Laura Joszt

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Despite major reports in 2019 and 2021 from National Academies of Science, Engineering, and Medicine (NASEM) calling on the integration of social care into healthcare delivery, the lack of payment reform has stymied efforts by clinicians and healthcare systems to address social barriers to care and social determinants of health (SDOH), according to authors in a paper 

Previous research has shown that comparable countries that spend more on social services versus healthcare services had better outcomes in infant mortality, life expectancy, and potential life-years lost, compared with the United States. Similarly, within the United States, those states with higher ratios of spending on social services and public health also had better outcomes in areas like obesity and mentally unhealthy days.

“The evidence is clear and growing, prompting insurers such as UnitedHealth Group to partner with communities to build housing because it lowers medical expenditures,” the authors wrote. “Other health care organizations are implementing strategies to address social risks and social needs for patients, families, caregivers, and communities.”

However, payment reform is still needed. Some initiatives launched by CMS, such as the Accountable Health Communities model, allow for some flexibility, but these need more development and are not widely adopted.

 focuses on the future of nursing and includes a chapter on paying for equity in health and healthcare. “Payment models can support nurses’ roles and functions to

address SDOH and advance health equity in four key areas: care management and

team-based care, expanded scope of practice, community nursing, and telehealth,” according to the NASEM report.

Despite years of efforts to move away from a fee-for-service system, that remains the way payment systems in the United States primarily pay for healthcare. However, in January 2021, CMS 

 advising how states can leverage existing flexibilities that address SDOH, such as housing-related services and supports, nonmedical transportation, home-delivered meals, and more.

“Unfortunately, our fee-for-service system inherently limits the doctor-patient relationship to what can be accomplished inside the four walls of a clinician’s office,” then-CMS Administrator Seema Verma said in a statement. She added that the guidance “to state health officials highlights strategies by which states can promote a value-based system that fosters treatment of the whole person and lowers healthcare costs.”

“This guidance was released by a Republican administration; these principles are bipartisan and financially smart,” the authors of the 

 article noted. “State Medicaid agencies should use these flexibilities to guide health plans and health care and social care providers.”

They also recommended that CMS “accelerate learning about how integrating health and social care can improve health and reduce health care costs.”

The authors noted that both NASEM reports recommend addressing social risk factors and social needs in alignment with healthcare by expanding the workforce to include social workers and registered nurses. Under fee for service, these workers and the time they spend addressing barriers to care are recognized by Medicare with billing codes, but a physician or other qualified health professional has to initiate the services and be regularly involved.

The authors suggest that social workers and nurses should be able to lead and seek reimbursement for this work, and that making this policy change would also allow organizations in diverse communities to hire and retrain the workforce.

“Payment reform that enables clinicians and organizations to address social barriers to health offers an opportunity to address inequitable health outcomes,” the authors concluded. “As the health care workforce shortage exacerbated by the pandemic worsens, supporting social workers and nurses to address people’s social needs can prevent high-cost, downstream health care and inequitable outcomes.”

Articles

Despite calls for better integration of social care into healthcare delivery, the lack of adequate payment models has stymied efforts to improve health and reduce costs by paying for social interventions.

Improved Payments for Social Care Can Promote Health Equity

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Asembia 2021: George Van Antwerp of Deloitte Dissects the Relationship Between Health Equity and Specialty Pharmacy

Steve Peskin of Horizon BCBS of NJ, executive medical director of Population Health at Horizon Blue Cross Blue Shield of New Jersey, shares forms of value-based contracting between payers and pharmaceutical companies.

Asembia 2021: Steve Peskin of Horizon BCBS of NJ Talks Value-Based Contracting Between Payers & Pharma Companies

Two posters presented at the Academy of Managed Care Pharmacy annual meeting evaluated health care resource utilization (HCRU) among adult patients taking insomnia medications.

 looked at adult patients with hypertension and comorbid insomnia who were treated with older generation insomnia medications. These patients were compared with a matched cohort with hypertension and no sleep disorders.

The researchers used the IBM MarketScan Commercial and Medicare Supplemental Databases to identify eligible patients for the retrospective cohort study. Eligible patients had one or more prescriptions for zolpidem immediate release (IR), zolpidem extended release (ER), trazodone, or benzodiazepines.

They matched 81,502 patients with hypertension and insomnia (H+I) with the control cohort. The H+I patients had higher adjusted odds of emergency department (ED) visits, outpatient visits, and non-insomnia prescription drug use within 12 months of their earliest fill date for an insomnia medication. H+I patients had longer inpatient stays, although they did not have higher odds of inpatient visits, particularly for patients with trazodone, benzodiazepines, or zolpidem IR.

Adjusted total costs per patient per month (PPPM) for the H+I patients was higher relative to the matched cohort ($2,343 vs $1,013). Costs for outpatient, pharmacy, and the ED were higher for almost all H+I patients compared with the matched cohorts. H+I patients taking zolpidem ER were the only H+I patients who did not have higher inpatient costs compared with the control group.

“Results suggest differences by medication class and/or mechanism that warrant further research on the impact associated with newer dual orexin receptor antagonists,” the authors concluded.

, from the same authors and using the same databases, evaluated HCRU and costs associated with insomnia and the same older generation insomnia drugs in adult patients with depression. The 21,027 patients with depression and insomnia (D+I) were matched 1:1 with a control cohort with depression but no sleep disorders.

While the D+I patients in general had higher adjusted odds of ED visits, outpatient visits, and non-insomnia prescription drug use compared with the control, the mean length of stay was not longer for patients prescribed zolpidem ER. Adjusted total costs PPPM were $2,450 for D+I patients compared with $1,095 for the matched controls.

