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National Academy of Medicine; The Learning Health System Series; Hunt A, Anise A, Chua PS, et al., editors. Valuing America’s Health: Aligning Financing to Reward Better Health and Well-Being. Washington (DC): National Academies Press (US); 2024 Feb 12.
Valuing America’s Health: Aligning Financing to Reward Better Health and Well-Being.
Show detailsThe examples described in Chapter 3 illustrate that approaches to whole person and population health can be successful when supported by complementary financial strategies and partnerships. The Steering Group largely agreed that global, capitated, and total cost of care payment models is the best platform to facilitate the implementation of comprehensive health and social services that promote population health. However, the right payment infrastructure—cohesive financial reforms and policy alignment—is needed to sustain and scale these models. Ultimately, the nation must pay for the right services at the right price and in the right way.
GOALS
The Steering Group held numerous discussions on the urgent possibilities for the future of health in the United States, from which an emphasis on creating goals arose organically. The Steering Group has summarized the following goals as both important and possible to achieve by 2030 if the will is marshaled by the critical stakeholders. Specifically, the Steering Group feels that by 2030, all U.S. stakeholders, including but not limited to the health system, should be able to build a system reflecting a commitment to whole person, whole population health by:
- 1.
Reducing by 50 percent public and private expenditures that are currently spent on health care services and processes that do not improve health.
The United States should stop paying for services that do not improve health. Previous IOM reports, including The Healthcare Imperative: Lowering Costs and Improving Outcomes (IOM, 2010), and subsequent follow-up studies (Berwick and Hackbarth, 2012; Shrank et al., 2019) estimate the cost of waste in the U.S. health care system (i.e., services that are provided to individuals and paid for but have no impact on their health and well-being) ranges from $760 billion to $935 billion, which accounts for nearly 25 percent of U.S. health care spending (Bauchner and Fontanarosa, 2019). This waste manifests through the delivery of fragmented, low-value, and excessive care, pricing failures, fraud and abuse, and excessive administrative complexity, and must be eliminated from the American health system (Lallemand, 2012).
Successfully addressing these sources of waste could reduce health care spending by more than $200 billion annually, thereby freeing up funding for better, more holistic interventions and providing better and more comprehensive care at lower costs (Shrank et al., 2019). Similar efforts, such as those taken by the One Percent Steps for Healthcare Reform, have identified tangible areas for action, such as capping provider prices and price growth, reducing waste in long-term care hospitals, and reforming home health care coverage to reduce fraud, that could yield an estimated $350 billion annually (One Percent Steps for Health Care Reform, 2022).
- 2.
Increasing by 50 percent public and private expenditures on social interventions that have been proven to improve health.
The United States must improve payment for services and providers that have been shown to advance whole health. This transformation must begin with formal recognition of the value of upstream services and programs that address social determinants of health (SDoH), such as access to stable, quality housing, nutritious food, and vocational support. These services and programs are critical to achieving whole health, and they must extend to the redesign of incentive structures to reward the full spectrum of team-based and multidisciplinary care.
The United States has the lowest ratio of social-to-health care spending among Organisation for Economic Co-operation and Development (OECD) countries. For every $1 spent on health care in the United States, about $0.90 is spent on social services. Meanwhile, in other OECD countries, for every $1 spent on health care, an average of $2 is spent on social services (NASEM, 2019). OECD countries that spend a higher proportion of their gross domestic product (GDP) on social services than on health care—including Germany, Japan, and the United Kingdom—have better health outcomes than those that do not, as described in Chapter 1 (Bradley et al., 2017; Rubin et al., 2016). This fact also holds true within the United States. States with higher ratios of social-to-health spending, including Washington, New Mexico, and Vermont, also appear to have better health outcomes than those with lower ratios (Bradley et al., 2016). Because the United States experiences serious levels of wealth inequality, poverty, and structural racism, increasing social spending (the lack of which has been a structural driver of poor health in the nation) would enhance health outcomes significantly (Avanceña et al., 2021).
Many of the models described in Chapter 3 have been proven to generate better health outcomes when compared to fee-for-service-dependent care. A substantial driver of this success includes their investment of more resources in social services that can positively influence the upstream SDoH and reduce downstream health care costs. Effective care models should invest in health-promoting interventions and care providers that make the most robust difference in the health and well-being of individuals and populations, including:
- Preventive services across the life span, particularly when implemented early in life, that will produce compounding returns on the health and well-being of the population served (Fried, 2016). For historically marginalized populations, this especially applies to interventions that address social needs and risk factors, starting at a young age and continuing through adulthood (NASEM, 2019).
- A life-course approach that intervenes throughout the national ecosystem—from households and educational institutions to health systems and community-based organizations—that supports whole person, whole population health and well-being. More important are the operational challenges of funding, measuring, and learning such interventions so that they are scaled through whole ecosystems.
- Screening and prevention through the expansion of Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit beyond children under the age of 21 to larger portions of the U.S. population. The EPSDT benefit is representative of whole health through its emphasis on promoting health, proactively screening for disease, and early treatment. Policies across sectors that prevent disease, tackle systemic racism, and assume a life-course approach to disease prevention and health promotion would help stem the crisis of our nation’s health.
- Flexible, multimodal approaches to clinical services that are designed to enhance access, improve outcomes, and meet the unique health, social, and long-term care needs of individuals, families, and communities throughout their life spans.
- Community-based organizations and nontraditional service providers (see Box 3), which are often better suited to operationalize and implement whole health interventions than traditional health care providers. These providers should be recognized through funding and integration into whole person and whole population health interventions, including primary care, as recommended by the 2021 National Academies report Implementing High-Quality Primary Care (NASEM, 2021a).
BOX 3
Innovative Whole Person and Whole Population Health Service Providers.
- 3.
Utilizing population-based global budgets across all payers to ensure that at least 50 percent of the U.S. population has access to the broad range of social interventions necessary to attain and maintain health and well-being.
A global budget provides a fixed amount of funding to an accountable entity for the totality of services associated with the care of a specified population over a fixed time, rather than payment for individual services or cases. This payment approach provides a foundation that enables the redistribution of current health care spending toward services that have been shown to advance population health and well-being, as outlined in Goals 1 and 2. These prospective population-based payments also offer providers financial resilience in the face of crises like the COVID-19 pandemic, allow for more flexible care delivery models, and allow for the integration of medical and social services (Gondi and Choksi, 2020; Levy et al., 2021).
Global budgets have supported the innovation behind the U.S. Department of Veterans Affairs’ (VA’s) Whole Health model of care as well as Southcentral Foundation’s Nuka System of Care, which are both featured as case studies in Chapter 3. As previously described, the Nuka System of Care offers a full continuum of care (including prevention, behavioral health, primary care, and supportive services) with a substantial portion of the operating revenue flowing from the federal Indian Health Service through a mechanism that functions like a global budget. Funding independent of service volume empowers Nuka’s integrated care delivery, allowing for more holistic care associated with positive health outcomes.
Thus, global budgeting should be the primary financing structure used by organizations capable of accepting total accountability for the needs and outcomes that matter to individuals, families, and communities. In scenarios where global budgeting is not applicable, such as due to organizational structure or program type, the ideas behind global budgeting can be approximated using creatively braided and blended financing streams to ensure that adequate, non-siloed funding is in place to support a holistic set of services designed to benefit whole person and population health.
