Integrating Social Care and Medical Care: From the Why to the How and Back Again

In recent years, there has been remarkable growth in support for integrating social and medical care in the United States. Integration is primarily understood as screening in the health care setting for unmet social needs (e.g., housing, food, transportation, assistance with domestic violence) and referring patients to organizations that provide assistance in these areas. Other approaches to integration involve coverage of a portion of social care costs by third-party payers, as in current Medicaid waiver projects. The rationale for integration—the “why”—begins with the recognition that health is primarily driven by social conditions, termed “social determinants or drivers of health” (SDOH), and health disparities are primarily driven by differences in SDOH. Many observers anticipate that the growing prevalence of value-based health care (in which payment is based on outcomes rather than procedure volume) will lead to financial support for social care integration.

FROM THE WHY TO THE HOW

Our excitement over new approaches to improved health generally outstrips our attention to how we can successfully implement them, and social care integration is no exception. In this issue of AJPH, Callahan et al. (p. 619) tackle a portion of the “how” question for integration through a case study of Eskenazi Health, the safety net health care system serving Marion County, Indiana. Building off the National Academies of Science, Engineering, and Medicine report Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health,¹ they describe how Eskenazi developed the infrastructure to implement screening and referrals to social care, and they calculate the average annual expenditures associated with infrastructure development to be $2 360 000. Noting that Eskenazi’s characteristics might in some ways result in lower-than-average costs (e.g., because of strong existing relationships with social care) and in other ways higher costs (e.g., because their patients have many social needs), they estimate that for most health care systems, integration infrastructure development costs will range from $1 million to $3 million annually for 5 to 10 years. (These are infrastructure development costs only, not taking into account, for example, additional funds needed to expand social care availability.)

In discussing their findings, Callahan et al. move further into the “how” of integration by asking who will pay the costs they have identified. They note that government and industry funding for social care tends to rely on short-term demonstration projects not conducive to developing durable infrastructure. Philanthropy sometimes offers longer-term investment, but competing for these funds means competing against the very organizations that address social needs.

So, how should we think about paying the costs of integration infrastructure development? In doing so, how should we use the kind of information provided by Callahan and his colleagues? One approach is to see such cost estimates as grist for an economic cost‒benefit analysis to be undertaken by health care systems and payers to determine whether to make infrastructure investments. Certainly, if we are to think critically about the economic opportunity costs of social care integration, be realistic about its feasibility, and determine how it can be funded, we must explore integration’s economic costs and cost savings. These considerations, however, should be part of a larger discussion. Cost‒benefit analysis offers the allure of “technocratic” solutions to complex decisions; however, it elides critical questions about how we monetize nonfinancial costs and benefits, how we think about costs and benefits we cannot monetize, to whom costs and benefits accrue, short-term versus long-term impacts, and the complexity of cause and effect in the real world.²

A number of issues illustrate the importance of developing an analytic framework for integration decisions that moves beyond the financial concerns of health care providers and payers to a larger set of societal considerations. These issues make it clear that to think about the “how” of integration, we must rethink the “why” of integration—what we believe integration accomplishes and how we regard those results.

FROM THE HOW TO THE WHY

Callahan et al. point us in this direction when they highlight nonfinancial challenges of integration infrastructure development. They indicate the importance of building community resources, rather than supplanting them. They also cite concerns over the medicalization of social needs. There is, in fact, a tension between the concern over medicalization and expansion of the role of third-party payers,³ which they cite as a piece of the funding solution. This tension does not negate the role of health care payers, but does highlight the importance of considering a variety of issues when thinking about how to support integration.

The importance of nonfinancial considerations in our approach to social care integration has been highlighted by Berkowitz et al.⁴ They point out that addressing social needs sometimes improves health without reducing costs, particularly short-term costs. Moreover, this is also true of many clinical interventions that we nonetheless provide because they align with our values around health. The authors suggest that we treat social care the same way—thinking about our collective values, not just economic “value.”

Berkowitz et al. also note that, to make financial benefits outweigh financial costs, some systems focus social care on those whose unmet social needs are linked to large health care expenditures. They question the alignment with our values of “equating deservingness of intervention with the likelihood of generating high healthcare costs” and caution against over-reliance on “market-oriented justifications” (i.e., cost savings to specific actors) for providing services.^4(p1917) Similarly, I would argue, the logic of purely market-oriented justifications is challenged by the differential impact of such reasoning on different health care systems. For example, does the “deservingness” of patients with social care needs vary based on differences in the opportunity costs of integration for their health care providers?

Our analytic framework must also be based on a more complete understanding of the effects of social care integration than that which now dominates our discourse. Gottlieb et al. note that even when referrals for social needs do not result in those needs being met, patient health often improves.⁵ Research suggests that the navigation services, strengthened patient connections to ambulatory care, and changes to health care delivery teams resulting from integration can enhance health by improving emotional support, ambulatory care use, and disease self-management. This broadened understanding of the “logic” behind social care screening and referrals changes the calculus around the benefits of incorporating social workers and community health workers into the clinical setting.

Moreover, in thinking about cause and effect, society must take the long view, although individual actors generally do not. Based on what we know of the effects of childhood environment,⁶ for example, meeting housing, food, transportation, and personal safety needs can have a significant impact on the well-being and health of future generations; this impact will not be measured by short-term research. Callahan et al. have provided us with important information about the “how” of integration that can help inform deliberation and decision-making processes. Ideally these processes will take a broad societal perspective in assessing and considering the requirements and results of social integration, the value it provides, and the ways in which it aligns with our values.