For both posters, the authors noted that since insomnia is underreported or underdiagnosed, some patients with insomnia may have been missed, and that the results may not be generalizable to a non–commercially insured population. For the second poster, the authors noted that a limitation of the study was that it did not control for whether depression was treated.

Treating insomnia with commonly prescribed, older generation medications increases health care resource utilization and costs in patients with comorbid conditions.

Understanding the Economic Burden of Insomnia Treatment in Patients With Comorbid Conditions

Early treatment of multiple sclerosis (MS) is associated with better physical outcomes. Now a Swedish study shows that early treatment may also be associated with better financial ones.

 of the Karolinska Institute and his colleagues divided 3,610 people with multiple sclerosis into two groups, those who started disease-modifying therapy (DMT) within two years of the onset of their disease (early treatment) and those who started DMT two years afterward (delayed treatment). They designed the study so a 95% decrease in annual earning was the main measure of financial outcome.

Multiple Sclerosis Journal — Experimental, Translational and Clinical

showed that patients in the delayed treatment group were more likely to reach that unfavorable financial threshold than the patients in the early treatment group.

Their findings were similar when they looked at slightly smaller group of people with MS and when they were likely to receive “social benefits,” such as a disability pension. Those in the delayed treatment group were more likely to receive social benefits than those in the early treatment group. More specifically, delayed treatment increased the “risk” of receiving benefits by 42%.

Kavaliunas and his colleagues said that this study was to their knowledge the first to examine the association between early and late treatment and the income of MS patients, although they have previously reported findings on early treatment and disability pensions, so the territory is not entirely uncharted. There is also a body of research that has shown an association between MS and lower income and early retirement.

In this study, the drugs that counted as disease-modifying therapy were interferon beta, glatiramer acetate, Tysabri (natalizumab), Gilenya (fingolimod), Rituxan (rituximab), Aubagio (teriflunomide), Lemtrada (alemtuzumab), mitoxantrone, and (Tecfidera) dimethyl fumarate.

“In conclusion, we confirm the benefits of early treatment initiation in the socioeconomic context using the novel and unbiased outcome, also support the idea that it can serve as a precise outcome measure and can be used as a proxy parameter of disability,” Kavaliunas and his co-authors concluded.

Earlier treatment of multiple sclerosis with disease-modifying therapy reduced the chances of a sharp decrease in income, according to Swedish researchers.

Study Shows Early DMT for Multiple Sclerosis Associated With Income Benefit 

Multiple sclerosis (MS) typically affects people in their prime working years, most often striking between the ages of 20 and 50. Rates of unemployment are high. As many as four out of every five people with the neurological condition that affects movement, gait and vision may be unemployed. 

 compares two groups of patients with MS to identify the factors that may influence their likelihood of holding a job.

“While much is known about the demographic and disease variables associated with 

unemployment in MS, less is known about the role of person-specific factors and one's engagement in health-related behaviors,” wrote author 

, Ph.D., senior research scientist at the Center for Neuropsychology and Neuroscience Research of the Kessler Foundation in East Hanover, New Jersey. The 

 funds research into people with disabilities and the employment issues they face.

Previous studies have examined MS and employment but were retrospective. The press release accompanying the publication of Strober’s findings says hers is the first to study the issue prospectively.

Strober’s study included 252 people with MS and divided them into two groups: “at risk” for leaving the workforce (n = 67) and “not at risk” (n = 185). The participants in the “at risk” group reported that they were considering reducing their hours or leaving the workforce altogether because of difficulties related to their MS.

Participants in the study were between the ages of 20 and 64 and were currently employed. They completed an online survey about a number of topics, including work status and history, disease symptoms, personality, coping, self-efficacy and disease management. Participants also completed the Symbol Digit Modalities Test (SDMT), which measures processing speed.

The “at risk” and “not at risk” groups were similar as far as age, gender, education, and disease duration were concerned. There was, though, a difference in disease course: A greater proportion of patients in the “at risk” group had a progressive course (13% vs 3%).

The “at risk” group also reported greater levels of fatigue, sleep disturbance, pain, depression and anxiety. Based on their survey responses, they also had greater levels of neuroticism; lower levels of extraversion, conscientiousness and agreeableness; lower MS self-efficacy; and a greater use of maladaptive coping.

In addition, they reported lower “locus of control” — how strongly people believe that they have power over situations and experiences that affect their lives. The “at risk” group was also less likely to engage in positive health-related behaviors, such as healthy eating, exercise and social/intellectual activities.

“What is perhaps is more novel and exciting about the present findings is the fact that engagement in health-related behaviors, specifically diet and exercise proved to be a significant predictor even when disease and person-specific factors were taken into account,” Strober wrote.

Among the limitations that she noted was almost all (94%) of the patients in the study had a relapsing-remitting course, which was likely because the individuals recruited were still working and at the early stage of being considered “at risk” for unemployment. The study also did not include a measure of disease severity, because it relied on medical information from the patients’ neurologists, many of which did not report something like the Expanded Disability Status Scale.

"Risk of unemployment is highest during the first three to five years after diagnosis, so we need to be able to intervene early to prevent job losses, and their subsequent impact on physical and mental health, as well as on personal and family finances. This study points to factors related to risk of unemployment that may be amenable to early intervention," Strober said in the 

. "While further research is needed, professionals who provide MS care should be aware of the potential impact of this diagnosis on future employment and be prepared to intervene before individuals leave the workforce."

People with MS who are at risk for joblessness have poorer health-related habits and lower “locus of control” scores, according to findings by Kessler Foundation researcher Lauren Strober.