A new Albany, New York-based independent practice association, focused on improving social determinants of health, has launched an innovative collaboration with a regional not-for-profit insurer. The initiative will give community based organizations in the Capital Region funding and technology access to better coordinate health and wellness services.

Healthy Alliance Independent Practice Association, a new IPA spearheaded by Dr. Jacob Reider, former Deputy National Coordinator for Health IT, bills itself as the first such organization focused exclusively on addressing social determinants.

The IPA is a project of the Alliance for Better Health, first launched in 2015 as part of New York's State Delivery System Reform Incentive Payment program, or DSRIP. Reider is its CEO.

Healthy Alliance's partnership with MVP Health Care (which covers 700,000 members in upstate New York and Vermont) is set to launch later this summer. It will provide funding to the tune of $800,000 for community based organizations in the Albany region.

The money will help those CBOs connect and coordinate with each other and with medical providers via Unite Us, a technology platform designed for referral and tracking around SDOH.

By helping address Medicaid patients' needs for housing, nutrition, transportation and other socioeconomic needs, the aim is to improve health and wellness and reduce unnecessary use of costly healthcare resources.

An added ambition for the project is to help CBOs find most sustainable sources of funding. While such social services groups have often relied on grant funding from states and various charities, such largesse isn't guaranteed.

Healthy Alliance IPA says it can help CBOs by aligning their missions with local managed care organizations – who have similar goals of keeping their members healthy.

"At MVP, we understand the important role that social factors can have on a person’s overall health and how those influences can affect short and long-term outcomes,” said MVP Health Care President Christopher Del Vecchio in a statement.

"Investing in the underlying social, economic, and environmental factors that contribute to an individual’s health, reinforces our commitment not only to the overall health and wellness of our members, but to the entire Capital Region community."

Demonstrating the business case

"I don't think it's debatable that someone who is homeless may not be as healthy as someone who has a roof over their head – whether it's summer and they're living on the streets in July or whether it's winter and they're living on the streets and it's too cold," said Jacob Reider in an interview with Healthcare IT News.

"Food would be another obvious example," he said. "People who are hungry or are not eating well, their health is going to be affected. And there's less obvious, slightly less tangible things around level of education, job training and access to other services such as transportation, or someone who's a recent immigrant. Or even isolation. There's increasing data, especially in literature around the elderly, that isolation is an obvious predictor of reduced health status."

More and more, of course, healthcare providers are beginning to recognize the importance of social determinants – especially as the financial demands of value-based reimbursement help help make the case for better outcomes at lower cost.

Still, as Reider discussed with us earlier this year, the challenges of effectively managing the data demands and patient engagement efforts around SDOH are considerable. But they're not insurmountable.

"I have now learned to think of health as three separate buckets: social health, behavioral health and physical health," he said. "And if we address the first two, I think it's now very clear that the third will be improved – and in fact  the money that we spend in bucket number three will be reduced if we can address number one and two."

"Typically you'll see IPAs nationwide that are independent physician groups that join together in order to contract with health plans. This isn't physician groups; this is community based organizations."

Dr. Jacob Reider, Healthy Alliance Independent Practice Association

This whole endeavor, with the new IPA and its partnership with MVP Health, "is the first step of demonstrating the business case," said Reider. "And the data will show that we're right."

While there may be a certain amount of care coordination between CBOs and medical providers via the United Us platform with this program, the main goal is supporting social programs and helping them better deliver the services they've always done – on a more efficient and sustainable basis.

"The community based organizations that are that are part of this endeavor are all organizations that have previously existed: the food pantry, the homeless shelter, the community outreach team," said Reider. "They've all existed for a long time. And the way that they have been funded is through foundation grants and state funding through various programs. But it's not been connected to help reduce total cost of care."

That's what led to the creation of the Health Alliance IPA, which comprises nearly 30 CBOs in the Albany and great Capital Region.

"This is the first that we know of that is an IPA that's representing community based organizations," he said. "Typically you'll see IPAs nationwide that are independent physician groups that join together in order to contract with health plans. This isn't physician groups; this is community based organizations.

"We're joining all these CBOs together to optimize their services," he added. "And then to commit to the health plans that the services that they're providing are going to align the individuals that are served in the community with better health – and that the consequence of better health will be reduced total cost of care."

'These things need to converge'

So how does it all work? The CBOs "are going to just do what they normally do and then, through technology, we are tracking the services that are provided using Unite Us as a technology platform," Reider explained. "Unite Us is connecting all of these community players, so that referrals are going into the community based organizations and also across, from one CBO to another."

For example, if somebody in a homeless shelter has a cough, "historically the homeless shelter wouldn't have had a network with which to engage them, and then the homeless shelter folks would have called 911 to get them to the ER," he said. "But that's not the appropriate use of the ER."

With this new initiative, the shelter can use the network to refer to primary care. And, by the same token, if a primary care provider recognizes that a patient has a food insecurity challenge or needs housing assistance, they can "make that referral into the network without having to memorize everybody who's in network and make specific referrals," said Reider. "All they need to do is identify the need, and then the network catches the referral."

The platform enables Healthy Alliance to monitor who's getting services, and where.

"We make sure that nobody falls through the cracks. Ands then, working with the health plans –  this arrangement with MVP is an example of something we hope to have more of – we look at utilization from a cost perspective. The health plan has this data. We can compare those two data sets and see which services are correlating with reductions in preventable medical utilization.

Relatively quickly, in other words, insurers, providers and CBOs alike will be able to see from the data what's working and what's not.

"We've been experimenting with these kinds of things for a couple of years, and this is the first time that we're doing it in collaboration with a health plan, and that's what's exciting about this activity," said Reider. "I think one of the lessons learned here is that these investments that have historically had been disconnected from the medical community need to be connected to the medical community so that there's accountability on all sides.

"We've certainly learned that in the last couple of years," he added. "That's been the messaging from HHS Secretary Alex Azar and CMS Administrator Seema Verma nationally. And the messaging here in New York from our Department of Health, their value-based payment roadmap even includes projections that these sorts of payments could be included in medical loss ratio – meaning, this isn't administrative spend, this is akin to medical spend."

In other words, federal and state governments are both "starting to recognize that these investments should be considered investments into individuals' health," said Reider. "And that's just now starting. These things need to converge so we can think of it all as one thing – health – rather than separate things: social, behavioral and physical."