Panelists Discuss Community-Based Approaches to Mitigate Costs, Improve SDOH Outcomes

At the Alliance for Better Health’s CONVERGE Virtual Conference, experts discussed the role social determinants of health (SDOH) play in community-based health initiatives and how the coronavirus disease 2019 (COVID-19) pandemic has spurred partnerships across the continuum of care to optimize health outcomes.

Defining health as social, behavioral, and physical well-being, panelists offered insights on crises the pandemic has wrought on communities and future steps to take for improvement. Specifically, the conference focused on initiatives spanning Albany, Rensselaer, Schenectady, Fulton, Montgomery, and Saratoga counties in New York state.

“The pandemic is exacerbating the food access and resource problems we already knew existed,” said Natasha Pernicka, the executive director of the Food Pantries for the Capital District. “Our food access referral line saw an increase of service of 1000% when the COVID-19 shutdown happened in the spring, and we’re continuing to see high increases in people seeking assistance.”

A lack of access to nutritious food on a consistent basis can affect chronic conditions like diabetes, heart disease, and hypertension; malnutrition in general is an underrecognized issue in the United States. Roughly half of hospitalized patients in the country are either malnourished or at risk of malnourishment, and only 8% of those patients receive a diagnosis of malnutrition while in the hospital, Pernicka explained.

To avoid future hospital administration costs and to enhance the healing process in high-risk patients, improved access to community-based nutrition resources is critical.

Elaborating on the problem of food instability, Peter Gannon, the president and CEO of United Way of the Greater Capital Region, noted than when children gain weight throughout the year, 50% of the weight gained is during the summer months, due largely to lack of access to nutritious food.

Once the pandemic is over, children will be returning to the school setting with physical health issues “that we may not be able to determine into their 20s, 30s, or even much later in their lives, as well as the impacts of mental health issues,” Gannon said.

Compounding the challenges, many of the nonprofit organizations working to improve conditions at the local level may not be able to endure the financial fallout of the pandemic. “We could lose 30% to 40% of 501c3s over the next couple of years,” Gannon said. “Yes, the safety net was in place this time, but…if something happens 2 years from now or 5 years from now, there’s going to be a disruption.”

However, the pandemic has also brought cross-sector collaboration like we have never seen before, Pernicka said, which can help alleviate roadblocks to resources and services. “We have community based-organizations, private businesses, health care, and government coming together to create programs that increase access, and we're hoping that this will continue.”

Importantly, awareness of these issues has been established, while institutions equipped to address the issues are already in place. “We know what works, we just need to direct resources in that direction,” Pernicka concluded, highlighting a major theme of the conference.

In addition to food insecurity, panelists also brought up the issue of housing instability. “When we think about what we need to do to create healthy equitable communities, I think we have to start by first acknowledging that all of us bring biases and emotions to the table when we talk about poverty,” said Kathy Sheehan, the mayor of Albany, New York.

To highlight the harmful impact of housing policies, Sheehan compared the system in place to that of Medicare. Currently, individuals who qualify for housing are unable to obtain it because there is not enough funding to provide all those eligible with housing.

“We don’t do that with Medicare, for example. When you turn 65, we don’t say, ‘Sorry we’re full, you have to wait for somebody who is in their 80s to pass away and then we’ll make a slot for you.’ We provide that health care,” Sheehan said. “If you qualify for Supplemental Nutrition Assistance Program (SNAP) benefits, you receive those benefits. But if you qualify for housing, which to me is one of the most fundamental underlying needs if you want to start to focus on health and healthy community, we make people wait in line sometimes for decades.”

Ultimately, these inefficient systems like those governing housing policies drive up health care costs in the long run. In 2020, Sheehan emphasized governments and health systems have access to the technology and data that can help individuals at the micro, block-by-block level. Improving systems, utilizing data, and including those who are most affected by the inequities in discussions on solutions are integral steps to a collaborative approach in improving outcomes.

One way of implementing these steps is through the Collaborative Approach to Public Good Investments or CAPGI, presented by Len Nichols, MA, PhD, the Director of the Center for Health Policy Research and Ethics and professor of Health Policy at George Mason University.

CAPGI, a financing process, was designed as a tool for communities to achieve their common will via multistakeholder coalition investments in SDOH like housing, food, and transportation.

“Those services directed to specific individuals in a timely fashion can lower costs and improve the mission congruent values of organizations of various types, including hospitals, insurers and city hall,” Nichols said. Investments in these services for individuals with specific social needs generate benefits for a wide array of individuals downstream, leading to “an economics of public good.”

In particular, CAPGI solves the problem that exists when people could benefit from others’ investments and therefore tend to underinvest, or the so-called “free rider” problem.

“There is no place in the country that has enough investment upstream to the health care system,” Nichols said. In order for CAPGI to work, there must be a functional operational events local stakeholder coalition, and a trusted broker, or someone trusted by the individual stakeholders enough that they are willing to share what they will pay to solve the problem. “The trusted broker then adds up those confidential bids and assesses if we have enough economic value here to justify the project.”

And, because of hospital readmission penalties, Medicaid expansion (thus, more homeless individuals on the rolls of insurance plans), and the opioid crisis, these 2 conditions are already present in many communities throughout the country. Community level coalitions spurred by these events look upstream together for solutions, Nichols explained.

“Our framework is: You reveal the willingness to pay to the trusted broker only, the trusted broker adds up the values, they assign the bids, and then can assign prices so that the surplus, the excess of value over cost, is fairly shared. And it is that surplus being shared and the return on investment that’s baked into the pricing structure that creates a self-interest that will drive the model to sustainability over time.”

Fairness constraints—no one ever paying more than they bid, everyone sharing a surplus, and each stakeholder sharing in the surplus in equal proportion—ensure that the system is beneficial and sustainable.

Thus far, 10 communities are poised to enact the model on a local level, and although communities may list the same SDOH as the most important upstream problems, the level of urgency among the communities differs. “I think that sometimes a sense of urgency can crystallize and catalyze a movement, and that’s kind of what we’re trying to do, to enable that to happen,” Nichols concluded.