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Social Determinants of Health
March 6, 2020

Putting Health at the Center of Care Management

Author Affiliations
  • 1Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 2Center for Public Health Initiatives at the University of Pennsylvania, Philadelphia
JAMA Health Forum. 2020;1(3):e200219. doi:10.1001/jamahealthforum.2020.0219

Health care systems across the US face a perennial financial challenge, with just 5% of patients accounting for half of health care spending. Certainly, those patients themselves are suffering. In 2011, Dr Jeffrey Brenner surged to prominence with a New Yorker profile describing his “strange new approach to health care,” which involved intensive attention to patients with the most complex, and also the costliest, health and social needs. Brenner created the Camden Coalition of Healthcare Providers in 2002, expanding the care team to include not just doctors, nurses, and social workers but also community health workers who understand the challenges of hardship in a city like Camden, New Jersey, where more than one-third of residents are poor.

The health care community has watched closely as the Coalition has built its program, its reputation, and its funding through philanthropic and government support, including a MacArthur Genius Award for Dr Brenner in 2013. For some observers, Camden has represented a hope that health care could do something transformative to heal lives and bodies worn by decades of discrimination and system failure, while also containing costs. Many health systems have optimistically pursued similar care management programs.1

That optimism was punctured by a recent randomized controlled trial by Finkelstein and colleagues.2 The study reported a straightforward bottom line:

“[Hospital] readmission rates were not lower among patients randomly assigned to the Coalition’s program than among those who received usual care.”2

This news was deflating, for sure. But for health system champions of addressing social needs and the social determinants of health, this is a moment of reckoning. We have much to learn from this study and others like it.

First, mind your end points. Though the recent randomized controlled trial findings were null, the research question was narrow. Finkelstein and colleagues chose an objective, readily available primary end point—any hospitalization within 6 months. That end point imperfectly captured the broader stated goals of the Camden Coalition: to improve health and reduce unnecessary health care utilization. Researchers tend to measure things that are easy to measure, even if they are not the most vital things to measure. We lean away from studying phenomena (eg, functional status) that are important—or even predictive of mortality—but more difficult to assess.3 From the study by Finkelstein et al, we know little about whether the Coalition’s care improved health and nothing about patients’ perspectives. For all studies of care management, the primary caution is that end points should capture the range of programmatic goals, including, in this case, measures of both health (eg, with patient-reported outcomes) and health care utilization (eg, with administrative data).

Second, match your intervention to your patients, or your patients to your intervention. Care management models cannot realistically answer every complex patient’s needs. Lifelong exposure to trauma and socioeconomic deprivation—common among patients with profound health and social needs—exacts a blow to health not easily reversed, even through the exhaustive efforts of multidisciplinary care teams. All the care navigation and primary care access in the world won’t house a person experiencing homelessness, and we know that housing is a critical component of health, as demonstrated in Housing First studies. Chronically ill patients with mental illness fare better in terms of health and social outcomes as well as health care utilization if they are first securely housed. In care management studies, it may be unreasonable to anticipate favorable health and health care utilization outcomes if patients’ most pressing social needs are not addressed by the intervention.4 Nonetheless, there is promising evidence that care management programs make sense for some groups of patients, notably those affected by conditions (such as diabetes and heart failure) that are responsive to short-term behavior changes achieved through coaching, improved primary care and medication access, and practical support.5,6 Care management programs, which themselves are heterogeneous, should not be expected to work equally well for all high utilizers.

Third, in evaluating care management programs, we can clarify our values and measure how well we are upholding them. A core value in health care is to improve the health of patients and populations. If care management can enhance patients’ health, quality of life, or functional status, then that is success. But in our evaluations, we must contend with more complex and often competing motivations. We implement care management programs to improve the lives and health of patients who are high utilizers, believing that fixing their problems will solve health care challenges that are not of their making. The problem is not the patient. The problem is a broken health care system in which it can cost $25 000 to spend an afternoon in the emergency room to have an abscess drained, as recently happened to one of our family members. This inflated cost is not about the patient herself, whose need was routine and readily resolved. Instead, the price tag reflects financial bloat in health care with many causes. Hospitals’ profit margins, averaging 8%, are higher than they have been in decades. The pharmaceutical and medical device industries enjoy still higher margins of 26% and 12%, respectively. Administrative costs in the US eclipse those in other nations, though care utilization is roughly comparable across high-income countries.7 CEO salaries at major nonprofit health systems climbed from an average of $1.6 million in 2005 to $3.1 million in 2015. Putting our most vulnerable patients on health care diets will not solve these escalating costs.

As we reflect on care management programs, we should ask whether the solutions to patients’ needs may be different from the solutions to unbound health care costs. The findings of Finkelstein and colleagues can prompt us to reexamine the goals of care management, our approaches to evaluation, and our cost-containment strategies. These findings also provide a wake-up call to reassert an emphasis on patients’ health. To rein in the high costs of health care, we should look to those who profit most—and not just to those who suffer most—in order to find the fat in the system and cut it.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Carolyn C. Cannuscio, ScD, University of Pennsylvania, 3620 Hamilton Walk, Anatomy Chemistry Bldg, Room 145, Philadelphia, PA 19104 (cannusci@wharton.upenn.edu)

Conflict of Interest Disclosures: The authors have both taught at and worked with past and current affiliates of the Camden Coalition but have not been directly employed by the organization.

References
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Scott  WK, Macera  CA, Cornman  CB, Sharpe  PA.  Functional health status as a predictor of mortality in men and women over 65.   J Clin Epidemiol. 1997;50(3):291-296. doi:10.1016/s0895-4356(96)00365-4PubMedGoogle ScholarCrossref
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Mackelprang  JL, Collins  SE, Clifasefi  SL.  Housing First is associated with reduced use of emergency medical services.   Prehosp Emerg Care. 2014;18(4):476-482. doi:10.3109/10903127.2014.916020PubMedGoogle ScholarCrossref
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Sochalski  J, Jaarsma  T, Krumholz  HM,  et al.  What works in chronic care management: the case of heart failure.   Health Aff (Millwood). 2009;28(1):179-189. doi:10.1377/hlthaff.28.1.179PubMedGoogle ScholarCrossref
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Taylor  CB, Miller  NH, Reilly  KR,  et al.  Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes.   Diabetes Care. 2003;26(4):1058-1063. doi:10.2337/diacare.26.4.1058PubMedGoogle ScholarCrossref
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Papanicolas  I, Woskie  LR, Jha  AK.  Health care spending in the United States and other high-income countries.   JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150PubMedGoogle ScholarCrossref
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