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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.

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.

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.

About Health Affairs

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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