How Investments in Primary Care Can Tackle Patient Social Needs

Millions of Americans have unmet social needs that can affect their physical and mental health. These social needs such as housing, food, transportation, and social support stem from social determinants of health, which are the conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes, and are estimated to account for 80% to 90% of the modifiable contributors to a population’s health. Underlying issues such as systemic racism and chronic poverty manifest in patient social needs that affect patient health outcomes. Research also shows that unmet social needs impact cost, quality, and access to care.

In its report, “Implementing High Quality Primary Care,” the National Academies of Science, Engineering, and Medicine primary care committee supports a payment model for primary care that assists primary care providers in addressing patient social needs. The work of gathering data on and addressing patient social needs often falls to primary care. While primary care is often the appropriate place to address social needs, providers need new types of payment and technical assistance.

Work is underway to support providers in incorporating data on social risk factors into their electronic medical records, and to enable providers to help their patients get their social needs met. On May 12, Blue Shield of California and Milbank Memorial Fund hosted Scaling Action on Social Determinants of Health and Social Needs in Primary Care, the third event in our primary care payment innovation series. Participants discussed how partnerships, payment innovation, and digital health in primary care can help address the social drivers of population health outcomes.

This conversation built off the first two events in the series: Scaling Innovation: Supporting Access and Equity in Primary Care Through New Payment Models and Innovation and Integration: Addressing the U.S. Mental Health Crisis through Primary Care Partnerships.

The third event, moderated by Joe Castiglione, Principal Program Manager, Industry Initiatives, Blue Shield of California, and co-hosted by Chris Koller, President, Milbank Memorial Fund, included panelists James Cruz, Chief Medical Officer, Blue Shield of California Promise Health Plan; Laura Gottlieb, Director, Social Interventions Research & Evaluation Network, and Professor, University of California San Francisco, Department of Family and Community Medicine; Rishi Manchanda, Chief Executive Officer, HealthBegins; and Kameron Matthews, Chief Health Officer, Cityblock Health.

Five Key Takeaways from “Scaling Action on Social Determinants of Health and Social Needs in Primary Care”

1. Primary care must address patient social needs

“We know that the upstream drivers of health… lead to the health care outcomes and inequities reported in our data today… We have to take a look at the value of holistic care, not just whole person, but a whole community approach to addressing the social drivers of health.” – James Cruz, Blue Shield of California Promise Health Plan

Evidence shows that primary care is vital to improving health equity. Primary care is a point of trusted contact where providers can engage people around social needs. These needs drive more health outcomes than the quality of care, and they are shaped by community-level social risk factors, like housing instability. Understanding the drivers and patterns of inequity allows us to reorganize care and address the needs of patients and communities. Community-based organizations are critical in this work, serving as the cornerstone to address health care inequities experienced by communities of color and low-income Californians and residents of other states. Payers and health care providers need to ensure we’re able to impactfully support the work of community-based organizations and provide them with the resources they need to help address patients’ social needs.

2. Payment model transformation is necessary to address patient social needs

“It is incumbent on us to learn from the different payment models and make sure that we’re looking not only at what makes us do more, and do it differently, but really what is achieving equity.” – Laura Gottlieb, Director, Social Interventions Research & Evaluation Network, and Professor, Department of Family and Community Medicine, University of California San Francisco

Embedding social care and prioritizing equity in primary care is difficult under a fee-for-service structure. Payers should develop payment models based on their population’s social needs. For example, Cityblock Health is paid via per member per month contracts to address their patients’ physical and mental health needs and provide and/or refer to additional social care resources where people live and work. As a result, they assume financial risk for high-cost patients, taking on the most complex populations. Through this model, hospitalizations and emergency department visits have decreased. The California Advancing and Innovating Medi-Cal (CalAIM) initiative also serves as an example for how patients’ social needs can be integrated into primary care. Medi-Cal has issued specific billing codes that allow for the reimbursement of services addressing a Medi-Cal member’s social needs.

3. Payment model transformation alone is insufficient to address patient social needs

“Payment reform is necessary but insufficient. Infrastructure, capacity, practice level transformation, payment transformation, and policy transformation all have to be operating at the same time.” – Rishi Manchanda, Chief Executive Officer, HealthBegins

No single lever exists to solve social needs. As Dr. Gottlieb mentioned at the event, recent studies indicate that the shift to value-based purchasing is not always associated with increased adoption of social risk screenings. Effective interventions often require technical assistance and screening standardization as well as funding, resources, and additional tools that value-based payment cannot alone solve. Communities should play a leading role in determining what is needed to address their residents’ social needs.

4. Organizations should employ a place-based approach to this work

“…[P]lans and providers and patients themselves should get themselves used to declaring a usual source of care, and I think that gets us closer to… a place-based approach to care…” – Chris Koller, Milbank Memorial Fund

A place-based approach to this work involves payers and their provider partners understanding the communities in which their patients and members receive care. Motivating patients or members to seek care from a trusted, usual source of care has historically been viewed in the context of health maintenance organizations and utilization management, but to tackle social needs, we must reframe and center a usual source of care in the context of building relationships and advanced primary care models. Additionally, mapping social needs can provide insights into the drivers of inequity. Area-based social risk data can be used to structure prospective payments. This approach can be leveraged in many ways, including, for example, by evaluating to what extent inequities in maternal mortality, diabetic outcomes, and access to post-hospitalization vary by census block.

5. To address social needs, organizations need to build partnerships to meet patients where they are

“The goal is to have relationships and partnerships in the community, with community-based organizations, other providers, specialty care, and inpatient care, so that we are actually bringing everyone to the table in a joint care team format.” — Kameron Matthews, Chief Health Officer, Cityblock Health.

The relationship between a patient and their primary care team is critical in that it enables the development of trust between patients and other parts of the health care system. Cityblock Health providers do not wait for office visits to offer care. They deploy outreach teams in the community and via telehealth to meet with patients and ensure that their health and social needs are met through screenings and interventions. Similarly, Promise Health Plan mobilizes community health navigators in a variety of settings, including federally qualified health centers. These care navigators assist the members in identifying resources to address their social needs and in navigating the health care system to ensure they’re able to access the clinical services they need.

Reflection on the Payment Innovation Series

This event and the others in the series have highlighted why primary care payment innovation should be a top priority for all stakeholders. We heard a variety of perspectives from across the health care ecosystem—payers, health systems, providers, digital health companies, academia, and consumer advocates—all of whom reinforced that primary care is an essential foundation for a high-quality health care system. Achieving desired outcomes on health equity, behavioral health, wellness, and social needs requires concerted action and investment in primary care. It is more urgent than ever that stakeholders work together to create a sustainable future in which primary care, and by extension, more people in the United States, can thrive.