BY Ketan Patel, Advisory Principal, Healthcare, KPMG
Can a produce store and better schools in a poor neighborhood reshape the trajectory of healthcare?
Social determinants of health are one of the biggest buzzwords in healthcare. It’s a buzzword with real-life consequences, however, pertaining to how poverty, housing, education, pollution, and neighborhood characteristics can affect health.
Health disparities between the richest and poorest ZIP codes in the city can mean a 10-year difference in average life expectancy, a 2019 report from Houston’s Department of Health said. Some sections of Houston have poverty rates that exceed a third of households and the U.S. Census as of last year had listed a poverty rate of 16.5% for Harris County.
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The difficulty for health policymakers is determining what interventions can make the biggest impact to reduce risks of cardiovascular disease, diabetes, kidney disease, obesity, and cancer. Addressing some social issues would require spending from already strained government budgets. The combination of targeted spending and identifying those who would best benefit from it can be profound.
With COVID-19 disrupting many providers’ finances, some have moved to capitation in their contracts with commercial payers. In this value-based reimbursement environment that shifts the financial risk to payers, the incentives could be there for the provider to cover some of those interventions.
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For example, a patient with multiple chronic conditions without access to transportation could possibly benefit from a ride service to take the patient to physician appointments to help manage his or her conditions.
The question for the healthcare policymakers then becomes: How many rideshares to need to pay for to prevent one hospitalization? Or would a cooling center during the summer months help reduce heatstroke and other related hospitalizations for the most vulnerable patients?
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Under these circumstances, it is important to be able to provide a deep dive into individual patient risks. Clinicians – and support staff — also need to ask about barriers to care in certain areas. The transportation issue is one of the easier ones to address. Other issues that may need to be addressed could be tied to broader questions around access to care and nutrition and their role in wellness and disease management.
Just the issue of food security alone has a significant impact on an array of medical conditions. The limited availability of nutritionally adequate foods is associated with chronic health problems, including diabetes, heart disease, high blood pressure, high cholesterol, obesity, and mental health issues, such as major depression.
Many of these issues are multi-factorial where patient education might need to be incorporated into a patient care program or a community health model. While this may take more time on the clinician’s part, patient education can help reduce unnecessary emergency visits from better disease or medication management.
From a financial standpoint, tax-exempt healthcare providers need to file Community Health Needs Assessments (CHNA) under the Affordable Care Act, as long as it is in force. Some hospitals have used this requirement to run programs around nutrition and smoking cessation.
The financial issues tied to value-based care may make a CHNA much more strategically focused and connected with community outreach and target social determinants of health to achieve better clinical outcomes.
CMS developed a healthcare disparities page (link: https://data.cms.gov/mapping-medicare-disparities) that can help some of the calculus involved in determining the costs of care for the Medicare population. For each Medicare beneficiary in Harris County, average healthcare costs exceed $24,000 for diabetes and $76,000 for heart attacks each year.
With numbers like that, targeted preventive care and addressing social determinants take on a new sens