The Healthy Alliance independent practice association in upstate New York allows community-based organizations (CBOs) to join together in a shared-governance association with health plans and medical providers. To study the impact of its work, researchers at Stanford University are beginning to compare patients residing in counties served by the Healthy Alliance IPA with a matched comparison group of patients from other counties, using measures of healthcare utilization, social service utilization, and total cost of care.
The research is part of Systems for Action (S4A), a signature research program of the Robert Wood Johnson Foundation (RWJF) that builds a culture of health by rigorously testing new ways of connecting the nation’s fragmented medical, social, and public health systems.
The study focuses specifically on the outcomes experienced by racial and ethnic minority populations and also examines the roles played by CBOs led by Black, Indigenous, Latino and other persons of color. The research team is led by Stanford University School of Medicine in partnership with the Healthy Alliance IPA, Albany County Department of Health, Rensselaer County Department of Health, and other community partners.
During a recent S4A webinar, researchers and Healthy Alliance leaders discussed the effort.
Jonathan Shaw, M.D., M.S., associate chair of the Stanford Department of Medicine, began by saying the work is part of the effort to address the “wrong pocket” problem, which occurs when one sector won't fund a program that is socially beneficial because the returns go to another sector. In other words, the return on investment goes to a different pocket. As an example, over the past two decades, there is mounting evidence that substance use treatment is cost effective. Paradoxically, at the same time, there's been a large contraction in substance use treatment programs, he explained. Substance use treatment is cost-effective because it leads to savings in criminal justice. But the programs are easy to cut from the healthcare systems perspective, because the returns on investment aren't going to their sector, they're going to criminal justice.
Shaw said the evidence is there that social and environmental factors play a huge role in health outcomes, but the policy has not caught up.
He noted that researchers want to look at which social services most directly improved health outcomes in a way that actually saves healthcare resources. One area that this could happen is if it empowers better management of individuals’ health conditions, such as asthma or diabetes, thus avoiding exacerbations that require urgent or emergent intervention, and that might show immediate or intermediate return on investment.
“We also have to think about what innovations are best to link the social and healthcare services in an ongoing and effective way. One important thing to keep in mind is the wrong pocket problem is particularly important from a health equity perspective, because it truly affects persons who have complex needs and rely on social services and health care organizations. And Medicaid, as the safety net, the largest safety provider in our country, has started to put a lot of lot more attention on addressing social determinants of health and increasingly states and counties are exploring using Medicaid waivers to expand how they address social determinants of health.”
But beyond nudging Medicaid to cover social services and expand beyond just direct medical care, Shaw asked, “are there other more innovative organizational models and solutions to the wrong pocket problem? That's where we come to Healthy Alliance as an organizational financing model. That is one approach that may solve this problem.”
Healthy Alliance was founded in 2018 and has connected social care providers, behavioral health providers, and health providers using a closed loop referral platform from Unite Us, explained Elena Rosenbaum, M.D., medical director at Healthy Alliance. This work started in six counties and Healthy Alliance now reaches 22 counties in New York State. The IPA was founded as a sustainability solution, basically to help secure funding for the programs on an ongoing basis after the original Delivery System Reform Incentive Payment (DSRIP) program funding runs out, she added.
The foundation is not just a closed-loop, referral platform infrastructure, she said. Healthy Alliance also provides other services that center on improving the health of individuals in the community, by supporting social care providers as well as healthcare providers in reaching their goals. For instance, for managed care organizations, there are New York State Department of Health requirements to address social determinants of health in some of their contracts, Rosenbaum said. Managed care organizations recognize the impact of social determinants of health on their members’ health as well as on costs. “They would like to provide funding with the ability to track referrals and find out what is happening when the members go to the organizations to get the services,” she said. Instead of contracting individually with each community-based organization in the community, MCOs can go to Healthy Alliance to contract for a diverse array of service providers.
Medical and behavioral health providers understand the importance of screening for social determinants of health. However, we need to be able to do something once we uncover a challenge, Rosenbaum said. The Healthy Alliance’s social determinants of health network allows healthcare providers and behavioral health providers to make referrals once they uncovered that there's an unmet social need for the individual.
For social care providers, the IPA is beneficial because they get support in terms of how to manage their data, as well as the ability to facilitate contracting, and the promise and the goal of sustainable funding that could occur if they had more willing payers.
Kyla Schmidt is founder and executive director of nonprofit Mom Starts Here, whose mission is to connect young mothers and families in need to the resources in the community that are available to them. “Our partnership with Healthy Alliance has aided us in so many ways,” Schmidt said. “It's been fantastic to have their support in improving our data management systems. Working in a network of providers has had a tremendous impact on our work. The ease in which we can send and receive referrals from other community-based organizations allows us to better meet the needs of families we serve. Collaborative opportunities have been born out of the utilization of the network and partnerships have been formed with the crossover clientele that we have with other organizations.”
Todd Wagner, Ph.D., director of the Health Economics Resource Center at the Palo Alto VA and an associate professor in the Department of Surgery at Stanford University, described what the research under way hopes to illuminate. “What we want to show is whether the Healthy Alliance has an effect on healthcare costs that might help us get more sustainability for such a system,” he said. “Do we see a decrease in emergency department utilization, for example?” The researchers will pull together data from the state all-payer claims database and the Unite Us database and compare costs in Healthy Alliance counties with comparable control group counties to see if they can identify the impact on total cost of care.
