Meals delivered to the homes of patients with Type 2 diabetes. Air conditioners installed to help asthma patients breathe more easily during the summer. Uber rides provided so patients without cars can get to their doctor’s appointments.
All of these ideas aren’t typically considered part of traditional medical care, but, increasingly, health insurers, hospitals, and government officials see them as ways to keep patients healthy. The alternative has long been to wait until patients get sick or need a trip to the emergency room, but doing so is costly.
And now, the Trump administration is taking a closer look at social services such as healthcare.
“What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food?” Health and Human Services Secretary Alex Azar said at an event in November. “If that sounds like an exciting idea… I want you to stay tuned to what CMMI is up to.”
Azar was referring to the Centers for Medicare and Medicaid Innovation Center, a government entity created by Obamacare that tests different ideas for improving care and lowering costs. The expected changes would take effect through Medicaid, the program that covers low-income people and other vulnerable populations, including pregnant women and people with disabilities.
The changes would follow other programs underway in the government and in the private sector.
Medicare, the other large government healthcare program that mostly covers seniors, doesn’t pay for services that aren’t directly tied to medical care, but the Trump administration beginning in 2019 will allow Medicare Advantage to reimburse for in-home services such as home-delivered meals, wheelchair ramps, bathroom grab bars, and housekeeping. Medicare Advantage is the privatized version of Medicare, and a small number of plans are planning to participate in the new program in 2019, with more expected to follow in 2020.
The Medicare Advantage program run by Humana, for instance, will be partnering with Meals on Wheels at the start of next year to deliver food in a handful of cities. It also provides volunteers to visit with patients, talk with them, and do light chores. Hospitals have been running programs, too. MedStar Health and Denver Health Medical Center used ridesharing to help patients get to their appointments.
Experts say that healthcare services account for only about 20 percent of what keeps people well. The rest is determined by the “social determinants of health,” meaning where people live, how much money they make, what their job is, and how well they take care of themselves by eating properly, and avoiding smoking or excessive drinking.
“These are the things that can really result in billions of dollars in healthcare costs and in exacerbating healthcare outcomes,” said Rashi Venkataraman, executive director of prevention and population health at America’s Health Insurance Plans.
That’s why healthcare payers are so focused on them. Through Medicaid, 19 states allowed private insurers that manage the plans to screen people’s social needs in 2017, according to the Kaiser Family Foundation. Several states also added services such as GED coaching, housing support, mother and baby support, and educational services. Other states reported that they provided safety items to patients, such as helmets or car seats.
Centers for Medicare and Medicaid Services Administrator Seema Verma, in a November press conference, cited North Carolina as an example other states might follow in addressing the social determinants of health. The Trump administration approved a pilot plan in the state in October to let insurers screen people on Medicaid to see whether they lack access to food, housing, or transportation. The program will refer patients to organizations that can help meet those needs and will then follow up with them.
J.T. Lane, former state health official of Louisiana and senior director with Alvarez & Marsal’s Health & Human Services practice in Washington, D.C., said that Medicaid already partners with agencies like the Department of Housing and Urban Development and the Supplemental Nutrition Assistance Program, formerly known as food stamps.
He noted that the programs may not yield results right away, and that the administration would need to find ways to measure how well they work.
“A lot of these programs sometimes can’t make significant changes in one budget cycle; it may make two,” he said, noting that states have the obligation to balance their budgets.
Federal law prohibits Medicaid from paying directly for rent, but a handful of states have used Medicaid funds to help people find housing. Other states have urged coverage for air conditioners, vacuums, and other cleaning supplies that would help reduce hospitalizations for patients with chronic lung diseases. Some states have a waiver that funds employment services for people with addiction or mental health disorders.
Despite the general consensus that the programs are full of promise, however, there still are roadblocks ahead. The burden to connect patients with social services may be too heavy for doctors, more than half of whom already report burnout. A 2017 survey of 600 doctors by Leavitt Partners found that while most agreed that social factors affect their patients’ health, they do not think addressing them is their responsibility or that of the health insurer.
“Generally we are asking healthcare payers and providers to play an untraditional role to what they have been accustomed to for years and years,” Lane said.
The decision about which programs to authorize also can be rife with political controversy. The Trump administration has said that it believes the programs it approved requiring certain Medicaid beneficiaries work, volunteer, or take classes to stay covered address social determinants. They’ve shown studies demonstrating that people who work are also healthier, but opponents to this approach note that in Arkansas, 12,000 people were removed from Medicaid because of the requirements. Without coverage first, they say, none of the other services can follow.
“Coverage will help them access healthcare and then address the broader array of needs they have,” said Samantha Artiga, director of the Disparities Policy Project at the Kaiser Family Foundation.
The programs ultimately may not work despite an organization or insurer’s best efforts. For instance, just because patients receive healthy food doesn’t mean they will eat it or won’t consume unhealthy calories later.
Lane said organizations can’t ultimately change the choices people make but they can create conditions that make healthier choices easier, and that they must couple their programs with education.
“There is a limit to how much we can solve,” Lane acknowledged. “When we say ‘whole person care’ we do mean from the angles that we can control.”
