We Know We Have to Address the Social Determinants of Health. Now What?


In the run-up up to this month’s mid-term elections, health care appears to be just one of many burning political issues that will be influencing Americans’ votes. But delve into nearly any issue—the economy, the environment, immigration, civil rights, gun control—and you’ll find circumstances and events influencing human health, often resulting in profound physical, emotional and financial distress.

Evidence suggests that separating immigrant children from their families could cause lasting emotional trauma. Gun violence and adverse weather events destroy lives and property, and create hazardous living conditions. Structural racism has been linked to health inequities, for instance where housing discrimination leads to segregation of black buyers and renters in neighborhoods with poor living conditions. The list goes on, and through every such experience, affected individuals, their loved ones, and their communities learn implicitly what health care providers have long known: that health status depends on much more than access to, or quality of, health care.

Some of the most influential factors are called social determinants of health, and they include education, immigration status, access to safe drinking water, and others. Society and industry must collaborate to address them if we are to reduce the extraordinary human and economic costs of poor health in our nation. Fortunately, many providers have embraced the challenge, and are tackling it in myriad, innovative ways.

Hundreds of providers across the country, like Yale New Haven Health, are helping patients who lack reliable, affordable transportation to stay on top of their health by offering free rides to the doctor’s office via ride-sharing services Uber and Lyft. Geisinger Health’s fresh food pharmacies help patients living in food deserts eat nutritiously, and thus head off or better manage chronic diseases like diabetes. Hospitals are paying to house homeless people, given evidence that stable housing helps reduce the need for acute medical care. An increasing number of providers (perhaps with an eye on the U.K.’s social prescribing movement) are also forging processes and partnerships to connect patients with assistance for a variety of health-related social needs.

Such innovative initiatives represent an encouraging trend. However, their positive impact and sustainability depend upon further rigorous study of their objectives, design and results. Their success also ultimately depends upon the type of business model supporting them. A business model encompasses an organization’s resources, processes, profit formula and value proposition. Depending on how these elements are designed, they can constrain or enable innovation toward a particular end. Evolution in the realm of provider payments illustrates how one such element of an organization’s business model—profit formula—affects innovation, depending on its design.

Most providers in the U.S. have historically been, and continue to be, paid a fee for each medical service they provide, usually by insurers. Because this payment method rewards pure volume of care, it creates the perverse incentive to deliver unnecessary care. It also constrains innovation, because it deprives providers from reimbursement for services that aren’t on an insurer’s approved services list, no matter how beneficial they may be to patients. Undoubtedly, many providers deliver unreimbursed services anyway from time to time. But care delivery organizations can’t run on compassion alone.

By contrast, “value-based” payment methods, which are gaining traction across the industry, are designed to reward providers for quality and cost-effectiveness of care, rather than pure volume. They take various forms, ranging from service fees with a bonus attached for care quality, to a fixed or “capitated” fee for all the care an individual needs over a specific period of time (usually a year). Payment models toward the latter end of that range facilitate innovation because they aren’t tied to a defined set of services.

Innovation to address social determinants of health is therefore much more likely to succeed and thrive within a business model whose profit formula is rooted in the appropriate form of value-based payments. And yet the right profit formula, while essential, is insufficient to ensure providers’ success in discovering and addressing patients’ social determinants of health. Resources (like funding and expertise) and processes (like strategic planning and performance management) must be aligned to enable these activities as well. Otherwise, providers will always be fighting an uphill battle to achieve their objectives.

The bottom line is that innovation isn’t some isolated, protected process in an organization; it’s profoundly shaped by an organization’s business model. Providers aspiring to positively influence the social determinants of patients’ health would be well-served to consider the ways in which their business model might enable or constrain innovation toward that important end.

Rebecca Fogg is a senior research fellow at the Clayton Christensen Institute, where she studies business model innovation in healthcare delivery, including new approaches to population health management and person-centered care.

19 replies »

  1. Two comments to add to this,

    1) As others have stated, I believe that the Medical system may not be the right group to organize and operate approaches to SDoH, but they certainly are holding onto the funds (30% of Healthcare is waste fraud and or abuse) that could be allocated to these areas. See this blog “Running to the Ball, the Shiny Object of Social Determinants of Health” https://accountablehealth.wordpress.com/2018/08/20/running-to-the-ball-the-shiny-object-of-social-determinants-of-health/,

    and PJNelson you are on target … this may be some more assistance:

    2) A group of us now has a bill before congress with bipartisan support, the Community Health Improvement, Leadership and Development Act of 2018, or the CHILD Act which will establish community Health Savings Accounts for Medicaid. If communities put in programs that reduce the burden of disease and/or costs to Medicaid, 70% of the savings would go back to the community and spending would be overseen by a local 7 or more person board. The savings are to be spent “for purposes of promoting the health and wellness of residents of such community”. Here is the bill https://www.congress.gov/bill/115th-congress/house-bill/7038. and here is my blog post https://accountablehealth.wordpress.com/2018/11/06/h-r-7038-the-child-act-incenting-communities-to-improve-the-health-of-their-medicaid-beneficiaries/.

