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Advancing social determinants of health interventions needs pragmatic framework to justify investment, experts say

Sufficient funding is rare and providers hold back on investing in such programs thanks to inability to quantify benefits.

Beth Jones Sanborn, Managing Editor

Despite a growing body of evidence, both data-driven and anecdotal, that efforting solutions for social determinants of health in a provider's community yields positive results in improving outcomes, cutting readmissions and facilitating better management of chronic illness, health systems still hesitate to invest in programs that seek to address these issues and significant funding is rare.

A new policy insight post published in Health Affairs proposes that because these programs are "public goods," their return on investment is harder to quantify. A financial model that might enable more investment includes focusing on these programs as being in the provider's "self-interest," making them an investment, not a donation.

"Decades of research have demonstrated that economic stability, physical environment, education, food, and social context are powerful upstream factors that largely determine one's health before the health system is able to intervene. Social determinants of health also influence the effectiveness of medical interventions. Antibiotics are of little help to those who drink polluted water every day," authors Len Nichols and Lauren Taylor wrote

Nichols is the Director of the Center for Health Policy Research and Ethics and a health policy professor at George Mason University. Taylor is a doctoral candidate in health management at Harvard Business school.

They pointed to three major reasons why hospital systems underinvest in social determinant programs. First, individual healthcare organizations find it challenging to accurately estimate the "full net benefit" of their investments in such programs due to a lack of good data on relevant costs and benefits.

Also, healthcare organizations might not be sure if or how social services would be delivered to the target group, since that work is done outside the hospital by non-healthcare personnel.  A lack of familiarity with or distrust of the local social services resources might contribute to this.

Finally, providers might fear loss of benefits from the program investments if the patient switches insurance coverage after they make the investment but before the benefit actualizes. The authors said plan switching is "fairly common" among the commercially insured and is especially prevalent in the Medicaid system as beneficiaries drift in and out of eligibility.

Their perception as a public good also clouds the waters. Public goods deliver benefits to different people and sectors at the same time. Though accurate, those benefits cannot be limited to those who directly pay for them and capturing the ROI is that much harder. This effect has been dubbed the "free-rider problem."

The authors propose a financial model that highlights the reality that social determinants programs are in a provider's own self-interest, making resources alloted to them sustainable investments that generate ROI, and not donations.

Central to this model is the selection of financially neutral "trusted broker," such as a local nonprofit or charity that can assemble local stakeholders like health plans, hospital systems, employers, community health centers, and county health and social service departments. That broker should be able to keep sensitive financial information confidential, be impartial and skilled in communication in order to promote the stakeholders' investment.

Informal conversations among the key stakeholders, meaning all those healthcare entities that bear financial risk for the healthcare of vulnerable patients, and technical advisers who help with facilitation, communication and data analytics, can identify community needs and gaps when it comes to social determinants.

The participation of all key stakeholders is key as is establishing trust among all the parties involved. The group should then determine where the greatest needs are in terms of community social determinants, possibly via a "landscape assessment" or community health assessment. Once stakeholders designate those areas of need, technical advisers can project potential ROI for possible interventions.

Those projections should be shared with all stakeholders such that plans to jointly fund an intervention can be formulated. Stakeholders can individually determine what they can invest in the intervention, perhaps with the help of the "trusted broker," who would ultimately determine what each stakeholder must pay to make the program happen.

A vendor can then be contracted to implement the intervention, whose actions will be ruled by a contract with "specific conditions, data reporting requirements, and deliverables."

The trusted broker manages the contract, updates stakeholders on progress, and ensures quality. Following the first year, the broker and stakeholders will assess the impact of the new program and returns to each stakeholder. Individual,stakeholder investments might be adjusted after this process.

Above all, Nichols and Taylor said investing in social determinants of health requires patience before returns emerge. Nonemergency medical transportation housing and nutrition assistance might yield faster results. Other programs might take three to five years to produce financial results. A focus on early victories, even small ones, should be highlighted to justify investments and strengthen trust.

Over time, it is possible that the definition of benefits, like better health status and not just financial gains, could emerge and enhance the ability to pinpoint ROI. 

For right now, a more pragmatic framework for formulating and justifying the programs is needed. Basing that framework on the notion that the programs are in a provider's own self-interest makes them seem more sustainable, the authors said. 

"Enlightened self-interest might not get us to the Promised Land, but if properly channeled, it could make local health systems considerably more efficient and humane than they are today."

Twitter: @BethJSanborn
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