As administrators of two of the largest health systems in the nation, we have long known that the best patient care cannot be delivered exclusively inside the walls of our facilities. No matter how high the standards of care, how cutting edge the technology, how sophisticated the systems – not even how talented and dedicated the staff – we cannot do our jobs unless we look outside the hospital and into the reality of our patients’ lives. And for the poor and low-income New Yorkers we serve, that reality can be bleak. Many are homeless or precariously housed, unemployed or underemployed, struggling to pay for nutritious food, and have limited education.
If you are poor, you face substantial barriers to good health. An estimated 40 percent of health outcomes are shaped not by genetics or bad habits, but by powerful social and economic factors – most notably income, education, and employment. If you are poor you are more likely to develop cancer or cardiovascular disease, or to become disabled. You are less able to access or afford healthy food, which often leads to obesity, hypertension and diabetes. You often do not have private insurance, may not know about the healthcare benefits you are entitled to, or have the resources to navigate a complicated insurance system.
Both of our hospital systems – one public and one private – recognize the importance of understanding the circumstances in which our most vulnerable patients live. Out of that understanding have come a number of initiatives designed to address the social determinants that lead to and exacerbate poor health – particularly for Medicaid and Medicare beneficiaries, who are among the highest users of the healthcare system, and most likely to face societal and economic barriers to effective care.
Addressing the multiple factors that determine health requires changing the way we think about it. Health is not the sole domain of medical practitioners, but a responsibility we share with myriad community partners, advocates, and social service organizations. Coordinating with these partners, we work to break down impediments to improved health, helping patients understand their health conditions, adhere to their care protocol, and access nonmedical services, such as financial and housing assistance, transportation, food and nutrition support, and employment services.
Among the social services initiatives that have been most successful in removing nonmedical barriers to better health outcomes are the partnerships we and other hospitals have forged with legal service providers, known as medical-legal partnerships. Across the country, attorneys are training healthcare professionals to understand the legal issues their patients face, and being integrated into low-income patients’ health care teams to address legal problems that impede treatment or recovery.
In New York, we are fortunate to have been working for many years with a division of the New York Legal Assistance Group (NYLAG), LegalHealth, which is the country’s largest medical-legal partnership. Their attorneys assist patients at locations within the hospital on a range of issues, including identifying healthcare coverage options, securing coverage, and helping patients negotiate with insurance providers when disputes arise. They also help patients deal with the threat of eviction, other landlord tenant issues, foreclosure or unemployment, and secure Social Security Disability and other benefits, among other matters.
Here is an example of how the partnership works: a woman suffering from Stage 3 breast cancer began missing chemotherapy appointments at the hospital. Because her healthcare team was trained to identify the health-harming legal needs of patients, when she next came in, they probed and discovered that due to her illness she had lost her job, fallen behind in rent, and was facing eviction. The stress of her legal problems was causing her to forego her treatment. The hospital staff referred the patient to an onsite LegalHealth attorney who represented her in housing court and successfully prevented the eviction, enabling the patient to focus once more on her health.
Patients are not the only ones these attorneys help – healthcare systems benefit as well. When a lawyer acts as a part of the healthcare team, doctors are not burdened with issues outside of their expertise, and can focus on their patients’ health. Healthcare institutions and practices benefit financially when their patients are not struggling with complicated legal issues that cause them to miss medical appointments and treatment, decreasing efficiency and productivity, and compromising care. And by assisting clients in obtaining health coverage, legal services help to move uncompensated care paid for by the hospital to compensated care paid for by third-party payors. From the hospital perspective, the return on investment can be substantial. According to a recent study commissioned by NYLAG, for every one dollar spent on their services, LegalHealth generates about two dollars in direct financial benefit for hospitals, and even more in indirect financial benefits.
Medical-legal partnerships and other social services are receiving increasing attention since the implementation of the Affordable Care Act (ACA) in 2013, which expanded federal Medicaid coverage to approximately 32 million more lower-income individuals with a host of unmet social needs that affect their health. In addition, various Medicaid reform programs underway across the country, such as New York State’s delivery system reform incentive payment (DSRIP) program, have the primary goal of reducing avoidable hospital use by 25% over five years. DSRIP puts particular emphasis on initiatives that bring together medical and social service organizations to move care out of hospitals and into the community.
The primary goal of every health care institution is to improve the health of the patients who walk through its doors. Doing so in today’s dramatically changing healthcare landscape demands that we leverage every opportunity to innovate and collaborate. By addressing the link between poverty and health, medical-legal partnerships have improved lives and lowered costs. There are now 273 hospitals and health centers in 36 states working in similar partnerships. Based on our own success, we urge every hospital executive to consider joining us.