  2. A very well written blog.

    It is very important to include new approaches to population health management and person-centered care/ patient-centered care. HealthViewX patient referral solution, care management solution, chronic care solutions, etc are some the industry can look into.

  3. Housing for the chronically homeless is supported by “permanent supportive housing vouchers” that a community may obtain through local non-profit contracts with HUD and the Veterans Administration. These housing vouchers include support for “wrap around” services to engage the other community services that are helpful as in mental health. The ROI for these vouchers is >7:1 as documented by its reduction in the cost of healthcare for these folks. There are also “temporary supportive housing vouchers” for young adults leaving Medicaid and person’s leaving penitentiary housing ordered by a Court.

    I spent 2 1/2 years volunteering with an out-reach team for the homeless here in Omaha, 8-11 PM Mondays, six years ago. We always carried sandwiches, water and blankets. Kindness and respect was eventually the path to safe housing.

  4. “It’s the same as expecting police/correctional officers to fix social problems by being mental health workers.”

    And it’s the same type of stupidity that has destroyed the teaching profession.

  5. pj, good work by Community Solutions , but I think lacking in the scope of the needed housing. I like the mixed housing solution as low income warehousing never works, but the funding is a little bit of a mystery other than foundation/donors/partners using tax deductible money, then patting themselves on the back. I’m not all negative, but would need more information beyond what I read on the web site.

    We need to also force builders to add mixed needs to their developments, but sadly buyers and neighbors would have to accept lower income in their backyard.

    I only see this as part of the solution as income disparity drives homelessness, or at least puts people on the edge of living on the street. Just having a job (or two or three) is not any more the road to upward mobility.

    In places like San Francisco where housing costs will not allow moderate incomes (like teachers) to buy into any market, rental or ownership, living out of their cars is a huge problem. I listened to an NPR program on the extent of this epidemic and things like – using sewer drains as toilets, getting parking without tickets and tows/impounds, health related maladies from little sleep, bad posture, poor hygiene etc. makes this type of housing extremely stressful, and that’s just for the adults. The community leaders/activists said they could manage the problem IF the numbers were not so high.

    “Make America Great Again” would need to take us back to the 1950s -60s.


  6. “To believe that a new governmental financial commitment can establish caring relationships within the micro-neighborhood network of each person’s family is ridiculous.”

    Well we believe that bestowing huge and disproportionate tax cuts on the wealthy (individuals and corporations) is the way to solve societal problems – is that working?

    “On the other hand, could the local stakeholders convene within each community to develop the problem solving strategies for resolving their own Social Capital deficits? It is already occurring within most communities, especially for homelessness.”

    By the homeless themselves? These at risk communities usually have no intellectual expertise to even know where to start – let alone any funding.

  7. Maya Angelou said:

    “I’ve learned that people will forget what you said,
    .people will forget what you did,
    .but people will never forget how you made them feel.”

    The likely reality is that a portion of the cost and outcome attributes of our nation’s healthcare industry are caused by the worsening “social determinants” of population HEALTH. It is similarly unlikely that the healthcare industry should be held responsible for solving the “social determinants” occurring within within each citizen’s community. An investment by our nation must coordinate a locally-managed focus on the neighborhood citizens that live within a city-block of each citizen’s family. With that as a GOAL, we have a very long way to go, community by community. To believe that a new governmental financial commitment can establish caring relationships within the micro-neighborhood network of each person’s family is ridiculous. This has been steadily evolving for 50 years, two or three generations. It will take a similarly sustained effort to reverse it.

    On the other hand, could the local stakeholders convene within each community to develop the problem solving strategies for resolving their own Social Capital deficits? It is already occurring within most communities, especially for homelessness. So, what are the governmental institutions, at all scales, doing to support this effort? The Cooperative Extension service for agriculture is probably the most focused effort. The non-profit philanthropy efforts has tended to focus on early childhood education. It is already occurring, but without much nationally defined cohesion. If you want information about these efforts, subscribe to the STANFORD SOCIAL INNOVATION REVIEW published four times a year.

