We need a better approach to studies that address health-related social needs
Studies have shown health-related social needs—food insecurity, housing instability, and lack of transportation—are associated with poor health outcomes, more health care use, and higher health care spending. Integrating human services that address health-related social needs into health care may address these issues, but we need better methods to study such programs, says Seth A. Berkowitz, MD, MPH, assistant professor of medicine in the division of general medicine and clinical epidemiology. Berkowitz suggests such a method in an article published today in the April issue of Health Affairs.
"Because the drivers of health and health care expenditures are increasingly recognized to lie both within and outside the health care system, integrating human services that address health-related social needs into health care may be a key mechanism to improve health," said Berkowitz, lead author.
"Although there are encouraging early results from such integration, rigorous evaluation of these programs is critical," Berkowitz said. "In particular, it is important to use strong study designs that can validly estimate what would have happened in the absence of the program and to avoid designs such as pre/post assessments that are subject to regression to the mean and other sources of bias."
Berkowitz proposes an innovative methodological approach (borrowed from developmental economics) called cash benchmarking.
"When control groups are used at all in health care and human service integration studies, the typical approach uses a usual-care design that compares the new program to current practice, which may be no specific intervention. In a cash benchmarking study, one group receives an intervention and another receives the monetary value of the intervention as a cash transfer."
Treatment effects estimated by such a study show the benefit of the intervention, above and beyond the cash value of the resources provided. This is particularly relevant for integrated health care and human services interventions, as the health-related social needs that these interventions seek to address are often rooted in a lack of financial means.
Discussing both the advantages and limitations of cash-benchmarked designs, Berkowitz, with authors Samuel T. Edwards, MD, MPH, at Oregon Health and Science University, and Daniel Polsky, Ph.D., at John Hopkins Carey Business School, conclude that "cash benchmarking can help stakeholders navigating closer to the promise, and away from the pitfalls, of health care and human services integration."