In the US healthcare system, one of the impediments to investments “upstream” of medical care — investments that could help improve health outcomes for individuals and control costs for insurers and healthcare providers — has been that investors may well not be the beneficiaries of their own investments. United Way, in its growing role as a convener and coordinator among disparate agencies in issues around social service and health care, sought a solution to that conundrum.
“This grew out of our Accountable Health Communities work,” recalls Jennifer Kons. “We had an advisory board composed of social service providers, health insurers and healthcare providers, public health departments, foundations, policy advocates, and other stakeholders. We wanted toget everybody on the same page to try to betteralign health care and social services.
So, in 2018,we brought in guest speakers. Our first was Lauren Taylor [a Ph.D. health policy and management researcher]. She had co-written a book called The American Healthcare Paradox, which asks why is it that the US outpaces other countries on healthcare spending but is near the bottom of the pack on quality outcomes. One conclusion that she came to was that we spend a lot on health care and not so much on social services or on the safety net itself, so we invited her to talk about that. She had also just published an article in Health Affairs that proposed a new model to bridge that gap.
That new model is the Collaborative Approach to Public Goods Investment (CAPGI), co-created by Taylor along with health economist Len Nichols, Ph.D. The general idea is to enlist a trusted broker—locally, United Way of Greater Cleveland—to get all the stakeholders to agree on a research-informed intervention, and then solicit confidential bids from the various interested parties that estimate the value of the intervention to that organization.
Then the investments are pooled. In this way, a collective upstream investment can be made to apply the intervention, without putting any one interested party at disproportionate risk.
The first cycle of the local CAPGI project in Cleveland, running during 2021 and 22, funded and evaluated Nutrition Solution, a program of social service provider Benjamin Rose Institute on Aging. “Nichols and Taylor picked 10 cities,” says Kons, “that already had a group of stakeholders at the table who were ready and interested and had community input.” Cleveland was one of those 10.
The initial goal in Cleveland was to deliver a program called Nutrition Solution to adults with chronic disease who experienced food insecurity and social isolation and then evaluate the intervention’s impact on their health care cost and utilization. Over 400 individuals initiated Nutrition Solution and 60% of those who stayed at least one month participated for five months or more.
Investors in the program include Buckeye Health Plan (Centene), CareSource, Cleveland Clinic, Humana, The MetroHealth System, Molina Healthcare Ohio, Mt. Sinai Health Care Foundation, Sisters of Charity Foundation, Sisters of Charity Health System, UnitedHealthcare Community Plan of Ohio, and Western Reserve Area Agency on Aging.
The first pilot focused on socially isolated adults 50 and older who have specific chronic illnesses and deal with food insecurity to receive weekly wellness calls, nutrition education, and home delivery of medically tailored meals.
Evaluation of the first cycle is underway. “We’re using several different mechanisms,” says Shelby McGhee, Associate Director of Health. “We looked at our processes and what worked as far as how we worked with our referring investors and the service delivery partner. We also looked at the actual outcomes of the evaluation with our customer clients: did they like the food, was the customer service good, and what did their self-reported health outcomes look like?
“Looking at the actual cost outcomes, there was variability between different kinds of investors. We’re able to share findings from across investors so we can all learn faster. Preliminary results indicate that the project is associated with significant cost savings for participants with the most chronic conditions and costly care, indicating those with more exacerbated health conditions. Next, we’re looking at the results of these evaluations and having one-on-one meetings with investors, not only about what was successful to get the most monetary value, but what else they hope to achieve.”
Round two of the pilot will apply lessons from the first round, again with guidance from Nichols and Taylor. After that, investors will have sufficient information to partner directly with organizations like Benjamin Rose Institute on Aging to continue the work beyond the pilot.
