularly in the current political environment, is neither viable nor sufficient. Health care remains central to efforts to reach many of the people we're trying to serve; for disadvantaged populations, especially, it may be the only consistent window into their lives.
On a policy level, a more nuanced approach to addressing the social determinants of health and improving health outcomes is value-based payment—moving away from volume-based, fee-for- service payment and holding the clinical delivery system accountable for health care resource use and health outcomes. This of course incentivizes the reduction of unnecessary tests and procedures, and promotes value-creating actions such as strengthening primary care and improving care coordination.
Clinical-community partnerships are critical to both the “value equation” and increasing overall health. But particularly for disadvantaged populations, more is needed to improve health outcomes, as issues such as food insecurity, unstable housing, and inadequate transportation will derail even the most well thought out medical treatment plans. To date, however, it has been incredibly challenging for health care providers to figure out how to effectively partner with community organizations to address these social determinants of health that are critical to health outcomes.
Getting the financial incentives right through value- based payment is not enough. Community-based organizations (CBOs) are a heterogeneous group, more fragmented than health care was decades ago. And with major differences between health care and CBOs in organizational culture and structure, staff capacity, technology infrastructure, regulatory requirements, and ways of measuring impact, aligning all those factors to create true partnerships is no small task. For those of us familiar with the struggle to coordinate primary and specialist care, and transitions between health care settings such as hospitals and nursing homes, the enormity of the challenge of coordinating with entities outside the health care system is no surprise.
BUILDING EFFECTIVE PARTNERSHIPS
We are learning, however, how to build productive relationships and ensure ongoing linkages and feedback between the two sectors, through projects such as our own Partnerships for Early Childhood Development. Working with 11 pediatric practices and their CBO partners, the initiative is helping health care providers routinely screen children ages 0-5 and their families for social and environmental risks that interfere with their development, and connect them with services that can address those risks. This year, UHF will be launching a similar initiative for adult primary care practices as well.
Over the next few years UHF will be spending increasing amounts of our time and resources on such clinical-community partnerships, explicitly recognizing the importance of the social determinants of health and the role that health care providers can play in addressing them. Creating effective, sustainable relationships between the two sectors is critical to the long-term success of value-based payment and to increasing the value of our health care spending but, most importantly, to improving the overall health of our nation.