As of 2018, only 5 percent of health care payments to service providers were population-based, although global budgets have also been implemented in a few states, such as Maryland and Vermont (NASEM, 2021b; Shrank et al., 2021). Over the last decade, the Center for Medicare & Medicaid Innovation (CMMI) has launched multiple value-based payment models with mixed results, with global budget demonstrations performing best among them (Smith, 2021). However, most of these models have not been mandatory nor required large shifts away from fee-for-service. As a result, their impact on cost and outcomes has been limited (Crook et al., 2021).
- 4.
Tying 75 percent of health care provider and plan revenues to performance metrics based on the most important health and well-being outcomes, according to the goals of the populations being served.
Accountability measures should align with the health and well-being outcomes that matter most to individuals, families, and communities. To reverse the declining health of our society, it is imperative to think beyond short-term financial returns and process indicators that do not equate to health outcomes valued by individuals, families, and communities, but on which our current quality measurement system overly relies. For instance, clinicians must evolve beyond asking patients, “Do you feel depressed?” to patient-centered questions such as “Have you stopped feeling suicidal? Are you able to take care of yourself (i.e., bathe, get dressed, and eat healthy foods), go to work, be with your family, etc.?” To ensure that financial incentives are aligned with what matters to individuals, families, and communities, quality measures must focus on patient-centered priorities, e.g., validated functional and patient-reported outcome measures (Burstin et al., 2017). There must be a fundamental alignment between the health system’s economic success and the community’s health, as defined by the community.
Strategies should also be deployed for the broad engagement of individuals, especially those from historically marginalized populations, in developing a series of measures that increase the overall accountability of health and health care providers to those they serve. These measures should assess and center health equity within the community and specify the key components for high-quality care for diverse and historically marginalized populations, such as health literacy, language access, and cultural competence. As the National Center for Quality Assurance suggests, measures to evaluate a health care organization based on a broader patient-centered framework could also include measures of healthy organizational culture and values, workforce diversity, community engagement activities, and patient engagement efforts (Bau et al., 2019). Furthermore, measurement data should be stratified to identify and track the existence of inequities across factors such as race, ethnicity, geography, disability, and income. An example of this work is CMMI’s recent identification of implicit bias in assessing health and risk status, model selection criteria, and the overall demographics of model participants. Mitigating the impact of this bias and more accurately accounting for the needs and outcomes for marginalized populations will be critical to achieving the Steering Group’s vision (Majerol and Hughes, 2022).
Rigorous measurement approaches should proactively identify any characteristics of care that systematically exclude individuals or treat populations inequitably. Where algorithms or artificial intelligence is applied, careful consideration in design and evaluation is required to ensure bias across race, income, geographic location, and other factors is minimized to promote equitable resource allocation and access to health care. Properly applied, measurement practices could inform continuous learning models to identify best practices that can be spread and scaled broadly.
To achieve individual health and well-being, incentives cannot stop at the exit door of the health care system. They must extend to the community and social contexts that also shape people’s health. At its most comprehensive level, such a system must also reward approaches that improve the health of people who do not engage with the health care system due to lack of access, financial barriers, or deep-seated mistrust rooted in historical trauma. The financing and payment system must support equitable health care that links all people, not just patients, to resources that meet their health-related social needs along with their medical needs, regardless of payer or socio-demographic group. This system should also encourage health care organizations to engage with their respective communities to tackle major threats to health, such as homelessness, poverty, violence, and racism.
- 5.
Substantially enhancing community health engagement and focus as reflected by progress in at least 50 of the 100 counties with the worst health status (as defined by years of potential life lost)—specifically, the success of stakeholders in:
Ultimately, if the goal is to improve health, the most needed step is to redirect resources and attention to the communities experiencing the worst outcomes. Individuals in these communities should have a voice in deciding which indicators to use for assessing health and well-being and be empowered to participate in multi-stakeholder deliberations on how to direct resources to improve these indicators. Those with the greatest health risks and historically marginalized communities (e.g., low income, rural, communities of color, and people with disabilities) should not only be represented but also have shared decision-making authority in community governance structures.
Examples of whole person and whole population health measures that community stakeholders could adopt include maternal or infant mortality, suicide rates, employment, educational attainment, self-reported health status, or patient-reported outcomes. Additionally, local cross-sector collaborations with defined accountability, community governance, and aligned incentives will be needed to improve the health and well-being of communities. Such structures are highly effective (as described in the Collaborative Approach to Public Goods Investments model in Chapter 3) and allow for private and public organizations (including federal agencies, such as the Centers for Medicare & Medicaid Services) that might work in siloes to meaningfully partner and coordinate care and services as a united team.
Multi-stakeholder community collaborations could include leaders from community member groups, grassroots community-based organizations, county and municipal government agencies, health care entities, employers, and local community foundations. These stakeholders should be deeply invested in identifying and addressing community needs. They must also provide the lived experiences and perspectives necessary to include and elevate diverse consumer voices in designing solutions. Figure 4 illustrates key components of such collaborations as described throughout this report.
FIGURE 4
Key components of multi-stakeholder community collaborations.
Furthermore, state governments, health care providers, and health plans must partner with these community collaborations and strengthen community infrastructures to achieve health and health equity for all community members. An example of this collaboration can be found in the work of West Side United, a community convener and pooled financing manager in Chicago, Illinois. Community infrastructure can enable communities to be efficient and operate at scale through community governance that facilitates shared goals and outcomes, community governance, workforce development, use of technology, sharing health data, analytics, as well as technical assistance to build and strengthen the capacity of local community-based organizations.
OPPORTUNITIES FOR STAKEHOLDER ACTION
The following section provides specific actions stakeholders can take to advance whole person and whole population health. Key stakeholders include:
- Patients, families, and communities
- State and local governments
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Legislative and executive branches
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Community benefit oversight
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Insurance oversight
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Public health agencies and departments
- Federal government
- Care delivery organizations and health systems
- Payers
- Employers
- Financial sector organizations
The Steering Group advocates for transformational change that will lead to meaningful reform in the health investment landscape. While incremental progress is helpful, these actions are unlikely to enable us to meet the above stated goals by 2030 and are, therefore, insufficient. Transformative change is necessary and will move the nation forward on the critical path to better health. In this context, the stakeholder actions are characterized as either transformative or intermediate/incremental.
Patients, Families, and Communities
Patients, families, and communities have a critical role in reversing the nation’s declining health trajectory through their lived experiences and power as voters and consumers of care. As demonstrated by the climate change movement, a broad-based grassroots movement will be necessary to push leaders to prioritize health above entrenched interests and to sustain the political will for change. As Daniel Dawes writes, the “political determinants of health,” or the relative empowerment across communities to participate in voting, governing, and otherwise influencing policy making, play an outsized role in creating a healthy and inclusive society (Erdelack, 2020).
Transformative Action
- Harness the political process and advocate for financial reforms and more equitable and inclusive health policies.
Intermediate and Incremental Actions
- Engage in advocacy skills training to enhance the power of the whole person, whole population health movement by expanding stakeholder networks. These activities could include educative, community-based public forums that increase civic engagement, improve health literacy, and provide lessons on effectively engaging policy makers and other public officials. New Orleans, Louisiana, and Charlotte, North Carolina, are two examples of cities that provide free training that helps residents build the necessary skills to improve quality of life in their communities.
- Develop and participate in community-based, multi-stakeholder coalitions to guide the design, implementation, and evaluation of programs to support whole person and whole population health and well-being.
- Ensure that a diverse array of community members is involved in the governance of local, state, and/or regional health coalitions to improve equity, inclusion, and representation as it pertains to race, ethnicity, age, and disability status, among other personal characteristics.
