Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care

Abstract

Importance: Health-related social needs are increasingly being screened for in primary care practices, but it remains unclear how much additional financing is required to address those needs to improve health outcomes.

Objective: To estimate the cost of implementing evidence-based interventions to address social needs identified in primary care practices.

Design, setting, and participants: A decision analytical microsimulation of patients seen in primary care practices, using data on social needs from the National Center for Health Statistics from 2015 through 2018 (N = 19 225) was conducted. Primary care practices were categorized as federally qualified health centers (FQHCs), non-FQHC urban practices in high-poverty areas, non-FQHC rural practices in high-poverty areas, and practices in lower-poverty areas. Data analysis was performed from March 3 to December 16, 2022.

Intervention: Simulated evidence-based interventions of primary care-based screening and referral protocols, food assistance, housing programs, nonemergency medical transportation, and community-based care coordination.

Main outcomes and measures: The primary outcome was per-person per-month cost of interventions. Intervention costs that have existing federally funded financing mechanisms (eg, the Supplemental Nutrition Assistance Program) and costs without such an existing mechanism were tabulated.

Results: Of the population included in the analysis, the mean (SD) age was 34.4 (25.9) years, and 54.3% were female. Among people with food and housing needs, most were program eligible for federally funded programs, but had low enrollment (eg, due to inadequate program capacity), with 78.0% of people with housing needs being program eligible vs 24.0% enrolled, and 95.6% of people with food needs being program eligible vs 70.2% enrolled. Among those with transportation insecurity and care coordination needs, eligibility criteria limited enrollment (26.3% of those in need being program eligible for transportation programs, and 5.7% of those in need being program eligible for care coordination programs). The cost of providing evidence-based interventions for these 4 domains averaged $60 (95% CI, $55-$65) per member per month (including approximately $5 for screening and referral management in clinics), of which $27 (95% CI, $24-$31) (45.8%) was federally funded. While disproportionate funding was available to populations seen at FQHCs, populations seen at non-FQHC practices in high-poverty areas had larger funding gaps (intervention costs not borne by existing federal funding mechanisms).

Conclusions and relevance: In this decision analytical microsimulation study, food and housing interventions were limited by low enrollment among eligible people, whereas transportation and care coordination interventions were more limited by narrow eligibility criteria. Screening and referral management in primary care was a small expenditure relative to the cost of interventions to address social needs, and just under half of the costs of interventions were covered by existing federal funding mechanisms. These findings suggest that many resources are necessary to address social needs that fall largely outside of existing federal financing mechanisms.

Figure 1.. Model Diagram

The model first simulates individual patients of any age who visit a primary care practice for health care and estimates their self-reported social needs in the domains of food, housing, transportation, and community-based care coordination; simulates their enrollment in existing programs to address those social needs; and simulates their eligibility and enrollment rates after screening and referral from their primary care practice to additional social needs interventions. The model computes the associated costs of the interventions by annual screening and referral within their primary care practice for social needs, with associated costs to the practice of training and deployment of a standardized, validated screening instrument, education and counseling to patients concerning their rights and social service options, and closed-loop electronically facilitated referrals. Enrollment in each program was simulated using data on program enrollment rates among those eligible and referred (Table 1) to account for both limited program capacity and the proportion of people who may not enroll for other reasons (eg, application difficulty). For patients ineligible for existing federally funded programs or not enrolling in them, the costs of providing additional, non–federally funded, evidence-based interventions were computed (Table 1; eMethods in Supplement 1). CHW indicates community health worker; FQHC, federally qualified health center; HRSN, health-related social needs; HUD, US Department of Housing and Urban Development; NHANES, National Health and Nutrition Examination Survey (2015-2018); NHIS, National Health Interview Survey (2015-2018); SNAP, Supplemental Nutrition Assistance Program; and WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Figure 2.. Projected Program Eligibility and Enrollment Rates for Social Needs Interventions

Rates determined for those identifying a need in the study sample of civilian, noninstitutionalized people in the US who reported visiting a primary care practitioner (weighted N = 251 406 318), based on the National Health and Nutrition Examination Survey (2015-2018), matched to the National Health Interview Survey (2015-2018). Household food insecurity was defined as moderate to severe food insecurity by the Department of Agriculture 6-item measure; housing insecurity as severe housing insecurity defined by having no housing, transient or other nonpermanent housing, or self-report of inability to afford current housing; transportation insecurity as reporting delay in getting necessary medical care in the past year due to inadequate transportation; and care coordination needs as having 2 or more chronic medical conditions or a history of hospitalization in the past year, corresponding to the most common inclusion criteria in the reviewed community-based care coordination studies.^,, Both the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were simulated, as well as programs to address persons not eligible or not enrolling in such programs; as a result, by definition, the any program eligibility spans all persons in need in a given category. Error bars indicate 95% CI. Programs are further described in Table 1.

Figure 3.. Projected Costs of Social Needs Interventions

Rates determined by subpopulation (A) and expenditure type (B) for civilian, noninstitutionalized people in the US who reported visiting a primary care practitioner (weighted N = 251 406 318), based on the National Health and Nutrition Examination Survey (2015-2018), matched to the National Health Interview Survey (2015-2018). The overall cost statistic represents a weighted mean of the subgroups, calculated using 2022 US dollars. Hence, while the highest Area Deprivation Index (ADI) tracts have a higher spending and the lowest ADI tracts a lower spending than the average, the overall statistic reflects the national mean. Error bars indicate 95% CI. FQHC indicates federally qualified health center.