The Health Care Ecosystem and Social Determinants of Health: Surveys Suggest the Stage Is Set for Novel Collaborations

Dr Hennessey relates her past personal experience with cancer care delivery when her mother was receiving chemotherapy for lung cancer, where an issue with care access could have significantly altered her mother’s life span. This experience inspired her career and prompts an exploratory discussion of how social determinants of health (SDOH) are currently addressed in health care today. Authors discuss definitions of social determinants of health, survey results of how organizations currently integrate SDOH, and insights on how to make better use of SDOH for more value-based care. 

Several decades ago, as a health care professional in training, I personally and powerfully experienced the impact social determinants wield upon health. My mother was receiving chemotherapy for lung cancer and contending with severe nausea and vomiting as a result. At the time, remedies for nausea were so ineffectual that she would reflexively feel nauseous when she saw her chemotherapy nurse in the local supermarket! My fiercely tenacious mother was ready to give up and lamented, “If I could just lie in bed at home and not move, I wouldn’t get so sick on the chemo.” Access to in-home infusions was rare in our community, but fortunately, a social worker gave me the name of an oncologist with a grant for a mobile chemo van, and he gave my mother infusions in bed at home. My mom, with an anticipated life expectancy of 6 months, lived another 7 years and saw the birth of her first grandchild, my sister’s high school graduation, my doctoral graduation, and other precious family milestones. 

Personally grateful, I found myself reflecting broadly and professionally on the impact of access to care on patients’ opportunities for life and quality of life. What would have happened if that oncologist had not provided in-home infusions? What if the social worker had not known, taken time, or been willing to share his name? How many people unnecessarily suffer or die due to poor care access? After graduate school, I took those lessons to heart when I began a career as a managed care executive tackling escalating and avoidable hospitalization and readmission rates among populations in rural, suburban, and urban areas that included the most impoverished and wealthiest American communities. These experiences offered opportunities to deploy analytics and leverage social and clinical networks. This work then encouraged innovations that led to models of subsidized patient transportation, in-home care programs, and telehealth outreach. The networking that took place around these programs reduced the impact of adverse social determinants to attain better clinical outcomes through improved care access and more efficient resource use.  

As my experience testifies, although addressing social determinants of health (SDOH; also called social risk factors) has occurred inconsistently for decades among health plans, delivery systems, and subpopulations, they are now emergent factors to be systemically addressed to improve population health and better deliver value-based care. This article will define and describe SDOH.^1,2 Further, it will comment on reasons for their growing importance and will share select insights from Precision for Value’s 2019 SDOH Survey regarding organizations’ approaches to SDOH. The article will also offer observations on ways that health care entities are addressing SDOH and conclude with a summary of opportunities for collaboration to accelerate effective action to address SDOH.

Definition of SDOH and Their Expanding Importance

While multiple definitions exist for describing SDOH, the Centers for Disease Control (CDC) and World Health Organization have provided some of the more commonly used descriptions. “Social determinants of health are economic and social conditions that influence the health of people and communities. These conditions are shaped by the amount of money, power, and resources that people have, all of which are influenced by policy choices.”³ Examples of SDOH include: access to quality health care, discrimination, education, employment, food security, income, safe housing, and social support.⁴ 

Given CDC estimates that SDOH account for 75% of population health,⁴ combined with findings that the United States spends far more than other high-income countries on health care (but falls comparatively lower on health care quality outcomes⁵), it is unsurprising that SDOH are receiving expanded focus among US health care entities. Plans, integrated delivery networks (IDNs), and quality organizations are among the entities increasingly recognizing that systemic assessment and intervention with SDOH offers opportunities for attainment of the Triple Aim: better care, healthier people, and smarter spending.⁶ 

At the 2019 National Quality Forum conference, Kate Goodrich, MD, MHS, of the Centers for Medicare & Medicaid Services (CMS) noted that SDOH or social risk factors are integral to CMS Strategic Priorities for 2019 and discussed ways CMS is embedding a focus on health equity within its programs.⁷ 

The Population Health Alliance has also weighed in on the importance of addressing SDOH. In a 2018 white paper, it declared that the emergence of value-based health care creates a United States imperative for multistakeholders to forge alliances to reduce the impact of SDOH on our population’s health.⁸ Yet another quality organization, the Pharmacy Quality Alliance (PQA), has commented on the importance of medication access within value-based care and noted that difficulty accessing needed medications substantially impacts population health. PQA recently authored a report describing a Medication Access Conceptual Framework with SDOH integrated within this framework.⁹ Finally, as an additional indicator of the urgency of systemically addressing SDOH, two highly influential organizations, United HealthCare and the American Medical Association, have joined forces to standardize how ICD-10 data is collected, processed, and integrated to assess and address SDOH, with the purpose of improving health care access and outcomes.¹⁰ 

The health care ecosystem is evolving from volume-based reimbursement models to value-based reimbursement paradigms with incentives and penalties linked to  quality performance and cost management. Both payers and providers—seeking to gain revenue, attract and retain members and patients, and avoid financial penalties—are transforming their systems to offer better health outcomes, enhanced patient experience, and more efficient cost management consistent with the Triple Aim. Many are developing population health management infrastructures to accelerate this process.¹¹ This transformation will continue as more entities reach a tipping point with payer and provider delivery systems merging and IDNs contracting to assume more financial risk for costs and quality of care. Precision for Value sought to gain insights into diverse health care stakeholders’ approaches to SDOH as they evolve to value-based care; summaries of select survey results follow.

