Bringing Social Determinants of Health to Life to Optimize Health Outcomes in Patients With Chronic Conditions

J Clin Pathways. 2022;8(1):20-25. doi:10.25270/jcp.2022.02.3.

Addressing social determinants of health (SDOH) has become a national priority in health care. The United States and the world have seen firsthand how these factors impact the mortality and morbidity of patients contracting the COVID-19 virus, with people of color disproportionately affected. As the pandemic enters another phase, organizations nationwide are increasingly looking to integrate SDOH and health equity into value-based strategies. Where do these organizations focus their efforts so as not to boil the ocean and fail? Payers and providers are considering patients with chronic conditions because they disproportionately consume a significant portion of the health care spend and system utilization. This article addresses health care disparities in patients with chronic conditions, the roles of health systems and payers in closing these gaps, and a customizable SDOH toolbox to help stakeholders improve health outcomes for all patients. 

Over the last few decades, SDOH have been recognized as factors that disproportionately impact certain racial, ethnic, and socioeconomic groups, leading to poor treatment adherence, worse patient outcomes, and higher costs of care. This has catalyzed some organizations, such as Aetna, Anthem, Kaiser, Highmark, and others, to integrate these factors into population health strategies. However, according to a study by Dartmouth University researchers in 2019, organizations have been slow to develop solutions.¹ The COVID-19 pandemic magnified health disparities, as people of color have been three times more likely to contract and die from the disease.² Such a flagrant disparity created a burning platform to address these factors.

PRECISIONvalue conducted a number of surveys from 2019 to 2021 among multiple stakeholders including health plans, pharmacy benefit managers, accountable care organizations, and health systems. Responses suggest that SDOH are now a priority within the health care ecosystem. One survey found that ≥80% of respondents listed access to care, such as transportation and telehealth (93%), access to medications (90%), social isolation (83%), and financial distress (80%) as SDOH that have risen in priority since the onset of COVID-19.³ In a 2021 survey, most respondents reported their organizations had initiatives in place to address SDOH, and those that did not had plans to do so within the next 18 months.⁴

Amid this pandemic, health organizations recognize that when patients can work and be physically active, while also having access to stable housing, nutritious foods, affordable health care services, and transportation, their health improves and they use fewer expensive medical services, including hospital and emergency services.⁵ Because patients with chronic conditions use health systems more frequently than those without, organizations are targeting this cohort for intervention as a way to manage the total cost of care.⁶

Chronic Condition Care Disparities

In 2019, the United States spent an average of $11,582 per person or $3.8 trillion⁷ on health care, with 90% of these expenditures on people with chronic conditions such as arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, HIV, hypertension, stroke, and weak or failing kidneys.^8,9 According to the Centers for Disease Control and Prevention, more than half (51.8%) of adults have at least one chronic condition and about 27% of patients have multiple chronic conditions (MCC). Patients with MCC are the highest users of health care, with a disproportionate number of them being minorities.¹⁰ When compared with those without chronic conditions, persons with one or two chronic illnesses pay double the out-of-pocket costs, and those with three or more chronic illnesses pay four times as much. With significantly lower median household incomes in many minority communities, these households are disproportionately challenged to absorb these health care costs.⁵

Over the last decade, significant improvements have been made in the care of people with chronic conditions due to increased access to care, focus on screenings, disease self-management care, new treatments, and follow-up care. However, not all populations and communities have benefited from these advances. The following groups are outliers:

Cancer:

• Blacks/African Americans have higher death rates than all other racial/ethnic groups for many cancer types.¹¹
• Asian Americans are the only racial or ethnic group for whom cancer is the leading cause of death in the United States.¹²
• Lesbian and bisexual women have higher rates of breast cancer and human papillomavirus infection–related cervical or anal cancers.¹³

Diabetes:

• Hispanics are twice as likely to be hospitalized for treatment of end-stage renal disease related to diabetes and 1.3 times more likely to die from diabetes as compared with non-Hispanic Whites.¹⁴
• American Indian/Alaska Native adults are almost three times more likely to be diagnosed with diabetes, 2.3 times more likely to die from diabetes, and twice as likely to be diagnosed with end-stage renal disease than non-Hispanic Whites.¹⁵