- Educate stakeholders on the need to advocate for policies that prioritize whole health, including the indirect impacts of other policy decisions on health.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Harness the political process and advocate for financial reforms and more equitable and inclusive health policies. | Transformative | 4.4 | 2.6 |
| Engage in advocacy skills training to enhance the power of the whole person, whole population health movement by expanding stakeholder networks. | Intermediate and Incremental | 2.8 | 3.6 |
| Develop and participate in community-based, multi-stakeholder coalitions to guide the design, implementation, and evaluation of programs to support whole person and whole population health and well-being. | Intermediate and Incremental | 3.2 | 3.4 |
| Ensure that a diverse array of community members is involved in the governance of local, state, and/or regional health coalitions to improve equity, inclusion, and representation as it pertains to race, ethnicity, age, and disability status, among other personal characteristics. | Intermediate and Incremental | 3 | 3.2 |
| Educate stakeholders on the need to advocate for policies that prioritize whole health, including the indirect impacts of other policy decisions on health. | Intermediate and Incremental | 2.8 | 3.6 |
State and Local Governments
Legislative and Executive Branches. State governments finance significant portions of health care through their Medicaid and public employee benefit programs that are directed and regulated by General Assemblies and relevant agencies. Decisions under the purview of these legislative and executive governing bodies, such as which services they pay for and how they negotiate contracts with health plans and providers, can significantly impact the health and well-being of state residents, making them important influencers of whole person and population health.
Transformative Actions
- Pursue and use 1115 waivers to cover innovative care and payment models that address social determinants of health. This waiver enables services determined by the state to be medically appropriate and cost-effective substitutes for covered services or settings under state Medicaid plans (OHA, 2023). Recent innovations in applying 1115 waivers include health-related social needs such as food-as-medicine interventions, safe housing, and water pollution (Held, 2022).
- Require managed care organizations to focus on prevention and social determinants of health through Medicaid managed care contracts. Examples of this include requiring managed care organizations to provide screening and referral services to address SDoH as seen in Wisconsin, embedding community health worker interventions delivered by culturally and linguistically competent community-based organizations (CBOs) as in Michigan, and collecting data on the housing needs of beneficiaries in Tennessee (ASTHO, 2022).
- Use accountable care organization models to assign providers responsibility for the costs and quality of a defined community’s health.
- Align policies across state health insurance programs like Medicaid, the Children’s Health Insurance Program (CHIP), and state employee insurance, as well as between state insurance programs and state social service entities to better support health outcomes. This alignment could be achieved by standardizing the data collected and eliminating barriers to interagency data sharing to identify gaps in access and track receipt of health-related services and supports across community settings.
- Require that all nonprofit hospitals (those hospitals receiving tax exemptions, as described in footnote 3) engage in multi-stakeholder collaborations to establish and finance locally controlled pools of funds with a neutral community entity as a fiscal agent similar to the Massachusetts Prevention & Wellness Trust Fund program (MPHA, 2019). The fund would create a sustainable mechanism for combining—either through braiding or blending1—financial resources from different sources to build and sustain community infrastructure (Urban Institute, 2022). Goals might include:
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50 percent of community collaborations (such as Accountable Communities for Health) establishing a locally controlled pool of funds, which would be governed by consumer-led advisory councils in 2030. This pool of funds would enable communities to make community-based decisions on allocating resources toward building and sustaining access to community-based interventions, infrastructure, and capacity building;
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50 percent of community collaborations with locally controlled pools of funds allocating sufficient funding for community infrastructure by 2030;
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50 percent of communities developing social service networks consisting of CBOs and entities. The network would specialize in providing services that address needs identified in community health needs assessments (CHNAs) and community health assessments (CHAs) by 2030; and
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50 percent of nonprofit hospitals in each state contributing to locally controlled community funds by 2030 to ensure more health financing is controlled by communities. The amount donated would be the difference between reported charity care as a percent of operating expenses in the current fiscal year and the charity care average of the past 3 years as a percentage of operating expenses.
- Design and require the use of Health Impact Assessments (HIAs)—like Environmental Impact Assessments (EIAs)2—to assess the impact of policy proposals and business activities on health, particularly in sectors where health impacts may not be currently considered (Cole and Fielding, 2007). HIAs could be applied to the creation of new policies, projects, and programs or the implementation of existing ones. HIAs can also inform EIAs, which often do not consider health outcomes. Mandatory HIAs would not force decision-makers to act on the information but would ensure awareness and consideration of the potential health effects when considering programmatic and policy decisions.
- Develop, or require the development of, cross-sector data sharing capabilities to facilitate cross-platform collaboration between public health, insurance, social services, and care delivery information systems. Health information exchanges, all payer claims databases, and social services referral networks are all examples of data aggregators that are not currently integrated in utilizing their data toward realizing whole person, whole population health in an aligned fashion.
Incremental and Intermediate Action
- Require nonprofit health systems to apply community benefit dollars3 toward impact investments that improve social, economic, and environmental conditions in disadvantaged communities while also producing economic returns for investors. Considering that for-profit hospitals in aggregate provided more charity care than nonprofit hospitals per every $100 in total expenses, this action would require the benefits of tax exemptions and subsidies to be passed onto the community (Hyman and Bai, 2022).
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Pursue and use 1115 waivers to cover innovative care and payment models that address social determinants of health. | Transformative | 3.6 | 4 |
| Require managed care organizations to focus on prevention and social determinants of health through Medicaid managed care contracts. | Transformative | 3.4 | 4 |
| Use accountable care organization models to assign providers responsibility for the costs and quality of a defined community’s health. | Transformative | 3.4 | 3 |
| Align policies across state health insurance programs like Medicaid, Children’s Health Insurance Program, and state employee insurance, as well as between state insurance programs and state social service entities to better support health outcomes. | Transformative | 3.4 | 2.8 |
| Require that all nonprofit hospitals engage in multi-stakeholder collaborations to establish and finance locally controlled pools of funds with a neutral community entity as a fiscal agent similar to the Massachusetts Prevention & Wellness Trust Fund program. | Transformative | 4.6 | 3.2 |
| Design and require the use of HIAs to assess the impact of policy proposals and business activities on health, particularly in sectors where health impacts may not be currently considered. | Transformative | 3.4 | 3.4 |
| Develop, or require the development of, cross-sector, data-sharing capabilities to facilitate cross-platform collaboration between public health, insurance, social services, and care delivery information systems. | Transformative | 3.4 | 2.6 |
| Require nonprofit health systems to apply community benefit dollars toward impact investments that improve social, economic, and environmental conditions in disadvantaged communities while also producing economic returns for investors. | Intermediate and Incremental | 3.3 | 3.8 |
Community Benefit Oversight. Nonprofit hospitals comprise about 70 percent of all hospitals in the United States. These hospitals are exempt from federal, state, and local taxes because they meet requirements to provide charity care and other benefits to the community in which they operate (CAP, 2022). However, the U.S. Internal Revenue Code requirements for nonprofit hospitals are relatively general and do not specify a minimum value or type of community benefits that must be provided to receive this exemption. States have the authority to strengthen, clarify, and expand these requirements in service of whole person and population health (CAP, 2022).
Transformative Actions
- Set performance goals to improve health outcomes and transform nonprofit hospitals’ approaches to consumer engagement and care. Key goals to achieve by 2030 could include:
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50 percent of nonprofit hospitals’ CHNAs and community health improvement plans (CHIPs) involve developing and/or engaging in cross-sector collaborations (such as local or regional accountable communities for health) that include consumers in at least 10 percent of activities;
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50 percent of CHNAs and CHIPs reported each year specify the dollar amounts necessary to build effective cross-sector collaborations or sustain those already in existence;
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50 percent of reporting entities’ community benefit investments emphasize or catalyze cross-sector collaborations aligned with priorities identified in local CHNAs and CHIPs; and
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50 percent of cross-sector collaborations formed by reporting entities are community-governed, with at least 20 percent authentic representation of consumers with lived experiences.
