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Transforming Care: Putting Social Risk into the Equation

Transforming Care: Reporting on Health System Improvement 468bf2d5-ceeb-4b60-b56b-df8c0c6f433c

In Focus: Creating Pathways and Partnerships to Address Patients’ Social Needs

Although health care professionals have long understood that social factors, including food insecurity and unstable housing, have an outsized effect on health, many have lacked the resources and financial incentives to intervene. This issue of Transforming Care looks at how new technologies and payment models can support efforts by health care providers and plans to assess patients’ nonmedical risks and work with nonprofit agencies, social services providers, and other community partners to help address them.

When Cincinnati Children’s Hospital Medical Center began surveying families visiting its primary care clinics about their financial, environmental, and psychosocial challenges in 2009, the results were troubling. Among other findings, nearly a third reported they were living in homes with cockroaches and mold—conditions known to exacerbate asthma and other respiratory conditions.1

A team led by pediatricians Robert Kahn, M.D., and Andrew Beck, M.D., began looking for correlations between patients’ housing conditions and health outcomes by combining the survey data with information gathered by the city’s housing authority. They found that kids who lived in neighborhoods within the highest quartile of housing code violations were nearly twice as likely as other children to have a return trip to the emergency department or hospital within 12 months.2

Armed with data suggesting a link between housing and health, Cincinnati Children’s partnered with the city’s health department and Legal Aid Society. The health department began performing home inspections for families who reported health hazards during their hospitalizations, while Legal Aid Society lawyers advocated for better housing conditions, benefits, or other support. Clinicians now make 800 to 900 such referrals a year to Legal Aid.3 Preliminary data suggest that children whose families received legal help had significantly fewer hospital admissions—from 230 per 1,000 kids six months before the intervention to 97 per 1,000 kids six months after.

Hospital leaders also convinced an affiliated organization that assumes financial risk for Medicaid patients enrolled in two managed care plans to support their work: in a pilot program, Health Network by Cincinnati Children’s directly reimburses Legal Aid when its lawyers provide advice ($250 per case) or represent their members ($1,200 per case).

We’re trying to think systematically about which social risks you can mitigate if working hand and glove with an effective community partner.

Robert Kahn, M.D. Associate chair of community health, University of Cincinnati Department of Pediatrics

Providers like Cincinnati Children’s aren’t just screening patients for social and environmental risks; they’re also developing interventions and partnerships to mitigate them. Such efforts are driven by pressure to contain costs and are adding to a growing body of evidence showing that when people have stable housing, good nutrition, reliable incomes, and other material needs met, they have better health, as well as lower medical costs.4 In a companion story, we look at several digital tools that help providers find and share information with community partners.

Making Social Risk Screening and Referral Routine

The Los Angeles–based cancer center City of Hope developed a touchscreen system, SupportScreen, to ask patients about social or financial problems that may affect their ability to follow recommended treatment, as well as stress they may be experiencing related to their cancer diagnoses. According to Matthew Loscalzo, executive director of the center’s Department of Supportive Care Medicine, routine screening sends a message to patients that the cancer center wants to help with more than just clinical needs: “Just asking patients the questions opens the conversation and tells the person, if you have these problems, we can help.” Surveys among 35,000 City of Hope cancer patients found, not surprisingly, that low income is by far the strongest predictor of poor health outcomes, as well as of practical problems and distress—more important than patients’ race or marital status.

The center uses tablets to administer the screening rather than face-to-face interviews because it finds patients are more forthcoming that way—consistent with research on social screening tools.5 In addition to flagging potential issues, SupportScreen serves as a triage tool, immediately routing responses to appropriate team members (e.g., social workers, financial services staff, chaplains, and others) so patients can confer with them during their medical visits.6

Offering Guidelines for Conversations About Social Risks

Federally qualified health centers (FQHCs) have been early adopters of social risk screening because they serve many poor, uninsured, and otherwise vulnerable patients. Health centers in 44 states and many other provider groups are using the PRAPARE tool (short for Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences), which was developed by the National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, and the Institute for Alternative Futures to promulgate a standardized approach for documenting the many social risks faced by their patients and using that information to improve population health.7

