By Brendan Abel, JD
The state’s Prevention and Wellness Trust Fund (PWTF) has run dry, ending (or at least interrupting) innovative, successful health care programs. The fate of that fund is recharging the debate in Massachusetts about who is responsible for preventive health services: the medical profession? Social service organizations or public health agencies? Communities themselves? All of the above? “That is the question of the moment,” says Lauren Taylor, co-author of The American Health Care Paradox: Why Spending More is Getting Us Less (PublicAffairs, 2015).
The PWTF, a $57 million program initiated in 2012 with support from the MMS, funded effective, evidence-based community partnerships through eight regional coalitions in Massachusetts. Those partnerships demonstrably improved health outcomes, reduced costs, and proved that organizations with compatible missions can collaborate to support patients in HIPAA-compliant ways. Now that the initial funding has dried up, the partnerships have either ended or will end soon unless funding is restored.
Addressing Social Determinants
Prevention has been an area of increasing focus in health care over the past decade. The Affordable Care Act, for example, eliminated copayments for wellness exams and vaccinations. But experts believe that the true potential of prevention falls outside the exam room. Studies have shown that health outcomes are driven primarily by social and environmental factors: the social determinants of health (SDOH). Advocates for prevention are asking, “Who owns this problem?” — and, more specifically, “Who should pay for it?”
“It’s the question that I think we should be focusing on from a health and social policy perspective,” says Taylor, a doctoral candidate in health policy and management at Harvard Business School. “Historically, SDOH were thought of as a public health or social services job. It’s really a function of changes in the regulation and financing of medical care that have brought SDOH into the mainframe of what a health system is doing.”
Defining Health Systems’ Role
Movements toward greater population health through payment delivery models — such as accountable care organizations (ACOs) — undoubtedly expand the prevention purview of provider organizations. A Chicago- area hospital recently began subsidizing the housing costs for a cohort of patients with housing insecurity that were among the highest utilizers of emergency department services. The new MassHealth ACO model is intended to fund programs aimed at prevention through partnerships between ACOs and community organizations. But there comes a point at which even a broad-based entity responsible for population health cannot justify covering certain preventative programs (transportation, for example).
In Taylor’s view, it would be poor policy, and unfair, to lay the burden of SDOH fully on the medical profession. On the other hand, she says, “I don’t see a vision of the future where health systems are just ‘doing medical care.’ So the question is how to bring medical professionals and health systems into the fold in a meaningful way and have them work with other types of professionals and organizations. The nitty-gritties of the integration of financing and care delivery are hard work, but I think that is the work before us.”
PWTF as Proof of Concept
Many believe the primary responsibility lies with government. In Massachusetts, the PWTF provides precedent. The initial trust fund was funded through assessments on payers and large hospital systems, and provided tailored, local interventions. These focused on four costly and prevalent health issues: pediatric asthma, falls in older adults, high blood pressure, and tobacco use.
In summer 2017, researchers at the Harvard Catalyst program released results of an evaluation of the first five years of the PWTF. The study confirmed that the PWTF “appears to be a very sound investment from the point of view of improving outcomes and controlling costs.” Clinical gains included a significant reduction in the blood pressure of patients and a projected decrease in falls by more than 3,000 incidents over five years.
How the PWTF Worked
“My sense was that the PWTF was able to achieve small-scale, meaningful two-way interactions between health organizations and community-based organizations or social service organizations,” says Taylor. “Perhaps most importantly, they worked through and around all of the HIPAA concerns. PWTF served as an important, local proof of concept.”
Legislative proposals supported by the MMS have been introduced to provide a sustainable funding source for the PWTF. The Medical Society strongly supports the prompt passage of legislation to refund and modernize the PWTF as an important step in addressing the social determinants of health of the patients of the Commonwealth.