Intermediate and Incremental Actions
- Amplify baseline federal requirements to promote meaningful engagement of cross-sector and/or community-governed collaborations in nonprofit hospitals’ CHNAs and public health departments’ CHAs. For example, by engaging community actors in assessing health and social service providers’ capacity as part of the needs assessment process, hospitals and public health departments can look beyond programming focused largely on addressing health conditions toward strengthening community infrastructure to improve wellness more broadly.
- Require the standardization and integration of CHNAs conducted by hospitals within the same health system to yield robust data on unmet health and health-related social needs within a designated service area. The data can then be shared across hospitals and with other community actors to inform system- and community-wide programs to address unmet needs across institutions and local jurisdictions.
- Leverage state authority to make appointments to the boards of public hospitals that ensure meaningful community representation. Require nonprofit hospitals to do the same, as a condition of their tax exemption.
- Use certificate of need decisions to address inequities and disparities relating to access to primary care, geographic location, race, ethnicity, disability status, etc.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Set performance goals to improve health outcomes and transform nonprofit hospitals’ approaches to consumer engagement and care. | Transformative | 3.8 | 3 |
| Amplify baseline federal requirements to promote meaningful engagement of cross-sector and/or community-governed collaborations as key components in CHNAs and CHAs. | Intermediate and Incremental | 2.6 | 3.2 |
| Require the standardization and integration of CHNAs conducted by hospitals within the same health system to yield robust data on unmet health and health-related social needs within a designated service area. | Intermediate and Incremental | 2.4 | 3.8 |
| Leverage state authority to make appointments to the boards of public hospitals that ensure meaningful community representation. | Intermediate and Incremental | 2 | 3.8 |
| Use certificate of need decisions to address inequities and disparities relating to access to primary care, geographic location, race, ethnicity, disability status, etc. | Intermediate and Incremental | 3 | 3.2 |
Insurance Oversight. States have the vantage point to see the health system as a whole in ways that individual providers, payers, patients, and even communities do not, putting them in the position to shape health payment systems through legislation and regulation of commercial payers selling plans to state employers and residents.
Transformative Actions
- Adopt and expand laws and regulations pertaining to health insurance rate review4 and, specifically approval authority. Use that authority to accelerate payer reform, alignment, and whole person and population health. Regulatory targets could include:
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Incorporate considerations around affordability and access, particularly for high-value primary care, into rate review criteria.
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Require disclosures of data on the health status of covered populations, including stratification across factors such as but not limited to race, ethnicity, geographic location, and income.
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Require the creation and implementation of equity plans to ensure that rate increases do not contribute to disparities in affordability and access. A component of this plan should be an assessment of coordination between in-network health systems and community-based organizations to evaluate access to health-related services such as food, housing, and transportation.
Intermediate and Incremental Action
- Leverage state insurance department approval processes to institute usual source of care requirements for fully insured health plans. These requirements could include screening and referral of enrollees to a usual source of care and educating program staff on usual source of care benefits. Requiring a usual source of care in health plans will increase care coordination across behavioral, oral, primary care, and specialty services, thereby improving health outcomes.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Adopt and expand laws and regulations pertaining to health insurance rate review and, specifically, approval authority. | Transformative | 4.2 | 3.2 |
| Leverage state insurance department approval processes to institute usual source of care requirements for fully insured health plans. | Intermediate and Incremental | 3 | 3.3 |
Appropriations. States also have the authority to appropriate and allocate funding toward policies, programs, and services that support whole person and population health, including education, public welfare, health care, infrastructure, legal services, and housing and community development initiatives. Allocation of resources with the goal of improving health would require states to consider and apply a health-in-all-policies approach.
Transformative Action
- Place unspent government funds from pandemic-era legislation such as the American Rescue Plan Act into community-governed pools and allow service beneficiaries and navigators to govern their use toward upstream determinants of health and social services. State dental funding in Hawaii and pooled HIV funding in New York are examples of this approach.
Intermediate and Incremental Action
- Earmark funds for structured training at the local level to strengthen political and health literacy, as well as civic engagement and community governance skills. New Orleans, Louisiana, and Charlotte, North Carolina, are two examples of cities that provide free training to help residents build the necessary skills to improve quality of life in their communities.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Place unspent government funds from pandemic-era legislation such as the American Rescue Plan Act into community-governed pools and allow service beneficiaries and navigators to govern their use toward upstream determinants of health and social services. | Transformative | 3.6 | 2.8 |
| Earmark funds for structured training at the local level to strengthen political and health literacy, as well as civic engagement and community governance skills. | Intermediate and Incremental | 2.8 | 3.4 |
Public Health Agencies and Departments. As discussed in Chapters 1 and 2, public health agencies at all levels of government have been chronically underfunded and underserved, limiting the impact they can have on the communities they serve. Responsible for health promotion and disease prevention, public health agencies are well suited to serve as backbone organizations of multi-stakeholder coalitions to address whole health issues at the local and state levels if properly resourced.
Transformational Actions
- Provided the necessary resources, lead the development of community-wide goals and collective impact strategies to improve health and equity, involving multiple government agencies, nonprofit partners, and the private sector. Support the full engagement of community residents in the process.
- Partner with health care organizations incentivized to better health outcomes to codevelop and lead community programs that advance prevention. Support the full engagement of community residents and local organizations in the process.
Intermediate and Incremental Actions
- Lead coordination of CHAs and CHNAs, so that they provide opportunities for meaningful engagement of community residents, address key determinants of health, and advance prevention across the community, shifting collective emphasis away from individual conditions (such as diabetes and heart disease) to community infrastructure that better supports health.
- Create protocols for systematically assessing the capacity of community health and social service providers to determine how the community as a whole can address service gaps in an efficient, collective, and sustainable way.
- Utilize public health authority as appropriate to allow community-supported strategies to have the greatest impact. For example, if a goal is to reduce falls among the elderly, the health department can receive reports of emergency department visits to identify areas of a community in need of additional resources.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Lead the development of community-wide goals and collective impact strategies to improve health and equity, involving multiple government agencies, nonprofit partners, and the private sector. Support the full engagement of community residents in the process. | Transformative | 4 | 2.4 |
| Partner with health care organizations incentivized to better health outcomes to codevelop and lead community programs that advance prevention. Support the full engagement of community residents and local organizations in the process. | Transformative | 4 | 3.8 |
| Lead coordination of CHAs and CHNAs, so that they provide opportunities for meaningful engagement of community residents, address key determinants of health, and advance prevention across the community, shifting collective emphasis away from individual conditions (such as diabetes and heart disease) to community infrastructure that better supports health. | Intermediate and Incremental | 3.2 | 3.4 |
| Create protocols for systematically assessing the capacity of community health and social service providers to determine how the community as a whole can address service gaps in an efficient, collective, and sustainable way. | Intermediate and Incremental | 2.4 | 3.6 |
| Utilize public health authority as appropriate to allow community-supported strategies to have the greatest impact. | Intermediate and Incremental | 2.5 | 2.3 |
Federal Government
The legislative and executive branches of the U.S. federal government are vested with the power to make new laws or change existing laws and implement or enforce laws passed by Congress, respectively. Where aligned, these two branches of the federal government (the legislative and executive) have substantial latitude to legislate and enforce landmark laws such as the Medicare and Medicaid Act or the Patient Protection and Affordable Care Act (ACA). Given the political will, the federal government could leverage its broad authority to significantly advance additional health-promoting policies and appropriate more resources to support the implementation of health-supporting programs (The White House, 2022a,b).
