Tim, an elderly man, visits his doctor with a persistent cough, but he might be suffering from more than allergies or a virus.
Unbeknownst to the physician — either because Tim isn’t forthcoming or the doctor lacks time, tools and resources to probe — is that Tim suffers from poor nutrition because he is food insecure, which, over time, has weakened his immune system and made him more susceptible to illness.
Back home, Tim’s cupboards are nearly bare. His wife passed away six months ago. As the homemaker, she did most of the grocery shopping and was the primary chef in the house.
In the practice of value-based care, an approach that focuses on quality over quantity, clinicians are increasingly finding that patients need more than treatment for their presenting clinical complaint. In many cases, it’s the social, economic and environmental circumstances — the social determinants of health (SDoH) — that are the root cause of why patients don’t achieve their best health outcomes.
When physicians and clinicians understand both the clinical and social circumstances of their patients, they can better pinpoint sources of poor health and take action to bring about short- and long-term sustainable solutions.
“To improve the healthcare system in the United States … there must be a vigorous effort to address significant economic, social and environmental barriers to health,” said David Himmelgreen, PhD, professor and chair, Department of Anthropology, University of South Florida and co-founder of the Hunger Action Alliance. “Research has shown that these barriers are not adequately addressed in our traditional healthcare system, influencing both physical and mental health.”
Care-delivery shift
Value-based care represents a significant shift from the traditional fee-for-service (FFS) design of the U.S. healthcare system. In a value-based structure, providers, including hospitals and physicians, are paid based on patient health outcomes.
As such, a value-based care setting demands that physicians create more comprehensive, holistic profiles of their patients, helping to manage or prevent disease before it happens by assessing and addressing root causes.
Many providers already are embracing value-based care, seeing fewer patients per day but spending more time with those they see. Investing in longer appointments allows for a more inclusive assessment, appropriate guidance and ultimately manifests in better health outcomes.
With value-based care and SDoH intertwined in shaping how providers care for their patients, health plans such as Humana are re-thinking their approach to collaboration with physicians and their practices.
To support value-based care, Humana developed a continuum of programs that offer financial incentives for improvements in quality, outcomes and costs. The programs are meant to help primary care physicians (PCPs) enhance population health management capabilities.
Since 2014, Humana has measured and reported health outcomes for Medicare Advantage (MA) patients affiliated with physicians practicing value-based care. The results are making marked differences in the way patients approach their well-being.
Because value-based care tends to foster more interaction, physicians are encouraging more engagement from their Humana-covered individual MA patients, 67% percent of whom last year saw PCPs who were in value-based arrangements with the company. That engagement shows in the form of increased rates of preventive care and screenings (up as much as 14% in some areas), lower incidences of ER visits and hospital admissions (down 7% and 5%, respectively) and overall increased HEDIS scores for practices (up 20% compared to those treated at FFS practices).
The positive trends are paying dividends to physicians as well, with PCP practices in Humana MA value-based payment agreements receiving more of the healthcare dollar. Those physicians received 16.8% of every dollar spent on member care in 2017 (the latest figures available), compared to 6.9% for non-value-based physicians.
PCPs can affect many areas of care — determining which specialists to use who achieve the best outcomes, providing needed prescriptions, coaching and educating patients on their health conditions. Some advanced population medicine practices have developed in-home capabilities with fully integrated care managers.
Humana develops analytics and insights and regularly shares those details with physicians to help identify care opportunities, trends in disease prevalence, outcomes and costs. From the patient perspective, the health plan teams with physicians to make patients aware of chronic condition management programs, education opportunities, fitness programs, mail order pharmacy, affordable premiums and predictable medical costs.
Setting a Bold Goal
Furthermore, Humana publicly announced a Bold Goal in 2015, a population health strategy to improve the health of the communities it serves 20% by 2020 and beyond. The effort has become the ethos of the company, focused on improving population health by addressing clinical gaps in care, as well as social determinants such as loneliness and food insecurity.
“Value-based care requires a close partnership with the payers and aligns everybody’s interests: patients, plans, providers,” said Larry Blosser, MD, outpatient medical director, Central Ohio Primary Care. “Everybody is moving in the same direction, trying to get to the same place. All have the same goal — to improve patients’ quality of care while preventing complications and additional healthcare costs.”
