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Public policy forum recap: Addressing the social determinants of health

2019 Public policy forum recap
Courtney Burke, HANYS' chief operating and innovation officer, moderates the panel discussion with (from left): Kate Breslin, president, Schuyler Center for Analysis and Advocacy; Elisabeth Misa, New York's deputy Medicaid director; Bea Grause, president, HANYS; and Anthony Shih, MD, MPH, president, United Hospital Fund.

On Jan. 24, HANYS held a special public policy forum to explore the impact of social determinants of health. Anthony Shih, MD, MPH, president of the United Hospital Fund, began the forum by outlining the existing challenges in addressing these many social, environmental, educational and economic factors.

Following his remarks, Courtney Burke, HANYS' chief operating and innovation officer, moderated a discussion panel, which included Bea Grause, president, HANYS; Kate Breslin, president of the Schuyler Center for Analysis and Advocacy; Elisabeth Misa, New York's deputy Medicaid director; and Dr. Shih.

Defining social determinants of health

The U.S. Centers for Disease Control and Prevention defines SDH as:

“life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life.”

These include access to care and resources such as food, insurance coverage, income, housing, environment and transportation.

The Robert Wood Johnson Foundation simplified the concept to: “Good health begins in the places where we live, learn and work and play.”

The growing provider and policymaker interest in social determinants of health

Dr. Shih and the panel covered a range of topics pertaining to SDH, from its tremendous impact on health and longevity to hopeful new interventions. Interest in SDH by healthcare providers and policymakers has grown in recent years partly because of the Triple Aim (which prioritizes population health improvement) and the advent of value-based payment (which has led providers and payers to look both inside and outside of medical care for factors impacting health outcomes).

Dr. Shih said his interest in SDH began in the 1990s, early in his medical career, at a community-based mental health clinic in Oakland, California, serving immigrant and refugee families.

“It was absolutely clear to me that despite the best medical care I could provide to those patients, I wasn’t going to have a long-term impact on their lives, which were so much more dictated by their situation, by their cultural and social isolation, unemployment and poverty,” he said.

Since that time, SDH has risen to the forefront of policy discussion.

Government action on social determinants of health

The federal government has taken a keen interest in addressing SDH. In November, Health and Human Services Secretary Alex Azar said forthcoming models from the Center for Medicare and Medicaid Innovation could include public reimbursement for non-health services such as housing and nutrition. Medicare Advantage plans will be permitted this year to begin paying for a wider range of health-related benefits, including home health visits, groceries and transportation to and from and medical appointments.

Last July, the federal government approved the third annual update of the New York State Value-Based Payment Roadmap, which emphasizes the role of community-based organizations and social determinants of health interventions as our state continues on the journey to VBP payment models.

Since 2012, the New York State Department of Health has invested in capital projects, supportive housing and other services targeted to high-utilizers of Medicaid. DOH established its Bureau of Social Determinants of Health in 2017 with a goal of incorporating community-based organizations and addressing SDH to improve the quality of care and health outcomes for vulnerable populations and increase Medicaid efficiency.

How New York’s healthcare providers are tackling SDH, despite barriers

At HANYS’ forum, panelists described the many health strategies New York healthcare providers are engaged in, such as supportive housing and medically-tailored meal programs that help at-risk individuals.

Hospitals are serving as anchor institutions in their communities as they work with a variety of community-based organizations to improve the health of residents in a particular region.

Collaborative community efforts such as those undertaken as part of New York's Delivery System Reform Incentive Payment program and the state's Prevention Agenda were cited as important foundations that warranted continued funding and attention.

Despite the increased interest and promising developments, the barriers to establishing a stable network of community and healthcare partners abound. In addition to the long-term commitment that these partnerships require, healthcare providers and community-based organizations encounter cultural, technological, financial, regulatory and, most importantly, trust issues that can impede progress.

Despite the barriers, Dr. Shih and the panelists emphasized the long-term benefits in health, education and criminal justice outcomes by investing in community-wide solutions, particularly by focusing on the SDH needs of special populations, such as children.

Reflecting on the past – and looking ahead

Looking toward a rapidly changing New York landscape, all panelists agreed that new entrants into healthcare, such as Amazon, Apple and the CVS/Aetna partnership, have not yet expressed interest in addressing SDH. Dr. Shih suggested that as SDH initiatives become more widespread and advanced, the state could help ensure that these companies leverage their expertise to help New York continue to improve health by tackling the many factors that impact the lives of both individuals and communities.

Dr. Shih’s early experiences with SDH have come full circle. As leader of the United Hospital Fund, Dr. Shih is driving research and pilot initiatives on ways to help vulnerable populations. He discussed UHF’s leadership in initiatives targeting SDH, including its Children’s Health Initiative; partnerships for early childhood development; a health and housing consortium; the Medicaid First 1000 Days initiative; and a collaborative with Montefiore Medical Center, Northwell Health and the Institute for Family Health to advance the collection of patient-reported outcomes in primary care, with a focus on housing, food security and domestic violence.

Recalling his early career, he said,

“Back then, we didn’t have conversations about the role of healthcare in addressing the social determinants of health. Fast forward to today, it’s something that we all talk about so it’s great. I couldn’t imagine 20 years ago that I would be speaking about this topic to the Healthcare Association of New York State.”

HANYS thanks Dr. Shih and all of the panelists for an enlightening dialogue on this critically important topic. While efforts to address SDH are just beginning, these initiatives hold great promise to improve population health. Healthcare providers are doing the right thing by taking a pivotal role in this endeavor. To truly make a dent in this far-reaching problem that has its roots in societal inequality, providers and CBOs will need resources going forward to coalesce these many separate efforts into an effective movement.