WHAT IF THE answer to ever-rising health care costs doesn’t lie in figuring out better ways to deliver medical care, but in things like ensuring access to good nutrition, adequate housing, or even job training?
That was the outside-the-health-care-box message members of the state Health Policy Commission heard on Tuesday morning from health policy researcher Lauren Taylor.
When it comes to health care, you don’t necessarily get what you pay for. The US spends, far and away, more than any country in the world on health care, yet stacks up poorly on all sorts of health measures, including infant mortality and maternal mortality in childbirth.
That puzzle has formed the focus of Taylor’s research, including a groundbreaking 2013 book she coauthored that has garnered lots of attention, The American Health Care Paradox: Why Spending More is Getting Us Less. Speaking Tuesday morning at the second and final day of annual hearings on health care cost trends in Massachusetts, Taylor said the spiraling US spending on health care – now about 18 percent of the national GDP – constantly has researchers “scratching our heads and saying, what can we do differently around health care?”
What she and her coauthor, Yale health researcher Elizabeth Bradley, concluded was “maybe what we can do differently is not even in health care. It’s about these other factors that have historically not even been represented in the analyses.”
She says all sorts of non-medical factors are known to play a big role in overall health, yet we don’t pay adequate attention to them when considering health care needs and spending.
Taylor, a doctoral student in health policy at Harvard Business School, said when health care and social service spending are lumped together the US falls more toward the middle of the pack among countries that are members of the Organisation for Economic Co-operation and Development (OECD). What’s more, she said, the ratio of social service spending to health care spending is more predictive of better health outcomes than health care spending alone.
The studies only show correlations and so cannot prove that greater social service spending yields better health outcomes. It could also be that more health care spending among a less-healthy population crowds out spending on social services. “It’s probably both,” Taylor said.
Her presentation drew rapturous praise from Stuart Altman, chairman of the Health Policy Commission. “Rarely have I heard a presentation that has more of an impact on my thinking,” said Altman. “I think you and your team are changing the thought process going on more than anyone.”
Changing the enormously complex health care delivery and financing system, however, will be much harder.
For example, health plans benefits should include an ability for doctors to “place a referral to the YMCA for a child with obesity,” said Dr. Elise Taveras, chief of general pediatrics at Massachusetts General Hospital who testified as part of a panel of providers following Taylor’s presentation. “We need to get rid of the firewall.”
Some of the integrating of health and social service spending Taylor is advocating is already taking place – and more of it is anticipated if the federal government approves a waiver application allowing for reforms to the Medicaid program that state officials are anxiously awaiting word on.
The waiver would ensure about $8 billion in federal funds over five years for the 1.8 million residents enrolled in MassHealth, the state Medicaid program. A big push under the waiver will be for more MassHealth patients to be cared for through “accountable care organizations,” which assume responsibility for the full care of patients, including integrating behavioral health care and health-related social services, under a set budget.
Taylor said her analyses show that housing assistance is the big “winner” among social services that can improve health outcomes. But she said in California and Oregon, state officials are “running into all sorts of walls” as they battle with federal officials over whether they can use Medicaid funds for housing costs or only for “the wraparound supportive housing services” that the program has traditionally funded.
Kate Walsh, the president and CEO of Boston Medical Center, said her hospital has already invested grant funds in housing services for patients with severe mental illness and has seen emergency room utilization and other inpatient costs among these patients drop. But she said making such services a more routine part of the health care system will require a huge shift in how hospitals operate and a new level of coordination with community organizations.
Taylor said groups trying to do that in New York have “found it much more difficult than they thought it was going to be to really get to a point where health service organizations and community-based organizations could contract with each other for services and go in on joint delivery of services.”
Asked whether the Medicaid waiver would start to move Massachusetts toward integrating health care and social service needs, Walsh said, “I would say it’s a beginning.”
“We’re going to be challenged to address it with the dollars that are available,” she said. “The ACO transformation of MassHealth will force us all to wrestle with this.”