Most physicians know how critical social determinants can be and wish they could do something about them. Among the most glaring needs that many patients have, in their doctors’ view, are fitness programs, nutritious food, and transportation assistance. Urban doctors attach special importance to employment assistance, adult education, and housing assistance.
With nearly half of physicians employed by hospitals, those doctors’ ability to respond to SDOH is circumscribed by their institutions’ policies. Up to now, as noted previously, most healthcare systems have not been especially motivated to address patients’ unmet social needs. Those that are doing anything on SDOH, such as Norton Healthcare in Louisville, Ky., tend to focus on supporting recently discharged patients so they don’t get readmitted, says Handmaker.
Some at-risk ACOs and medical groups are going further. Rio Grande Valley Health Alliance, for example, has contracted with Uber and Lyft to ensure that patients can get to doctor appointments. In addition, the ACO directs patients who have insufficient food to food pantries. In some cases where people have had their electricity cut off because of unpaid utility bills, the ACO has even intervened to get the lights turned back on. If an elderly or disabled patient can’t afford a walker, the ACO will pay for that.
The Heritage Provider Network, similarly, has long intervened to help patients with unmet social needs. Mark Wagar, president of Heritage Medical Systems, says this has been one of the keys to the organization’s success.
Wagar is encouraged by payers’ newfound interest in SDOH. “Some payers, including Medicare Advantage plans, are starting to provide resources for this. If you do these things the right way, you’ll get paid for it,” he says. “We were doing some of that already, but now we can be more aggressive on it when we know there’s some return.”
Doing the Right Thing
Not all of the doctors who see benefit in addressing SDOH are at financial risk. For example, Gregory King, MD, a partner in a small family practice in Bennington, Vermont, said the Vermont Blueprint for Health has helped his practice tremendously. Before the Blueprint came along, he told Medical Economics in 2017, he’d encourage patients with social needs to get in touch with various community agencies. But his office didn’t have time to look up contact information or introduce the patients to the right people. So, his advice had little effect.
Now that he has access to a community health team, however, he can direct these patients to professionals who know how to get them the help they need, he said.
Montefiore Health System has an extensive care management program funded by New York’s DSRIP program. Montefiore, based in the Bronx, employs about 600 care managers, including nurses, social workers, and health educators, who address the chronic diseases of high-cost patients and connect them with community resources if they have unmet social needs.
Asif Ansari, MD, medical director of one of Montefiore’s physician practices, told Medical Economics that he wholeheartedly supported this program. Many of his and his colleagues’ patients, he said, have trouble paying for medications and lack transportation and access to healthy food.
“Our physicians understand that we need this collaboration, this support and these resources to impact our patients’ lives and their health,” he said, referring to the social workers and other non-medical professionals at Montefiore. “When I compare practicing here 10 years ago and now, the difference in what I can do for my patients is significant.”
Behavioral health may be impacted by an individual’s environment and other social determinants of health. For these reasons, efforts to address social needs are often combined with an emphasis on behavioral healthcare.
Individuals with mental health and substance abuse conditions cost 2.5 to 3.5 times more to care for than do patients who have none of these issues. When health-related productivity costs are combined with medical and pharmacy costs, in fact, the most expensive condition is depression, followed by obesity, arthritis, back/neck pain, and anxiety.
Despite these facts, insurance companies still emphasize physical health more than behavioral health in their coverage policies. They cover behavioral health care to some extent, but generally pay therapists much less than other clinicians—except for psychiatrists, who mostly prescribe medications and care for people with severe mental illnesses.
More than a quarter of U.S. adults have some kind of mental disorder, but only 43% of these people received any treatment in 2018. From 10% to 20% of patients in primary care practices have mental health problems, and a much larger percentage of high utilizers do. Primary care doctors, however, receive little training in behavioral health care and find it hard to counsel patients. So, they tend to prescribe medications and/or refer patients to psychologists, licensed clinical social workers or psychiatrists. But the patients often fail to follow up.
Integration with Primary Care
Behavioral health care is more effective when behavioral health professionals practice alongside primary care doctors. For example, integrating depression treatment with medical care has been shown to be twice as effective as traditional depression care.
The National Committee on Health Assurance (NCQA), as a condition for patient-centered medical home recognition, requires that practices support patients’ behavioral health and collaborate with behavioral health professionals. However, it doesn’t mandate the colocation of behavioral health providers in primary care practices.
The Patient-Centered Primary Care Collaborative (PCPCC), in contrast, strongly supports the integration of behavioral health and primary care.39 The PCPCC points to studies that document the decreased costs associated with this kind of integration. One of these studies showed that depression treatment in primary care resulted in a cost savings of $3,300 per patient over four years, returning $6.50 for every dollar spent.
Nevertheless, few primary care practices—whether or not they’re medical homes—include behavioral health professionals. According to a Commonwealth Fund report, “Behavioral health integration is still rare, and the integration of substance abuse services [is] even rarer, in part because there’s been little or no financial incentive or administrative advantage to bringing what are now standalone medical and behavioral health operations together.”
Excerpted from Physician-Led Healthcare Reform: A New Approach to Medicare for All by Ken Terry.