Background

The current design of the US healthcare system is not well aligned with the actual drivers of health.

Clinical care accounts for only 20% of patients’ health outcomes, yet it accounts for the overwhelming majority of health care spending. Meanwhile, little investment has been made in addressing the social determinants of health, which account for 40% of health outcomes and drive health inequities.

Failure to address patients’ social health needs directly contributes to two major problems in health care:

  • Health inequities: Social determinants of health linked to social, political, and regulatory forces contribute to significant racial disparities in access to education, employment, income, housing and health care. Because social health needs vary significantly across race/ethnicity, unmet social needs such as food insecurity, housing instability, and timely access to quality health care result in profound health inequities.

  • Low-value care: Unmet social needs often result in complex, high-cost care that may otherwise be avoided. Patients with poor access to health care frequently miss out on low-cost high-value preventive care and instead present with complications of disease that are frequently highly morbid and costly.

Many health care providers and health plans appreciate the large contribution of social determinants of health to patient outcomes including health inequities, but few interventions are implemented to help them.

Because of unmet social needs, patients fall into predictable patterns of high-cost and low-value care across the disease spectrum that disproportionately impacts minority and underserved populations.

The existing Blue Cross Blue Shield of Michigan (BCBSM) collaborative quality initiatives (CQIs) provide an ideal structure for implementing high-impact social health interventions to improve health outcomes while also providing more equitable, higher-value care.

There is a growing evidence base showing that interventions addressing social determinants of health are associated with better health outcomes, lower costs, or both. Identifying patients at highest risk for high-cost and low-value care due to unmet social needs is critical to the success of effective interventions.

MSHIELD focuses on social health interventions with the highest impact in the medical literature. Click on each domain to learn more:

We use the existing structure of the BCBS collaborative quality initiatives to increase awareness of social health needs so that we can focus on patient-specific needs with greatest health impact and foster integration of a system for screening and referral into the existing BCBS CQI structure.

The ultimate goal is to partner all BCBS CQIs – across surgical and medical conditions – with communities across the state to ensure all patients have access to social health interventions needed for optimal care and health outcomes.

To address the social health needs of high-risk medical and surgical patients, MSHIELD works closely with existing community “hub” programs in four geographic regions based on social service leadership initially implemented as Community Health Innovation Regions (CHIR) under the State Innovation Model and coordinated by the Center for Health and Research Transformation (CHRT). Each hub program provides an array of supportive social services to individuals who need safe and affordable housing, access to food, mental health and substance use services, complex care management, health education, assistance accessing care, transportation, utility needs, and other social and behavioral services.

Individuals often fall through the cracks as they struggle to navigate complex systems across multiple agencies – widening health disparities. The programs employ community health workers and care managers to help individuals navigate complex systems of health care and social services to get the support they need to improve their health.

Health and social services providers also encounter significant coordination challenges among themselves, and often lack the information they need from one another to meet clients’ needs. These hub programs connect care managers and community-based organizations with community health information technology hubs that provide the clinical and communications platforms to link people to services, link service providers to each other, and link the ‘community enterprise’ to the ‘medical enterprise’.