Housing as Health Care — New York's Boundary-Crossing Experiment (New Eng Jour Med)
We need more of this type of planning and implementation. ~ pinto
Housing as Health Care — New York's Boundary-Crossing Experiment
Kelly M. Doran, M.D., M.H.S., Elizabeth J. Misa, M.P.A., and Nirav R. Shah, M.D., M.P.H.
N Engl J Med, December 19, 2013
Among the countries in the Organization for Economic Cooperation and Development (OECD), the United States ranks first in health care spending but 25th in spending on social services. These are not two unrelated statistics: high spending on the former may result from low spending on the latter. Studies have shown the powerful effects that “social determinants” such as safe housing, healthful food, and opportunities for education and employment have on health. In fact, experts estimate that medical care accounts for only 10% of overall health, with social, environmental, and behavioral factors accounting for the rest. Lack of upstream investment in social determinants of health probably contributes to exorbitant downstream spending on medical care in the United States. This neglect has ramifications for health outcomes, and the United States lags stubbornly behind other countries on basic indicators of population health.
The role of social determinants of health, and the business case for addressing them, is immediately clear when it comes to homelessness and housing. The 1.5 million Americans who experience homelessness in any given year face numerous health risks and are disproportionately represented among the highest users of costly hospital-based acute care. Placing people who are homeless in supportive housing — affordable housing paired with supportive services such as on-site case management and referrals to community-based services — can lead to improved health, reduced hospital use, and decreased health care costs, especially when frequent users of health services are targeted. These benefits add to the undeniable human benefit of moving people from homelessness into housing.
With runaway Medicaid costs crippling states throughout the country, leaders are looking for innovative solutions to bend the cost curve. We in New York State are testing one such innovation: investment in supportive housing for high-risk homeless and unstably housed Medicaid recipients. These recipients include not only people living on the streets or in shelters but also thousands boarding in nursing facilities, not because they need the level of care provided but because they lack homes in the community to which they can return. New York Medicaid payments for nursing-facility stays are $217 per day, as compared with costs of $50 to $70 per day for supportive housing. Furthermore, preventing even a few inpatient hospitalizations, at $2,219 per day, could pay for many days of supportive housing.
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To truly reform U.S. health care and lower costs, we suggest that it's time to broaden our thinking and spending to reach outside conventional health care silos. Social determinants of health should be central to mainstream discussions and funding decisions about health care. For many patients, a prescription for housing or food is the most powerful one that a physician could write, with health effects far exceeding those of most medications. We envision a Medicaid system in which spending on social determinants of health such as housing is not only allowable, but recognized as a best practice. Work toward this goal could begin through state Medicaid waivers and demonstration projects, which would produce evidence to guide best practices that could then be expanded through federal law and incentives. New York's plan to use Medicaid for supportive housing represents one such experiment that crosses traditional boundaries to improve care for high-need, high-cost Medicaid recipients.
http://www.nejm.org/doi/full/10.1056/NEJMp1310121?query=TOC
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