    To more fully understand Social Capital, see http://smg.media.mit.edu/library/putham.pdf

    To understand meaningful change, see http://dx.doi.org/10.1016/j.jebo.2012.12.010

  8. “Attempting to correct social issues through the medical care system is by far the most expensive, least effective and least efficient way of doing so. This is just dumping on doctors problems that no one else wants to address.”

    Sadly I have to agree. It’s the same as expecting police/correctional officers to fix social problems by being mental health workers.

    The foundational way to correct these problems (over time) is spending money, lots of it, on neighborhoods with public health workers, schools, and life coaching. But as long as Americans choose to invest more tax subsidies on the top 1% while keeping wages at or just above poverty level, with crushing personal debt, these problems will not be fixed.

    Welcome to the corporate feudalism society.

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  10. Attempting to correct social issues through the medical care system is by far the most expensive, least effective and least efficient way of doing so. This is just dumping on doctors problems that no one else wants to address.

    That the moronic-to-the-point-of being-dangerous clowns at the AAFP are incredibly enthusiastic about holding family physicians responsible for all aspects of their patients’s lives – housing, transportation, nutrition, etc., – is good evidence of what a terrible idea this is.

  11. I have a belief that true structural healthcare reform should be limited to $1.00 per citizen annually for a new semi-autonomous institution, similar to the Federal Reserve. This new institution would mobilize a nationally identified, @800, collection of separate communities nation-wide (about 400,000 citizens each). These groups would be locally funded and managed by their community’s legitimate stakeholders. They would receive nationally coordinated and regionally mediated training/advisory processes.
    See my URL beginning at https://nationalhealthusa.net/initiative/ and its five Sub-Pages for the duties of the new institution, provisionally identified as NATIONAL HEALTH. Its home office would be located in Saint Louis (It is close to our nation’s population center that is located 80 miles west of St. Louis.). There is also a proposed Strategic Development Plan at https://nationalhealthusa.net/primary-goals/strategic-plan/

    The evidence for this structure can be seen in our nation’s Cooperative Extension Service established in 1914 by Congress for the improvement of our nation’s agriculture. It is likely that this program has led to our nation’s agriculture industry become the most efficient and effective among the OECD nation’s of the world. Its appropriate to label our nation’s healthcare industry just the opposite. The evidence is further supported by research regarding HEALTH and Trust indicating that they exhibit reverse causality. Trust improves HEALTH within a community and the resultant improved HEALTH improves the level of Trust within a community. See http://doi:10.1136/jech-2015-205822 and its application to a study of ACA 2010 withn our nation at http://dx.doi.org/10.1016/j.socscimed.2017.08.012

    My underlying bias is that social capital is uniquely driven community by community. It would not be efficient or effective to determine the strategies for improving any community’s Social Capital by a centralized, bureaucratic and regulatory (aka coercive) institution. Many communities already do this in one form or another. They would be required to maintain a few measurement tools of their own choosing along with two measurement tools for the purposes of NATIONAL HEALTH.

    In addition to the community strategy, the central focus of NATIONAL HEALTH would to mobilize the priorities within the healthcare industry to support equitably available and ecologically accessible, enhanced Primary Healthcare within each community.

    FYI The same Congress that established the Cooperative Extension Service for agriculture also established the Federal Reserve for our nation’s monetary policies. REALLY!

    For the most carefully considered and described, ten page, analysis of Social Capital, see summary by Robert D. Putnam at http://smg.media.mit.edu/library/putnam.pdf

  12. Continuing the sentiments already spoken:
    Do you really think that medicalizing the address of social ills will be cost effective? You will hit 30% GDP trying to prove it I suspect.
    Social problems need to be solved directly, not by handing it to some growth driven industry. Sort of like the so called “correctional” industry where we have more people in jail than some countries have free. Not sure what that is correcting.
    “Prevention” has fallen into the same trap (because most of it has nothing to do with prevention). It is simply medicalized hyper-vigilance.
    SNAP is another fantastic example of what you are suggesting: dumping millions of dollars into the soda industry in the name of “feeding the poor”. It ends up being little more than a processed food industry subsidy, which eventually creates reward for the diabetes industry, who then turns around and increases the number of diabetics and raises the cost of treatment. So much for curing diabetes. You couldn’t stop if you wanted to, because now it is a profit platform where all associated industry colludes to use patients as soil to plant their money trees in.
    Google “poverty industry” or “disaster capitalism” if you would like to explore similar models to what you are suggesting.

