The previous three posts in this series raised several important points regarding the overall alignment of sectors to support and address payment reform for community-wide population health. Karen Hacker discussed how health care delivery systems can collaborate with multiple sectors to support community health improvement. Rick Gundling highlighted the value of data in engaging the interests of health care delivery systems and community-based partners to pursue mutually-beneficial interventions. Tricia McGinnis noted limitations in payment reform and explored ideas for the creation of the right incentives for population health investments.
While multi-sector alignment and collaboration is powerful, it is not easy to achieve. It is even harder to build the kind of alignment needed for payment models to be able to support community-wide population health. It takes significant effort to create conditions for relationships to develop across sectors before common goal-setting and plans for aligned spending can occur. Through the evolution of the Robert Wood Johnson Foundation-sponsored Payment Reform for Population Health (P4PH) effort, we have learned that a trusted convener, multi-sector care delivery integration, and the supporting data and metrics all play a critical role in aligning alternative payment models with other sources of financing to support broad investment in community-wide population health.
A trusted convening organization, representing diverse community partners, can be a catalyst, helping to identify and align interests and foster investment in community-wide health interventions. AcademyHealth convened five such trusted conveners, along with some of their partners, at a workshop in January 2017 to share and discuss plans to connect medical and non-medical services more closely through alternative payment models. One lesson learned was that the most effective conveners have the trust of their partners and provide an equal voice to all community representatives.
Multi-Sector Care Delivery Integration
High-impact collaboration for on-the-ground coordination and integration can align health care, social services, and public health efforts in order to develop and pay for community health interventions. For example, the Vermont Blueprint for Health integrates community health and health care through its community health teams, advanced primary care practice transformation, and a connected information technology platform. It took multi-sector collaboration over an extended period of time to develop and implement those supportive structures. We have found that delivery system transformation efforts provide a foundation upon which payment reform models can be built.
Data and Population Metrics
A recent AcademyHealth report found that data sharing, integration, and use is a key element in community-based population health efforts. Data alignment across sectors can support numerous facets related to paying for population health. Integrated data can inform a shared understanding of population health challenges in the community and the opportunities to address those challenges given that community’s landscape. Additionally, data integration can provide guidance and support for the coordinated delivery of health and non-health services interventions. Finally, integrated data provide a foundation for population health metrics needed to evaluate the impact of the multi-sector interventions. Payment systems used by health plans and providers rely on an understanding of all three of these aspects: understanding which needs should be paid for; paying for the actual community-focused intervention; and monitoring outcomes to assure that there is value produced by those investments. A recent blog post by the RWJF-supported DASH (Data Across Sectors for Health) gives an overview of a HealthDoers Peer-to-Peer event that highlighted promising approaches for combining social determinants of health data with traditional health care data.
Beyond the Foundational Elements
While multi-sector alignment and integrated data analytics are valuable elements for effective health care and non-health care sector collaborations, these efforts must be supported by sustainable financing. Incorporating dollars that flow through the health care payment system and incentivize investments in population health should be considered as part of the financing solution.
The bright spot examples described in this series represent small steps that are difficult to sustain over the long-term. Small-scale funding of collaborative efforts can be a first step to allow for them to be proven effective before scaling to reach broader populations. These pockets of innovative collaboration are more often financed through operational (i.e., grants or administrative) and community benefit dollars, which may not provide the long-term stability that an on-going payment stream could allow. In order to support the integration of social determinants of health with the health care system, alternative payment models and, more broadly, payment reform, can be effective levers.
In a fragmented health care system with so many competing interests and misaligned incentives, it can be very difficult to reform the way in which care is delivered and health is improved, let alone how it is paid for. Further complicating this is the demand by payers or investors to see proof of the return on investment (ROI) before agreeing to support such investments. However, as one of our guiding committee members, ReThink Health’s Stacy Becker, notes in a recent blog post, using ROI in population health can be tricky. An investment in a non-clinical social support can have knowable up-front costs. Yet, savings estimates are either more long-term (and thus make business case decisions more difficult) or the savings may accrue to other sectors or other organizations than the one paying for the upfront investment.
As the P4PH Project moves forward, we will focus efforts on understanding the business case (i.e., the need for evidence and ROI) and the “nuts and bolts” mechanics of those payment models that can incentivize health care sector investment in population health.
Stay tuned here, at the AcademyHealth blog, for updates on our initiative’s progress and emerging findings. If you are doing related work, please contact Enrique Martinez-Vidal; we’d like to include you in our efforts!