Addressing the drivers of health

To understand where health system and health plan organizations are building solutions and strategies to address the DOH for their employees, the people they serve, and their larger community, we surveyed 300 leaders from large health system and health plan organizations. We also talked to experts from academia, community organizations, and industry associations to understand the practical implications of these survey findings (see sidebar “Research methodology”). Throughout the survey and discussions, we referred to areas of need as the “drivers of health.” Many organizations may refer to these as the “social determinants of health.” We use this  term because there has been a shift in parts of the health care system away from referring to these as “determinants” and rather as “drivers” to emphasize that nothing predetermines health (see sidebar “Words matter: Social determinants of health versus drivers of health”).

Most health care organizations are still screening their patients more than they are actively connecting them to services

Our 2017 survey found that most hospitals (88%) were screening for social needs at the time. However, only 33% of them reported having a well-defined process for connecting people with social-needs-related resources for their entire target population. The 2021 survey revealed that this gap still exists. For example, while most health care leaders (79%) say they are screening the populations they serve to understand whether they face challenges paying bills, only 35% say they have formal partnerships with community organizations to help patients address need in this area. Few health care leaders (29%) say they are screening patients and members for education level or connecting them to community partners who could help advance their education (18%) (figure 2).

Many are not leveraging partnerships with CBOs enough

There is increasing evidence on how insights into their communities can help health care organizations identify patients’ and members’ health needs in a timely manner.⁵ About two in three respondents say they have general partnerships with local community- and/or faith-based organizations to help address DOH needs. But, fewer than one-third of overall respondents say that they are leveraging community partnerships to address specific DOH needs in their larger community. For example, a little more than half (54%) of health care leaders say they are screening their larger community for access to stable housing, and only 29% say they have formal partnerships with community organizations to address housing needs in the community or communities they serve (figure 3).

More ecosystem partners are needed to bolster DOH efforts

Extending relationships to new partners, including organizations traditionally considered competitors, could help organizations address DOH needs. Many health care leaders already recognize this: Nearly half of health system leaders (49%) and health plan leaders (45%) say they have partnered with other health care organizations to address DOH needs. Nontraditional players are increasingly playing a role in addressing needs, too. More than half of health plan leaders (55%) say they partner with technology vendors that provide solutions like ride-sharing or digital financial literacy vendors (figure 4).

Employees’ DOH needs receive the least attention from health care organizations

In earlier research, health care CEOs we surveyed identified improving the health of their workforce through DOH as a top focus area. However, this survey revealed that gaps remain in making progress toward that priority. Respondents indicated that, compared with patients and members and their larger community, employees are the least likely group to be screened for DOH or be connected to services to address those needs. For instance, fewer than 50% respondents say their organizations screen employees’ food, housing, transportation, and financial needs, and even fewer act on those needs (in-house programs, community partnerships) (figure 5).

Multiple studies have tied employee health and well-being with organizational productivity, engagement, and profitability.¹⁰ Low attention to the employees' DOH prove to be a blind spot for organizational growth.

Growth in value-based care is leading more health care organizations to invest in DOH than four years ago

Health care organizations appear to be shifting away from launching DOH initiatives just because it “feels good” or “we do it because we know it is good for patients.” Instead, more leaders are seeing a business case for this investment. Indeed, the survey revealed significant increases in two areas among health systems,¹² compared to 2017:

• A 12 percentage-point increase (from 13% to 25%) in the number of health system respondents that said a top goal around their DOH initiatives was to meet new market expectations or adjust to changes in the market

• A 10 percentage-point increase (from 16% to 26%) in the number of health system respondents who said improving financial performance was a top goal

This likely is explained at least in part by an increase in focus on value-based care since the last survey. In 2017, 20% of health system leaders said that value-based models or initiatives that emphasized the integration of DOH into health care would lead them to increase their organization's investments in this area. This increased to 58% of health system leaders this year.

The Centers for Medicare and Medicaid Services (CMS) has launched several initiatives focused on shifting care into nontraditional settings. For example, it launched the AHC model out of the Center for Medicare and Medicaid Innovation (the Innovation Center). AHC programs aim to promote collaboration between clinical health care services organizations and CBOs. As of 2021, there are 28 active organizations participating in the program. Initial evaluations show that individuals who qualified for services through these programs are disproportionately likely to be low income, racial and ethnic minorities, and, among Medicare beneficiaries, disabled, and that the most common health-related social need reported was food insecurity.¹³ As CMS tests more of these models and increasingly shifts payment away from fee-for-service and toward paying for outcomes, more health care organizations may see a business case for investing in DOH initiatives. For now, these programs are small-scale.