The Bold Goal uses the Centers for Disease Control and Prevention’s Healthy Days assessment tool to measure an individual’s self-reported physical and mental Unhealthy Days over a 30-day period. MA members living in the company’s original seven Bold Goal communities across the country have seen a 2.7% reduction in their Unhealthy Days since their 2015 baseline.
Food insecurity and loneliness are areas of focus due to their correlation with Unhealthy Days.
One in eight Americans is listed as food insecure, and more than 4 million of those are seniors, according to Feeding America. Food insecurity is associated with the following statistics:
- 50% more likely to be diabetic
- 14% more likely to have high blood pressure
- Nearly 60% more likely to have congestive heart failure or experience a heart attack
- Twice as likely to have asthma.
The impact of the 43% of older adults who are lonely is just as substantial, studies show. Loneliness is associated with the following:
- More than doubles their risk of Alzheimer’s
- Makes them 3.4 times more likely to suffer from depression
- Places them in a position to be roughly 30% more likely to die prematurely.
To those areas and beyond, Humana has created — and continues to develop — tools driven by data aggregated from physicians and other sources and analytics that help physicians and their care teams inside the clinical setting address both clinical needs and social determinants of health.
“Patient care is our top priority”
The positive impact of this approach can be seen across the country. Take Hatfield Medical Group, for instance. The Phoenix-area organization comprises four practices and 15 PCPs and has 876 patients with Humana MA coverage. The group transitioned in recent years from FFS to value-based care, intent on keeping the well-being of its patients above all else.
“When a patient walks into Hatfield Medical Group, we want it to be clear that patient care is our top priority,” said David Hatfield, MD, chief executive officer and lead physician. “From our staff that greets each patient by name, to our posted motto, ‘Quality, compassionate care to every patient, every day,’ it’s clear that high-quality care is the central focus of our practice.”
Part of Hatfield’s accomplishment is attributed to how the practice impacts the outcomes of patients. To better help those with diabetes, for example, Hatfield brought one of the most common diabetic preventive services — a retinal eye exam — into its clinics.
The comprehensive diabetes care HEDIS measure that includes the annual retinal eye exam tends to have one of the lowest scores due, in part, to the inconvenience and additional cost — two other social barriers — of having to schedule the exam with an ophthalmologist.
With patient well-being at the forefront, Hatfield saw an opportunity to improve the patient experience and provide the screenings by investing in retinal cameras and training staff to perform the exams in the clinics.
Nowadays, hardly a patient with diabetes leaves the practice without receiving a diabetic retinal eye exam. That has led to Hatfield receiving a top rating of five stars on the HEDIS metric.
Being able to conduct retinal exams on-site — and then immediately have them read by an ophthalmologist — allows Hatfield physicians to identify patients who have diabetic retinopathy earlier so action can be taken right away, if needed.
Elevating SDoH
Humana continues to work to address social determinants through direct interventions and through integration into clinical operating models.
The company’s well-being platform, Go365, now includes a SDoH screening in the annual well-being assessment. Humana at Home, the principal disease-management program, has integrated SDoH screenings and care plans.
Humana is also working with the National Quality Forum to develop an approach to more effectively address food insecurity.
The ultimate goal is to elevate social determinants of health to the same status as clinical gaps in care. The desired end state is that it becomes the norm to assess and address both clinical and social needs during the course of any interaction with a health professional.
That way, the likelihood of patients such as Tim staying healthy improves.
“As physicians, we are often unaware of the daily struggles preventing patients from adhering to our best-laid treatment plans,” said Sarah Moyer, MD, director, Louisville Metro Department of Health and Wellness. “We know that social determinants — your income, the neighborhood in which you live, your race, your education level — are powerful predictors of how healthy you will be. Only when we understand these outside factors can we address the obstacles that stand in the way of better health.
“Public health is the work of all of us. It’s what we do together that gives every single person in our community the best possible chance at a healthy and productive life.”
Explore Related Content
More Insight Articles