In a pilot of PRAPARE involving seven FQHCs and three FQHC networks, center staff including nurses, community health workers, medical assistants, care coordinators, and others asked patients about their material security, transportation, housing security, stress, personal safety, social demographics, and other issues. Staff used the tool as a “guideline for conversation,” says Michelle Jester, research manager at the National Association of Community Health Centers, often using empathic inquiry, motivational interviewing, or other approaches to elicit patients’ trust. Most of the nearly 2,700 patients screened reported between four to seven risk factors; the greater the number, the more likely patients were to have hypertension.8

Starting with Subgroups of At-Risk Patients

The Oregon Primary Care Association has been encouraging its member FQHCs to identify subpopulations of patients with unmanaged health conditions and use PRAPARE to figure out what nonmedical factors may be at play. This population segmentation work is part of a new Oregon Medicaid alternative payment model that gives clinics per member per month payments and, with them, the flexibility and incentive to address the social determinants of health. In some parts of the state, savings to Medicaid are already being redeployed to fund locally determined health improvement efforts.

Exhibit: Oregon Primary Care Association’s Population Segmentation Approach


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© Oregon Primary Care Association 2017

For example, the Rinehart Clinic on Oregon’s far north coast began with 126 hypertensive patients. When interviews revealed most of these patients felt socially isolated, the clinic engaged them in a group wellness class. Many patients also admitted they lacked money to buy healthy food, and so the clinic created a partnership through which it can refer patients to a food bank. (The clinic has not yet tracked results of these efforts.)

Building Clinical–Community Partnerships

A common concern among those involved in the pilot was not being able to address the problems they found during screening. PRAPARE partners and health center staff determined that the most effective way to address this concern was to tell staff that “We won’t know what the needs are unless we ask. And hopefully documenting them will help us figure out which partners we should be working with,” says Jester.

The Parkland Center for Clinical Innovation (PCCI)—a nonprofit research firm spun out of Dallas’s safety-net hospital, Parkland Health and Hospital System—created a citywide information exchange portal to facilitate such partnerships between health care and social service providers. The Dallas Information Exchange Portal is built to use diagnostic codes and natural language processing (which can, for example, capture clinicians’ notes about “noncompliant patients” or “missed appointments”) to gather information from electronic medical records that may indicate a nonmedical problem, such as lack of appropriate housing, food insecurity, or lack of transportation to medical appointments. With patients’ consent, providers use the portal to share relevant medical and social information with homeless shelters, food banks, and other nonprofits. The portal now includes information for over 200,000 Dallas residents and is used by 55 community partners.

Exchanging information about medical conditions and social risks has created a “no-wrong-door” approach for people looking for help, says Yolande Pengetnze, M.D., medical director at PCCI. For example, staff at a local food pantry—whom PCCI trained in how to support patients’ dietary needs—used the tool to help a woman with diabetes and high blood pressure choose appropriate groceries. When she confided to staff there that she had been having trouble scheduling a medical appointment and had stopped taking one of her medications because she couldn’t afford it, they were able to use the platform to connect her to Parkland staff who could help.

PCCI creates incentives for community partners to use the Information Exchange Portal by including case management tools that help them do their work. And, in a pilot, it made small payments (from $25 up to $200 per patient) to The Bridge, a Dallas homeless shelter, when they used the portal to help patients after hospital discharge by finding them short-term housing or transportation to follow-up appointments. There was a 40 percent relative reduction in emergency department visits among the 15 patients engaged in this way, compared with those not engaged.

This May, PCCI was one of 31 sites to be awarded a grant from the Center for Medicare and Medicaid Innovation for the Accountable Health Communities Model—the first federal effort to test whether addressing people’s social needs impacts health care quality and expenditures. Along with Parkland, four other local health systems will be using the Dallas Information Exchange Portal to partner with 289 community organizations and Texas Medicaid.

Focusing on Patients’ Priorities

Along with these health system–led efforts, health plans are starting to attend to members’ social needs. Five years ago, when Dayton, Ohio–based CareSource—which operates Medicaid managed care plans as well as marketplace plans in five states—began enrolling newly eligible Medicaid beneficiaries, their extreme poverty and other social challenges came to the fore. To figure out the best way to offer a hand and make their plans attractive to potential members, the health plan convened focus groups to explore one question: If we were to do one thing in addition to providing coverage that would have a significant impact on your overall health and well-being, what would that be? Overwhelmingly, people reported they wanted help finding good jobs. 

