Using Pay-for-Success to Increase Investment in the Nonmedical Determinants of Health

 A mother gives infant a nebulizer treatment to prevent an asthma attack.

The combination of fee-for-service payments and the U.S. health care system’s standing commitment to treating existing illness discourages spending on the behavioral, social, and environmental (that is, the nonmedical) conditions that contribute most to long-term health.

Pay-for-success, alternatively known as social impact bonds, or SIBs, offers a possible solution. The pay-for-success model relies on an investor that is willing to fund a nonmedical intervention up front while bearing the risk that the intervention may fail to prevent disease in the future. Should the intervention succeed, however, the investor is repaid in full by a predetermined payer (such as a public health agency) and receives an additional return on its investment as a reward for taking on the risk.

Pay-for-success pilots are being developed to reduce asthma-related emergencies among children, poor birth outcomes, and the progression of prediabetes to diabetes, among other applications. These efforts, supported by key policy reforms such as public agency data sharing and coordinated care, promise to increase the number of evidence-based nonmedical service providers and seed a new market that values health, not just health care.


This research was not funded by the Robert Wood Johnson Foundation but was made available in this special issue of Health Affairs because it focuses on community health research. Funding was provided by the Federal Reserve System.