Podcast: Structural racism as a social determinant of health.
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Tuesday, March 8, 2022 | The Latest Research, Commentary, And News From
Health Affairs

Dear John,

Today's newsletter comes from the desk of Seth Berkowitz, assistant
professor in the Division of General Medicine and Clinical Epidemiology
at the University of North Carolina School of Medicine.

From Seth Berkowitz

In the latest issue of Health Affairs, my colleagues and I published a
study where we evaluated a nonemergency medical transportation program

offered to members of a Medicare Accountable Care Organization (ACO).

This program primarily provided transportation to outpatient health care
appointments via a ride-sharing app. One goal of the program was to
lower health care spending, with the idea being that if people could
access their outpatient appointments more easily, some emergency
department visits and inpatient hospitalizations might be avoided.

We found evidence that the program was associated with increased
utilization of outpatient health care, as intended, but this was not
associated with fewer emergency department visits or inpatient
hospitalizations, or lower health care spending overall.

However, participants highly valued the program, noting that it helped
them feel more engaged with their care and less dependent on others.

I research health-related social needs (HRSNs) and have followed the
field somewhat closely for the past decade. We all know that HRSNs, such
as food insecurity, housing instability, and transportation barriers can
have detrimental effects on health.

Fortunately, we are now in a time of intense experimentation to
determine how health care systems and health insurers might address
these issues. For interventional studies, there seem to be three
possible outcomes.

Some programs will work as intended and should be scaled up. Others may
be well-intended but show no benefits. These should be chalked up to
learning experiences that we build on to develop better interventions.

But there is also a third category where, like the present study, the
intervention may not have had the intended effect on health care use or
cost, but still benefited patients in areas of well-being,
health-related quality of life, and or other aspects of health.

I think that now is a good time to consider how we deal with this
outcome.

My first thought is that studies of interventions related to HRSNs
should try to measure a comprehensive set of outcomes (not just typical
health services metrics), because we may miss important effects.

Additionally, to understand the real value to patients, we should
'cash benchmark' the intervention-that is, compare the treatment
effects of an HRSNs intervention to the treatment effects of an
unconditional cash transfer, on a broad set of outcomes.

This would help us understand the value of the service provided beyond
any financial value of the intervention.

Another thought is to view the outcomes that are unrelated to the health
care use and cost as positive externalities. In my work as a clinician,
my focus is on health outcomes and not on cost. But ACOs and other
payment models are built around the idea of using upfront spending to
generate lower subsequent health care expenditures.

Many HRSNs interventions are undertaken with this goal in mind. This is
what is sometimes meant by terms like "return on investment" for
HRSN interventions. But important benefits (like those related to
well-being) are difficult to price into such a transaction-the money
spent may buy something beyond what was intended.

Standard economic theory would suggest that positive externalities lead
to underinvestment-that is, if those financing the intervention do not
see every benefit, they will pay for less intervention than might be
socially optimal.

One solution to the positive externality issue would be to subsidize
health systems or health insurers' actions regarding HRSNs. If these
programs have important benefits, but those benefits do not result in
the cost reductions that some health care financing mechanisms rely on,
then some of the program cost could be shared publicly.

There is some irony in that something intended to contain health care
costs could lead to an argument for greater health care spending!

Another approach is to turn from health policy to social policy. Part of
the reason many health systems and insurers have taken on trying to
address HRSNs is because the American political climate looks hostile to
implementing social policy that would address HRSNs. But we may be
bumping up against the limitations of this approach.

Addressing HRSNs only after they occur, intersect with other health
issues, and come to the attention of the health care system may simply
be rather limited in the benefits it can offer. Further, political winds
can change quickly. For example, the CARES Act, passed by a divided
Congress, provided historically generous income, unemployment, and
nutrition supports. I think it is time to press the case that HRSNs
invite social policy solutions, not just health policy solutions.

Ultimately, there are many instances where some involvement of health
care systems in HRSN programs provides benefit. We are in an exciting
time where research will find those cases. But fundamentally such
programs need to be viewed as complements to, not substitutes for,
social policy to prevent poverty, material deprivation, and HRSNs.

Elsewhere At Health Affairs

Today in Health Affairs Forefront, Linda Richter and coauthors argue
that smart use of new federal funding for youth mental health
initiatives

and effective allocation of state opioid settlement funds can prevent
youth substance use and mental health problems.

Elevating Voices: International Women's Day: In her December 2021
Narrative Matters essay, Shivani Nazareth describes her quest to find
the genetic underpinnings

of her mother's dementia.

Also in the December 2021 issue, Christopher Whaley and authors indicate
that over the course of a career, female US physicians were estimated to
earn $2 million less
than male
US physicians after adjustment for factors that may otherwise explain
observed differences in income.

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Health Policy Podcast Fellowship

Health Affairs is accepting applications to the the Health Affairs
Podcast Fellowship program. This program is an opportunity for
U.S.-based applicants who are in the early or mid-early stages of their
career.

The program is intended for professionals with an interest in health
policy and storytelling to pursue an audio project with support of their
employer, school, or as a freelancer to dedicate the time and resources
to complete their project.

Listen to the Health Affairs Pathways podcast

to see what the latest cohort of the Health Policy fellows produced.

Apply Today

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Ruth Zambrana Argues Structural Racism Is A Social Determinant Of Health

Ruth Enid Zambrana from the University of Maryland joins Health Affairs'
Editor-in-Chief Alan Weil to discuss the intellectual history of
scholarship on racism and health.

Listen Now

Daily Digest

Evaluating A Nonemergency Medical Transportation Benefit For Accountable
Care Organization Members

Seth Berkowitz et al.

How To Invest Opioid Settlement And Federal Funding To Prevent Substance
Use And Promote Youth Mental Health

Linda Richter et al.

To Uncover My Mother's Genetic Disorder, I Had To Lead The Way

Shivani Nazareth

Podcast: Ruth Zambrana Argues Structural Racism Is A Social Determinant
Of Health

Alan Weil and Ruth Zambrana

 

 

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