In response, CareSource launched a Life Services program in its Dayton market, offering members the support of a coach to help them find training programs, apply for jobs, tap sources of child care and transportation, and take other practical steps. These services are coupled with health coaching when needed. Over two years in nine Ohio counties, coaches worked with 1,200 people, helping 450 secure full-time jobs and another 250 find training and educational opportunities. CareSource tracked a decrease in emergency department and hospital use among those receiving such help, as well as an increase in medication compliance. Based on these results, the health plan expanded the program to its Indiana and Georgia markets.

CareSource also received approval from Ohio and Indiana Medicaid agencies to add questions about members’ social and economic status—their educational level, employment, social supports, and other issues—in their health risk assessments. “A member might not be a smoker, might not have diabetes. But think of the 22-year-old mom with no GED, inconsistent housing, who doesn’t know what her next steps are,” says Karin VanZant, executive director of Life Services. “If we just had the usual health assessment, we’d put her in the healthy maternal category and stop outreach.” By intentionally asking about nonmedical issues, CareSource has a chance to “help that mom get her GED, find employment, and get on the path to sustainability,” she says.

Challenges and Early Lessons


As these examples make clear, there’s a great deal of experimentation as health care professionals partner with nonprofits to meet patients’ needs beyond medical care.

One prominent challenge in this work is that many circumstances mediate health: factors like income, education, housing, and nutrition that are highly correlated with health are also correlated with each other, making it difficult to discern which has the greatest influence and is most amenable to change.9 In addition, relevant risk factors may vary by condition: food insecurity may play a significant role in diabetes control, whereas exposure to violence may lead to behavioral as well as physical health problems. “To study it in a classic way is difficult. It would be challenging to do a randomized control trial to sort it out with so much variation in patients,” says Kahn.

Despite the challenges, there are efforts to build the evidence base, such as one led by University of California, San Francisco, researchers known as SIREN (Social Interventions Research and Evaluation Network) that compiles and disseminates evidence of the effectiveness of social interventions and evaluation tools.

It’s also clear there are gradations of risk—some people have trouble affording rent, while others have nowhere to sleep most nights. That’s why it’s important to ask patients about the urgency of their need and let them select priorities, says Zach Goldstein, principal of innovation at Health Leads.10

It may also be helpful to ask patients about their social risks in the context of broader conversations about their lives. Family medicine physicians at Bronx-based Montefiore Medical Center routinely ask patients about their goals, support network, activities they enjoy, and other assets that support their well-being.


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Screenshot of electronic medical record used by Montefiore Family Medicine Clinicians

Because of this complexity, health care leaders say it’s too soon to categorize patients by their social risks or weight their relative risk levels, as has been done for clinical conditions. “We’re very clear that social determinants of health matter,” says Alicia Atalla-Mei, Oregon Primary Care Association’s social determinants of health manager. “But we want to get a better picture of their impact and map out evidence-based interventions to address them before we develop and assign risk scores.”11

It’s also an open question whether it’s necessary to screen all patients for social risks or more efficient to tap other available sources of data to understand patients’ potential needs. For example, some providers are using geographic mapping to identify neighborhoods where there’s a high prevalence of deteriorated housing, gun violence, or other circumstances.12 “At Cincinnati Children’s we’re trying to map risk,” says Kahn. “Here’s a neighborhood with some of the highest readmission rates in the county, where 80 percent of people don’t own a car, and there’s no pharmacy within two miles. What happens when you discharge a patient there?” One goal of such work, Kahn says, would be to convince a pharmacy to partner with the hospital to address the problem of “pharmacy deserts.”

Vendors such as CentraForce Health have developed tools that leverage this kind of mapping data as well as other data sources outside of health care (e.g., consumer surveys describing shopping habits of individual patients and populations, their media usage, transportation, and other critical social factors such as education level and access to healthy food) that are being used by health systems to generate actionable insights about their patients’ lives and potential risks. 

