Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes

Abstract

r Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources.Context: Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models.Methods: Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources.Findings: Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible upfront funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions.Conclusions: Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes

“…40 Future research evaluating the integration of SDoH strategies should incorporate longer time horizons to fully understand the health benefits of these approaches. 41 This study has several limitations. The close connection of the clinics within the same health system was a limiting factor in that some control sites began adopting elements of the DCII during the study period, thus reducing our ability to capture the full impact of the DCII.…”

Development of PRAPARE Social Determinants of Health Clusters and Correlation with Diabetes and Hypertension Outcomes

“…Our simplified SDoH clusters could also be used to inform risk adjustment for more appropriate payment for organizations serving higher-risk patient populations. 33,34 Our study builds on prior literature linking SDOH to adverse chronic disease outcomes. A study using the National Health and Nutrition Examination Survey found that race (black vs white) and insurance status (uninsured vs insured) were strongly associated with uncontrolled hypertension among US adults with hypertension.…”

What Should Antiracist Payment Reform Look Like?

“…Many insurance plans provide limited or no coverage for interventions to address patients' social needs and SDOH. 32 Interventions for marginalized populations are frequently held to the higher bar of cost savings rather than value. For example, the Affordable Care Act of 2010 required budget neutrality or cost savings for models of the Center for Medicare and Medicaid Innovation (CMMI) to be continued even if there were big payoffs in health with slightly more money included.…”