Transformative Actions
- Expand ACA requirements governing “essential benefits” for plans sold in the individual and small group markets. Added supports and services could include integrative care, home- and community-based services, and caregiver services.5
- Review Employee Retirement Income Security Act of 1974 (ERISA) and large group insurance requirements to add integrative care and home and community services and supports as essential benefits.
- Revise the medical loss ratios (MLRs) used in the ACA to become “health loss ratios” that support health rather than health care. The MLR is a financial metric to ensure health plans provide value to enrollees by spending 80 percent or more of their premium income on health care claims and quality improvement (as opposed to administration, marketing, and profit). A health loss ratio would require plans to spend a certain percentage of their premium income not only on paying medical claims but on proven investments to maintain and improve their enrollees’ health, providing flexibility for health plans and, by extension, health service providers to invest in more non–health care related social drivers and community resources.
- Design and require the use of health impact assessments (HIAs)—like environmental impact assessments (EIAs)6—to assess the impact of policy proposals and business activities on health, particularly in sectors where health impacts may not be currently considered (Cole and Fielding, 2007). HIAs could be applied to the creation of new policies, projects, and programs or the implementation of existing ones. HIAs can also inform EIAs, which often do not consider health outcomes. Mandatory HIAs would not force decision-makers to act on the information but would ensure awareness and consideration of the potential health effects when considering programmatic and policy decisions.
- Supplement federal health care reform efforts to create a federal benefits package that incentivizes an expanded or reconsidered set of “essential benefits” (e.g., home- and community-based services [HCBS],“in lieu of ” services).
- Require that all nonprofit hospitals engage in multi-stakeholder collaborations to establish and finance locally controlled pools of funds with a neutral community entity as a fiscal agent similar to the Massachusetts Prevention & Wellness Trust Fund program (MPHA, 2019). The fund would create a sustainable funding mechanism for combining—either through braiding or blending7—financial resources from different sources to build and sustain community infrastructure (Urban Institute, 2022). Goals might include:
- —
50 percent of community collaborations (such as accountable communities for health) establishing a locally controlled pool of funds, which would be governed by consumer-led advisory councils in 2030. This pool of funds would enable communities to make community-based decisions on allocating resources toward building and sustaining access to community-based interventions, infrastructure, and capacity-building;
- —
50 percent of community collaborations with locally controlled pools of funds allocating sufficient funding for community infrastructure by 2030;
- —
50 percent of communities developing social service networks consisting of CBOs and entities. The network would specialize in providing services that address needs identified in CHNAs and CHAs by 2030; and
- —
50 percent of nonprofit hospitals in each state contributing to locally controlled community funds by 2030 to ensure more health financing is controlled by communities. The amount donated would be the difference between reported charity care as a percent of operating expenses in the current fiscal year and the charity care average of the past 3 years as a percentage of operating expenses.
- Require nonprofit hospitals and health systems to apply community benefit dollars8 toward impact investments that improve social, economic, and environmental conditions in disadvantaged communities while also producing economic returns for investors. Considering that for-profit hospitals in aggregate provided more charity care than nonprofit hospitals per every $100 in total expenses, this action would require the benefits of tax exemptions and subsidies to be passed onto the community (Hyman and Bai, 2022).
- Create a parsimonious set of performance measures that provide meaningful information on the most important outcomes at the individual and community levels. An important model in this respect is presented in the 2015 Institute of Medicine report Vital Signs: Core Metrics for Health and Health Care Progress. These measures could be created by building off Vital Signs measures, and the related work of the Centers for Medicare & Medicaid Services (CMS) on Medicaid HCBS, as well as for Medicare-Medicaid enrollees in its Meaningful Measures initiative. These measures would be whole person (i.e., not focused on one diagnosis or a narrow set of clinical experiences) and inclusive of an individual’s nonclinical needs, preferences, and goals for enhanced health and well-being in ways that matter to the individual. In addition, the measures should be stratified across race, ethnicity, income, and disability to ensure a focus on monitoring and targeting inequities and implicit bias in measure sets.
- Require a 2 to 5 percent withholding from current federal grants to state programs to create a flexible federally funded pool for which localities or states could apply to implement community-governed whole person health improvement strategies. Eligibility would be provided to communities with the worst health outcomes and applicants would include a wide array of participants across the care and services continuum with an aligned governing structure and strategic plan. This funding pool would employ flexible federal requirements across programs that waive existing and conflicting program rules; optimize existing funds to support regional or local whole health interventions; offer tax credits and subsidies for entities that meaningfully participate with funding from the pool; and would require that earned interest be used for social service alignment.
- CMS should stop paying for interventions or services not proven to improve health outcomes (such as low-value care identified by the Choosing Wisely campaign) in the vein of CMS’s 2008 rule ending reimbursement for hospital-acquired conditions. CMS should also increase scrutiny of new and existing therapeutics and adjust their reimbursement policies accordingly, following the example of a 2022 rule requiring Medicare Part D sponsors to establish drug management programs for beneficiaries who are at risk for misuse or abuse of opioids.
Intermediate and Incremental Actions
- Create a funding pool modeled off the CMMI State Innovation Model (SIM) that would incentivize less-resourced states or regions to adopt population-based global budgets, specifically focusing on improving children’s health,9 as communities, health care payers, and providers often need financial support to transition to innovative payment models that support whole person care (e.g., all-payer global budgets).10 For example, Pennsylvania received $25 million from CMS to provide technical assistance and other support through its new Rural Health Redesign Center.
- Increase funding and support for programs that address health-related social factors. Other sources of funding include private philanthropy, foundations, and the global budgets themselves, which can be set up to provide additional room for population health investments (Sharfstein et al., 2017). These programs could be supported in part by providing flexibility and guidance to stakeholders with respect to better unifying federally funded programs across a whole-of-government framework on whole person health and well-being. A focus on whole health would enable the government to fill the gaps between federally funded programs across the U.S. Department of Education (Individualized Education Programs), the U.S. Department of Agriculture (Supplemental Nutrition Assistance Program and National School Lunch Program), the U.S. Department of Health and Human Services (Temporary Assistance for Needy Families, Federally Qualified Health Centers, and Medicaid), the U.S. Department of Labor (workforce development programs), and others. By filling these gaps, the integration of these programs would result in a comprehensive suite of population-based health services and supports. Financial incentives could also be provided to drive collaboration and alignment between Medicaid and social service programs at the state level.
- Create a commission to deliver recommendations to Congress on how to restructure existing health and social service programs to bring greater value to consumers and taxpayers.
- Strengthen and optimize Community Health Needs Assessments to center on community-governed interventions and funding in order to enhance collective financing mechanisms listed in the previous section.
