Nearly a decade has passed since Healthy People 2020positioned social determinants of health (SDoH) at the forefront of healthcare reform. As defined by the report, SDoH are the “conditions in the environment in which people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality of life outcomes.” Examples of social determinants include:
Resources to meet daily needs (e.g., safe housing and local food markets)
Educational, economic, and job opportunities
Community-based resources in support of community living and opportunities for recreational and leisure-time activities
The ability to influence
social determinants largely falls outside of the health care system’s reach.
Therefore, a key to address opportunities for health involves collaboration between
health care and different industries such as education, housing, and
transportation. Both the public and private sectors have made significant
efforts to bridge the gap between physical, mental, and social care by
experimenting with non-traditional partnerships.
The Center for Disease Control and Prevention (CDC) has spearheaded multiple programs with government agencies and community partners to achieve the goals outlined in Healthy People 2020. One of the most notable successes is the Childhood Lead Poisoning Prevention Program, an initiative by the CDC with the Department of Housing & Urban Development and the U.S. Environmental Protection Agency. Through housing rehabilitation, enforcement of housing and health codes, and partnerships with healthcare experts, the program helped Healthy People 2020 exceed their target of reducing blood lead level in children.
Other programs such as the “National Program to Eliminate Diabetes Related Disparities in Vulnerable Populations,” leveraged community partners and resources to increase food security, health literacy, and physical spaces for active living. In one of their projects, the program partnered with community health workers (promotoras) who spoke Spanish to engage with Hispanic/Latino communities where participation to Diabetes Self-Management Education (DSME) was low. The community health workers provided linguistically and culturally-sensitive materials that effectively increased participation in DSME among the targeted population. The outcomes from such initiatives have inspired more health and community organizations to work together to reduce health disparities.
Today on Health in 2 Point 00, Jess is in Italy…and has me up far too early in the morning for this episode. On Episode 79, Jess asks me for an update on uBiome after their raid by the FBI. We also talk about nutrition startup Noom’s $58 million raise and clinician house-call platform DispatchHealth’s $33 million raise. In other news, Kaiser Permanente is launching a network to integrate the social determinants of health with their EHR. –Matthew Holt
By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA
Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.
our standard screen for safety at home had been completed long ago, I wanted to
probe further, knowing that many patients with obesity, chronic pain and other
chronic conditions have suffered an adverse childhood – or adulthood –
experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough
latitude for me to ask about a history of trauma when it can occur in so many
forms, in so many ways and at different times of life? Furthermore, suppose she
did report a history of trauma or adverse experience. What then? Would I be
able to help her?
I began: “Jenny, many patients with symptoms like yours have been abused,
either emotionally, physically, or sexually, or neglected in their past.
Sometimes they have suffered loss of a loved one, or experienced or witnessed
violence. Has anything like this ever happened to you?”
yielded our first breakthrough. Yes, she had experienced neglect, with parents
who were separated for much of her childhood, and then later divorced. She had
seen her father physically abuse her mother. With little parental oversight,
she had engaged in drug and alcohol use throughout her teenage years. But, she
wanted to be sure we understood that this was all behind her. She had gotten an
education, was in a committed relationship, and had a stable job as a teacher.
That part of her life was thankfully now closed.
The Robert Wood Johnson Foundation (RWJF) has partnered with Catalyst @ Health 2.0 to launch two innovation challenges on Social Determinants of Health (SDoH) and Home & Community Based Care. As a national leader in building a culture of health, RWJF is inspiring and identifying novel digital solutions to tackle health through an unconventional lens.
Health starts with where we live. As noted in Healthy People 2020 social determinants
of health are, “conditions in the environments in which people are born, live,
learn, work, play, worship, and age… [that] affect a wide range of health
functioning, and quality-of-life outcomes and risks.” For example, children who
live in an unsafe area cannot play outside making it more difficult for them to
have adequate exercise. Differences in SDoH heavily influences communities’
well-being and results in very different opportunities for people to be
Despite our knowledge on SDoH, the current healthcare system utilizes care models that often fail to take into account the social and economic landscape of communities– neglecting factors such as housing, education, food security, income, community resources, transportation and discrimination. Little progress has been made on incorporating SDoH into established health care frameworks. Healthcare providers and patients alike either have limited understanding of SDoH or have limited opportunities to utilize SDoH knowledge. RWJF established the “Social Determinants of Health Innovation Challenge” to find novel digital solutions that can help providers and/or patients connect to health services related to SDoH.
