Top health industry issues of 2018

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Social determinants come to the forefront

The US spends more on healthcare per capita than other developed nations yet lags in outcomes.1 Researchers say social factors such as education, income, nutrition and housing explain the difference.2 As the industry continues transitioning to value-based care in 2018, healthcare organizations should figure out how to address the social factors that affect health.

Greater attention to social factors can affect care utilization patterns, strengthen prevention, and shift services from higher-cost emergency rooms and hospitals to lower-cost primary care settings. PwC estimates that health disparities account for $102 billion in direct medical costs annually.3 Insurers that address them can reduce costs, and providers can improve their brand and reduce their risk in value-based payment schemes.

All health sectors have started to try their hand at social interventions. Some providers and insurers are broadening their care teams to include nutritionists, behavioral health specialists, social workers and community health workers trained in addressing nonmedical health-related issues. Pharmaceutical companies are working to address health disparities at the community level.

A 2016 HRI report estimated that relying on an extended care team that includes nutritionists, social workers and community health workers could save providers $1.2 million a year per 10,000 patients in a value-based payment environment.4 “I spent $300k on my medical education. I’m the most important, right?” said Dr. David Berg, co-founder of Redirect Health, a Phoenix-based company partnering with employers to simplify healthcare for lower-wage employees. “Nope. The most important part of getting good results is not the knowledge of the doctors, not the treatment, not the drug. It’s the logistics, the social support, the ability to arrange babysitting.”

Seventy-three percent of provider executives and 50 percent of payer executives surveyed by HRI said their organization has created or is creating partnerships with allies in local communities—including schools, grocery stores, churches and others—to address social issues. This is important to consumers (see Figure).

Some collaborations already have paid off. In Toledo, Ohio, ProMedica’s screenings and interventions for food insecurity were associated with a 3 percent drop in emergency visits, a 53 percent drop in hospital readmissions and a 4 percent increase in primary care visits.5 In San Antonio, Humana’s Bold Goals program using community partnerships was associated with a 9 percent decrease in “unhealthy days,” the program’s measure of physical and mental health.6

In Memphis, biotechnology company Genentech’s initiatives to address racial disparities in breast cancer outcomes resulted in 80 percent of targeted women taking steps to manage their breast health, such as getting screened or visiting a resource directory.7 Early-stage breast cancer treatment has been found to increase the five-year survival rate by over 70 percentage points—and shave $100,000 off the lifetime cost.8


Expect more attention at the federal and state levels

The Centers for Medicare and Medicaid Services (CMS) granted $157 million this year to 32 healthcare organizations in its two-track Accountable Health Communities Model. The five-year demonstration will test innovative payment and delivery models such as becoming a hub to align community organizations or helping patients connect with such organizations.[9] States are pushing value-based reimbursement models for Medicaid amid probable funding changes in 2018 and may look to Section 1115 Medicaid demonstration waivers under the Affordable Care Act (ACA) that let them test models such as pay for performance or accountable care.[10] Providers should brace for more risk sharing for this population, which is disproportionately affected by social disadvantages.

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Focus on sustainability

Taking social responsibility has helped some organizations engage, maintain and recruit employees. Eighty-four percent of providers said that workforce development and management is important to their success in the next five years. “The millennial generation wants to help people and feel like they’re making a difference,” said Catherine Hamilton, vice president of consumer services and planning at Blue Cross Blue Shield of Vermont. Conversely, organizations that fail to improve their communities may damage their reputations and bring their not for-profit status into question. 

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You can’t fix what you don’t know

Seventy-eight percent of provider executives say they lack the data to identify patients’ social needs. While clinicians routinely gather standard demographic information in their electronic health records (EHRs), social and lifestyle information—beyond tobacco and alcohol use—is spottier.[11] Only 4 percent of clinicians responding to an HRI survey said they use community data sets to fill in the blanks. Data sharing partnerships and cross-sector collaborations will be critical to match patients with the support services they need.

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1 MD Chen, Pauline W, "Spending More and Getting Less for Health Care,” The New York Times, Nov. 21, 2013,

2 Dennis Rosen, "‘The American Health Care Paradox’ by Elizabeth Bradley and Lauren Taylor." The Boston Globe, Oct. 28, 2013, paradox-why-spending-more-getting-less-elizabeth-bradley-and-lauren-taylor/ynV1Sl5n0jZ1FUN817j4XN/story.html

3 PwC analysis using the following: Joint Center for Economic and Political Studies, “The Economic Burden Of Health Inequalities in the United States,” 2009; National Urban League; “State of Urban Health: Eliminating Health Disparities to Save Lives and Cut Costs,” 2012; Bureau of Labor Statistics, “Consumer Price Index,” 2016; Health Affairs, “The Relative Contribution of Multiple Determinants to Health,” 2014

4 PwC Health Research Institute, “ROI for primary care: Building the dream team,” October 2016,

5 Ian Morrison. "Social determinants of health: The ProMedica story." Trustee, Sept. 11, 2017.

6 Bold Goal: 2017 Progress Report. Humana, 2017.

7 David Waters. "Memphis working to close the breast cancer disparity gap." Commercial Appeal (Memphis), Sept. 30, 2015.; CDC - 2017 National Cancer Conference - Examining Cancer Health Disparities: Public Health Responses to a Persistent Trend." Centers for Disease Control and Prevention. Last modified September 20, 2017.

8 "Cancer of the Breast (Female) - Cancer Stat Facts." National Cancer Institute. Accessed Oct. 19, 2017,

Bijou R Hunt, Steve Whitman, and Marc S. Hurlbert. "Increasing Black:White disparities in breast cancer mortality in the 50 largest cities in the United States." Cancer Epidemiology 38, no. 2 (2014), 118-123. doi:10.1016/j.canep.2013.09.009

9 “HHS Announces Accountable Health Communities Model - 2016 - Washington Highlights - Government Affairs.” Association of American Medical Colleges. Last modified January 8, 2016,

10 Paradise, Julia. “Data Note: Medicaid Managed Care Growth and Implications of the Medicaid Expansion.” The Henry J. Kaiser Family Foundation. Last modified April 24, 2017,

11 PwC Health Research Institute, “Clinician Survey,” 2017

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