- Pioneer the development and implementation of payment models based on priorities of community-based organizations and designed with their partnership. These payment models would reward health systems for contributing to community health and well-being improvements.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Expand ACA requirements governing “essential benefits” for plans sold in the individual and small group markets. | Transformative | 4.2 | 2.8 |
| Review ERISA and large group insurance requirements to add integrative care and home and community services and supports as essential benefits. | Transformative | 3.6 | 2.6 |
| Revise the medical loss ratios used in the ACA to become “health loss ratios” that support health rather than health care. | Transformative | 4.4 | 3.0 |
| Design and require the use of health impact assessments to assess the impact of policy proposals and business activities on health, particularly in sectors where health impacts may not be currently considered. | Transformative | 3.8 | 2.8 |
| Supplement federal health care reform efforts to create a federal benefits package that incentivizes an expanded or reconsidered set of “essential benefits.” | Transformative | 4 | 2.8 |
| Require that all nonprofit hospitals engage in multi-stakeholder collaborations to establish and finance locally controlled pools of funds with a neutral community entity as a fiscal agent. | Transformative | 3.8 | 2.4 |
| Require nonprofit health systems to apply community benefit dollars toward impact investments that improve social, economic, and environmental conditions in disadvantaged communities. | Transformative | 3.4 | 3.4 |
| Create a parsimonious set of quality measures that provide meaningful information on person-centered health and well-being outcomes. | Transformative | 3.6 | 4.4 |
| Require a 2% to 5% withholding from current federal grants to state programs to create a flexible federally funded pool for which localities or states could apply to implement community-governed whole person health improvement strategies. | Transformative | 3.6 | 3.2 |
| CMS should stop paying for interventions or services not proven to improve health outcomes and increase scrutiny of new and existing therapeutics, adjusting their reimbursement policies accordingly. | Transformative | 3.4 | 3.2 |
| Create a funding pool modeled off the CMMI State Innovation Model that would incentivize less-resourced states or regions to adopt population-based global budgets, specifically focusing on improving children’s health, as communities, health care payers, and providers often need financial support to transition to innovative payment models that support whole person care (e.g., all-payer global budgets). | Intermediate and Incremental | 2.8 | 3.4 |
| Increase funding and support for programs that address health-related social factors. | Intermediate and Incremental | 3.0 | 2.6 |
| Create a commission to deliver recommendations to Congress on how to restructure existing health and social service programs to bring greater value to consumers and taxpayers. | Intermediate and Incremental | 2.0 | 4.4 |
| Strengthen and optimize CHNAs to center on community-governed interventions and funding in order to enhance collective financing mechanisms listed in the previous section. | Intermediate and Incremental | 3.2 | 3.8 |
| Pioneer the development and implementation of payment models based on priorities of CBOs and designed with their partnership. | Intermediate and Incremental | 3.2 | 3.2 |
Examples of how federal government policy changes, actions, and communications can influence a multisector cascade of change, including in state and local governments as well as the financial sector, are detailed in Appendix C.
Care Delivery Organizations and Health Systems
Comprising more than 15 percent of the U.S. economy and standing at the front lines of health care, care delivery organizations, including hospitals and health systems, play a vital role in ensuring the health of patients, families, and communities. To ensure these organizations most efficiently, effectively, and equitably foster whole health, incentives must be restructured to reduce the financial benefits of volume-dependent care and increase the attractiveness of value-based models that incorporate community health workers and other health professionals. Financial incentives must also be directed toward public health, especially social drivers of whole person, whole population health. Moreover, whole ecosystems adjacent to health systems, including information technology infrastructure, schools, and the legal system, must be meaningfully engaged to build the necessary upstream conditions to ensure the key tenets of whole person, whole population health, which include human thriving, sharing data to improve care quality, and targeting population-specific health issues.
Transformative Actions
- Transform the landscape of economic incentives to support whole person health by transitioning 75 percent of the health system reimbursement framework to population-based payments.
- Pursue multilevel approaches to working collaboratively with community stakeholders, such as:
- —
Fair compensation for community health workers;
- —
Credibly and meaningfully integrating community voices into health system strategy and decision-making; and
- —
Building meaningful alliances with a broad ecosystem of CBOs like social services, food and nutrition experts, behavioral health experts, and substance use experts, in addition to law enforcement, emergency response, criminal justice, and schools.
- Invest in information technology infrastructure that can catalyze gains in community health, such as robust information exchange and data-sharing processes between care delivery organizations and CBOs, as well as “digital front doors” (i.e., health kiosks) in the community. Where technology is used by the public, these services should also reduce the digital divide through reduced barriers to access, education on technology navigation and use, and the availability of nontechnological alternatives.
- Screen patients for health-related social needs—such as access to food, shelter, and transportation—and provide closed-loop referrals via community information exchanges to social service entities and community-based organizations that can meet those needs.
Intermediate and Incremental Actions
- Set goals for an increased amount of community benefit dollars and grants spent on evidence-based services and strategies that strengthen whole person, population health and well-being (e.g., public transportation services, nutritious meals programs, and stable housing initiatives).
- Align the compensation structure of senior executives to health system performance on a set of community defined health metrics.
- Establish a community liaison infrastructure within the health system to align activities and create shared expectations with CBOs.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Transform the landscape of economic incentives to support whole person health by transitioning 75% of the health system reimbursement framework to population-based payments. | Transformative | 4.6 | 2.2 |
| Pursue multilevel approaches to working collaboratively with community stakeholders, such as fair compensation for community health workers, credibly and meaningfully integrating community voices into health system strategy and decision-making, and building meaningful alliances with a broad ecosystem of community organizations. | Transformative | 3.8 | 2.6 |
| Invest in information technology infrastructure that can catalyze gains in community health, such as robust information exchange and data-sharing processes between care delivery organizations and CBOs, as well as “digital front doors” (i.e., health kiosks) in the community. | Transformative | 3.4 | 3.4 |
| Screen patients for social determinants of health and health-related social needs and provide closed-loop referrals to social service entities and CBOs that can meet those needs. | Transformative | 4.2 | 4.5 |
| Set goals for an increased amount of community benefit dollars and grants spent on evidence-based services and strategies that strengthen whole person, whole population health and well-being. | Intermediate and Incremental | 3.2 | 3.6 |
| Align the compensation structure of senior executives to health system performance on a set of community defined health metrics. | Intermediate and Incremental | 3.2 | 2.2 |
| Establish a community liaison infrastructure within the health system to align activities and create shared expectations with CBOs. | Intermediate and Incremental | 2.8 | 3.4 |
Payers
By negotiating rates for provider services and setting premium and deductible rates for consumers, private and public payers control key financial levers needed to transform care delivery (Brookings Health System, 2022). As a result, payers’ negotiation, contracting, and other business practices have tremendous power to cultivate whole person, whole population health.
Transformative Actions
- Establish processes to routinely identify the social needs of health plan members and direct investments toward resources to address those needs. Engage entities such as the United Way, CMMI, CMS network lead entities, and others that are either large payers or entities that can credibly convene authentic and diverse community voices (churches, youth groups, school associations, etc.) to surface member needs and priorities.
- Create a population health business model where private payers such as commercial health insurance plans, insurance plan providers, health systems, and, if possible, CMS pay CBOs to create value and improve health and well-being by facilitating healthy opportunities.
- Evaluate and expand on the scope of “essential benefits” (e.g., HCBS, “in lieu of ” services) required under the ACA to include guaranteed coverage for services that produce whole health and well-being.
- Reimburse care delivery organizations, social service entities, and community-based organizations for closed-loop referrals targeting member social determinants of health and health-related social needs.
- Hold health systems accountable to anchor organization11 practices that will promote whole person, whole population health through payer-provider contracts. Examples of these practices include the Anchor Mission approach, which encourages hospitals and universities to create pipelines for local community members to obtain employment and upward mobility within anchor organizations; procure services through local businesses; utilize available cash reserves toward long-term community projects that will enhance sustainability and inclusion; and utilize grants or impact investing to develop affordable housing. These practices also provide opportunities to impact key health system issues such as the fair compensation for community health workers or the need to include historically and/or presently marginalized communities in organizational decisions. Hospitals such as Bon Secours Mercy Health in Ohio and the Richmond University Medical Center in Virginia have implemented elements of this approach.
