February 2020 Newsletter

Early Signs of Spring!


Welcome to the February 2020 newsletter. You can find past newsletters with additional background materials, and different stories and initiatives in my LinkedIn articles and on my website. Join me in improving and coordinating initiatives that advance health, health equity and community and healthcare redesign.

This month you can read about: the politics of health inequality; varying roles of plans and hospitals in communities, services and investments; New Mexico and Rhode Island thinking more holistically; Colorado and California trying new levers to address social needs; Healthy Alliance IPA convener model for CBO collaboration; several community investments – Molina, OneCity, Inspira Health and the AMA; research and metrics continue to grow and be debated; and some past and future SDOH events.

Shannah’s Insights and Reflections

Politics puts an added spin on the already difficult task of addressing needed improvements in living conditions. At all intervention levels, we are seeing more organizations and analysts grappling with the right models and roles, particularly what are the right roles and responsibilities for health plans, health systems and health professionals.

The questions about the right models and the alternative approaches in the states offer more promise as they break away from the comfort zones of most health delivery systems.  The NM model seems to leave out the older adult population on the thriving side of the equation. RI’s size always raises questions on whether larger states could ever take a similar approach, but perhaps at a sub-state level. Some of the health system models also break the mold, like Healthy Alliance’s convener model and Inspira’s school-based food pantries with counseling.

Research continues to lag behind many of these newer models and often raises more questions than it answers. However, the latest IMPaCT study continues to demonstrate ROI for a program aimed at addressing social needs distinct from traditional healthcare delivery. It should be a wake-up call to all Medicaid programs and Medicare Advantage plans. The value-based investment in well-trained and placed community health workers should be on the radar of all healthcare plans and at-risk delivery systems.

Finally, we are in the midst of opposing trends. Last month’s SDOH legislation versus Medicaid block grants and the public charge rule. This month the emphasis on the need for more use and better understanding of Z-codes as ONC announces its efforts to reduce EHR reporting and health IT burdens.

The sustained momentum and focus on living conditions is alive and well!

Share your personal or community stories by connecting via LinkedIn or email kossoncare@starpower.net I welcome suggestions in all topic areas, particularly community driven models.

A personal or individual story

I’m trying to wind up my monthly newsletter and it is Super Tuesday. An article on Julia Lynch’s book, “Regimes of Inequality: The Political Economy of Health and Wealth,” caught my eye with its clear statement that the way we are going about addressing health inequality is destined to fail, much of it is driven by an inability or unwillingness to address fundamental social inequalities. She suggests we should go back to older previously accepted mechanisms of taxing and redistributing wealth. See what you think about her core statements.

Community Initiatives

Should payers be leaders or followers in addressing improved living conditions? Rebecca Pifer’s article shows the range of perspectives.

Sara Heath’s article on New Jersey Hospitals being a community anchor for improved living highlights the role of required community benefit contributions and the delivery of uncompensated care.

Cascadia Behavioral Health Land Trust and perhaps “whole life” model. They are anticipating breaking ground for a 71-unit affordable apartments that will reserve 18 units for people with mental health issues.

Background on community investments and initiatives outside of healthcare

New Mexico is working to be the first family friendly state. Five services for surviving – “stable housing, secure nutritional food supports, behavioral health care, medical/dental care and transportation to vital services.”  Five services for thriving – “parent supports, early childhood learning programs, fully resourced community schools with behavioral health care staff, youth mentors and job training.”

In Rhode Island they have tied their Opportunity Zones designed to foster developers working in disadvantage communities to the Health Equity Zones to ensure they are engaged and to minimize gentrification.  RI gives the communities a voice in determining their greatest needs and how to address them. It then uses “braided” funding, multiple program and funding streams, to enable plans to address the priorities in each health equity zone.

Government Initiatives Federal and State (national initiatives)

Proposed Colorado legislation that would fund addressing social needs through taxes?

“By simply increasing alcohol and tobacco consumption taxes to national medians and adding a one cent per ounce tax on beverages with added sugar, Colorado could pilot an innovative method to directly respond to our declining life expectancy and key drivers of increased cost.”

California Governor proposes that Doctors should be able to prescribe housing.

Health System and Community-based Services

Healthy Alliance IPA (Independent practice Association) is using a convener model to facilitate health system and CBO collaboration that does not rely on direct investment from plans to Community-based organizations. Instead they provide an infrastructure to foster referrals and enable direct billing by CBOs.

Molina Health is opening an SDoH Innovation Center in Columbus OH

OneCity and New York City Health and hospitals invest $4.3M to address housing and food insecurity.

Inspira Health announces monthly healthy food pantries and counseling in partnership with schools.

“The AMA is making a $2 million investment in a Chicago-based collaborative, West Side United, that is working to promote health and well-being for a portion of the city where life expectancy is far below the national average and 14 years lower than in the Windy City’s famous downtown “Loop” just five miles away.”

Research, Metrics & Technology

An article on 3 quality of life measures: Healthy days; PROM – patient reported outcome measures, uninterpreted, e.g., how well do you carry out your social activities and roles?; and, quality adjusted life years (QALYs), highlights the complexity on examining characteristics that  are unique to an individual’s circumstance. All measures are rooted in hearing from patients about outcomes. These types of measures are perhaps a needed to understand the impacts of programs seeking to address social needs.

Yin and yang on data needed for improved healthcare. The ICD10 Monitor highlights the limited use of Z codes relating to socioeconomic and psychosocial circumstances emphasizing that likely health professionals, social workers and even coders don’t know the breadth of codes or when to use them. This is likely given that there are 10 categories all with subcategories and these are all a subset of the >69,000 ICD10 codes. The yang comes in with the new ONC report on reducing the burden of HealthIT and EHR regulations.

A recent study featured in Health Affairs shows definite ROI on use of community health worker intervention that addresses unmet social needs for disadvantaged people. The study used a random control trial of Individualized Management for Patient-Centered Targets (IMPaCT). ROI results showed saving of $2.47 for every dollar spent. IMPaCT is a highly structured program and the participants were Medicaid beneficiaries or uninsured, with at least two chronic illnesses and residents from high poverty neighborhoods.

Another study featured in Health Affairs indicates health systems have spent $2.5 Billion on SDoH in years 2017-2019 mostly on housing projects. An important context for this amount is total US health expenditures for approximately the same amount of time was greater than $11 Trillion making it an ~.02% investment. In fairness these investments didn’t really start taking off until 2019. In addition, flagging these numbers in the early stages is misleading regardless of where you stand on the need for social services investments.

Please share the newsletter and connect via LinkedIn or email kossoncare@starpower.net with your reactions and input.


National Association of Chronic Disease Directors created a 10 series Podcast on Social Determinants of Health to share practical examples of ways to address social causes of chronic illness.

Manatt’s February 27 Webinar Social Determinant of Health Trends was a good overview for anyone new to the game and to cover the landscape in an hour. Each trend could of course be its own webinar. Here are the 10 trends they discussed:

  • 1. Progress from Theory to Implementation
  • 2. Debate Remains on Drawing the Line and Defining Healthcare’s Role
  • 3. Attention Grows on Measuring the Value
  • 4. SDOH Focus Areas Expand
  • 5. Children Begin Moving into the Conversation
  • 6. Upstream Investment Emerges
  • 7. Community‐Based Organizations Shift to Center Stage
  • 8. Digital Solutions Abound to Support Data Exchange and Analysis
  • 9. States Strategically Push in Medicaid Managed Care
  • 10. Medicare Gets into the Game

RISE National Summit on Social Determinants, March 15-17, 2020 Nashville there is a virtual attendance option.

Background and Definition

I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible.  This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020