It is the story of summer 2017 and a nation’s differences are laid bare as Congress struggles to formulate an acceptable law to replace the Affordable Care Act. Are the proposed replacements “mean,” or do they not go far enough? How do leaders reconcile the practical drive to slash the nation’s public health care spending with the repugnant (and politically unattractive) prospect of leaving at least 22 million fewer Americans without health insurance coverage?
How do legislators come to terms with proposed Medicaid cuts that would jeopardize health care for more than 70 million people—among them children, the elderly, people with disabilities and pregnant women—by 2026?
There is no doubt that health care expenditures in the United States need to be curbed; compared with other industrialized nations, we spend the most per capita but deliver inferior care. Medicaid as we know it has been prone to waste and fraud. However, simply cutting the federal health care budget will only worsen the situation for those at the lower rungs of society. These are the men, women and children our government is dutybound to provide for, and to do it well.
Simply cutting the federal health care budget will only worsen the situation for those at the lower rungs of society.
True reform—a goal apparently lost in the partisan bickering—would be to get smarter about exactly how health care dollars are spent, so that costs can decrease even as the quality of care improves.
A revolutionary experiment underway in a handful of states is aiming to do just that. California, Kansas, Massachusetts, New Jersey, New York, Oregon and Texas have authorized versions of the Delivery System Reform Incentive Payment program. At its heart is the value-based payment formula, which stipulates that health care providers are compensated based on their patients’ longer-term health outcomes rather than the volume of services provided (that is, transactions such as office visits and tests).
The D.S.R.I.P. model—executed in New York State by 25 performing provider systems (also known as P.P.S.’s)—incentivizes health care providers to keep a close eye on their patients’ progress, monitor adherence to medical directives, assess mental health factors and empower patients to self-manage chronic conditions. The objective is to prevent 25 percent of unnecessary hospitalizations, which, at the end of the program’s five-year mandate, is projected to save New York taxpayers $12 billion.
Imagine such a strategy implemented in all 50 states; the Affordable Care Act’s goal to cut Medicaid spending could be achieved even as the quality of care improves. This is truly the best of both worlds, satisfying both patient advocates and budget hawks.
The objective is to prevent 25 percent of unnecessary hospitalizations, which is projected to save New York taxpayers $12 billion.
The visionary behind D.S.R.I.P. is Jason Helgerson, the Medicaid director of New York’s Department of Health, who passionately argues that we must take into account the social determinants of health as well as a patient’s medical condition. On this score, the United States lags behind other developed nations that recognize the significance of these factors in providing health care to the poorest citizens.
Social determinants include patients’ housing situations as well as their economic, employment and educational status. In many cases, they are also affected by the criminal justice system. These nonclinical issues directly impact physical as well as mental health, and they should be taken into consideration as part comprehensive health care designed to produce lasting results.
Case in point: A recent briefing for P.P.S.’s by the New York State Department of Health on housing issues reported that indigent households often choose to pay rent over buying food; this is a practical decision but one with serious health implications, particularly for young children. Rent and housing instability is shown to put mothers at a 200 percent higher risk of depression. There is also the impact of mold, lead paint and pest infestations. As a recent study by New York University’s Furman Center showed, an increase in “poverty concentration—the extent to which poor New Yorkers are living in neighborhoods with other poor New Yorkers” compounds the impact of a troubled housing situation as a social determinant of health.
In the vision of Helgerson—who likens the D.S.R.I.P. model to a start-up driven by venture capital—the neighborhood-based primary care physician becomes a true community leader who engages local leaders and activists in the areas of housing, employment and education to form community action teams. Their mandate is to make comprehensive resources—both medical and nonmedical—readily available to the poorest Medicaid patients in order to ensure their long-term flourishing.
Comprehensive, holistic care is the solution to keeping Medicaid patients healthier, taking control of chronic illnesses and avoiding expensive emergency room visits and hospitalizations. Such comprehensive care is commensurate with respect for the human dignity of each and every human being. Our nation’s political leaders should commission research into the social determinants of health and refocus their attention on health care reform that provides states with incentives to being truly smart and innovative in how public health care funding is spent. Billions of dollars can be saved while millions of lives are lastingly improved.