Capturing Value in Social Health: Lessons in Developing the Business Case for Social Health Integration in Primary Care

Abstract

• Issue: The integration of social health interventions, including screening patients for unmet social needs and linking them with services and other supports, requires long-term funding. Securing this funding requires a clear articulation of the value of such interventions that is supported by data.
• Goals: To develop a practical approach for business case analysis to support the spread and sustainability of social health interventions in varied institutional and market settings.
• Methods: Analysis of findings from the Health Leads Collaborative to Advance Social Health Integration (CASHI), in which 12 primary care teams from across the country received coaching to develop business cases for their social health interventions.
• Key Findings: The analysis provided insights into cost drivers of social health interventions, opportunities for efficiencies, and approaches to spreading these interventions to new sites or populations.
• Conclusion: Quantifying the financial benefits of social health integration helped institutions see how they could succeed under value-based contracts.

Introduction

The growing emphasis on redesigning models of care delivery and payment to improve health outcomes instead of increasing the volume of services is encouraging health care organizations to attend to the underlying social and environmental factors that affect health.¹ Yet many social health interventions — such as those that address essential resource needs like food and housing and refer patients to social services and other supports — are pilot projects rather than standard components of care.

The integration of these services with primary health care will necessitate long-term funding. And securing this funding will require health care leaders to articulate the value of these services, supported by evidence of their impact on health and costs. Despite new value-based payment opportunities, leaders of many health care organizations do not know how to develop the business case for integrating social interventions into routine care for all patients who need them.

Below we describe a practical approach to supporting the spread and sustainability of social health interventions in varied institutional and market settings. It was developed by Health Leads’ Collaborative to Advance Social Health Integration (CASHI), a breakthrough series–style learning collaborative involving primary care teams in a mix of urban, rural, and suburban settings (see box).²

Making the Business Case

CASHI sought to make social health interventions a standard part of primary care across multiple sites. Participating teams paired the systematic identification of patients’ unmet essential resource needs with follow-up support from a community health worker (CHW) or navigator, sometimes with intensive navigation or case management.

The teams set out to develop business cases to demonstrate the value of their efforts to health plan leaders, health system executives, state policymakers, and other stakeholders in a position to invest in social health integration. (This work builds on and aligns with the Return on Investment (ROI) Calculator for Partnerships to Address the Social Determinants of Health, developed with support from the Commonwealth Fund and the SCAN Foundation, by exploring practice costs associated with social health interventions and the various funding opportunities available to sustain and scale these services.³)

All participating health systems were early adopters of social health interventions, recognizing the strong alignment of these services with their mission. While decisions to spread and scale these interventions were not dependent on a clear ROI, participating leaders sought a deeper understanding of the pathways to sustain them financially, given the evolving policy and reimbursement landscape. Teams used a framework to articulate value created by measuring financial and nonfinancial benefits, clarify the funds needed for the social health intervention, and identify opportunities to bring in additional funds if necessary (Exhibit 1).

For most teams, this meant analyzing the business case for investing in the staff and technology to integrate the screening of patients for unmet essential resource needs and provide community referrals to fill those needs within the care delivery model. Only a few teams included the cost of providing essential resources directly, such as those providing medical–legal partnerships. Most teams did not collect service delivery costs among community partners because of the large number of community-based organizations to which practices referred their patients for various needs.

Key Insights from the Collaborative

1. Business case analyses were closely tied to health care organizations’ level of value-based payment (VBP) adoption.

Most CASHI teams sought to move away from grant funding and instead access sustainable funding sources for their social health interventions. As such, each business case was largely based on the incentives in their organization’s value-based contracts (Exhibit 2). Teams engaged with their leaders — and, in some cases, with payers directly — to identify sources of value.

Teams working under risk-based payment models, such as accountable care organizations (ACOs) that assume responsibility for patients’ health outcomes and costs, needed to show cost savings across all contracts. They also had to demonstrate that the costs of adding staff members such as community health workers (CHWs) would not exceed any savings. Initial estimates of reductions in the total cost of care from social health interventions, plus evidence of savings from related initiatives, was often enough to elicit buy-in for reconfiguring some staff positions to make whole-person care delivery accessible to a broader patient population. However, more rigorous evaluations would be needed to make the case for funding the creation of new positions.

Other organizations worked under contracts that did not entail financial risk but instead offered incentives for meeting quality benchmarks. The business cases these teams developed demonstrated that their social health interventions were associated with greater use of primary care and behavioral health care — both of which have been shown to reduce total health costs over time and are incentivized in many contracts. Furthermore, these teams hypothesized that as health care providers offer patients support in meeting their essential resource needs, patients’ trust in the health care system builds, their confidence in managing their health grows, they become more engaged in their care, and costs ultimately fall. Similar hypotheses have been demonstrated in research on equity-oriented health care models.⁴

Many teams, however, worked in organizations that were still largely paid on a fee-for-service basis. These teams focused on demonstrating reductions in uncompensated care, greater use of ambulatory care relative to emergency and acute care, and higher levels of patient and physician satisfaction. While reductions in emergency department use in the short-term yielded financial returns, some teams pointed to these early results as evidence of the social health intervention’s contribution to better patient care management — and thus as an indicator of potential future success under value-based contracts. Multiyear analyses will be required to prove these hypotheses; however, early data provided clarity on where positive clinical and financial impacts may exist.

2. Health care organizations can align the business case for social service interventions with the value created for patients and the broader community.

While reimbursement had a significant influence on the business case, creating value for patients, health care payers, and members of the broader community also was compelling, particularly for health care organizations that see themselves as collaborators in local efforts to improve community health. Leaders saw value in this both from the perspective of their mission and their long-term success under value-based care contracts.