Cardiovascular Disease:

• While modest gains have been made in reducing racial health inequities in urban areas, large gaps in death rates between Black and White adults persist in rural areas, particularly for diabetes and hypertension.¹⁶

Post-COVID syndrome or Long COVID: 

• Although much is yet to be learned, an estimated one-third of individuals who had COVID-19 experience symptoms after the acute infection subsides, sometimes severely limiting abilities to work or manage family obligations. Concerns exist that individuals from historically marginalized or vulnerable communities will be disproportionately impacted by this emerging chronic condition¹⁷ that has become associated with creation or exacerbation of other chronic conditions.^18,19
• From a geographic disparities perspective, the states with the estimated highest numbers of individuals with long COVID-19 are presently California, Florida, and Texas.²⁰

Rural:

• Compared with urban areas, rural areas have higher rates of cancer, infant mortality, diabetes, drug overdose and opioid misuse, and a higher mortality rate from heart disease and stroke.²¹

Payers, health systems, and provider practices can have a significant impact on patient health outcomes and the total cost of care by targeting people with chronic conditions to reduce disparities, as well as moving upstream to help prevent these diseases from occurring in high-risk communities.

The Role of Health Systems and Payers

Health systems and payers are in a distinctive position to support the closure of disparities in populations with chronic conditions. Medical care only accounts for approximately 10% to 20% of the modifiable contributors to improved health outcomes. Conversely, holistic care supported by payers, health systems, and providers can significantly impact the social determinants that drive more than 80% of health outcomes.²² To deliver holistic care, we must look at four elements: the patient journey, infodemiology, enablers, and multiple cross-sectional partnerships. 

The Patient Journey

The patient journey does not start when a patient presents with a problem. We can identify the patient’s journey starting point by leveraging data and analytics to understand the patient’s local environment for crime rate, safe spaces, available housing, and food access. 

Payers and systems can focus on access to care in the patient’s community to facilitate early screening and diagnosis and ensure successful treatment and outcomes. As patients go on the journey from diagnosis to treatment and chronic care management, medications are a first choice for medical intervention for 88% of the population with MCC. However, within six to 12 months of therapy, up to 50% of patients on chronic therapy become nonadherent.²³ The challenges and barriers around adherence are complex; medication reminders are insufficient. Some of the most common SDOH issues include cost, health literacy, traditional beliefs, trust, transportation issues, misinformation, hierarchy of needs, food insecurity, isolation, housing insecurity, and the list goes on. Health care practitioners who earnestly want to address medication nonadherence will need to go beyond the one-size-fits-all adherence fixes to truly understanding the societal challenges that keep patients from taking their medications as prescribed. Providers and pharmacists alike must screen their patients for SDOH risk factors and develop individualized care.²⁴

Infodemiology: The Surgeon General’s Call for a “Whole-of-Society Effort” to Combat Misinformation Threats

Misinformation is also emerging as a SDOH and is currently particularly pernicious, poorly understood, and contributing to health disparities among diverse populations, including highly educated individuals.²⁵ The term infodemiology, referring to “the epidemiology of (mis)information,”²⁶ was developed nearly 20 years ago, and during the past year The Johns Hopkins Center for Health Security, within their school of public health, noted that “health-related misinformation or disinformation can lead to more infections, deaths, disruption, and disorganization” of COVID-19 response efforts.²⁷

Recently, the Surgeon General’s advisory has noted that “health misinformation is a serious threat to public health. It can cause confusion, sow mistrust, harm people’s health, and undermine public health efforts.” Misinformation is often written to “connect viscerally, distort memory, align with cognitive biases, and heighten psychological responses such as anxiety.” The Surgeon General’s advisory cautioned that “. . . even brief exposure to COVID-19 vaccine misinformation made people less likely to want a COVID-19 vaccine,” and reminded us that “Health misinformation has also reduced the willingness of people to seek effective treatment for cancer, heart disease, and other conditions.”²⁸ The Surgeon General’s advisory called for a “whole-of-society effort” to tackle misinformation, stating that “it is critical for the longterm health of our nation.”²⁷ In other words, all stakeholders within and beyond the health care ecosystem can make contributions to mitigating infodemics that serve as accelerants for both chronic and pandemic diseases.

