The extra mile: Social risk factors and patient-centered care

The shift to value-based care in the healthcare industry may have many physicians feeling like teachers.

America’s educators increasingly are judged on students’ performance on a variety of standardized tests and measures, producing a familiar lament: “What about the parents and guardians? Who is measuring their performance?”

The temptation to think something similar about noncompliant patients or the influences in their lives that disrupt care plans and quality scores is not unheard of, despite physicians’ penchant for empathy. That sentiment seems to be gaining attention from researchers and healthcare writers, alike.

Consider healthcare spending nationwide, as did David H. Freedman writing for POLITICO: Annual Medicare spending at $672 billion, plus $565 billion for Medicaid, $329 billion for pharmaceutical companies and $1 trillion for hospitals do not add up to the best outcomes. Freedman noted how other areas of society — housing and education, for example — sometimes create adverse downstream effects for healthcare providers.

In other words: Rising costs are influenced by existing factors that complicate efforts for preventive healthcare or other care plans before a patient sets foot inside the practice. “The broader American health system really isn’t set up to benefit from long-term preventive investments,” Freedman wrote, adding that the systems that do — such as Veterans Affairs — are closed, payer-provider systems, and some (like the VA) offer benefits such as housing. While the VA has not solved homelessness, the emphasis on social risk factors puts the system ahead of many others struggling to make sense of it all.

Even accounting for the costs of social risk factors is a difficult task. A recent paper in the HSOA Journal of Community Medicine & Public Health Care [PDF] does just that, noting that healthcare costs were $65 higher per month per Medicaid beneficiary for those who needed assistance with basic needs such as food, clothing or housing. Despite controlling for past hospitalizations, age, gender and chronic conditions, those patients’ costs were higher because of the social risk factors.

The paper’s lead author, Art Jones, MD, chief medical officer, Medical Home Network, Chicago, noted that his organization — which manages a Medicaid accountable care organization — developed a five-minute risk assessment to better understand the social and behavioral risk factors.

In one-on-one encounters with patients, providers may understand patients’ risks and the issues that cause them, but that does not always translate into actionable data.

To that end, the National Quality Forum (NQF) released a blueprint in September 2017 on identifying “differences in care among certain patient populations.” But developing the level of data to do that properly is not something providers can do on their own, noted Shantanu Agrawal, president and chief executive officer, NQF, Washington, D.C. “We’ve got to start with partnerships with communities,” Agrawal said.

Many healthcare providers understand that they have limited control in their patients’ lives and level of engagement in their own healthcare, but that is no reason to give up the fight or lay blame elsewhere. Innovations are born out of obstacles like these, such as building partnerships with local transit authorities or ride-share companies to ease the transportation burdens for patients who might otherwise skip a visit.

The medical practice remains a vital part of our communities, but oftentimes the task of improving the health of the patient population extends beyond the practice. Practice leaders who exercise an active voice on the broader social issues can enable positive upstream changes that will transform patients’ lives.