  13. The level of Social Capital shared among our nation’s citizens, the expression of Trust, Cooperation and Reciprocity, is at an all time low. We would need to implement a generational, community by community strategy to augment this attribute nationally. With slow implementation and locally driven strategies to enhance their own Social Capital, you are correct for a staged implementation of individual/family health care financing. I am still a bit hesitant about the sustainability of social responsibility within the C-Suite of most hospital-based enterprises. Maybe they just need to be threatened by the Joint Commission accreditation review process based on their level of community involvement (such as their community’s level of equitably available Primary Healthcare). Furthermore, the financing of post-graduate medical education is largely funded by Medicare and based substantially on the relative research budget of each specific medical school. We don’t generally recognize the paradigm-paralyzing influence of the AAMC and NASEM ( aka Academy of Medicine) folks.

  14. “You’re going to have such great health care, at a tiny fraction of the cost, and it’s going to be so easy.” – Candidate Donald Trump, Oct 2016 Florida campaign rally.

    “Who knew health care could be so complicated?” – President Donald Trump, 2017.


  15. Two disruptive ideas:

    1.Because the demand for inpatient care is–or should be–highly inelastic, try running it somewhere as an experiment in a public good (no bills or charging apparatus; only medical records kept). Inelastic means your costs are essential so that you might avoid some gaming through moral hazard on the part of the patient. And, if you run it through a local hospital district or county, you avoid provider-induced demand because these payers are never going to have a surfeit of money.

    [Everyone on salary; drugs obtained through monopsonic purchasing; funding by local or county taxes and perhaps CMS venture capital; tight hospital-admission algorithms]

    2. To give patient a skin-in-the-game, try running health care somewhere by using convertible dedicated-health vouchers so that all payments are finally issued by the patient. Like the old indemnity system or yore. Truly patient centered health are, alas. Unused vouchers remit value to patient or estate, so that the patient considers these money. The reason for vouchers is that we have to try to help needy by subsidies of vouchers and if we use ‘banal’ money, it is too easily diverted from health care purposes. Claims payments in these Medi-bucks go to patient first. If he or she doesn’t pay provider, provider gets a message of quality deficiency or patient dereliction. He can improve service or sue or refuse further service. Pharma has to agree to try this too….and hospitals and all providers. It should probably be tried in a certain area first, rather than nationwide.

    [This is an attempt to mitigate the faults, somewhat, of the third party payer conundrum, which is said to be by many to be the single and glaring canonical defect in our health care system.]

    Needless to say, there are scads of details in these two ideas that I do not have room for here.

  16. @pjnelson below clearly understands what healthcare incumbents and the consultants that cater to them clearly do not. Our “providers” are already wasting (and sometimes defrauding) society to the tune of $1 trillion per year as compared to healthcare prices in other rich nations. This $trillion would be much more effectively spent on education, healthy food, and parks than among the healthcare incumbents.

  17. Is it possible that our nation’s healthcare industry is the least efficient and effective among the other 34 OECD nation’s of the world? See the JAMA population health study reported by Irene Papanicolas et al ( https://doi.10.1001/jama.2008.1150 ). Oddly, the effectiveness issue might be, best described as uneven. Look up Maternal Mortality on page 1030 of the JAMA report. I won’t cite the reported data, its a black mark on our nation’s health priorities. This statistic has worsened now for 30 years annually, with no evidence of improvement.

    We speak of social determinants as if it could be identified as a Diagnosis that is associated with a scientifically established basis for a treatment plan that lends itself to implementation by health care. Such is not the case. Is there any doubt about the role of homelessness as a cause of poor health? Of course not, but the treatment plan of simply purchasing a home by a hospital will not solve the social dilemma of homelessness. Similarly, the loss of Social Mobility and its impact on Well-Being within certain population groups cannot be solved with a monthly check.

    Furthermore, there is no evidence that our current “work-around” strategies for healthcare reform have accomplished meaningful results ( see Milbank quarterly report 2018 by Burns and Pauly from Wharton School https://doi.org/10.1111/1468-0009.12312 ) I quote: “The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent. In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence.” This may described at best as shrouded, but strong, language from two economists from the University of Pennsylvania.

    We continue to dither while our nation’s attention is distracted by all sorts of divisiveness. The reality is that our nation’s Medicare-eligible population represents a classic “population bulge” that will eventually produce an economic crisis of unforeseeable dimensions. Can we really afford another round of hospital bed expansions, community by community? Of course not. Do we have the resiliency to withstand an influenza pandemic? Probably not. Do we have a nationally supported and locally managed plan to assure that each infant can confidently reach the age when they are required to care for themselves and their community? NO!