Health disparities domestically and globally can often be attributed to social determinants of health (SDoH). According to Healthy People 2020, SDoH are conditions and resources in the environments in which “people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Examples of these include: resources to meet daily needs (e.g. access to and quality of housing and food markets), educational opportunities, employment opportunities, and transportation. Despite well-established literature on the importance of SDoH, these factors are often overlooked and excluded in health care frameworks.
Concurrently, health services provided in
traditional settings such as hospitals and clinics can be expensive and
inaccessible. There are a large number of communities, from rural areas to
major cities, that are in need of high-quality care. Innovative technologies
can mitigate these challenges. Home and community-based care models coupled
with digital tools provide the opportunity to serve patients where they feel
most comfortable in a cost-effective manner.
For the SDoH Challenge, innovators were asked to
develop novel digital solutions that can help providers and/or patients connect
to health services related to SDoH. Over 110 applications were submitted to the
SDoH Challenge. For the Home and Community Based Care Challenge, applicants
were asked to create technologies that support the advancement of at-home or
community-based health care. Nearly 100 applications for Home and Community
Based Care Challenge were received.
In an AARP survey of 2000 adults, 6 out of 10 respondents indicated they prefer to stay in their home and community for as long as possible. This desire increases with age; more than 75% of adults over 50 would rather remain in a familiar environment where they have strong connections to friends, neighbors, and businesses. However, for the elderly and people with chronic illness or disabilities, remaining at home can be difficult. These populations require services that are often provided at long term care facilities (e.g. nursing homes) and/or formal medical settings– which can be costly, inconvenient, and inefficient.
Individuals of all ages across the health spectrum have also expressed interest in receiving health services in the home or community as a means to access higher quality and convenient care. With consumer demand for patient-centered care, the U.S. healthcare system has steadily steered away from institutional services in favor of home and community-based services (HCBS). Since 2013, Medicaid expenditures for HCBS has continued to exceed spending for institutional services. HCBS now accounts for 55% of Medicaid Long Term Care spending.
As the largest payor for healthcare in the United States, the Center for Medicare and Medicaid Services (CMS), is often the first to experiment and adopt new care delivery models. With Medicaid’s perceived benefits with HCBS, the CMS has also changed what is covered under Medicare Advantage (MA) to accommodate for the transition towards home and community based care. In 2018, CMS added “non-medical in-home care” as a supplemental benefit for 2019 MA plans. This year, CMS continued to broaden the range of supplemental benefits for MA 2020 to cover any benefits “that have a reasonable expectation of improving or maintaining the health or overall function” of beneficiaries with chronic conditions or illnesses.
The Robert Wood Johnson Foundation (RWJF) has partnered with Catalyst @ Health 2.0 to launch two innovation challenges on Social Determinants of Health (SDoH) and Home & Community Based Care. As a national leader in building a culture of health, RWJF is inspiring and identifying novel digital solutions to tackle health through an unconventional lens.
Health starts with where we live. As noted in Healthy People 2020 social determinants
of health are, “conditions in the environments in which people are born, live,
learn, work, play, worship, and age… [that] affect a wide range of health
functioning, and quality-of-life outcomes and risks.” For example, children who
live in an unsafe area cannot play outside making it more difficult for them to
have adequate exercise. Differences in SDoH heavily influences communities’
well-being and results in very different opportunities for people to be
Despite our knowledge on SDoH, the current healthcare system utilizes care models that often fail to take into account the social and economic landscape of communities– neglecting factors such as housing, education, food security, income, community resources, transportation and discrimination. Little progress has been made on incorporating SDoH into established health care frameworks. Healthcare providers and patients alike either have limited understanding of SDoH or have limited opportunities to utilize SDoH knowledge. RWJF established the “Social Determinants of Health Innovation Challenge” to find novel digital solutions that can help providers and/or patients connect to health services related to SDoH.
Home and community-based care is also important to enable Americans to live the healthiest lives possible. In-patient and long-term institutional care can be uncomfortable, costly, and inefficient. Digital health solutions in the home and community offer opportunities for care that better suit the patient and their loved ones. For example, innovations such as remote patient monitoring (RPM) have created new care models that allow the providers, caregivers, and patients to manage care where a person is most comfortable. RPM serves as a reminder that technologies in the home and community offer alternatives methods to engage the patient, increase access to care, and receive ongoing care. Therefore, RWJF is launching the “Home & Community-Based Care Challenge,” to encourage developers to create solutions that support the advancement of at-home or community-based health care.
The 2019 ACA plan year is notable for the increase in insurer participation in the marketplace. Expansion and entry have been substantial, and the percent of counties with one insurer has declined from more than 50 percent to approximately 35 percent. While urban areas in rural states have received much of the new participation, entire rural states have gained, along with more metropolitan urban areas.
Economic theory and common sense lead most to believe that increased competition is unquestionably good for consumers. Yet in the paradoxical world of the subsidized ACA marketplace, things are not so simple. In some markets, increased competition may result in a reduction in the purchasing power of subsidized consumers by narrowing the gap between the benchmark premium and plans that are cheaper than the benchmark. Even though the overall level of premiums may decline, potential losses to subsidized consumers in some markets will outweigh gains to the unsubsidized, suggesting that at the county level, the losers stand to lose more than the winners will win.
One way to illustrate this is to hypothetically subject 2018 marketplace enrollees to 2019 premiums in counties where new carriers have entered the market. Assuming that enrollees stay in the same metal plan in both 2018 and 2019, and that they continue to buy the cheapest plan in their metal, we can calculate how much their spending would change by income group.
Under these assumptions, in about one quarter of the counties with federally facilitated marketplaces (FFM) that received a new carrier in 2019, both subsidized and unsubsidized enrollees would be better off in 2019, meaning that they could spend less money and stay in the same metal level. In about thirty percent of these counties, all enrollees are worse off. In almost all of the rest, about forty percent, there are winners and losers, but in the aggregate, the subsidized lose more than the unsubsidized win. Overall, in about 70 percent of FFM counties with a new carrier, subsidized enrollees will lose purchasing power, while in about 66 percent of these counties, unsubsidized customers will see premium reductions. In population terms, about two-thirds of subsidized enrollees in counties with a new carrier will find plans to be less affordable, while a little more than half of unsubsidized enrollees will see lower premiums.
The Robert Wood Johnson Foundation (RWJF) is striving to build a Culture of Health in this country where everyone has an equal opportunity to live the healthiest life possible, no matter where they live, learn, work, and play.To get there, we need to make sure that everyone is getting the high quality, affordable care they want and need whether this care is provided inside or outside the health care system.Right now in the U.S., we spend a lot of money on health care, especially as compared to other countries, but we don’t have the outcomes to show for it.Last year, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 that would change how Medicare pays physicians with the goal of getting higher value for our health care dollars. And recently, the Centers for Medicare and Medicaid Services (CMS) proposed rules for how these payment and reporting requirements would be implemented.
On June 23, 2016, RWJF submitted comments on these proposed rules.We believe that changing health care payment in this country to reward better, rather than more care, is critically important.In our comments, we shared lessons and insights from RWJF grantees to encourage CMS to design incentives in ways that will truly transform our health care system to provide measurably better outcomes for all.We focused our comments on three areas: fostering integrated care, ensuring patient goals and needs are at the center of all we do, and providing high value care for everyone.
By ALEXANDRA HUBENKO, MATTHEW BIETZ, & KEVIN PATRICK
The Health Data Exploration project, sponsored by the Robert Wood Johnson Foundation, is building a network of academic, public sector, and corporate partners working together to catalyze the use of personal health data to conduct research that benefits the public good.
Individuals are tracking a variety of health-related data via a growing number of wearable devices and smartphone apps. More and more data relevant to health are also being captured passively as people communicate with one another on social networks, shop, work, or do any number of activities that leave “digital footprints.” Self-tracking data can provide better measures of everyday behavior and lifestyle and can fill in gaps in more traditional clinical or public health data collection, giving us a more complete picture of health.
Many of the nation’s nurses understandably erupted in anger when the co-hosts of ABC’s The View mocked Miss America contestant Kelley Johnson for her pageant-night monologue about being a nurse — and for wearing scrubs and a “doctor’s stethoscope” (their words) in the talent competition. The co-hosts, Joy Behar and Michelle Collins, have since apologized, especially for implying that only doctors use stethoscopes. “I didn’t know what the hell I was talking about,” Behar later said.
It would be easy to attribute this episode solely to the ignorance of some TV personalities, but as most nurses know, the problem goes far deeper. The fact is that much of the nation doesn’t really understand nursing, either.
It’s true that the public rates nursing in Gallup surveys as the most honest and ethical profession. Yet it’s unlikely that most Americans understand the range of critically important roles that nurse’s play across the health care continuum, from health promotion, prevention, and research, to palliative and hospice care.
How many Americans know that patients who obtain organ transplants will have far more contact with – and obtain more hands-on care from – a transplant nurse than a surgeon? Or that two-thirds of all anesthetics given to US patients are delivered by certified registered nurse anesthetists, rather than anesthesiologists with medical degrees?
You got me. I still won’t cop to eating at a Cheesecake Factory, but I am all about the Apple Store. In fact, I’m a teensy bit over the top about it. Seriously, I beg of you—could we, please, have just a little genius bar with our health care?
I’m no doubt somewhat of a freak (I got up at 2:55 a.m. ET on September 19th to, you know, pre-order the iPhone 6). A month or so later, I was more than ready to upgrade my aging iPad2, so obviously at the first opportunity I ordered a new iPad Air 2 online from the Apple website. I requested pick-up at my local Apple Store—because it’s convenient—and, well, I just love going there. A few minutes after I made my online purchase, I received an email informing me that the store staff was ready for me. My new baby was waiting! Serious goose bumps.
I made my way to the mall. It was pretty crowded, as usual. I walked right past The Cheesecake Factory, into the mall, turned left and into the gleaming Apple Store—smiling, not quite skipping, all along. Several staff members greeted me almost the minute I arrived. I explained why I was there. When she understood my reason for coming to the store, the first staff person handed me off to another. I showed him the email on my iPhone. We traded some numbers. He entered those on his iPhone and went back to get my waiting . . . Air 2!!
For the past several months the Robert Wood Johnson Foundation has been promoting a particular vision– of a Culture of Health in America, where everyone has the opportunity to live the healthiest life possible, no matter their income, or where they live, or work, or play.
With that vision in mind, geriatrician Dr. Leslie Kernisan asks an important question in her Oct 7 Health Care Blog post, “Why #CultureofHealth Doesn’t Work For Me.” She writes: “Is promoting a Culture of Health the same as promoting a Culture of Care? As a front-line clinician, they feel very different to me.”
For physicians treating the chronically ill and patients facing the end of life, good health might seem like a pipe dream. Kernisan and some of her commenters even wonder if the phrase “Culture of Health” could be misconstrued as “blaming the victim.”
So much so, that when I approached a conference speaker, to briefly comment on my interest in helping beleaguered family caregivers with their carees’ health and healthcare issues, I was advised to work on promoting a culture of health.
Hm. Funny, but as a generalist and geriatrician who focuses on the primary care of older adults with multiple medical problems, I’d been thinking more along the lines of:
Promoting the wellbeing of older adults and their caregivers.
Optimizing the health – and healthcare — of my aging patients.
In other words, I’d been thinking of a “Culture ofCare.”