Dear friends,

Five years ago, I wrote that in the quest to address health-related social needs, we could begin by improving the transactions between healthcare and social-service providers—but we could not end there. To move the needle on social needs and broader health equity, we had to invest in the relationships between patients and caregivers, healthcare and social-service professionals and institutions, and leaders across sectors. Those relationships are the fuel to drive our work from transactional to transformational.

Now, a growing movement to address health-related social needs through Medicaid is bringing this imperative to a whole new scale. The impact of investing in institutional relationships is not incidental. In fact, a 2016 study published in Health Affairs demonstrated that the density of relationships among population-health organizations in a community correlates with lower mortality. Community social capital, as this resource is called, has the potential to be lifesaving.

This power was palpable at a recent meeting of 120 community-based organizations (CBOs) in Southern California, all partnering with a Medicaid managed care organization to provide social services through California’s Medi-Cal transformation initiative, CalAIM. Many of them have been pursuing health equity for years in isolation. Now they are seizing the opportunity (and challenge) to build systems of coordinated care, often from scratch.

Yet when I talked with them, many of their concerns were not just about the technical challenges and transactions of billing and referrals but about how to improve and sustain the quality of institutional relationships in their community.  This is how I answered three of their core questions:

1. How do we sustain this work?

I see three key strategies here. (a) We can build the capacity of regional hubs to manage the contracting and billing administration that many small CBOs don’t have the capacity or training to do. (b) In calculating these partnerships’ return on investment, we should assess impacts beyond short-term financial gains. The ROI Calculator, created by HealthBegins, the Commonwealth Fund, and the SCAN Foundation, is a powerful starting point. But we also help partners assess their value of investment across a range of outcomes, including quality and safety, utilization, patient experience, employee satisfaction, institutional reputation, and community health equity. (c) We should consider how to share the upside rewards of this work, not just the downside risks, with CBOs, so that they can keep doing it.

2. How do we deepen our partnerships?

We need to test and innovate new partnership models, both strategic and financial. This means that (a) we must evolve our health equity work from a patchwork of programs to a portfolio of investments, addressing the drivers of inequity at multiple levels. This way, our work becomes more about outcomes than mere compliance, and our partners become essential colleagues, not just contractors. (b) We can develop new financial incentive models, such as those already being tested through the federal ARPA-H HEROES program, which incentivizes preventive care by pooling funds from “outcomes buyers” to pay for health outcomes for an entire geographic population.

3. How do we stay engaged and excited about this work even as we get into the weeds?

The first answer may be unexpected. It is (a) to develop narratives and expand storytelling. Stories are an age-old mechanism to stir hearts and sustain energy, and can pack more power than our strongest data can alone. Yet sourcing, crafting, and telling stories effectively requires specific skills, which can be learned. We should be as diligent in this practice as we are in our technical operations. (b) As we move from managing a patchwork of programs to place-based portfolios, we need to go beyond only delivering services to reallocating power and resources to promote healing and justice. This means supporting efforts led by institutions as well as equity-focused power-building groups, and investments in cross-sector infrastructure and cooperation. These investments—both financially and relationally—are the means by which we improve our work and build the community social capital that saves lives.

When writing in 2019, I articulated HealthBegins’ commitment to driving transformational, not just transactional, improvement. Now is a time to redouble it:

Wherever and with whomever we work, we will strive to transform both the relationships and the social structures that influence health, not only the transactions of care. We invite you to make that commitment, too.

Best,

Rishi Manchanda, MD, MPH.