Hello from my second official week of internal medicine residency at Brigham and Women’s Hospital! I’m looking forward to sharing some of my clinical experiences with you through Research Corner to make the implications of new research for both patients and clinicians even more tangible.

If you’re also a trainee or a former resident with tips on thriving in the wards, I’d love to hear from you on Twitter @Soleil_Shah! 

P.S. Due to the July 4 holiday, Research Corner is taking next Tuesday off.

Putting a Price Tag on Patients’ Social Needs

Rotating through the hospital as a medical student, I often encountered patients struggling with everyday challenges, like unstable housing or lack of transportation, as much as their medical difficulties. In those days, with fewer responsibilities and patients, I had ample time to help people address their social problems, too. But even then, it was often hard to connect people with the resources they needed — a shelter bed, perhaps, or a new wheelchair. 

Now as an internal medicine resident physician pressed to see many more patients in a given day, I worry I will be less equipped to meet people’s nonmedical issues. It’s a conundrum I’ve heard about from many of my primary care mentors — knowing that people’s social circumstances are profoundly affecting their health but lacking the resources to change that.

It’s also the topic of a timely new study in JAMA Internal Medicine.

Federal funding does not adequately cover the cost of social supports 

The study tries to answer the question: What would it cost to effectively address every primary care patient’s social needs — and how far are we from achieving that goal? The work was led by Sanjay Basu, a co-founder of a growing number of startup companies seeking to address the so-called social determinants of health. 

Basu and colleagues used a sophisticated computer simulation involving 19,225 children and adults seen at primary care practices between 2015 and 2018. The sample reflected the U.S. population — with patients of different ethnicities and income levels visiting different types of care sites.

The model then identified those patients’ social needs in four areas (food, transportation, housing and care coordination) and estimated the full cost of addressing them through a range of existing, evidence-based programs like food stamps, rides to medical appointments and help from community health workers.

After running their simulation, the researchers found that: 

• The full cost of meeting a patient’s social needs, including screening, referrals and service delivery, would average $60 per patient each month. Costs were higher for patients seen in low-income areas ($93) versus patients in high-income areas ($24).
• Existing federally funded programs like SNAP and Medicare only cover about half ($27 per month) the full costs of people’s social needs. The rest ($33 per month) would have to come from expanding existing federal programs or other sources.
• Of that $60 per month, the estimated cost to primary care clinics is relatively small — just $5 — for screening and referring patients to these social programs.

Primary care clinics struggle to connect patients with existing social programs

The researchers also looked at how the current system is doing at holistically meeting people’s needs and found that: 

• While some programs could help many people, their enrollment is limited. For example, 78% of people with housing needs were eligible for assistance programs, but only 24% enrolled, likely due in part to inadequate program capacity.
• Strict eligibility rules are hampering other areas of need. For example, just 26% of people who needed transportation were even eligible for any relevant supports.

The study has limitations. It’s based on a simulation, meaning that it may not be reflective of actual costs. It also didn’t look at the cost saving potential of these interventions.

From the Centers for Medicare and Medicaid Services to the Assistant Secretary for Planning and Evaluation, federal health officials have been encouraging health care organizations to more holistically address the many factors that shape someone’s health, from where they live to what they eat.

But as this study makes clear, without more funding and programs to offer our patients, we primary care providers will continue referring far too many people, as the study authors put it, to “a bridge to nowhere.”