Home and community-based care is also important to enable Americans to live the healthiest lives possible. In-patient and long-term institutional care can be uncomfortable, costly, and inefficient. Digital health solutions in the home and community offer opportunities for care that better suit the patient and their loved ones. For example, innovations such as remote patient monitoring (RPM) have created new care models that allow the providers, caregivers, and patients to manage care where a person is most comfortable. RPM serves as a reminder that technologies in the home and community offer alternatives methods to engage the patient, increase access to care, and receive ongoing care. Therefore, RWJF is launching the “Home & Community-Based Care Challenge,” to encourage developers to create solutions that support the advancement of at-home or community-based health care.
As U.S. providers continue their slow but steady march away from fee-for-service reimbursement and toward value-based payments, they’re increasingly seeking means of addressing patients’ health-related social needs. That’s because social determinants of health—life circumstances including socioeconomic status, housing, education, and employment—are estimated to have at least twice the impact on risk of premature death than health care. So addressing them is an important part of value-based strategies aiming to improve health while reducing health care costs.
Hennepin Health, a safety-net Accountable Care Organization (ACO) serving Medicaid patients in Minneapolis, Minnesota, is an encouraging example of the trend. Hennepin Health’s ACO is a partnership between the county’s local Human Services and Public Health Department, a local teaching hospital, a Medicaid managed care health plan, and a Federally Qualified Health Center. Its innovative care model is designed to meet the unique needs of the partners’ shared, “high-risk” members, whose complex combination of issues—such as mental illness, addiction, homelessness and/or other hallmarks of social deprivation—often prevent them from accessing or receiving appropriate care through the traditional health system.
The ACO is staffed by an integrated care team comprised of
physicians, nurses, pharmacists, social workers and community health workers.
Unlike traditional care processes, which often only involve medical assessment,
Hennepin Health’s begins with an assessment of members’ social needs, like
housing and food insecurity, or lack of transportation and unemployment, so
that its care team can tackle those barriers to health in conjunction with
members’ medical problems. And throughout members’ care, the team strives to
develop and maintain a trusting relationship with members, many of whom have
been let down by traditional health care, so that they can continue to identify
and assist with more health and social needs over time.
Results thus far has been impressive—according to a Commonwealth Fund case study, the ACO’s medical costs fell an average of 11% per year between 2012 and 2016. And, between 2012 and 2013, its members’ emergency room visits decreased by approximately 9%, with hospital admissions remaining flat and outpatient visits increased by 3.3%. Assuming its results have continued on the same trajectory (we could not find more recent figures), Hennepin Health’s innovative care model shows significant promise.
But does it have the potential to disrupt America’s traditional, episodic, acute care delivery model? We put it to the test with six questions for identifying a Disruptive Innovation.
How can understanding the underlying social risks impacting patient populations improve health outcomes AND save health plans some serious per-member-per-month costs? You’re probably familiar with the concept of ‘Social Determinants of Health’ (SDOH) but Dr. Trenor Williams and his team at health startup Socially Determined are building a business around it.
By looking at data around what Trenor calls ‘the Significant 7’ social determinants (social isolation, food insecurity, housing, transportation, health literacy, and crime & violence) he and his team are working to help health plans intervene with their most vulnerable populations and bring down costs.
What kind of data is Socially Determined looking at? Everything from publicly available data on housing prices and air quality, to commercial datasets on buying preferences and more. Plus, with help from their health plan partners, they’re using clinical and claims data to create a complete picture of health care spend, utilization, and outcomes.
Trenor walks through some very specific examples in this interview to help illustrate his point. In one, Socially Determined was able to identify how Medicaid could better help asthmatics manage their asthma AND save a thousand dollars per affected member each month. Another project in Ohio identified that a mother with a history of housing eviction was 40% more likely to give birth to a baby requiring NICU care – opening up myriad opportunities for early intervention and the potential to positively impact the lifetime health of both mother and child.
As healthcare continues to realize its ‘data play’ – and look beyond the typical data sets available to healthcare companies – the opportunities for real and meaningful impact are tremendous. Listen in to hear more about what Trenor sees as the new opportunity for Social Determinants of Health.