Making the Business Case

Documenting the impact of social needs interventions on health care use and costs may create the rationale for greater investment, whether from payers like Medicaid, which in places like Cincinnati have begun to invest in housing to promote better health, or from safety-net hospitals like Parkland that are channeling funds to community partners that help them reduce acute care use.

CareSource pays for its Life Services program through its foundation because Medicaid funds cannot be used to pay for workforce development, but that may be changing, according to VanZant.13 “We’re having conversations with legislators to say: If we want to pay for value, might there be an incentive for the number of people we transition off Medicaid to employer-sponsored insurance? Rather than focusing just on the sickest 10 percent of patients, might we shift a portion of funds to help the healthiest 50 percent gain independence?” she says.

With widespread awareness that health care is an important part of advancing health in America, “hospitals understand that is necessary to address patients’ social risk factors,” says Jay Bhatt, D.O., chief medical officer of the American Hospital Association’s Health Research and Educational Trust. “The challenge, of course, is what happens after a positive screen. Hospitals and other health care providers need to be able to connect patients with appropriate services, but frameworks and examples, resources, frontline clinician and leadership buy-in, and effective community partnerships all need to be in place to do so.”


1 Among other findings, one of five said they failed to fill prescriptions for lack of money; and one of six admitted they diluted infant formula to ensure limited supplies reached month’s end.

2 A. F. Beck, B. Huang, R. Chundur et al., “Housing Code Violation Density Associated with Emergency Department and Hospital Use by Children with Asthma,” Health Affairs, Nov. 2014 33(11):1993–2002.

3 See A. F. Beck, J. M. Simmons, H. S. Sauers et al., “Connecting At-Risk Inpatient Asthmatics to a Community-Based Program to Reduce Home Environmental Risks: Care System Redesign Using Quality Improvement Methods,” Hospital Pediatrics, Oct. 2013 3(4):326–34 and M. D. Klein, A. F. Beck, A. W. Henize et al., “Doctors and Lawyers Collaborating to HeLP Children—Outcomes from a Successful Partnership Between Professions,” Journal of Health Care for the Poor and Underserved, 2013 24(3):1063–73.

4 See, for example, Leveraging the Social Determinants of Health: What Works?, Blue Cross Blue Shield of Massachusetts Foundation, June 2015, and Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment, Manatt Health Solutions, May 2014.

5 See, for example, L. Gottlieb, D. Hessler, D. Long et al., “A Randomized Trial on Screening for Social Determinants of Health: The iScreen Study,” Pediatrics, 2014 134(6):e1611-8.

6 City of Hope has integrated all supportive services under one department, including: pain and palliative care, psychology, psychiatry, social work, education, and navigation.

7 National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, Institute for Alternative Futures, Accelerating Strategies to Address the Social Determinants of Health: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (Bethesda, MD: NACHC; 2016). Available at Health centers already collect some relevant information as part of the Uniform Data System. Health centers already collect some relevant information as part of the Uniform Data System. The PRAPARE tool facilitates the process by providing a template that embeds questions in electronic health records; a companion toolkit outlines practical steps to address identified needs. The National Academy of Medicine has also created a standardized tool to screen patients for health-related social needs. See

8 National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, Institute for Alternative Futures, Accelerating Strategies to Address the Social Determinants of Health: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (Bethesda, MD: NACHC; 2016). Available at Sample size = 2,694 patients; r = 0.61.

9 V. R. Fuchs, “Social Determinants of Health: Caveats and Nuances,” Journal of the American Medical Association, Jan. 3, 2017 317(1):25–6.

10 For example, a recent study found that patients who screened positive for food insecurity did not always want help from their providers with that issue. See C. J. Bottino, E. T. Rhodes, C. Kreatsoulas et al., “Food Insecurity Screening in Pediatric Primary Care: Can Offering Referrals Help Identify Families in Need?” Academic Pediatrics,

11 The National Quality Forum has developed recommendations on how to adjust for socioeconomic factors, as well as race and ethnicity, in performance measurement. See

12 A. F. Beck, M. T. Sandel, P. H. Ryan, and R. S. Kahn, “Mapping Neighborhood Health Geomarkers to Clinical Care Decisions to Promote Equity in Child Health,” Health Affairs, June 2017 36(6):999–1005.