Intermediate and Incremental Actions
- Pioneer the development and implementation of payment models based on priorities of community-based organizations and designed with their partnership. These payment models would reward health systems for contributing to community health and well-being improvements.
- Build alliances with key community partners (e.g., law enforcement, emergency response, criminal justice, schools, and social services providers) that encourage cooperation within the local ecosystem to support outcomes aligned with the Quintuple Aim. Examples include the BUILD Health Challenge Model and the Washington State Accountable Communities of Health.
- Reduce practice consolidation by implementing payment policies inclusive of small, independent health care practices. This strategy would involve aggregate12 practices across specialties and functions in aggregate entities that are less formally integrated than managed services organizations.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Establish processes to routinely identify the social needs of the health plan members and direct investments toward resources to address those needs. | Transformative | 4.3 | 4.4 |
| Create a population health business model where private payers such as commercial health insurance plans, insurance plan providers, health systems, and, if possible, CMS pay CBOs to create value and improve health and well-being by facilitating healthy opportunities. | Transformative | 4.4 | 3.4 |
| Evaluate and expand on the scope of “essential benefits” required under the ACA to include guaranteed coverage for services that produce whole health and well-being. | Transformative | 3.8 | 3.2 |
| Reimburse care delivery organizations, social service entities, and community-based organizations for closed-loop referrals targeting member social determinants of health and health-related social needs. | Transformative | 3.4 | 3.2 |
| Hold health systems accountable to anchor organization practices that will promote whole person, whole population health through payer-provider contracts. | Transformative | 3.8 | 2.0 |
| Pioneer the development and implementation of payment models based on priorities of CBOs and designed with their partnership. | Intermediate and Incremental | 3.2 | 3.2 |
| Build alliances with key community partners (e.g., law enforcement, emergency response, criminal justice, schools, and social services providers) that encourage cooperation within the local ecosystem to support outcomes aligned with the Quintuple Aim. | Intermediate and Incremental | 3.2 | 4.0 |
| Reduce practice consolidation by implementing payment policies inclusive of small, independent health care practices. | Intermediate and Incremental | 2.8 | 4.0 |
Employers
Employers from all sectors collectively employ more than 164 million people in the United States. Through the work environments they foster and the benefits they offer, employers play a significant role in shaping the health of their employees, as well as others in their communities (BLS, 2022). In addition to creating healthy work environments and providing leadership on community health issues, employers can use their significant collective economic clout to advance employee-driven population health initiatives and negotiate with providers to accelerate the routine delivery of whole person care.
Transformative Actions
- Enhance workforce well-being by establishing an expanded set of “essential benefits” in health benefit packages provided to employees that includes relevant social services (see federal government section for additional detail).
- Establish linkages and partnerships with health care, local government, CBOs, and philanthropies that leverage employers’ position as community cornerstones, which includes:
- —
their ability to influence individual employees within and outside the workplace,
- —
their power as purchasers of health plans, and
- —
the impact of their businesses on the local environment.
- Join forces to apply employers’ collective economic power in their communities to address health-related social challenges impacting members of the community, including employees. An example of one such partnership is the NOLA Coalition, which aims to harness members’ collective resources to create a safer and more prosperous New Orleans through near-term actions to reduce violence, in addition to a 3-year, $15 million program that aims to strengthen social services to support youth and drive generational change (NOLA Coalition, 2022).
Intermediate and Incremental Actions
- Capitalize on sector market power to purchase health plans that provide access to closed-loop referrals that target members’ health-related social needs, including access to food, shelter, and transportation.
- Set minimum expectations for how health plans should contract and collaborate with community-based organizations.
- Incentivize employees through employer-purchased health plans to seek care from in-network practitioners with expertise in health behavior change, healthy lifestyles, and wellness (e.g., lifestyle medicine, integrative medicine).
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Enhance workforce well-being by establishing an expanded set of “essential benefits” in health benefit packages provided to employees that includes relevant social services. | Transformative | 4.0 | 3.8 |
| Establish linkages and partnerships with health care, local government, CBOs, and philanthropies that leverage employers’ position as community cornerstones, which includes: their ability to influence individual employees within and outside the workplace; their power as purchasers of health plans; and the impact of their businesses on the local environment. | Transformative | 3.4 | 3.6 |
| Join forces to apply employers’ collective economic power in their communities to address health-related social challenges impacting members of the community, including employees. | Transformative | 3.4 | 3.0 |
| Capitalize on sector market power to purchase health plans that provide access to closed-loop referrals that target members’ health-related social needs. | Intermediate and Incremental | 3.3 | 3.5 |
| Set minimum expectations for how health plans should contract and collaborate with CBOs. | Intermediate and Incremental | 2.6 | 2.6 |
| Incentivize employees through employer-purchased health plans to seek care from in-network practitioners with expertise in health behavior change, healthy lifestyles, and wellness (e.g., lifestyle medicine, integrative medicine). | Intermediate and Incremental | 2.8 | 2.6 |
Financial Sector Organizations
As of September 30, 2022, the total market capitalization of the U.S. stock market was around $46 trillion, with capital invested in 11 sectors of publicly listed companies, including but not limited to health care, financials, real estate, consumer staples, and energy (MSCI, 2022; Siblis Research, 2022). The substantial overlap and market power of these companies provide a significant opportunity to reshape markets to incentivize and reward whole person, whole population health. The following are opportunities for action for finance leaders both within and beyond the health care sector that would significantly impact how health is valued and financed. These stakeholders include chief financial officers of corporations, investment units within banking institutions, and leaders of venture capital/private equity firms.
Transformative Actions
- Create industry and professional standards (e.g., for hospitals, health plan actuaries, and chief financial officers at all health care organizations) that redefine return on investment (ROI) in a way that explicitly quantifies the economic value of health in the population being served. Consider the business case for financial returns derived from economic productivity driven by better workforce and community health.
- In tandem with the right regulatory incentives, forge partnerships with a diverse array of entities to ensure that financing sources correspond with the entities that benefit from services in terms of ROI. For example, if an asthma remediation effort reduces employee absenteeism (because working parents less frequently have to stay home with asthmatic children), employers should contribute toward the cost of the remediation effort in the community. In forging these partnerships, financial sector organizations should consider the following:
- —
Benefits and their impact across sectors must be captured, defined, and measured.
- —
Subsidies might be necessary if the sum of the benefits, properly mapped to various nongovernmental stakeholders, does not equal the cost of the intervention, as benefits would also accrue to the public sector (e.g., in the form of reduced service needs or program payments). Subsidies could take the form of tax or direct expenditures proportional to the value placed on the benefits accrued by the public sector.
- —
The challenge of ROIs not accruing to specific stakeholders/investors or not accruing fast enough in measuring social services impact and calculating subsidies, as well as funding and implementing health-related social services, must be addressed.
- Form an entity (similar to MedPAC13) that can influence investors to redefine actuarial ROIs, allowing for longer time horizons and a more dedicated focus on collaboration and well-being. This entity would establish common standards and outcome metrics that can be used both for self-accountability and external accountability.
- Create and finance opportunities to improve the health of communities, such as the Healthy Neighborhoods Equity Fund described in Chapter 3 (HNEF, 2022).
- To promote the economic viability of investments that promote whole person health, encourage reporting of financial measures (such as revenue growth) and health measures (such as improved patient-reported outcome measures) over longer time horizons. By de-emphasizing monthly, quarterly, or annual growth, innovative financing models could be given a chance to be fully implemented and delivered before the need for financial returns are required.