Precision for Value 2019 Survey on SDOH

In March 2019, Precision for Value used its RapidPulse^TM tool to conduct a survey of health care access decision makers to gain insights into their approaches to SDOH (N=30). The majority of respondents (77%) reported current initiatives to address SDOH, with another 17% planning to do so within the next 18 months. A minority (two respondents or 7%) indicated that their organization did not have initiatives to address SDOH and had no plans to do so. These two respondents were excluded from additional survey participation. Thus, responses were further analyzed from 28 respondents, representing an estimated 244 million lives, to investigate their approaches to SDOH. Respondents (N = 28) represented Health Plans/PBMs (n=9) and ACOs/Health Systems/IDNs (n=19). Half of the 28 respondents reported that they presently offer all patients services to assess and address SDOH. (Due to rounding, percentages may surpass 100%; lives may be double-counted where medical plans use a participating pharmacy benefit manager.)

The paragraphs that follow summarize some of the key survey findings and comment on opportunities for future stakeholder collaborations.

Organizations’ Rationale for Current Initiatives

When we asked organizations about their reasons for addressing SDOH, the majority of respondents surveyed (86%) selected clinical outcomes as the most significant reason. Also, frequently identified as important were alignment with their organization’s mission (79%) and total cost of care management (71%). 

Further, most respondents indicated that addressing SDOH was an important initiative for their organization to attain better performance on reduction of admissions or readmissions (93%) and reduced emergency department utilization (93%). The majority (89%) said that SDOH initiatives were important for better performance on chronic disease quality measures. When asked about their organization’s therapeutic priorities for addressing SDOH within the next 18 months, diabetes (43%) and cardiovascular disease (43%) were the therapeutic areas selected as their highest likely future priorities.

To summarize, survey findings suggest that most respondents perceived SDOH as important factors to be addressed for obtaining better clinical outcomes, reducing admissions and readmissions, and avoiding unnecessary emergency department use, and many respondents said that total cost of care management was a significant reason to address SDOH. The majority found SDOH to be an important factor in managing chronic disease and prioritized diabetes and cardiovascular disease as two areas to be addressed through implementation of SDOH initiatives within the next 18 months. Further, more than three-quarters of respondents cited alignment with their organization’s mission as an important reason for addressing SDOH, suggesting that activities to mitigate the impact of adverse social determinants are consistent with their organization’s values and culture.

Infrastructure to Address SDOH

From an infrastructure perspective, the majority of respondents (68%) now have a stated mission within their organization to address social determinants impacting health. The majority also reported the use of a structured assessment tool to assess SDOH (64%). Although 64% stated that they have a formalized process to refer or provide patients with enabling services, nearly half (43%) did not yet use an electronic resource directory to facilitate that process. 

Particularly noteworthy, entities appear to be lagging in the integration of SDOH data into the patient stratification frameworks necessary for population health management (PHM). Although only 50% reported presently doing so, an additional 36% reported plans to integrate SDOH within stratification frameworks in the next 18 months. Acknowledging the importance of data integration, Allen Daniels, EdD, director of clinical solutions at InfoMC—a national health care technology company offering a platform for payers, health plans, and provider organizations—commented, “Impacting health behaviors necessitates that organizations are able to identify and stratify individuals at SDOH risk, and provide care teams the technology and tools to coordinate care and improve physical, behavioral, and social health outcomes” (email communication, April 12, 2019). 

Services Being Provided

The majority of respondents (82%) reported currently addressing access to affordable health care services and medications, but more than two-thirds (68%) said they need moderate to significant levels of support to provide these services. Similarly, more than two-thirds (68%) of respondents presently offer transportation to support access to health care services and medication, but more than half (54%) need moderate to significant levels of support to provide those services. These findings suggest that, while many organizations are addressing access to health care and medications, more resources are required to close existing accessibility gaps.