13 CareSource was able to negotiate from Ohio Medicaid a $500 per-member support fund, which cannot be paid directly to members but can be used to pay for services, e.g., training, that cannot be found for free in the community. CareSource says it has rarely had to use these funds because patients themselves have identified their own social supports.

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Leveraging Technology to Find Solutions to Patients’ Unmet Social Needs

Just as Yelp enables people to find and rate restaurants willing to deliver Chinese food at 2 a.m., several technology vendors are helping health care providers and their patients find local resources such as food banks and housing agencies and evaluate their effectiveness. The platforms developed by companies like One Degree and NowPow also serve as electronic bridges between health care and social service providers—enabling them to share information with one another. The data these companies and others have collected are helping to identify neighborhoods where demand for social supports outstrips supply. These tools may also help researchers evaluate the impact of social service interventions on health outcomes and health care spending.

Rey Faustino created One Degree—an online resource for people looking for help with housing, employment, education, jobs, and other support—out of frustration. Faustino had been working for a San Francisco Bay Area nonprofit that helped low-income students complete high school and pursue a college education. He often found that the barriers to academic achievement were social ones—problems like homelessness and hunger that made it hard for kids to succeed. Finding resources to help them was a persistent challenge. “Here we were right down the street from Google and Facebook and all these other amazing technology companies, and I was relying on a dusty paper binder to find information: phone numbers were often wrong, organizations had closed. I wanted to build a system that would empower people to find resources on their own,” Faustino says.

In 2012, with many volunteers and a budget of $24,000, most of it supplied by foundations, Faustino began to build a database of local social service organizations and programs. They found more than 8,000 in the Bay Area. “That’s the beauty of One Degree. We can quantitatively show the number of resources in our community in a way that has never been done before. One of the things we see is a plethora of after-school and summer programs for children but, on the flip side, only one diaper bank in a county that has 40,000 low-income young mothers.”

One Degree’s platform allows users to search for support for a variety of medical and nonmedical needs


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To date, 200,000 people have used the platform, half in the last year. The vast majority (85%) are the end users of services. Social service agencies in Los Angeles County will begin using the platform, its screening tools, and case management functionality to make and track referrals from health care settings to social service organizations. Anyone in the county will be able to use it.

Similarly, NowPow, a digital platform developed by a Chicago startup, is enabling large health systems like that city’s Rush University Medical Center to find and make referrals to community organizations. Many of NowPow’s clients have entered into risk-based contracts and understand that addressing social needs may help them improve health outcomes and lower health care spending for their patients.

Designed to be integrated into electronic health record (EHR) systems, NowPow’s platform culls information from health records including social risk assessments and clinical diagnoses to make recommendations. Mold abatement and pest control services may be suggested for a patient with asthma, for instance, while healthy eating and exercise classes may be suggested for those diagnosed with diabetes or hypertension. Providers can curate the recommendations, tailoring them to patients’ priorities, preferred language, and financial circumstances, and then write a prescription for services—dubbed a HealtheRx. “The recommendations are based on what an expert would say this person needs to do to practice self-care when they go home,” says the company’s CEO Rachel Kohler. Its algorithms focus on 30 conditions, including Alzheimer’s disease, sexually transmitted diseases including HIV, and congestive heart failure.


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NowPow offers providers a detailed description of services—including hours of operation, primary contacts, and required documents among other things—so a provider can easily find a food pantry that is open in the evenings and within walking distance for a patient without a car. They can also track referrals and see whether a patient followed through and, if not, send a reminder.

The algorithms are based on input from clinicians and research conducted by the company’s founder, Stacy Lindau, M.D., as part of a Center for Medicare and Medicaid Innovation (CMMI) grant. Clinicians at the University of Chicago and some 30 other sites including federally qualified health centers issued more than 250,000 prescriptions for support services during the demonstration; some of the most frequently prescribed services were referrals to food pantries, classes on healthy eating, and individual counseling.1


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Health systems are interested in using NowPow data to identify unmet needs and identify successful methods of engaging patients. “They want to know what the most referred resources are, whether it is better to text or email the patient, and which populations are most responsive to those interactions,” Kohler says.

