Money Moves the Mare: The Response of Community-Based Organizations to Health Care's Embrace of Social Determinants

Abstract

Policy Points Health policies that encourage health and social integration can induce community-based organizations (CBOs) to adopt new ways of working from health care organizations, including their language, staffing patterns, and metrics. These changes can be explained by CBOs' perceptions that health care organizations may provide new sources of revenue. While the welfare implications of these changes are not yet known, policymakers should consider balancing the benefits of professionalizing CBOs against the risks of medicalizing them.

Context: Recent health policies incentivize health care providers to collaborate with community-based organizations (CBOs), such as food pantries and homeless shelters, to address patients' social determinants of health (SDOH). The perspectives of health care leaders on these policy changes have been studied, but the perspectives of CBO managers have not.

Methods: Our research question was: How are CBOs in Massachusetts perceiving and responding to new Medicaid policies that encourage collaboration between health care organizations and CBOs? We interviewed 46 people in leadership positions at CBOs in Massachusetts for approximately an hour each. We analyzed these data abductively, meaning that we iterated between inductively coding transcripts and consulting existing theories and frameworks.

Findings: We found evidence of a knowing-doing gap among CBOs. Even though CBOs value their distinctiveness and autonomy from health care, they have undertaken a series of organizational changes in response to the new Medicaid policy that make their organizations appear more like health care organizations. These changes include adopting new performance metrics, hiring clinical staff to the board and senior management positions, and using medical language to describe nonmedical work. Drawing on institutional theory, we suggest that the nonprofits undertake such changes in an effort to demonstrate legitimacy to health care organizations, who may be able to provide new sources of critically needed revenue.

Conclusions: Massachusetts CBOs perceive health systems as potential sources of revenue, due in part to an ongoing Medicaid redesign that encourages the integration of health and social services. This perception is driving CBOs to appear more like health care organizations, but the impacts of these changes on welfare remain unknown.

Keywords: community-based organizations; knowing-doing gap; medical sociology; social determinants.

Figure 1

CBOs’ Knowing‐Doing Gap

Figure 2

Explaining CBOs’ Behavior Through the Lens of Institutional Theory