There’s been considerable discussion recently about building a “Culture of Health” in communities across the nation. This is now a core strategic focus of the Robert Wood Johnson Foundation, and it’s aligned with many pilot projects and other efforts in the public and private sectors to improve nutrition and exercise opportunities, early childhood programs, social supports, and the other big influences on population health. One of the most promising yet most challenging fronts in these efforts is bridging the gap between good “health” and good “health care.”
Insurers, hospitals, and healthcare systems are increasingly investing in efforts to improve prevention, wellness, and care management. Especially for populations with limited means, however, studies show that some of the best long-term ways to improve health outcomes are through addressing social service needs—including housing, environment, income and education. This means linking the healthcare infrastucture with public health, social service and community organizations. A hospital that invests in a community-based asthma program to teach patients how to manage their disease and avoid triggers, for example, may be able to prevent emergency room visits and hospital admissions by partnering with social workers or community health programs that can do family education and home modifications. But to make such a reform sustainable, the hospital would need to shift its payments from Medicaid, Medicare, and private health insurers from paying for the asthma complications to paying for keeping asthma patients well. This may be difficult – especially for hospitals that don’t have a well-integrated working relationship with social service providers, and for health insurers who would like hard evidence that these new payment reforms will really deliver on improving health and keeping overall costs down.
Health care reforms that focus on preventing complications are occurring. Payment reforms are now driving providers to better utilize health care resources to improve patient outcomes. After Medicare began penalizing hospitals with high levels of avoidable readmissions, many set up care management programs to help patients avoid readmission. This included clearer discharge instructions, medication assistance and better coordination with patients’ primary care physicians, and even some non-medical services like transportation to follow-up appointments for patients who can’t easily transport themselves. A growing number of health care providers have become Accountable Care Organizations (ACOs), which enables them to be paid at least in part based on reducing costly disease complications and providing better-coordinated care.
Unfortunately, proven, examples of extending health care reform to integrate community interventions that reduce short- and medium-term costs remain scarce. Collaborating with social service and community organizations also presents logistical and bureaucratic obstacles for clinicians. For this reason, ACOs have generally not made significant investments in non-medical, community-based prevention and wellness interventions
Some state Medicaid programs have tried to promote community-based reforms in ACOs or similar accountable-care arrangements. These initiatives involve a partial global or person-level payments that increase with better population health outcomes, plus steps intended to make it easier to coordinate services and integrate funding streams between health care providers and community-based health promotion initiatives. Some health care providers involved, including hospitals working with pediatricians, are using this promise of financial support if their efforts succeed to work with social service and community-level support systems. But many health care providers are reluctant to go down this path because of uncertainties about how and whether these programs would actually work, given the administrative and logistical challenges, not to mention uncertainties about whether these efforts will actually reduce costs enough to earn the additional funding.
Developing better evidence on health care reforms that bring health care delivery and community-based health improvement together is a critical policy priority. What evidence and changes in policy do health care payers and providers need to move forward with these reforms? Is it possible to develop better practical guidance for payers and providers on how they could implement such reforms now?
At the upcoming Population Health Forum on Oct. 22-24 in Washington, I plan to explore these kinds of novel payment approaches with on-the-ground implementers and experts who are developing successful strategies for health care providers to work more effectively with community health programs. Through collaboration and shared accountability between hospitals, health systems, clinics, behavioral health services, community organizations and patients, it is indeed possible to shift our focus from episodic acute care to a holistic approach that keeps populations well. But we have a lot of questions to answer before these strategies will successfully transform health care and population health.