Health Leads, a Boston, Mass–based nonprofit that has been a national pioneer in the field of health-related social needs screening and interventions, has developed screening tools for assessing patients’ unmet needs related to food, transportation, and employment among other issues. Social service referrals are overseen by navigators (e.g., community health workers and volunteer college students) who not only link patients to community services but track the results of their referrals in a case management system. In 2013, the organization launched Health Leads Reach, a cloud-based tool that helps health care providers find resources. Built on a Salesforce platform, it too can be integrated into an EHR system.

By aggregating and analyzing the data, health systems can begin to identify community-based organizations with which they have the most effective partnerships and instances where the availability of resources or restrictive eligibility criteria for services limit efforts to help patients. “This is where the power of the data comes alive,” says Zach Goldstein, principal of innovation at Health Leads. “We can help health systems navigate what is often a complex resource landscape and better identify the organizations offering the services that best align with the needs of the patient population.”


1 S. T. Lindau, J. Makelarski, E. Abramsohn et al., “Community Rx: A Population Health Improvement Innovation That Connects Clinics to Communities,” Health Affairs, Nov. 2016 35(11):2020–29.


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Newsletter Article


Publications of Note

Home Visits by Nurses and Lay Health Workers Help Lower Total Cost of Care

Researchers studying five models of home-based care funded by the Center for Medicare and Medicaid Innovation (CMMI) found visits led by practice extenders including nurses and lay health workers were associated with reductions in costs, hospitalizations, and emergency department use. The five models emphasized care coordination and patient and consumer engagement and sought to strengthen connections to primary and palliative care. Two models achieved significant reductions in Medicare expenditures, and three reduced utilization of emergency department (ED) visits and hospitals or both relative to comparison groups. The researchers say additional research is needed to determine whether programs led by clinicians other than physicians/nurse practitioners offer particular benefits for high-need populations. S. Ruiz, L. P. Snyder, C. Rotondo et al., “Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use,” Health Affairs, March 2017 36(3):42532.

Specialty Medical Homes and Patient Navigation Reduce Costs for Cancer Patients at the End of Life

A study of innovative models of care for Medicare beneficiaries with cancer found one that established medical homes for oncology patients and another that deployed lay navigators who fostered end-of-life care discussions and identified palliative care needs were associated with decreased costs in the last 90 days of life ($3,346 and $5,824 per person, respectively) as well as fewer hospitalizations in the last 30 days (57 and 40 per 1,000 people, respectively). The navigation model, which also focused on helping patients assess and manage symptom flare-ups, was associated with fewer ED visits in the last 30 days of life and increased hospice enrollment in the last two weeks of life. E. M. Colligan, E. Ewald, S. Ruiz et al., “Innovative Oncology Care Models Improve End-Of-Life Quality, Reduce Utilization and Spending,” Health Affairs, March 2017 36(3): 43340.

ACA Narrows But Does Not Close Income– and Race–Based Disparities in Care

Researchers found that lack of insurance is one factor that contributes to worse health outcomes among lower-income Americans and racial and ethnic minorities but only explained a small to moderate portion of the disparities. Through a national survey of 8,000 Americans, they found lower-income families and racial and ethnic minorities experienced more cost-related barriers to care, worse perceived health care quality, and had more difficulty obtaining appointments than white and higher-income patients. Cost-related delays in care and use of emergency departments due to lack of available appointments were twice as common in the lowest income group and less than 40 percent of these disparities were related to insurance. They also found quality of care was worse among blacks and Latinos, with 16 percent to 70 percent explained by insurance. At the same time, lower-income and minority groups were generally more likely than whites and higher-income adults to say the Affordable Care Act was helping them and that quality and/or affordability had improved. B.D. Sommers, C. L. McMurthy, R. J. Blendon et al., “Beyond Health Insurance: Remaining Disparities in U.S. Health Care in the Post-ACA Era,” Milbank Quarterly, March 2017 95(1):43–69.

