There are several efforts underway at state and federal levels to secure adequate and predictable government funding for public health infrastructure that also supports primary, upstream prevention. Concurrently, the population health function of health care systems is taking on more upstream prevention roles addressing the social determinants of health (SDOH) that might otherwise be part of an adequately funded public health system – but typically restricted to their own patient and client populations. There seems to be an emerging tension over whether the growth of health care-based SDOH interventions is a good idea, and even if it isn’t, whether adequate government funding for public health can be attained even in “favorable” political climates.
We should not allow this distinction to become a false choice. Both approaches are necessary. Health care certainly has a critical role in building healthy communities, but relying entirely on medical treatment systems to fund and implement community-based upstream interventions has limited scaling potential and a host of equity concerns. This is especially the case when their efforts do not include aggressive, vocal lobbying for the large-scale systemic changes this country needs to move the needle, such as reforming the nation’s food systems.
With the (slow) transition to value-based care, providers have some incentive to prevent many costly outcomes for their patients by addressing individual social needs and investing locally in upstream health interventions. But medical treatment is a business. They have built their business models on an expected level of demand. Success in addressing upstream determinants of health through community-based prevention means significantly reducing that level. Does it make sense to ask a business, even a “non-profit” one, to be responsible for activities intended to significantly reduce demand for its services?
That inherent conflict of interest could exacerbate inequities and create harmful inefficiencies. Would a hospital system facing reductions in treatment revenue because their community is healthier feel compelled build a revenue stream – or a profit center – from addressing social needs and upstream determinants? If that happens, would those services be available to everyone in their community, or only those with health plans that cover the service?
Take healthy food prescription programs as an example. Once payers agree to cover it, a hospital can start billing payers more than the cost of the program in order to cover administration or offset falling revenue from somewhere else. With success, the program expands and food prescriptions become billable for a wider range of diagnoses. The hospital then needs more administrative capacity, charges payers more for that, and their program demands more fresh fruits and vegetables – potentially affecting local supply and prices. So now you have fresh produce potentially becoming more expensive and less available for other consumers. Some patients may benefit greatly and the hospital itself may realize significant ROI by preventing the costly outcomes, but this will have been achieved in the most inefficient way possible while potentially reducing access for those outside their patient populations. Proponents of food prescription programs should compare their cost-per-unit of healthy food delivered to government-funded SNAP benefits, especially when those benefits are combined with public health-driven efforts to improve healthy food access for everyone. Another efficiency concern is that food prescriptions are secondary prevention applied after an acute outcome or diagnosis. SNAP and community-based efforts to increase healthy food access can prevent that acute outcome or diagnosis.
I’m not arguing that something like this is inevitable, but we should be vigilant about scrutinizing health care’s SDOH interventions in communities where what’s really needed are wider systemic changes supported by governmental public health. And in the words of Health Affairs Editor in Chief Alan Weil at the 2019 Colorado Health Symposium, “everything health care touches becomes more expensive” (https://www.youtube.com/watch?v=5Hv4mvp3kjI, 10:40)
In the abstract, payers would seem to be the more logical entities to drive (and profit from) upstream investments. If their premium-paying client base generates fewer claims, payers’ margins increase. But payers seem hesitant to invest in SDOH efforts in their own communities, partially because their client populations churn. A neighborhood food desert intervention could help prevent someone from developing type 2 diabetes five years down the road, but by that time they may be on a competitor’s plan. If coverage rates start to fall with the demise of the individual mandate, the justification for direct, local investment becomes even less clear. Governmental investments in public health prevention and industry-wide lobbying for large-scale SDOH-related systems change would seem to be the best bet for payers. If successful, those investments should reduce claims across the board, without payers making the initial upfront investment.
In their chapter of the just released Practical Playbook II, John Auerbach and Karen DeSalvo point out that efforts to secure infrastructural public health funding aren’t likely to succeed anytime soon, and that we should further explore how the private sector, health care, and philanthropies can invest in public health prevention. I would argue that the best way for those entities to invest in public health prevention and intervene on the social determinants of health is to use their considerable political power to lobby for that infrastructural public health funding and the other systems changes we all desperately need.