- Apply, where possible, an HIA to assess the value of health to financial sector organizations, the impact of specific government or private sector actions on health, and the impact of health or morbidity on a local, community, business, or national level. This assessment may also adopt a framework that accounts for relationships between:
- —
An organization’s actions and its impact on population health;
- —
Population health and its impact on an organization’s reputation; and
- —
Population health status and its impact on society at large.
Intermediate and Incremental Actions
- Recognize and account for the “wrong pocket problem” in calculations investors make, as payers may not be the sole beneficiaries of the returns accrued.
The following table provides an overview of the Steering Group’s judgment of the impact and feasibility of the priority actions described above.
| Priority Action | Category | Impact Rating (1 to 5) 1-least impactful; 5-most impactful | Feasibility Rating (1 to 5) 1-least feasible; 5-most feasible |
|---|---|---|---|
| Create industry and professional standards (e.g., for hospitals, health plan actuaries, and chief financial officers at all health care organizations) that redefine ROI in a way that explicitly quantifies the economic value of health in the population being served. | Transformative | 4.0 | 2.4 |
| In tandem with the right regulatory incentives, partner with a diverse array of entities that benefit from health-related social services to finance them. | Transformative | 3.6 | 2.8 |
| Form an entity (similar to MedPAC) that can influence investors to redefine actuarial ROIs, allowing for longer time horizons and a more dedicated focus on collaboration and well-being. | Transformative | 3.6 | 3.0 |
| Create and finance opportunities to improve the health of communities, such as the HNEF. | Transformative | 3.8 | 3.4 |
| To promote the economic viability of investments that promote whole person health, encourage reporting of financial measures such as revenue growth and health measures such as improved patient-reported outcome measures over longer time horizons. | Transformative | 4.4 | 2.8 |
| Apply, where possible, an HIA that would assess the value of health to financial sector organizations, the impact of specific government or private sector actions on health, and the impact of health or morbidity on a local, community, business, or national level. | Transformative | 3.8 | 2.8 |
| Recognize and account for the “wrong pocket problem” in calculations investors make, as payers may not be the sole beneficiaries of the returns accrued. | Intermediate and Incremental | 3 | 3 |
CONCLUSION
The path toward creating a nation that values whole person and whole population health in an equitable manner requires more than the sum of the transformative and intermediate/incremental actions described in this chapter. Ultimately, change of this magnitude will require shifts in key principles. First, our system must redefine what it means for individuals, communities, and private enterprises to be successful in today’s society. Our current definition of success—quarterly growth, return on investment, and economic gains—must be redefined to, at least in part, recognize the societal value of individual and collective health. Second, each and every stakeholder must leverage their capabilities, invest their resources, and realign incentive structures to promote and purchase health. For example, employers can create conditions to help employees thrive, while clinicians can engage consumers more meaningfully in both personal health and strategy decisions to deliver more meaningful outcomes at the community level. Third, each stakeholder must re-examine the notion of being one entity, organization, or stakeholder whose actions are contained to their specific segment of the system and accept responsibility for their contribution to declining American health and well-being. This realization would open doors for system stakeholders—from insurers and the federal government to the financial sector and patients, families, and communities—to partner and unlock their shared power, volition, and resources to realize the vision of whole person, whole population health. As emphasized by the next chapter, time is of the essence. The nation’s continuing health crisis requires transformative, disruptive action to ensure we can stop the backsliding in overall life expectancy, health equity, and health system performance.
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Footnotes
- 1
Blended and braided funding involves combining two or more sources of funding toward a program or activity. Braided funding pools funding streams toward a single purpose while accounting, tracking, and reporting for each funding source. Unlike braided funding, blended funding does not account, track, or report for each funding source. These strategies can be used to attract limited financing from more than one source to fund needed public policy priorities. However, effectively braiding funding streams requires organizations to track requirements, metrics, and measures of different funders.
- 2
An Environmental Impact Assessment evaluates the environmental consequences of a policy, plan, or project before a decision to move forward is made. It requires decision-makers to consider environmental values in their decisions and to justify those decisions should they decide to implement a plan.
- 3
Almost 70 percent of U.S. hospitals are not-for-profit entities and are therefore exempt from federal, state, and local taxes in recognition of their “community benefit.” Community benefit refers to the activities undertaken by these hospitals to improve the health of the communities they serve. The Affordable Care Act (ACA) added a section to the IRS code that contained new requirements related to community benefits that nonprofit hospitals must meet to qualify for tax-exempt status. These requirements include conducting a CHNA and having a written financial assistance policy for medically necessary and emergency care.
- 4
Health insurance rate review is a process “designed to improve insurer accountability and transparency [by evaluating] whether insurers’ proposed annual rate increases are based on reasonable cost assumptions and solid evidence and [allowing] consumers the chance to comment on proposed increases.” See https://ratereview
.healthcare.gov (accessed October 5, 2022). - 5
The ACA requires health plans in small and individual group markets to cover essential health benefits, which include services in 10 benefit categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. While these essential health benefits reflect comprehensive coverage of health care services, they do not include many services that have been shown to improve health. Expanding this definition of essential health benefits for small group and individual insurance plans to encompass integrative care, home- and community-based services, and caregiver services as appropriate would go far in ensuring people are connected with support to maintain and advance whole health.
- 6
An environmental impact assessment evaluates the environmental consequences of a policy, plan, or project before a decision to move forward is made. It requires decision-makers to consider environmental values in their decisions and to justify those decisions should they decide to implement a plan.
- 7
Blended and braided funding involves combining two or more sources of funding toward a program or activity. Braided funding pools funding streams toward a single purpose while accounting, tracking, and reporting for each funding source. Unlike braided funding, blended funding does not account, track, or report for each funding source. These strategies can be used to attract limited financing from more than one source to fund needed public policy priorities. However, effectively braiding funding streams requires organizations to track requirements, metrics, and measures of different funders.
- 8
Almost 70 percent of U.S. hospitals are not-for-profit entities and are therefore exempt from federal, state, and local taxes in recognition of their “community benefit.” Community benefit refers to the activities undertaken by these hospitals to improve the health of the communities they serve. The ACA added a section to the IRS code that contained new requirements related to community benefits that nonprofit hospitals must meet to qualify for tax-exempt status. These requirements include conducting a CHNA and having a written financial assistance policy for medically necessary and emergency care.
- 9
A new SIM grant focused on children’s health would yield long-term returns on population health (NASEM, 2021). In the past, it has been challenging to justify investments in pediatric health models due to a narrow 3- to 5-year time horizon for measuring returns on investment under the typical performance period for Center for Medicare & Medicaid Innovation models (Podulka and Narayan, 2021). However, with a longer-term focus, investments in children’s health would be easier to defend from a financial perspective. This challenge underscores the need to lengthen the time frame for calculating and evaluating actuarial return on investment.
- 10
A National Academies’ committee recently noted, “Even when there is financial alignment, organizations with fewer resources may not be able to respond … without upfront resources” (NASEM, 2016).
- 11
Anchor institutions are nonprofit or public place-based entities such as universities and hospitals that are rooted in their community through mission, invested capital, or relationships to customers, employees, residents, and vendors.
- 12
Aggregation can be defined as the partial linking of distinct units. These units can include hospitals, practices, claims, electronic health records (EHRs), or any other component within the health care system (Liaw et al., 2017).
- 13
The Medicare Payment Advisory Commission (MedPAC) is an “independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.” See https://www
.medpac.gov/what-we-do (accessed October 7, 2022).
- INVESTMENT GOALS AND PRIORITY ACTIONS - Valuing America’s HealthINVESTMENT GOALS AND PRIORITY ACTIONS - Valuing America’s Health
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