Rethinking value: Advancing equity requires showing impact beyond ROI

Data analysis & integration Strengthening ecosystems of care Funding & financing Measurement & evaluation SDOH & health equity

By Jason Turi, RN, MPH, Director of Field Building & Resources; Ellen Schultz, MS, Independent Consultant; Rebecca Sax, MPH, Senior Program Manager for Field Building & Resources

In today’s healthcare system, “value” is everywhere. Value-based purchasing is the focus of major reform efforts. Building a value-case is the “make-or-break” imperative for many programs seeking to improve complex care delivery, address social determinants of health, or transform healthcare to advance equity. But what does “value” really mean? And perhaps more importantly: who gets to define value?

In healthcare, the term “value” often comes with financial connotations. But as the interconnections between healthcare, public health, education, housing, transportation, economic opportunity, and so many other social factors are revealed, purely financial notions of “value” – and, in particular, financial notions connected only to healthcare – require closer examination and perhaps, redefinition.

In 2014, the Camden Coalition launched a randomized controlled trial (RCT) to assess the impact of the Camden Core Model. The RCT focused on hospital readmissions as a proxy for showing financial return-on-investment (ROI). The results in 2020 showed no difference between study groups in hospital readmissions after six months, but did find increased enrollment in supplemental nutrition (also known as SNAP) programs among the Camden core model group. These findings underscored that narrow definitions of value based only on short-term financial and clinical impact did not adequately capture the many different ways that participants and stakeholders described benefitting from the Camden Core Model.

More recently, as part of its work developing the Building the Value Case toolkit, the Coalition heard from health and social system leaders that the value case for complex care programs must recognize non-financial returns including “equity, trust in the community, transformed lives, and doing the right thing for people who deserve better care.” Similarly, a national pilot project from the Health Leads Collaborative to Advance Social Health Integration (CASHI) found that demonstrating the value of programs that integrate social health interventions into primary care required going beyond purely financial considerations. Leaders of that program noted, “While reimbursement had a significant influence on the business case, creating value for patients, healthcare payers, and members of the broader community also was compelling, particularly for healthcare organizations that see themselves as collaborators in local efforts to improve community health. Leaders saw value in this both from the perspective of their mission and their long-term success under value-based care contracts.”

In 2021, the National Center for Complex Health and Social Needs convened a series of eight key informant focus groups with program staff, leaders, and community members participating in the Community Ecosystem Learning Collaborative. These focus groups explored how different organizations and community members engaged in each of six cross-sector collaboration efforts define and measure the value of cross-sector collaboration. It resulted in the publication of Rethinking value: Perspectives on the benefits of cross-sector collaboratives serving populations with complex health and social needs.

These conversations revealed a nuanced and holistic understanding of “value” that extends far beyond financial considerations. Participants described cross-sector collaborations as valuable when they:

  • Provide intrinsic benefits by aligning with shared purpose – the missions, values, and beliefs that motivate individuals and organizations to action. Participants described finding joy in participating in collaborative work to solve complex problems and finding a sense of self and purpose in giving back to their communities.
  • Meaningfully engage community members and individuals with lived experience in identifying needs, developing solutions, and sharing information. Participants talked about developing a better understanding of the issues that lead to poor health outcomes and gaining buy-in for the resulting collaboration. Community members talked about appreciating responsiveness to their suggestions and the importance of being able to see the impact of their contributions.
  • Demonstrate outcomes at multiple levels. Participants emphasized the need to demonstrate value through individual-, organizational- and collaborative- level outcomes. Individual-level outcomes, such as long-term stability and recovery for individuals, often focused on the core mission of providing services and meeting needs. Organizational-level outcomes, such as improving health and social conditions for a group of clients or patients, were specific to each sector. These tended to be the most well-defined of all measures of “value” participants discussed. Participants also discussed a desire for collaborative outcomes — shared measures across organizations that demonstrate the impact of the collaborative. However, collaborative outcomes were often ill-defined or only emerged over time as a collaborative matured.
  • Lead to sustained improvements for individuals with complex health and social needs. Participants emphasized the importance of addressing systemic issues in a sustained way through long-term relationships, robust communication channels, and co-developed solutions among organizations. 

Hearing these varied dimensions of “value” emerge from a sample of 45 participants shows that it is multidimensional, contextual, and dependent on perspective. Individuals, organizations, and sectors approach collaborative work with different priorities and definitions of success. Among these, “value” was not solely dependent on financial ROI. Indeed, participants in these focus groups mentioned financial considerations as secondary to intrinsic benefits, community engagement, demonstrated outcomes, and sustained improvements. Though these are preliminary findings from a small sample and require further exploration, the rich and diverse understandings of “value” from even a small sample highlight just how much is missing when conversations around value begin and end with dollars. 

As the drumbeat calling for more equitable public health, healthcare and social service systems grows louder, it is imperative that stakeholders explore broader definitions of a program’s value beyond financial returns. To more holistically understand the value of work that addresses complex health and social needs, practitioners, funders, and evaluators would do well to unpack the multiple layers and perspectives on the work’s importance, impact, and benefits to all the many stakeholders involved or affected by it, especially marginalized populations who experience the greatest inequities. Three ways to begin this process include:

  • Talking directly to people who bring different perspectives — especially those who are intended beneficiaries or recipients of services — about what they see as most important
  • Asking open-ended questions about importance, benefits, contributions and effects on individual lives, organizational mission, and collective goals
  • Considering benefits to practitioners as well as to intended recipients

In September 2022, the National Center will dig deeper into questions of value by focusing its Putting Care at the Center conference on the theme of Values and value in complex care. The many and varied perspectives on value that will emerge from the conference will no doubt show the importance of exploring and defining value beyond ROI, and how a shared definition of the work’s value can foster the cross-sector collaboration needed to advance health equity.