3. Teams identified multiple sources of value that could be demonstrated in the short and long term.

It is challenging for health care organizations to evaluate the impact of social health interventions that target multiple domains — such as unmet needs for food, housing, or transportation — and large populations.⁵ First, monitoring what happens after patients are referred to social services is difficult. Second, it can be hard to access medical claims data, though teams in organizations with more advanced value-based contracts had an easier time obtaining these data sets. To overcome these challenges, teams collected data on a range of impacts they could demonstrate over time (Exhibit 3).

The collection of qualitative data, such as stories from patients and clinicians, helped to explain trends observed in the quantitative data. Such qualitative findings were particularly helpful in convincing leaders to sustain funding while more quantitative evidence was being gathered to prove hypotheses. For example, stories illustrating how social health interventions helped make clinicians more effective and reduced burnout held significant weight, as clinician burnout has been increasing for years and is costly to practices.⁶ Patients’ stories also demonstrated how addressing unmet essential resource needs helped them manage their health conditions and receive appropriate care.

4. Quantifying the actual and potential financial benefits of social health integration helped institutions see how they could succeed under value-based contracts.

Many teams were able to quantify the estimated savings of their efforts to address patients’ essential resource needs by reducing uncompensated care or use of emergency or acute care. Often, savings exceeded costs of their social interventions. Teams also saw improvement in measures of health care quality — for example, those tracking blood pressure control or receipt of cancer screenings — as well as higher engagement in primary and behavioral health care. All these improvements can bring additional revenue to the practice under value-based contracts.

Some teams used their actual results to project the potential financial benefits of spreading the social health intervention to additional sites. Such analyses helped teams secure operational funds for their social health interventions and identify further opportunities to create value-based arrangements to support them (Exhibit 4).

5. The analyses helped teams understand cost drivers, identify opportunities for efficiencies, and plan for spread.

Teams sought to track the costs of their social health interventions, many through studies of the average time staff took to complete each step, from screening through referrals. This approach enabled teams to understand what drove costs, consider opportunities for efficiencies, and project what resources would be required to spread the intervention to additional sites or populations.

Conducting cost analyses was useful in supporting participants’ plans for spreading social health interventions beyond the pilot. Screening was found to be relatively inexpensive. The largest driver of cost was the time used to locate and follow up with patients. Several teams recognized the need to improve efficiencies in closing the loop on referrals, including leveraging social health resource referral platforms. However, teams recognized that referral pathways and communication with community partners would need to be improved for closed-loop-technology solutions to be effective and efficient.

Exhibit 5 shows one team’s time-study cost analysis. It demonstrates the efficiencies gained by adopting closed-loop referral software and by collaborating with CHWs and case workers across a network of community service and primary care providers that all use a common language and shared workflows.

Understanding the costs also led teams to identify opportunities to operate more efficiently by redirecting resources. For example, one team found that attempting to connect patients with housing was extremely time-intensive and had a very low success rate, compared with connecting patients with assistance in paying utility bills, which was straightforward and had an immediate impact on health. Moreover, many patients screened positive for this specific need.

Teams also considered how to redistribute activities across team members, including social workers, community health workers, navigators, and nurses. One team calculated the financial impact of efficiencies gained by having CHWs and navigators focus on patients’ essential resource needs while nurse care managers focus on clinical issues. This analysis supported a request to leaders to hire additional CHWs.

Analyzing the costs of different services enabled teams to make evidence-based cases. Not only could they discuss ways to deploy resources to have the greatest impact, but they also could forecast what it would take to spread their social interventions based on such factors as population size, health needs, and staff required.

Despite these benefits, many teams struggled to access cost data, especially when it came to allocation of fixed costs or overhead. Having more support from finance staff could help teams maximize their investments in social health interventions.

Discussion

Many of the teams involved in the Collaborative to Advance Social Health Integration were early adopters of social health interventions, and decisions about whether to spread their social health interventions were not entirely dependent on demonstrating a clear ROI. However, identifying pathways and opportunities to sustainably integrate social health with their work and invest resources for the greatest impact was of deep interest to participants.

Through this work, it became clear that securing adequate reimbursement for navigation services to help patients access essential resources is critical. Social health workforces, including CHWs and navigators, are rarely able to bill for their services. This puts them in the position of being cost centers to their institutions instead of revenue generators, even though their work has value to their institutions, patients, and care teams.

To drive community health and equity, we believe the sector will need to move beyond a business case that quantifies the value of health care institutions’ efforts to address essential resource needs to one that quantifies the value of collaboration among health care organizations and their community partners. Applying our framework could shed light on the costs of services provided by each partner and the value they create. This, in turn, could inform the reallocation of resources to drive value at the community level. As one CASHI team found, effective use of closed-loop referral software across multiple community-based service providers yields insights into the amount and type of unmet essential resource needs within a community and the capacity available to address these needs.

Combining these data with rigorous cost and impact data among community partners has the potential to support more effective resource planning at the community level. However, this will require inclusion of community members in business case analyses to identify what it will cost to meet those needs and where targeted funding is most likely to support equitable health outcomes.

Finally, payment models that promote health care innovation and offer well-aligned incentives to drive health equity are needed.⁷ None of the CASHI teams were operating under payment contracts with explicit incentives to reduce racial and ethnic health inequities, despite the fact that estimates have placed the value of eliminating them at more than $200 billion.⁸ As such, efforts to understand the impacts of social health interventions across subpopulations, including patients of different race and ethnicity, were rare. More work needs to be done at the provider level to fine-tune data collection and analysis to identify inequities and understand how health care and other sectors can help eliminate them, including what the most suitable financing models are.