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Healthcare Isn’t the Place to Solve All Problems
Should scarce, expensive medical staff be deputized for social work?
In a recent Politico Pro article (subscription required, briefly summarized outside the paywall), public health experts are worried that the “equity tool could backfire.” I find the focus on equity a bit concerning not because people in dire social circumstances shouldn’t be helped, but rather whether we are utilizing resources efficiently. Must we deputize health workers — especially doctors, and hospital staff who are trained to heal — to try to tackle the many problems our social policies have been unable to solve despite spending trillions since the “War on Poverty?” Medical professionals are very expensive and enlisting them for social work is not exactly a great idea, especially given the current and predicted shortages. In the Politico story, the worry is that the tool that CMS intends to use in its REACH ACO program, the Area Deprivation Index (ADI), which measures the level of deprivation in a Census block group, would have the unintended consequence of excluding some deprived residents from urban areas. Back to the ADI tool in a minute.
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How much of a person’s health depends on social circumstances and how much of it depends on access to medical care? Studies vary but the generally accepted are that the medical system contributes to only about 11% to 20%. If that’s the case, government policy to remediate through the healthcare system will have limited effects. Yet since 2015, CMS is fully committed to remedying inequities in healthcare — those largely attributable to social circumstances, or as formally called, health related social needs (HRSN), which is nothing but individual manifestation of the social determinants of health (SDOH) — for its 170 million beneficiaries (more than half of Americans). For more than a decade, CMS has been focused on addressing inequities in healthcare for its beneficiaries, releasing multiple frameworks to guide their actions. Taking a cue from the administration, several states have adopted Section 1115 waivers to address unmet needs.
Evidence on the effectiveness of equity programs is limited. But the few I’ve seen don’t seem very encouraging. Doctors and medical professionals aren’t really trained social workers, so the best they can do for socially deprived patients is to refer them to existing social services. For example, Kulie and co-authors expended much effort to collect data and refer qualifying Medicaid beneficiaries to services they qualify for. Less than 1% found relevant services from referral agencies. We are, in effect, expending valuable resources — both hospitals and providers — to only refer patients to existing services. One of the biggest challenges facing Medicaid is the low provider participation rate, an average of 62-63% (exception Minnesota). Adding more data collection burdens for such unproven benefits seems imprudent and might lead to even more providers dropping out. In the latest of iteration of CMS’ framework for health equity, the top priority is to
. . . improve our collection and use of comprehensive, interoperable, standardized individual-level demographic and SDOH data, including race, ethnicity, language, gender identity, sex, sexual orientation, disability status, and SDOH. By increasing our understanding of the needs of those we serve, including social risk factors and changes in communities’ needs over time, CMS can leverage quality improvement and other tools to ensure all individuals have access to equitable care and coverage.
Data collection is obviously important, and in the absence of credible data, CMS uses various tools to offer incentives for providers to attend to patients with “unmet needs.” This is where the ADI previously mentioned comes in. As part of the REACH model, ACOs are being compensated for addressing the needs of deprived communities. However, in large urban areas, deprived communities are very close to affluent ones, even at the Census block group level. Thus, many participating ACOs with members in urban areas would be at a disadvantage.
If both community-level and individual-level data are hard to collect and use, what can CMS do? Honestly, I think the focus on equity is misplaced. The healthcare system isn’t the place to solve all of society’s problems. Looking at the data elements CMS is interested in collecting, one can reliably guess that it could even have the opposite effect. Is getting an additional patient from a disadvantaged group, who will come with extra record-keeping and other added responsibilities, worth the cost for medical professionals trained to heal?
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