The most recent addition to the lexicon of health services research is ‘social determinants of health’. Arguably, it joins value-based purchasing and evidence-based medicine as the most transformative themes in the modern era of U.S. healthcare. But it poses a unique challenge.
The social determinants of health (SDOH) are the economic and social conditions that influence individual and group differences in health status. (World Health Organization). Unlike signs, symptoms, and co-morbidities that clinicians consider in diagnosing and treating individual patients by abstracting data from their medical records, SDOH involves assessing the circumstances in which an individual lives and works. Per the US Center for Disease Control and Prevention, social determinants include housing, poverty, food security, working conditions, public safety and others.
Traditionally recognized as risk factors by clinicians, they are inadequately integrated into how care is delivered. Though SDOH factors are directly responsible for at least 40% of total health spending, they have taken a back seat in the health system’s deployment of its resources and attention.
Studies by the Urban Institute, Commonwealth Fund, Kaiser Family Foundation, Institute for Health Improvement and others have quantified wide disparity in access to care. In short, if an individual has health insurance, more education or income and is Caucasian, timely access to doctors, hospitals and other services is significantly higher than if not. But for everyone, regardless of socio-economic status or health status, SDOH impact their wellbeing. As Jack Wennberg (Dartmouth Atlas) observed 20 years ago, where you live is the key predictor about the quality of care you get.
Last week’s Annual Conference of America’s Physician Groups (APG.org) was themed “Quality and Efficiency: How to Succeed in Risk Based Models.” The 2000 attendees heard about artificial intelligence, clinical integration, risk-based contracting with health plans and employers, the future of alternative payment models like bundled payments and accountable care organizations and forecasts for managed Medicaid and Medicare Advantage. Implicit to the success in all these is the necessity of measuring, monitoring and improving the SDOH for their patient populations. It’s fundamental to risk-based contracting by provider organizations with payers.
But risk-based contracts with payers represents less than 30% of payments to providers. The majority is still fee-for-service, volume-based. Most patient care is delivered under traditional models wherein physicians base their diagnoses on conventional clinical measures and anecdotal information about social determinants that might be even more important. A physician’s educated guesses about SDOH in treating their patients has been the staple of the system for most patient encounters.
Will the use of SDOH data become as essential to a clinician’s differential diagnosis as genetic testing and lab results? Regardless of whether the patient is insured, un-insured or covered in an at-risk contract with a health plan, will systematic inclusion of SDOH become central to effective care? In all likelihood, yes, but for many physician organizations and health systems, they’ll encounter challenges:
Integration of SDOH into care management requires closer collaboration between local public health and social services programs with local providers. Historically, the issues related to food insecurity, affordable housing, income security, air quality and other social determinants were addressed through a variety of federal/state public agencies and programs. Most are funded by taxpayers but largely disregarded by local providers. Instead, community health centers, agencies and a boatload of city, state, public agencies and private not-for-profits fill the void. Thus, the synergies between social services programs that serve the most at-risk populations has operated in the shadow of the traditional system of hospitals and medical practices that serve others. For SDOH to be fully integrated into a community’s health delivery system, the two must work as one.
Mainstreaming SDOH into clinical care requires physician training. Clinician interaction with patients from different SDOH circumstances is a challenge: most physicians are intellectually aware of SDOH distinctions. They learn context-sensitive word choices, listening skills and techniques for optimal interaction with patients. But CME training is not enough. Medical school must take SDOH seriously. For example, food insecurity is an issue of growing import but nutritional education in medical school is less than 19 hours of training in their four-year curriculum and most of that is about nutrients and vitamins, not access and habits.
Social isolation is observed in clinic settings but addressed anecdotally in most patient interactions. Assessments about housing, or income security are not systematically collected for most patient encounters and so on. Data about how the social determinants of health for individual patients is not been readily accessible to physicians. In most cases, they deduce what they think a patient’s SDOH profile is by direct observation and limited data from their chart.
SDOH is an imperative whose time has come. It parallels the growing use of risk-based contracting by payers and public recognition that healthiness has a lot to do with where you live and work.
In developed systems of the world, social services programs and healthcare are more directly integrated; in the U.S., for a variety of reasons, they’re not. Some SDOH programs are addressed as public programs that regrettably get labeled “welfare” programs by some. Some are run by state’s as part of their public health apparatus and some are positioned as United Way efforts to improve a community.
As the U.S. electorate considers Medicare for All, Repeal and Replace of the Affordable Care Act vs. Fix and Repair or alternative proposals to transform the system, approaches that more directly and effectively integrate SDOH into how care is delivered in every community should be considered. In Modern Healthcare’s “2019 Future of Healthcare” poll of industry leaders, 67% think it likely “HHS will encourage the integration of health and social services programs and encourage its funding to address social determinants of health” vs. 15% who think it unlikely. We’ll see.
“The state of nutrition education at US medical schools. JBiomed Educ. 2015;2015:1-7. doi:10.1155/2015/357627Google ScholarCross.
“Social Determinants of Health”; Active Initiative, Urban Institute, 2019; https://www.urban.org/policy-centers/cross-center-initiatives/social-determinants-health
“An Evolving Roadmap to Address Social Determinants of Health” Commonwealth Fund, January 2019; https://www.commonwealthfund.org/blog/2019/evolving-roadmap-address-social-determinants-health
“Beyond Healthcare: The Role of Social Determinants Promoting Health and Health Equity”; May 2018, Kaiser Family Foundation; http://files.kff.org/attachment/issue-brief-beyond-health-care
“Making Sense of the Social Determinants of Health“; January 2019, Institute for Healthcare Improvement; http://www.ihi.org/communities/blogs/making-sense-of-the-social-determinants-of-health