Among Early CMMI Programs, Savings Appear to Be Larger for Those Targeting Clinically Fragile Patients

An analysis of ambulatory care innovations funded by CMMI in the first round its awards program found those that used health information technology or community health workers achieved the greatest cost savings (estimated savings exceeded $150 per beneficiary per quarter for both). Savings closer to $100 were found for medical home and behavioral health programs and even greater savings were found for programs that targeted clinically complex populations at risk for disease progression. They say the results should be interpreted cautiously because of wide confidence intervals for many of the effects. Meta-analyses of a larger number of delivery system innovations will be necessary to clearly establish their potential for cost savings, they say. K. W. Smith, A. Bir, N. L. B. Freeman et al., “Impact of Health Care Delivery System Innovations in Total Cost of Care,” Health Affairs, March 2017 36(3):50915.

Integrated Care Management Program Appears to Drive One ACO’s Savings

Researchers found patient participation in a Pioneer accountable care organization (ACO) had a modest effect on spending while participation in its care management program was associated with substantial reductions in hospitalizations and ED visits, as well as Medicare spending. They note ED visits decreased relatively quickly, particularly for conditions amenable to outpatient care, while hospitalization rates increased initially before decreasing. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. They conclude targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs. J. Hsu, M. Price, C. Vogeli et al., “Bending the Spending Curve by Altering Care Delivery Patterns: The Role of Care Management Within a Pioneer ACO,” Health Affairs, May 2017 36(5):87684. 

Recommendations for Promoting Care Process Innovation Within Health Systems

The authors of this article describe successful models of supporting care process innovation in academic health systems—among them the Cleveland Clinic, Mayo Clinic, University of Pittsburgh, University of Pennsylvania, and Geisinger Health System—and draw lessons for other health systems and practices. Requisites for success include making sufficient resources of money and space available; offering coordination and consultation regarding intellectual property and licensing, and enabling access to engineers, software developers, and behavioral scientists. Other lessons include: making providers and patients available to innovators, having a sufficiently long-term view, and insulating the innovation group from operational demands. D. W. Bates, A. Sheikh, and D. A. Asch, “Innovative Environments in Health Care: Where and How New Approaches to Care Are Succeeding,” Health Affairs, March 2017 36(3):4007.

Meta-Analysis Finds PCMHs Not Achieving Intended Effects

Researchers found use of patient-centered medical homes (PCMHs) had an effect on screening for breast and cervical cancer and two utilization measures—producing reductions in specialty care visits and total cost of care excluding pharmacy spending—but no effect on other utilization measures, including those assessing primary care, ambulatory caresensitive inpatient care, and ED visits. They say further research is needed to understand the contextual features that make some PCMH initiatives more successful and identify the extent to which PCMH activities have differential impacts across patients groups. A. D. Sinaiko, M. B. Landrum, D. J. Meyers et al., “Synthesis of Research on Patient-Centered Medical Homes Brings Systematic Differences into Relief,Health Affairs, March 2017 36(3):5008.

Tiered Health Plan Designs Reduce Total Health Care Spending

An evaluation of a tiered-network health plan designed to steer patients toward higher-quality, more efficient providers found it reduced total health care spending, including inpatient, outpatient, and outpatient radiology spending for nonelderly enrollees. The tiered network was associated with $43.36 lower total adjusted medical spending per member per quarter ($830.07 versus $873.43), representing a roughly 5 percent decrease in spending relative to enrollees in similar plans without a tiered network. Similar levels of spending reductions were found for outpatient (4.6 percent) and outpatient radiology spending (6.5 percent). A. D. Sinaiko, M. B. Landrum, and M. E. Chernew, “Enrollment in a Health Plan With a Tiered Provider Network Decreased Medical Spending by 5 Percent,” Health Affairs, May 2017 35(5):8705.

Oregon’s CCOs Slow Health Care Spending Relative to Neighboring State

A study of Oregon’s coordinated care organizations (CCOs), which assume financial risk and responsibility for the medical, behavioral health, and dental care of Medicaid enrollees across geographic regions, found that relative to Washington State the CCOs produced savings of 7 percent across five service areas: evaluation and management, imaging, procedures, tests, and inpatient facility care. The largest reductions were observed in inpatient hospitalization. Both states saw reductions in avoidable ED visits, while primary care visits declined in Oregon, an area of concern given that its CCOs emphasize the medical home model, the researchers say. They say this differential may reflect tightening primary care capacity in Oregon. K. J. McConnell, S. Renfro, R. C. Lindrooth et al., “Oregon’s Medicaid Reform and Transition to Global Budgets Were Associated with Reductions in Expenditures,” Health Affairs, March 2017 36(3):4519.