As expected, most respondents (96%) are currently offering services and information for non-English-speaking patients. However, only (68%) reported offering services to support patient health literacy. Since 57% of respondents needed moderate to significant levels of support to provide literacy services, it appears more resources are needed to close this gap, particularly given that health literacy is associated with adherence. Further, health literacy interventions are associated with improvements in treatment adherence, suggesting that this is an actionable population health priority for health care organizations.¹² 

Particularly concerning was a service currently overlooked by health care organizations. Less than one-third of respondents (32%) reported offering services to decrease social isolation, with more than one-third (39%) reporting no plans to do so in the future. Given that research suggests the impact of isolation and loneliness on health and mortality are of the same order of magnitude as high blood pressure, obesity, and smoking, neglecting social isolation as a SDOH represents a glaring PHM gap.¹³ 

One solution, however, may be found through the use of telehealth services. The majority of respondents (86%) now offer telehealth, and 11% more plan to do so within the next 18 months. Hossam Mahmoud, MD, MPH, medical director for Regroup, a national leader in telepsychiatry, has published extensively on telehealth, including the stressors experienced by those living in remote and rural areas. Dr Mahmoud and his colleagues have described telemental health as a cost-efficient, effective means of offering care in remote and rural areas, resulting in a high degree of patient satisfaction.¹⁴ Although social isolation is present in rural, remote, and urban areas, it may be that telehealth offers a potential solution currently within many health care organizations’ toolboxes. Connecting patients to clinicians through video calls is a potential solution mentioned in a 2018 white paper on social isolation, and entities may wish to pilot the impact of offering supportive telehealth services as a means of reducing social isolation and associated health risks for vulnerable patients identified during SDOH screenings.¹⁵  

Key Collaborators

As expected, respondents reported that, currently, their most frequent collaborators to address SDOH are primary care provider groups (68%), hospitals (68%), and health plans (64%). 

Most noteworthy, the least-reported collaborators were pharmaceutical and device manufacturers. Only 18% of respondents reported current collaboration plans with manufacturers to address SDOH; however, the remaining 82% either planned collaborations within 18 months or were willing to consider future collaborations.  

Opportunities for Collaboration 

Progress on mitigating the adverse impact of SDOH requires alignment, collaboration, and delivery system transformation among all health care stakeholders to attain the Triple Aim.  Below is a summary of collaborative opportunities suggested by the Precision for Value survey results.

Opportunity #1. Respondents collaborate with multiple entities to address SDOH and are open to additional collaborators (including pharmaceutical and device manufacturers) to expand expertise, resources, and initiatives to better address SDOH.

Opportunity #2. Respondents view addressing SDOH as an important factor in managing chronic disease and are prioritizing diabetes and cardiovascular disease as two conditions to be better managed through future implementation of SDOH initiatives.

Opportunity #3. Although respondents are developing infrastructure for better management of SDOH and PHM, gaps remain, including the development of electronic resource directories and integration of SDOH into patient stratification frameworks.

Opportunity #4. Affordability and transportation are two barriers to accessing health care and medications and more than half of respondents indicated needing moderate to significant levels of support to provide services to close gaps in access, suggesting opportunities for future collaboration to provide additional support.

Opportunity #5. Nearly one-third of respondents did not report offering services to support health literacy, and more than half indicated needing moderate to
significant levels of support to provide these services. Health literacy interventions are associated with better treatment adherence and offer an opportunity for population health improvement.

Opportunity #6. Less than one-third of respondents reported offering services to decrease social isolation, with more than one-third reporting no future plans to do so. This is a troubling PHM oversight, and innovative use of technology (eg, telehealth) may offer opportunities to address this social risk factor.

Conclusion

As the United States transforms its fragmented health care system to value-based care, developing strategies to address SDOH will play a vital role in PHM. Within the health care ecosystem, we are still in the early stages of integrating approaches to social risk factor mitigation. Precision for Value 2017 and 2019 PHM surveys have found that payers and organized providers are open to collaborations, including collaborations with pharmaceutical manufacturers, to address population health challenges.^11,16 This survey extends that trend, indicating that payers and organized providers are open to multistakeholder collaborations. However, particularly in the area of addressing SDOH, pharmaceutical and device manufacturers are an underutilized PHM resource. These series of surveys help establish that a consensus exists for collaboration among multiple stakeholders and the stage is set for novel collaborations to further tackle SDOH and other PHM challenges to successfully lower the total cost of care.

References

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9. Pharmacy Quality Alliance. Access to care: development of a medication access framework for quality measurement. https://www.pqaalliance.org/assets/Research/PQA-Access-to-Care-Report.pdf. Published March 2019. Accessed April 29, 2019.

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14. Mahmoud H, Sers M, Tuite J. Enhancing telemental health for rural and remote communities. Becker’s Health IT & CIO Report. January 4, 2018. https://www.beckershospitalreview.com/healthcare-information-technology/enhancing-telemental-health-for-rural-and-remote-communities.html. Accessed April 29, 2019.

15. Bipartisan Policy Center. Rural aging: health and community policy implications for reversing social isolation. https://bipartisanpolicy.org/wp-content/uploads/2018/07/Rural-Aging-Health-and-Community-Policy-Implications-for-Reversing-Social-Isolation.pdf. Published July 2018. Accessed April 29, 2019.

16. Precision for Value. RapidPulse^TM PHM Survey [proprietary data]. January 2019.