Another area where CMS is pushing health care organizations to think beyond the four walls of the hospital is in Medicare Advantage (MA). As we described in Leveraging digital solutions to engage, attract, and retain Medicare Advantage members, regulatory changes, combined with market pressure from COVID-19, have led many MA plans to stand up services and benefits around the DOH. Almost all MA health plans offer supplemental coverage—benefits above traditional services offered to fee-for-service beneficiaries. In 2019 and 2020, CMS expanded the definition of these benefits to include nonhealth benefits that may impact health, such as in-home support services, meal delivery, and nutritional food.¹⁴ While only 1% of MA health plans included in-home support services for the 2019 benefit year, more than 845 MA plans offered special supplemental benefits for the chronically ill (SSBCI), including pest control, transportation, meals, and even pet support in 2021 (the number was 245 in 2020).¹⁵ Indeed, our 2019 study of 14 managed care organizations (MCOs) and MA plans found that most of the executives interviewed plan to continue their DOH investments because they align with their mission to improve the health of the communities they serve, and because they have faith that the savings derived from better health outcomes and lower health care utilization will eventually exceed the cost of those interventions.¹⁶

Conclusion

How do the DOH relate to the larger issue of health equity? And how can health care organizations make an impact?

Our nation has long faced a health equity crisis rooted in structural inequities. Racism and bias, disparities in the DOH, and structural flaws in the health system have led to quantifiable differences in health-related outcomes, disproportionately affecting racially and ethnically diverse communities.

Tackling health equity takes a multipronged approach. Organizations should acknowledge all of the ways in which they can do this:

• Dismantling the overt and covert racism and bias built into the foundation of the health care system over centuries

• Expanding access to coverage and care for communities and populations that have historically lacked it

• Looking outside of the traditional health care system to address the social, economic, and environmental factors that lead to healthy or unhealthy outcomes

Previous research we published aims to tackle the first two areas.¹⁷ In this study, we focus on implications for the last area in more detail, which broadly align with four domains of health equity (figure 6).

Create accountability: Organizations should put DOH at the top of leadership priorities

Only one-third (31%) of respondents say they have a dedicated leader or team committed to establishing and developing processes to systematically address the DOH as part of clinical care. Moreover, fewer than one-third (28%) say they have defined teams with accountability for connecting their entire patient population (versus just a targeted population) to community-based resources. Effectively linking DOH initiatives to health equity strategy, as well as the strategy for the larger organization, will likely require assigning accountability and teams with oversight into and responsibility for creating efficiencies across the organization. Creating clearly defined strategies dedicated to addressing health equity and the DOH should be clear priorities for these roles. Only one in four organizations we surveyed have defined health equity or DOH strategies.

Measure and evaluate: Programs and investments need clear goals—and goals should look beyond traditional financial and health outcomes

Fewer than one in five (19%) respondents say they are measuring outcomes or results from DOH activities for their entire population. Investing in data, technology, and capabilities can be a way to reveal new insights and activate solutions based on findings. As services and programs are implemented, organizations should ensure that metrics and goals are focused not only on financial improvements, but on health outcomes and individual patient or member priorities. For example, focusing on metrics such as increasing the number of children in a given community who show up and are ready to learn on day one of kindergarten could help shift the focus away from typical clinical measures and toward measures that align to the larger DOH.

Expand offerings: Embed DOH approaches into clinical care

Health care organizations can look at all the ways they can address DOH through the products and services they deliver. Leaders could consider offering “farmacies” or care management approaches that account for broad needs. Education and training for clinicians should extend beyond traditional medicine and into areas like social work and public health. Beyond that, organizations should consider taking steps to address environmental factors that are within their control, such as working with local, state, and/or federal governmental agencies to support infrastructure enhancements and performing climate assessments for their communities.

Look inward: Ensure your own employees’ needs are being addressed

According to estimates from 2017, nearly one in five employed women (18%) and nearly one in four (23%) employed Black women work in the health care field. A significant portion of those workers, however, make less than US$15 an hour—34% of all female workers and nearly half of Black and Latina female health care workers. Moreover, a significant portion of those populations lack access to health insurance and or are on Medicaid (7.1% and 10%, respectively).¹⁸ As large employers, health care leaders should ask themselves questions such as: Is the pay for my employees equitable and is it sufficient to support their needs for food, shelter, transportation, and even health care?

Extend a hand: Diversify and expand community-based partnerships

Health care organizations should continue to create new relationships, including with community-based partners. Leaders can look beyond organizations that touch directly on health outcomes to ones that are investing in infrastructure critical for equitable health, (e.g., developers, community investment funds).

Reach outward: Create relationships with ecosystem partners that help further DOH goals

Extending the reach of DOH initiatives into the larger community will likely require leveraging relationships beyond existing partners. For example, this may mean building and sharing free operational tools or technology resources to help organizations across industries take more effective action to address the DOH. Beyond that, it may require leveraging new datasets, like employment data or local data on homelessness rates, which will likely come from new partners as well. Less than half (49%) of health system leaders and 59% of health plan leaders say they’re using health data from sources other than claims (e.g., census, local public health data) to understand their community’s needs. Moreover, only 38% of health system leaders (59% of health plan leaders) are using nonhealth data like access to transportation or data on homelessness to understand their community’s needs.