Exercise and Diet Intervention Reduces Hospitalizations and ED Use

A study of a diabetes prevention program run by the YMCA and funded by CMMI found it reduced total medical costs for fee-for-service Medicare participants by $278 per quarter for the first three years of the intervention. Total decreases in inpatient admissions and ED visits were significant for participants in program, which focused on helping patients lose weight and increase physical activity. The study found there were 9 fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. M. L. Alva, T. J. Hoerger, R. Jeyaraman et al., “Impact of the YMCA of the USA Diabetes Prevention Program on Medicare Spending and Utilization,” Health Affairs, March 2017 36(3):41724.

Practices with Higher Proportions of High-Need Patients Had Lower Spending

In medical practices with a substantial proportion of high-need patients (more than 10% of the practice panel) and in those with a moderate proportion (2% to 10%), high-need patients incurred less spending than those in practices with a minimal proportion of high-need patients (less than 2%). High-need patients in those practices were also less likely to be admitted to the hospital or to visit the ED. Composite quality-of-care scores for practices with a substantial proportion of high-need patients were significantly worse than for practices with a moderate proportion. Small practices with one or two physicians also had worse scores compared with large practices. High-need patients were defined as those with two or more chronic physical, mental, or behavioral health conditions that generate significant health care use. D. A. Cross, G. R. Cohen, C. H. Lemak et al., “Outcomes for High-Needs Patients: Practices with a Higher Proportion of These Patients Have an Edge,” Health Affairs, March 2017 36(3):47684.

Researchers Find Readmission Penalties Are Persistent Over Time

Researchers studying the characteristics of hospitals that received penalties during the first five years of the federal Hospital Readmissions Reduction Program found more than half of participating hospitals were penalized by the Centers for Medicare and Medicaid Services in all five years of the program. They found the penalty burden was greater in hospitals that were urban, major teaching, large, or for-profit and for those that treated larger shares of Medicare or socioeconomically disadvantaged patients. They also found hospitals treating greater proportions of medically complex Medicare patients had a lower cumulative penalty burden compared with those treating fewer proportions of these patients. Because persistent penalization may limit hospitals’ capacity to respond, they say alternate penalty structures may be needed. M. P. Thompson, T. M. Waters, C. M. Kaplan et al., “Most Hospitals Received Annual Penalties for Excess Readmissions, But Some Fared Better Than Others,” Health Affairs, May 2017 36(5):893901.

Weak Relationship Between Physician Practice Pricing and Quality and Efficiency

To examine the relationship between physician practice prices for outpatient services and the practices’ quality and efficiency of care, researchers linked national data from the Consumer Assessment of Healthcare Providers and Systems survey to claims for Medicare beneficiaries. They found compared with low-price practices, high-price practices were much larger and received 36 percent higher prices. Patients of high-price practices reported significantly higher scores on some measures of care coordination and management but did not differ meaningfully in their overall care ratings, other domains of patient experiences (including physician ratings and access to care), receipt of preventive services, acute care use, or total Medicare spending. E. T. Roberts, A. Mehrotra, and J. M. McWilliams, “High-Price and Low-Price Physician Practices Do Not Differ Significantly on Care Quality or Efficiency,” Health Affairs, May 2017 36(5):85564.

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Editorial Advisory Board

Special thanks to Editorial Advisory Board members Marshall Chin, M.D., M.P.H., and Laura Gottlieb, M.D., M.P.H., for their help with this issue.

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Mike Chernew, Ph.D., professor of health policy, Harvard Medical School

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, Rand Corp.

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families

Kathleen Nolan, managing principal, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., associate professor of family and community medicine, UCSF School of Medicine

James Pelegano, M.D., M.S., assistant professor of healthcare quality and safety, Thomas Jefferson University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, director of quality and operations support, The Permanente Medical Group

Stephen Somers, Ph.D., president and CEO of Center for Health Care Strategies

Mark A. Zezza, vice president, Lewin Group

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