By Chris Gay, CEO, CareAdvisors
The shift from a traditional volume-based to a value-based reimbursement structure in healthcare has been challenging for providers and health plans across the country for many years. The evolution that began decades ago has seen significant progress since the Affordable Care Act was enacted in 2010, primarily because value-based care incentives that link provider payments to improved performance were incorporated in the legislation. With a goal of better health, value-based healthcare is intended to decrease chronic conditions, resulting in lower healthcare costs. Closely-related, value-based social care focuses on addressing social determinants of health to achieve health equity.
At Chicago Health Executives Forum’s 2021 Annual Meeting, David B. Nash, MD, MBA, Professor of Health Policy, Jefferson College of Population Health, spoke at length about the role of population health in this period of transition, saying: “think of it as a roof and the roof of the house has pillars: one pillar is public health, another pillar is quality and safety, then health economics, including: ‘What does it cost? What’s the return on our investment?’ And, of course, health policy and now, the data science of population health. These are all the pillars that hold up the roof. Maybe an easier way to visualize it, is that we are going to connect healthcare and health. This is the bridge between health and healthcare.”
His contention was that this system was built to produce healthcare and to deliver services. “That’s how we get paid; that’s how we are trained,” he stated. “That’s what we do.” According to Dr. Nash, a very modest part of that system is built to improve health.
Indeed, the pandemic has exposed the inadequate funding for the nation’s public health infrastructure. In a February 2021 article, American Medical Association President Susan R. Bailey, MD, wrote: “Public health infrastructure enables every level of government to prevent disease, promote health, and prepare for and respond to both emergency situations and ongoing challenges…Persistent disinvestment in governmental public health agencies has limited our ability to effectively respond to SARS-CoV-2 and other crises.This neglect has serious consequences as the pandemic took hold late last winter, when our lack of widespread testing permitted faster spread of the virus.”
The warning signs were there before the pandemic as communities struggled with the extensive needs of their most vulnerable. A 2017 U.S. National Academy of Medicine report recognized the policy challenges, stating that: “improving the care management of high-need patients will require bold policy action and system and payment reform efforts by a broad range of stakeholders at multiple levels.”
With increasingly constrained health and social care funding, patients with complex cases that include chronic health conditions and social care needs, such as housing, food insecurity, transportation, unemployment and isolation, found their already difficult situations exacerbated during the pandemic. In response, academics and activists have called for a social determinants of health approach as the U.S., and countries around the world, strive for a more equitable, post-pandemic world. In our healthcare industry, a light has shone on the growing issue of health disparities and health equity and how rapid access to social service benefits can lead to lower uncompensated care costs and improved patient outcomes.
“When you think about the way COVID came in, who did it hit the hardest?” Allison Arwady, MD, MPH, Commissioner, Chicago Department of Public Health, asked at the February 2021 CHEF Annual Meeting, where she co-presented with Dr. Nash. “People with underlying chronic disease. Why did we see these differing rates of chronic diseases? Because we haven’t set up a system that makes sure people have access to the things that allow them to have healthy lives. COVID has shined a light on our failings as a health department, as a health system, as a city, and as a country. I think it is as much about the fact that we’ve created a system that sets up these kinds of inequities and we’ve not been serious about addressing the work underlying them.”
As healthcare organizations take on this renewed commitment to strive to meet health and social needs and invest in community health to improve health equity, the Centers for Disease Control and Prevention (CDC) will soon issue a Notice of Funding Opportunity (NOFO) for Closing the Gap with Social Determinants of Health Accelerator Plans. The FY2021 Consolidated Appropriations package included portions of the Social Determinants Accelerator Act, directing the U.S. Department of Health and Human Services, through the CDC, to make $3M in grants available to states and local governments to develop Social Determinants Accelerator Plans. The CDC is currently developing a NOFO to distribute the grants, with plans to award eligible state and local governments in August 2021 to develop multi-sector action plans that address social determinants of health.
In connected social care networks legislative news, U.S. Senators Chris Murphy (D-Conn.) and Dan Sullivan (R-Alaska) introduced the Leveraging Integrated Networks in Communities (LINC) to Address Social Needs Act in Congress in February 2021. The LINC to Address Social Needs Act would offer one-time seed funding for states to help establish partnerships between healthcare and social service organizations for referral, capacity management, and outcome tracking purposes. The goal of this bipartisan legislation is to improve the coordination of healthcare and social services.
As value-based care programs are adopted across the country, it’s no surprise to healthcare providers that all predictions point to an increase in alternative payment models. “We copyrighted a phrase: ‘No outcome, no income,’” Dr. Nash shared at the recent CHEF meeting. “What it means is if you focus on getting a good clinical outcome, then you ought to get rewarded. I see on the horizon a return, and a real emphasis on, value-based payment…getting paid to do a better job. And that job, as I see it, is to improve health.”
Dr. Nash even took it a step further when he spoke about one specific category of the current ecosystem that is aligned economically to go upstream and reduce utilization and improve health. “…the for-profit managed care industry,” he announced. “Anthem, ’Cigna, Humana – the large, national, for-profits of the world — they are the ones that have the economic incentive to do what we’re talking about. So maybe, there are some partnership opportunities. The rise of the ‘payvider.’
“Imagine, if we could find innovative ways to focus on nutrition, health, exercise, all the rest,” Dr. Nash concluded. “We have an opportunity and, hopefully, a light at the end of the tunnel.”
About the Author:
Chris Gay is the CEO of CareAdvisors, a Chicago-based healthcare technology firm that provides value-based social care automation to some of the largest U.S. health systems and health plans. The company recently built one of the largest navigation programs in the nation, helping millions enroll in social services and gain access to vital resources. Contact Chris at email@example.com.