Pay For Success Can Be A Tool To Improve Social Determinants Of Health

By Keller Anne Ruble, Associate Director of Policy Research

What do you think is the biggest contributor to a person’s overall health? Genetics? Health insurance coverage? How much water you drink during the day?

None of the above.  In fact, genes and access to medical care only account for 40% of your overall health (20% each, respectively).

The Social Determinants of Health that surround you exert the largest influence on how healthy you are, the health of the community in which you live – 60% of your health stems from your social determinants! The World Health Organization conceptualizes social determinants as, “factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family.” They are categorized into several key domains by Healthy People 2020:

  • economic stability,
  • education,
  • the strength of one’s social networks and community resources,
  • healthcare, and
  • your community’s built environment.


These factors individually and/or collectively can either foster healthy child development and flourishing or present health-harming barriers to development that can stymie a child’s short and long-term educational attainment, economic participation, and cause costly, chronic conditions.

This graphic, adapted from Anderson et al, 2003; Marmoetal, 1999; and Wilkinson et al, 2003, illustrates the impact of community assets on a flourishing community..

Paying attention to social, physical, and economic needs with population health in mind can generate significant health care savings and create conditions for vibrant, healthy communities. Pay for Success has been successfully deployed in several communities across the country to do just that, and more evidence-based possibilities ripe for Pay for Success are emerging.

Where are we seeing PFS used to improve physical environments or family stability?

The Green and Healthy Homes Initiative (GHHI) aims, “to break the link between unhealthy housing and unhealthy families by creating and advocating for healthy, safe and energy efficient homes.” GHHI is using PFS financing coupled with value-based contracting to allow for reimbursements for services that address social determinants of health. Some services include home inspections, pest management (as droppings trigger asthma), in-home health management education (like action plans for asthma and/or adherence to medical instructions), hypo-allergenic home cleaning kits, and referral to other services as-needed. These interventions have resulted in avoided hospitalizations, energy bill savings and more. Avoided hospital visits and better managed chronic illnesses mean children are in school more regularly and more ready learn.

Cuyahoga County, Ohio is employing Pay for Success to reunify homeless, housing insecure or unstable families with children in out-of-home placement. Service providers offer comprehensive, trauma-informed case management that emphasize housing supports, in order stabilize families through affordable housing. The project aims to reduce days children spend in foster care, and the processes of the project have improved understanding of family needs, county practices to serve families, and overall inter-agency collaboration.

As the broader field has demonstrated, PFS can be used to successfully and thoughtfully scale interventions that create value and generate savings. One such intervention ripe for PFS that addresses a family’s social determinants of health are Medical-Legal Partnerships (MLPs). In the MLP model, doctors and lawyers work together to diagnose and treat health issues and to identify and act on health-harming civil legal barriers a family may be experiencing. And the need is clear: the vast majority of low-income families have 2 to 3 unmet civil legal needs, most of which are either directly or closely tied to their overall health.

What does this type of partnership look like in practice? The graphic below shows the typical approach to treating a child’s recurring asthma, and what it could look like to use an MLP to break the cycle of hospital visits.

And this approach works: In New York City, hospitals saw a 90% reduction in asthma patients who received legal help from an MLP for a housing issue. A pilot MLP program in Pennsylvania found that of high-need, high-use patients, the overwhelming majority had at least 2 civil-legal needs. Once these legal needs, most of which centered around housing adequacy, were tackled, hospital admission, ER usage, and overall costs were halved (See: The Law as Healer)

As we look to the future of the Pay for Success field and as communities put forth projects eligible for SIPPRA funds, stakeholders could find significant long-term value by prioritizing social determinants of health in considering an intervention for their community.

Did this pique your interest in Medical-Legal Partnerships? The Institute for Child Success will release a paper this August on the MLP model, its evidence-based impact on children and families, and will highlight the broader research on ways in which stability and healthy environments foster healthy, whole-child development. Make sure you are on our mailing list to get it straight to your inbox!

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