By Kathryn Jantz and Eva Batalla-Mann

Health-and-social-care partnerships have a narrative problem disguised as a math problem. And this problem is hindering the partnerships that would bring critical services to communities, sustainability to social-care organizations, and value to health care.

To understand why, consider the challenge faced by community recreation centers.

Community recreation centers provide infrastructure, resources, and support that undoubtedly improve the health of their patrons. Their offerings include life-changing programs like group classes for older adults, life-saving training like swim lessons, evidence-based health interventions like diabetes prevention programs, critical respite for parents such as “parents’ night out,” and more. Yet recreation centers have struggled to establish contracts with healthcare partners that would make their work scalable and sustainable, thereby ensuring needed support for low-income community members.

In every sense, the devil is in the details. Recreation centers and other community-based organizations (CBOs) have found that when they are able to contract with healthcare partners, the arrangement often doesn’t support their normal operations. For example, a health plan may cover recreation center membership for one person when the recreation center’s model is based on providing family memberships, or it may pay only for visits when the recreation center’s preferred model is monthly membership. Other CBOs report similar challenges, such as health plan contracts that require the provision of medically tailored meals in multiples of ten when the CBO typically delivers them in units of eight. More broadly, the reimbursement may simply be too low. The result is contracts that social-care providers cannot reasonably execute without restructuring their organizations or operating at a loss.

These contracting difficulties erupt in the contracting process but are directly tied to something far more foundational: beliefs around the value of the investment of addressing social needs.

The challenge springs from our cultural narrative: the stories we tell ourselves about what we value and how we measure that value. When pondering a potential investment, an improved dialysis machine may feel like it is worth more than supportive housing. New pharmaceuticals to address heart disease seem like a no-brainer; regular food deliveries may not. These instincts grip us despite the sometimes marginal impact of the former and the often profound impact of the latter. Even when we wield the language of data and science, cultural biases persist, often hidden even from ourselves: well-meaning Upstreamists working hard to do the right thing for communities and the healthcare systems we operate in.

Consequently, CBOs across the country face contracting challenges that stall or halt meaningful health-and-social-care partnerships that would make these essential programs more sustainable. 

HealthBegins has been working with health and social care partners to use a Value on Investment approach to articulate and measure program impact beyond short-term financial returns so as to build sustainable and scalable contracts. However, we have increasingly seen that even when partners work to shift their perspective on returns and value, ingrained cultural biases do not disappear. 

Cultural assumptions about the inherent value of social care are ever present and can impact the decisions of partners with even the best intentions. These biases can be especially tricky to spot in the context of investment conversations, which appear on the surface to be quantitative and unbiased. We instinctively believe that math doesn’t lie—but the truth is that our calculations are only as good as the assumptions that underpin them. 

Our recent work supporting CBOs to articulate the value of their programs has shown us just how vital it is to look broader and deeper than our usual impact measures and examine the cultural values that shape them.

In January 2024, HealthBegins launched a pilot Value on Investment (VOI) Accelerator to support organizations navigating the complex world of VOI. Participating CBOs hailed from California, Delaware, Georgia, Montana, New York, Ohio, Pennsylvania, South Carolina, and Washington and provided a range of services including medically tailored food, care coordination or navigation, interpersonal violence interventions, and perinatal support. The assumption behind this accelerator was that by helping CBOs clearly articulate VOI for healthcare investors, a CBO’s path to sustainable and scalable contracting would be smooth. 

We found that the reality was more complicated. Using the combined frameworks of Return on Investment and Value on Investment did help CBOs more accurately and completely communicate their value. For some healthcare organizations, this more complete articulation was enough to move forward with more sustainable contracting. Yet for many, this was insufficient because underlying cultural beliefs around social services ultimately undercut the value of the CBO’s program. 

This experience earned us a critical lesson. We had assumed that the primary barrier to contracting was difficulty aligning health care’s needs and priorities with the value of social care. Yet it turned out that even when that alignment was perfect, the discussion with healthcare partners often went in perplexing directions, with rhetoric we wouldn’t expect to hear about investments in a new x-ray machine or pharmaceutical.

The lesson for everyone working at the intersection of health and social care is this: to build sustainable partnerships that effectively address health-related social needs, we need to examine and challenge our underlying perceptions of value. The three biggest cultural sandtraps we witnessed our CBOs and healthcare partners get caught in were the following:

• We need a high return on investment: Early in the accelerator, we discussed what participants would see as a good investment in their personal lives or for other organizational investments. The answers were far more modest returns than what was expected in the context of healthcare and social care partnerships. Five to seven percent is generally considered a good return on investment—and when paired with improving the health of vulnerable individuals is outstanding. Yet many social care partnerships demand a 50% to 75% return on investment. It can be helpful to start contract discussions with a shared understanding of the return that a healthcare organization expects from other investments to ensure cultural biases are not seeping in. 
• We don’t have enough evidence: CBOs and internal healthcare champions often find themselves facing skepticism about the impact of social investments. While it is true that there is not yet a randomized clinical trial to gauge whether inadequate nutrition affects health outcomes, it is also true that we have more than enough evidence that nutrition is critical to health. To more fairly interpret available data, we need to start by recognizing what level of uncertainty is tolerated for other clinical interventions. A senior executive for a large Britain-based drug company is quoted as saying that less than half of patients prescribed certain drugs derive any benefit from them. This is supported by the fact that an analysis of 3,000 randomized controlled trials found almost 400 examples of “medical reversals,” or situations where a medical intervention was found to be less effective than a less invasive, less costly intervention or no intervention at all. If we can tolerate that level of uncertainty about the benefits of costly medical interventions, then we must give social care interventions the same flexibility.    
• Social interventions should be reimbursed at cost, or below: CBOs and their healthcare partners often start contract negotiations with a goal of covering the cost of social interventions (and not a cent more). This is particularly notable against the backdrop of a healthcare system that expects its own services to be covered amply enough to pay staff well and maintain surplus working capital for desired resources and organizational investments (even or especially in nonprofit healthcare organizations). This disparity is deeply intertwined with the historic undervaluing of work primarily done by women and people of color, such as that which attends to basic needs like food and rest. The job of a care coordinator in a homeless shelter is as, if not more, complex than that of a hospital care coordinator. The need for and impact of a homeless shelter care coordinator is at least equal to that of a hospital care coordinator, yet the salaries of most homeless shelter staff are dramatically less than those working in most hospitals. This is purely a cultural artifact that we must examine and work to dismantle and rebuke within our personal and professional spaces. Our financial models, in turn, must reflect the value we claim to place on these services and secure a living wage for the critical staff who do this work. 

We are grateful to the participants of the 2024 VOI Accelerator for sharing their experiences and lessons and for the impactful work they do in their communities every day. As we all work to strengthen healthcare investing in social care, we invite you to partner with us in not only changing the numbers in the calculations but also the narrative around them. 

Contact us if you’d like support in calculating as well as changing the narrative around the value of health care and social service partnerships: