On February 21, the Department of Treasury issued a Notice of Funding Availability inviting states and local governments to apply for approximately $75 million in awards under the Social Impact Partnerships to Pay for Results Act (SIPPRA). It is an opportunity for states and localities to scale evidence-based health interventions that can improve population health. Applications must be submitted by May 22, 2019, with letters of intent encouraged for submission by April 9, 2018.
SIPPRA was passed by Congress as part of the Bipartisan Budget Act of 2018 to support ‘Pay for Success’ (PFS) projects that produce “measurable, clearly defined outcomes that result in social benefit and federal, State, or local government savings.” Pay for success projects are a way to fund social programs in which the government works with non-governmental investors to support the implementation of evidence-based, cost-effective services to improve policy outcomes in areas such as child welfare, homelessness, education, health, and employment to populations in need. Once an evaluation demonstrates that outcomes are achieved, the government reimburses the private investor.
Roles of Organizations Involved in Pay for Success Projects
SIPPRA attempts to catalyze these projects at the state and local level by funding independent project evaluations and, if outcomes are achieved over a seven-year intervention period, by paying back the initial investment made by private sector partners with interest. These payments can occur over the course of time as the programs achieve the various outcomes agreed to when the program was established.
Timeline of SIPPRA
Opportunities to Improve Health
Of the 21 outcomes of interest in SIPPRA, at least four are directly relevant to population health improvement:
- Reducing teen and unplanned pregnancies;
- Improving birth outcomes and early childhood health and development among low-income families and individuals;
- Reducing the rates of asthma, diabetes, or other preventable diseases among low-income families and individuals to reduce the utilization of emergency and other high-cost care;
- Improving the health and well-being of those with mental, emotional, and behavioral health needs.
Other qualifying outcomes such as reducing the rate of homelessness among vulnerable populations are also indirectly related to population health and topical for state and local health departments. For example, rapid re-housing and supportive housing models have been shown to reduce periods of homelessness and emergency-department use while improving health outcomes. It is important to note that SIPPRA requires that at least 50 percent of federal payments be used to support initiatives that directly benefit children.
With respect to the four outcomes relevant to population health improvement, evidence-based interventions not only exist but are ready for scaling and discussed below.
Reducing teen and unplanned pregnancies
For the last nine years, the Office of Adolescent Health at the U.S. Department of Health and Human Services has led a Teen Pregnancy Prevention national program which funds organizations to implement evidence-based teen pregnancy prevention programs as well as develop and evaluate new and innovative approaches to prevent teen pregnancy. The program’s process for reviewing evaluation studies and identifying evidence-based programs has been lauded by evidence advocates. The national program has identified 44 programs that have each shown, in at least one evaluation, to have a positive impact on preventing teen pregnancies, sexually transmitted infections, or sexual risk behaviors.
Improving birth outcomes and early childhood health and development
Home visiting programs in which nurses provide low-income pregnant women and their families with resources and guidance on caring for and raising young children have been shown to improve maternal and child health and prevent child abuse and neglect. Health policy experts of all political persuasions have lauded these programs for both addressing income disparities as well as reducing long-term government spending on Medicaid, SNAP, and other assistance programs. As an example, South Carolina obtained a 1915(b) Medicaid waiver to launch a pay-for-success home visiting program in 2016. The Health Resources and Services Administration leads the Maternal, Infant, and Early Childhood Home Visiting Program which provides funding to organizations to implement evidence-based home visiting services. Services must be selected from those identified by the Home Visiting Evidence of Effectiveness project which conducts a thorough review of the quality of the evidence.
Reducing the rates of asthma, diabetes, or other preventable diseases
While asthma is one of the most common chronic childhood diseases, there are cost-effective, home-based asthma interventions that reduce the environmental triggers that can lead to emergency department visits and unplanned hospitalizations. These simple interventions can yield significant savings in other, more expensive parts of the healthcare system. For example, University of Michigan and George Washington University researchers recently modeled the potential impact of an evidence-based multicomponent childhood asthma intervention among low-income children enrolled in Medicaid in Detroit. They found that targeted, home-based asthma interventions to high-risk children could yield substantial savings for the federal and state Medicaid programs ($1.4 to 2.8 million and $634,000 to $1.3 million in savings, respectively). The Green and Healthy Homes Initiative is one organization supporting pay-for-success interventions across the country which provide in-home resident education and housing interventions that address asthma triggers for children.
The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program shown to reduce the progression from pre-diabetes to diabetes. Starting in 2014, Medicaid revised payment regulations to allow preventive services to be provided, at state option, by practitioners other than physicians or other licensed practitioners. This has led to several states now having some form of Medicaid coverage for the DPP. Since then, the Medicaid Coverage for the National Diabetes Prevention Program Demonstration Project, funded by the Centers for Disease Control and Prevention, has further elucidated how to achieve sustainable coverage of the program for Medicaid beneficiaries under current Medicaid authorities. SIPPRA may spur additional interest from more states on how to increase access to and coverage of DPP for beneficiaries with prediabetes.
Falls are the leading cause of older adult injury death resulting in 3 million emergency visits annually and over 800,000 hospitalizations. Medicare and Medicaid shoulder 75 percent of the estimated $50 billion in total medical costs for falls. Affordable, home-based modifications, such as bathroom grab bars, no-step entry, and eliminating the needs to use stairs, and community-based falls prevention programs, such as A Matter of Balance and Tai Chi for Arthritis, are central to falls prevention.
Improving the health and well-being of those with mental, emotional, and behavioral health needs
Pain in the Nation: The Drug, Alcohol and Suicide Epidemics and the Need for a National Resilience Strategy, a report by the Trust for America’s Health and Well Being Trust contains information on evidence-based programs that reduce substance abuse and mental illness. These includes suicide prevention programs, school-based drug-use prevention programs, and recovery high schools. The Prevention Institute also develops strategies and practices in conjunction with partners across the country to promote mental wellbeing.
In addition to identifying service providers who can implement evidence-based interventions to achieve the outcomes of SIPPRA, prospective applicants will need to identify investors. They may find a welcome partner in local or national philanthropic organizations who wish to accelerate scaling of programs which improve population health. In addition, companies with robust philanthropic or corporate social responsibility departments can prove to be useful partners. Applicants will also need to ensure that their evaluation strategy is robust enough to be able to demonstrate outcomes achieved in the designated time frame.
One previous limitation for state Medicaid programs to implement PFS programs has been the inability to use federal Medicaid dollars (or savings) to pay back private investors. While SIPPRA doesn’t change this policy directly, in essence, it fills the funding gap. Given that SIPPRA’s health outcomes are especially critical for the Medicaid population, SIPPRA should be seen as a major step forward to improve outcomes for vulnerable populations.
At a time when federal funding is tight, innovative funding pathways to support public-private partnerships should be pursued, and state governments should capitalize on SIPPRA funding to improve health in their state.