Filmed at AHIP’s Consumer Experience & Digital Health Forum in December 2018.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
Historically, the Centers for Medicare & Medicaid Services’ (CMS) stance on the influence that social determinants of health (SDOH) have on health outcomes has been equal parts signal and noise. In April 2016, the agency announced it would begin adjusting the Medicare Advantage star ratings for dual-eligibility and other social factors. This was amid calls for increased equity in the performance determinations from the managed care industry. At the same time, CMS continued to refuse risk-adjustment for SDOH in the Hospital Readmissions Reduction Program (HRRP) despite the research supporting the influence of these factors on the HRRP.
It wasn’t until Congress interceded with the 21st Century Cures Act that CMS conceded to adjusting for dual-eligibility under the new stratified approach to determining HRRP penalties beginning in fiscal year 2019. The new methodology compares hospital readmission performance to peers within the same quintile of dual-eligible payer mix. The debate surrounding the adjustment of incentive-based performance metrics for SDOH likely is to continue, as many feel stratification is a step in the right direction, albeit a small one. And importantly, the Cures Act includes the option of direct risk-adjustment for SDOH, as deemed necessary by the Secretary of Health and Humans Services.
SDOH are defined as “the conditions in which people are born, grow, live, work and age.” The multidimensional nature of SDOH reach far beyond poverty, requiring a systemic approach to effectively moderate their effects on health outcomes. The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received and are not readily modifiable by health care providers.
The question of modifiability is central to the debate. In the absence of reimbursement for treating SDOH, providers lack the resources to modify health outcomes attributable to social complexities. Therefore, statistical adjustments are needed to account for differences in these complexities to ensure risk-adjusted performance comparisons of hospitals are accurate.
It’s been established that an effective way to manage an individual’s health is to address the root cause of health complications, known as social determinants of health (SDOH).Unfortunately, interventions that address SDOH often exist outside the scope of the traditional healthcare payment system.
There is a relatively new methodology that can be used to increase spending on SDOH while transparently enforcing accountability and outcomes. Social impact bonds, also known as“pay-for-success” models, are multi-stakeholder performance-based contracts.
The five key stakeholders and their roles are as follows:
1) Service Provider:Agrees to conduct a program designated to yield a future outcome that is valuable to the payer.(Usually a nonprofit organization.)
2) Investor:Provides up-front working capital for the service provider to channel toward the designated program.In exchange, the investor will receive a “success payment” if the committed outcome is produced on schedule.
3) Payer:Commits to pay the service provider a “success payment” when the specified outcome is produced.(Usually a government agency.)
4) Intermediary Organization:Facilitates the SIB contract, establishes payment and financing terms, and supervises the service provider’s program.
5) Independent Evaluator:Determines if the committed outcome was achieved upon conclusion of the contracted period.
Here it’s argued that we need to retire the health care fallacy, “We spend more on health care than other rich countries but have worse outcomes.” The fallacy implies U.S. health care is deficient in spite of being costly. Indeed our health care costs too much, but there is little evidence that our care is less effective than care in other countries. On the other hand, there’s plenty of evidence that our social determinants of health are worse.
The argument segues off a recent article by Victor Fuchs. The case is presented by using a simple linear model to explore how life expectancy might change when we substitute the numbers of other countries’ determinants of health for U.S. numbers. After making these substitutions and holding health care spending constant the model predicts U.S. life expectancy is right there with the other OECD countries, 81.6 years compared to their average 81.4 years. This what-if modelling makes clear what should be obvious but the fallacy hides, that health care is only one part of population health.
The Fuchs Essay
Victor Fuchs’s recent essay1 impressed me. He wrote of the lack of a positive relationship between life expectancy and health care expenditures (HCE) in OECD countries. A chart was included for empirical support. I liked the idea behind the chart which demonstrated his point using data from select countries and our 50 states. Professor Fuchs has written on this topic for years (e.g., in his 1974 book “Who Shall Live?”). I posted on the fallacy in March 2013 but was not as nuanced.2
So much so, that when I approached a conference speaker, to briefly comment on my interest in helping beleaguered family caregivers with their carees’ health and healthcare issues, I was advised to work on promoting a culture of health.
Hm. Funny, but as a generalist and geriatrician who focuses on the primary care of older adults with multiple medical problems, I’d been thinking more along the lines of:
Promoting the wellbeing of older adults and their caregivers.
Optimizing the health – and healthcare — of my aging patients.
In other words, I’d been thinking of a “Culture ofCare.”