Imagine being discharged from the emergency room after a severe asthma flare-up, only to return to a home located near factories or congested roadways that heavily pollute the air. Or having your health care provider tell you to eat more whole foods to lower your blood pressure but not having a grocery store in your neighborhood. For millions of Americans, this is the reality: a health care system that focuses on addressing clinical conditions without addressing the social conditions that affect a person's health.
Since social and behavioral factors have been shown to account for a larger proportion of a person's overall health status than clinical services, some health care experts believe it's time to invest in approaches that effectively combine clinical care with targeted social care services to optimize prevention, health promotion, and treatment outcomes. However, others worry that expanding health care to include social services would result in unnecessary and inflated health care costs.
Health policy experts gathered recently at the Johns Hopkins University Bloomberg Center in Washington, D.C., to discuss the pros and cons of integrated clinical and social care within the Medicaid program, the largest single source of health care coverage in the U.S. Watch the full conversation
The event was hosted by the Institute for Policy Solutions at the Johns Hopkins School of Nursing, which aims to improve our health system by eliminating health inequities, leveraging the leadership and innovation of nurses.
"This is a crucial conversation about solutions with real potential to repair our nation's broken health system," said Vincent Guilamo-Ramos, the institute's executive director and an expert in social determinants of health. "Medicaid is central to the health care of about 80 million people in the United States, and there's mounting evidence to suggest that if its programs redefined the traditional boundaries of health care to more deliberately and precisely integrate aspects of social care with clinical care, health outcomes would likely improve, and costs would decrease."
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Addressing social needs in Medicaid: How it works
There is growing recognition that effectively improving health outcomes requires addressing social drivers of health, such as housing, food security, and transportation—especially among high-need populations like those served by Medicaid. States and territories that integrate social care into their health care approach often use a tool called Medicaid Section 1115 waivers, which allow them to design and test innovative approaches for delivering services.
This approach is not new—Medicaid's 1115 waivers have been paving the way for social and clinical integration since the 1970s, including patient-centered medical homes, the standard recovery model of mental health, and community integration advocacy for people with disabilities, according to Kate McEvoy, executive director of the National Association of Medicaid Directors.
Integrating social determinants of health into clinical care
In April 2022, North Carolina used a 1115 waiver to launch a first-in-the-nation pilot program that offered food, housing, and transportation support, among other services, to more than 13,000 people in three mostly rural areas.
Within two years, an independent evaluation of the program found a statistically significant reduction in emergency department visits and hospitalizations among program participants. This netted savings of $85 per person per month, according to Kody Kinsley, former secretary of the North Carolina Department of Health and Human Services and the senior policy advisor at JHU's Institute for Policy Slutions. "$85 per person per month, in insurance capitation, is real dollars, especially as states are looking for ways to try to curb costs per managed care," Kinsley said. "So it's exciting."
Supporters of this approach to integrated care believe it can improve health outcomes and lower costs. And though addressing harmful social determinants of health using Medicaid dollars may not be the most ideal cost-efficient approach, Kinsley said, right now, it's the only available mechanism to address both the clinical and unmet social care needs of Medicaid recipients without relying on broader social welfare and public health systems reforms upstream.
"That's what I think keeps pulling us in the direction of Medicaid as the tool that seems to be on the table right now," he said.
Avoiding the pitfalls of the fee-for-service model
While experts may agree that many social factors affect a patient's health, some caution against integrating social and clinical care—particularly if using the predominant fee-for-service reimbursement model.
"There's almost nothing that doesn't influence human health," said Chris Pope, senior fellow at the Manhattan Institute. This makes it difficult to pinpoint the specific and most effective social care services to be included in entitlement programs, Pope said. This lack of clarity forces policymakers to consider the boundaries of health policy and financing, especially as health care spending in the U.S. continues to climb.
Additionally, while issues of health care, housing, and nutrition may overlap, each of them has its own political and legal challenges, Pope said. Trying to solve them primarily through the lens of health care could produce blind spots that lead to ineffective solutions at the end of the day, he added.
In the current fee-for-service model of health care in the U.S., in which payers reimburse for the provision of specific clinical care services, it would be challenging to define and pay for social care services that are upstream, Pope added.
Proponents of integrated social and clinical care agree that the current fee-for-service model is a major limiting factor. "When it comes to optimizing health outcomes, it's all about the approach," Guilamo-Ramos said.
"There is an effective way and an ineffective way. The ineffective way is viewing social care as simply an add-on to our existing fee-for-service model, which incentivizes services or procedures over health outcomes," he said. "Doing this would likely just lead to a billing bonanza. Implemented effectively, as part of a structurally integrated health care and social welfare system, the evidence shows that integrated clinical and social care can be a leap forward for better health outcomes and the elimination of unnecessary costs."
Guilamo-Ramos emphasized the value of a team-based model of care driven by nurses, who have the skills and trusted relationships with patients, families, and communities that uniquely position them to optimize the value of integrated clinical and social care.
"As trusted leaders and members of the largest segment of the health care workforce, nurses know how to optimize clinical and social care—and have the expertise and proximity to patients to understand the real-world benefits in human terms," he said.
Guilamo-Ramos also noted three areas for integrated care innovation:
Reimagined system: Our health care system must evolve to focus on holistic prevention and health promotion, prioritization of primary care, and locationally flexible community-based care delivered in settings like community health centers, mobile health clinics, and homes. Integrated care should also emphasize multidisciplinary care teams made up of professionals like nurses, social workers, community health workers, and behavioral health specialists, and these teams should be culturally responsive and representative of the patients they care for. In this evolved health care system, interprofessional workforces can coordinate interventions that alleviate the health-related social needs that are proximally linked to health outcomes.
Bridged infrastructure: Currently, the burden of navigating fragmented services falls unfairly on patients and communities. A more effective approach is to build a system that bridges effective care coordination infrastructure and strategic partnerships among hospitals and clinics, departments of health, social welfare organizations, and the patient communities being served. This would ensure continuity of services across a holistic set of health-related social needs, and optimal involvement of the sectors best positioned to impact positive outcomes.
Strengthened safety net: A strengthened safety net is essential to meaningful health care reform. While clinical care is critical, many of the factors that influence health—such as housing, food security, education, and transportation—lie outside the traditional health care system. These social determinants of health must be addressed through a robust social welfare infrastructure. By investing in this broader safety net, we can improve individual and community health outcomes, reduce costly health inequities, and build a healthier, more equitable nation.
"Just imagine the possibilities of a newly improved health system that effectively meets the clinical and social needs of everyone," Guilamo-Ramos said. "It would be a game changer."
