Know Your Members: Identifying and Addressing Social Determinants of Health in Low-Income Populations

According to a report from the Kaiser Family Foundation, social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work, and age.” They include factors like socioeconomic status, education, physical environment, employment, and social support networks, as well as access to health care.

Consider, for a moment, some statistics: 

• 28% of US adults reported that they had at least two chronic conditions.

• 26% of US adults said that they had experienced emotional distress in the past year that was difficult to cope with alone.

• US adults were more likely than adults in all other countries to report that they were “always” or “usually” worrying about having enough money to buy nutritious meals and to pay their rent or mortgage.

• 33% of US adults reported that they had a cost-related access problem in the past year. US adults are the most likely to report financial barriers to health care compared to other countries.

Those who work in health care tend to assume that health care consumers care about the same things we do—getting and staying healthy by participating in annual well visits, managing chronic conditions, taking medications as prescribed, and being a well-educated patient. However, we need to acknowledge that these things are not often on the minds of the typical health care consumer, especially those experiencing socioeconomic barriers to care. Health care may be one of many competing priorities that goes on the back burner when compared with a much longer list of more important things like paying the rent, finding a job, or simply getting to an appointment. 

Resources to address socioeconomic barriers often fall outside the benefit structure of health plans or the scope of providers. However, one could argue that you cannot effectively care for people when ignoring life factors that have such an enormous impact on health. It is critical for health care organizations to direct efforts and resources toward addressing issues of social inequities, diagnosing problems, and removing barriers that negatively affect the health status and quality of life of their members. But how to do this when this type of information does not come on a claim? 

Identifying Social Determinants

Health care organizations need to go beyond claims data and have conversations with consumers to identify life circumstances beyond the models by: 

• Developing strategies to assess and address social determinants of health, and have a direct and open dialogue with members. 

• Asking members about access to life necessities such as food, shelter, and housing as well as access to transportation to get to doctor’s appointments. 

• Assessing members’ mental and physical health changes and housing stability over time, as well as financial worries, caretaker stress, and their perceived ability to overcome problems and seek help when needed. 

• Listening to their responses, and connect them with plan and community resources that can help them overcome barriers to care. 

Sometimes this last strategy comes in the form of a care manager, Meals on Wheels, or a ride to an appointment. Often times these little fixes can have big impacts on someone’s life. For example, one member was flagged for transfer to a care manager who learned that the member was suffering from chronic back pain, exacerbated by an old mattress. The care manager worked with a local nonprofit that picked up the member and helped her get a new mattress within a week.

Through our work surveying health plan members via interactive voice response technology, we found that social determinants of health affect members in a variety of ways. People who
reported concerns about life necessities (food, shelter, safety) were five times more likely to report having poor health, two-and-a-half times more likely to report their health negatively affecting their work, and eight times more likely to report high emotional stress. Among low-income populations, those who are dual-eligible for Medicaid and Medicare, have shown to have the most concerns about life necessities, followed by Medicaid enrollees and then Marketplace members, of which, about 85% are below 400%  of the federal poverty level (Figure 1). 

Risk Factors

Age and disability status play a large role in social determinants of health, particularly when coupled with income. Dual-eligible members with concerns for life necessities are more likely than Medicaid enrollees to report that physical and emotional health problems affect “productivity,” or their ability to do a good job at work, at home, or when caring for others.

Having concerns about life necessities also means that members are less likely to be active participants in managing their health. Among Marketplace members, those who had concerns with meeting life necessities were up to 9% less likely to close preventive care gaps like breast and cervical cancer screenings, than those with no concerns about life necessities (Figure 2).

The Time For Action

It is important to use multiple opportunities to collect social determinants of health responses from members throughout their tenure with a plan and monitor any changes over time. Offer immediate assistance to people who report issues for which resources are available to address barriers to care. Then analyze health behaviors in light of responses and interventions to glean lessons learned and evaluate programs. 

There is extensive evidence proving the relationship between socioeconomic factors and health outcomes, so it is time to stop analyzing the problem and collectively come up with some solutions to address socioeconomic barriers to care. Early screening and identification of social determinants of health through interactive conversations with members is one way to ensure low-income
populations are connected with effective interventions to address the underlying factors influencing health.