Written by Joyce Frieden, News Editor, MedPage Today

WASHINGTON — Accountable care organizations (ACOs) and other players in the healthcare system need to look after patients’ non-medical needs if they want their health outcomes to improve, several speakers said Thursday at a briefing on the “Culture of Health” sponsored by Health Affairs.

“The culture of health is about meeting people’s needs to attain health and well-being,” Alan Weil, editor-in-chief of Health Affairs, explained at the start of the briefing. “And if there’s one thing we heard this week [in the election], it’s that there are a lot of people in the country who don’t feel like their needs are currently being met to provide them with the well-being that they think is warranted given the work that they do and the efforts that they make, and pulling those things together in the context of culture is important for us as we think about health and healthcare going forward.”

Taressa Fraze, PhD, research scientist at the Dartmouth Institute in Lebanon, N.H., presented her group’s study on what some ACOs are doing to help meet their members’ non-medical needs. Fraze’s study, like the others presented Thursday, appears in the November issue of Health Affairs. Fraze’s group interviewed leaders at 32 ACOs and found that 16 of them were working to address patients’ non-medical needs. Housing instability, food security, and transportation were among the most common needs addressed, with various methods being used for each. For example, an ACO might discover that a patient wasn’t taking her diabetes medication because it needed to be refrigerated and she didn’t own a refrigerator; the plan would then find the funds to buy her one.

In the transportation area, “ACOs in areas with high-quality public transit typically relied on existing infrastructure,” Fraze and colleagues noted in their article. “For example, some ACOs gave transportation passes to patients before their appointments. One ACO provided monthly bus passes — which could be used for any transportation need — to all patients who had four or more medical visits per month.”

ACOs in suburban or rural areas had more challenges with transportation. One rural ACO provided transportation services through an external for-profit transportation company. The ACO paid the company a per-member-per-month rate. Another ACO in an urban area with poor public transportation was considering developing a mobile device application that would allow patients to request transportation from local drivers, who would be paid by the ACO.

To address food insecurity, one ACO worked with a local food bank to provide food for patients, but noticed that the patients were making unhealthy selections, so the ACO arranged for the food bank to provide fresh, healthy meals each day.

“The first thing we noticed is that ACOs tended to segment their patient population,” Fraze said at the briefing. “That makes perfect sense if, for instance, the ACO has several quality measures related to how it cares for diabetic patients. So it may develop a [housing] program just for them, but it’s not just diabetics who have housing instability, so they are still missing out on a large part of their patient panel that has similar needs.”

Sandra Newman, PhD, a professor of policy studies at Johns Hopkins University, in Baltimore, and colleagues looked a little more intensively at the housing issue. “The greatest, most prevalent housing problem faced by low-income families with children in the U.S. is housing affordability,” she pointed out. “It far outruns physical problems in the home.”

She noted that while it’s widely believed that unaffordable housing — housing that costs a family more than 30% of its income — strains the family budget and forces cutbacks in other expenditures that benefit themselves and their children, some people also believe that spending too little on housing also is bad because it is not likely to result in a high-quality home or a high-quality neighborhood with lots of amenities.

If both of those theories are true, researchers would expect to find an “inverted U”-shaped relationship between the cost of housing and children’s scores on cognitive tests — one measure of children’s health.

And, in fact, that is exactly what Newman and her colleagues found in their study of 688 children whose family incomes were no more than 200% of the federal poverty level — a group of families in which excessive housing cost burdens are common. “This is … the first hard empirical evidence” showing that families shouldn’t spend more — or much less — than 30% of their income on housing, she noted.

In another study, Elizabeth Rigby, PhD, assistant professor of public policy and public administration at George Washington University here, and colleagues found that three economic policies — tax credits for the poor, a higher statewide minimum wage, and not having a right-to-work law — were associated with better health outcomes. “These policies seemed to be associated with a range of measures of population health — for example, improving the earned income tax credit shifts mothers’ behavior in a way that impacts low birthweights,” Rigby said.

“We know that income and wealth are key determinants of health, so policies that redistribute income and wealth would seem to be policies we should care about.”

Community health infrastructure is another social good that seems to benefit communities, according to Glen Mays, PhD, MPH, professor of health services and systems research at the University of Kentucky, in Lexington, and colleagues. They studied data from the National Longitudinal Survey of Public Health Systems, which tracks 360 communities across the U.S. with at least 100,000 residents. The survey follows the communities over a 16-year period and measures the availability of 20 recommended community health activities, including developing a community-wide health improvement plan and linking people to health and social services.

“Communities that have comprehensive health systems see a large reduction in their overall mortality rate,” Mays said. “Large health gains accrue to a comprehensive system.”

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