December 24, 2019

The Shifting Boundaries of Health Care

The following is an interview with Patrick Scott Romano, MD, MPH, FACP, FAAP, Professor of Internal Medicine and Pediatrics at UC Davis Health and C0-Editor in Chief of Health Services Research.

Austin Frakt: Among health care systems, plans, and programs, there has been increasing discussion of, if not investment in, approaches to addressing social needs. What is driving this phenomenon? Why is it happening now (as opposed to, say, 10 years ago)?

Patrick Romano: I see several factors driving this discussion and the associated (modest) investments:

  1. Increasing and universal recognition of the importance of social determinants of health, in the wake of reports from the National Academy of Medicine, National Quality Forum, and elsewhere.
  2. Increasing attention to the tax benefits received by nonprofit hospitals, and the fact that those benefits often seem disproportionate to the community benefits provided by those organizations. The Affordable Care Act of 2010 (ACA) requires tax-exempt hospitals to create a hospital community health needs assessment every three years; these CHNAs often highlight the importance of social determinants in the populations that hospitals serve.
  3. A policy environment in which both hospitals and health plans are increasingly held accountable for outcomes beyond their doors, for which social determinants play a significant role – for example, 30-day readmission measures for hospitals, potentially avoidable hospitalization measures for health plans, accountable care organizations, cost measures, etc.
  4. The ACA-driven expansion of state Medicaid programs, which has focused more attention on the needs of Medicaid beneficiaries and the cost of these programs to state governments.

To what extent should the health system be involved in addressing social needs? After all, these are not traditionally in the purview of health care. Are the boundaries of health care shifting? Should they?

The boundaries of health care are shifting, but arguably not enough and not quickly enough. The forces protecting and preserving the status quo are very strong. Fee-for-service remains the dominant mode of payment across the American health care system, despite the fact that it encourages fragmentation and unbundling of care, and provides relatively little incentive for provider organizations to address social needs. Despite these forces and barriers, innovative health care organizations and public health agencies are addressing social needs (e.g., housing, food and nutrition, transportation, employment) more than ever before, and some are reporting success in reducing undesirable utilization of health services.

Are we making progress in addressing social needs and/or social determinants of health? How would we know if we are? What would constitute “success”? How should we measure it?

It is easy to say that we are making progress when the economy is growing, unemployment is relatively low, and the social safety net (in Medicaid expansion states only) is relatively robust. The true test will be what happens when the system is stressed by an economic recession, rollback of Medicaid expansions, or other macro-level disruptions. Ultimately, our success will be measured by traditional public health metrics such as life expectancy, maternal and infant mortality, mortality due to causes amenable to health care, hospitalization rates, disability-adjusted life expectancy, workforce participation, etc. These metrics have budged relatively little, perhaps because progress on some fronts (e.g., cardiovascular disease, tobacco control, cancer screening) has been eroded by challenges on other fronts (e.g., opioid use and overuse, firearm violence, obesity and diabetes).