Enablers

An enabler is a person or thing that makes something possible. Enabling infrastructures and capabilities must be put in place to support the patient’s health care journey. Some of these enablers include insurance benefit design, federal policy, and workforce diversity efforts.

Insurance Benefit Design. Public and private insurers are beginning to incorporate SDOH into their benefit designs and insurance coverage. For example, the department of Health and Human Services has incorporated SDOH objectives into national initiatives like Healthy People 2020 and Healthy People 2030²⁹ and published new rules that allow insurers to offer supplemental SDOH-related benefits for Medicare Advantage (MA) plans.³⁰ Companies including Aetna, Anthem, Cigna, Humana, UnitedHealth Group, and many others have incorporated benefits such as the reimbursement of telemedicine services, transportation options, fitness programs, companionship benefits, and adult daycare to improve the focus on health and prevention for MA beneficiaries of all ethnic groups. The Centers for Medicare & Medicaid Services has also worked with states to integrate SDOH into their contracts with Medicaid managed care organizations.³¹ Further, the Center for Medicare and Medicaid Innovation is assessing the Accountable Communities Health Model to discover if systematic identification and intervention addressing health-related social needs will favorably impact health care costs and use among Medicare and Medicaid beneficiaries.³² Within the employer landscape, The Health Enhancement Research Organization has issued a call to action for employers to address social risk factors serving as impediments to a healthy, high-performing workforce. Their report cites examples of employer initiatives and suggests next steps, including analysis and evolution of insurance benefits, to mitigate adverse SDOH.³³

Policies. Public and private payers, systems, and providers are supporting policies and practices that will make health care and coverage, including the Affordable Care Act, more accessible to all through enhanced subsidies, capping patient out-of-pocket costs, Medicaid expansion, and accelerating broadband access for the use of Delivery System Reform Incentive Payment waivers for provider systems to implement initiatives to address SDOH among Medicaid beneficiaries. The Medicare Fee-for-Service Program (also known as original Medicare) is also now incentivizing systematic psychosocial assessment and coordination of home and community patient services through reimbursement codes for physicians and some additional practitioners performing those services.³⁴

Workforce. Many organizations are now looking how to cast their recruitment nets wide enough to identify qualified racially and ethnically diverse clinicians. In some cases, organizations like Kaiser Permanente’s Apothecary Circle Program for pharmacists have gone further upstream to colleges and high schools to educate students about health care careers in pharmacy and create internships and training programs that enhance opportunities for minorities to get into pharmacy school and eventually have a career in pharmacy. Other programs are providing students with mentorship opportunities with health care professionals of color to generate interest early in their formative years.

Multiple Cross-Sectional Partnerships

As an old African adage goes, it takes a village to raise a child. So it is with addressing SDOH: it will take multiple cross-sector partnerships to address the health of patients with chronic conditions. Two critical partners for payers and health systems are community-based partners and the pharmaceutical industry.

Community Partners

Community partnerships with payers and health systems are essential to advancing health equity for patients with chronic conditions. These partners include federally qualified health centers, community-based organizations, faith-based organizations, businesses, academia, nonprofits, and agencies that oversee housing, public safety, and transportation.

Currently, there are a number of partnerships that address SDOH like Humana’s Bold Goal Project, YMCA’s  Healthy Communities Initiative, Kaiser Permanente’s “Total Health” framework, and many others. Below are key examples of partnerships to address the needs for people with chronic conditions:

Screenings

• RWJBarnabas Health launched Health Beyond the Hospital to assess patients for factors that contribute to chronic disease while removing the stigma around questions of housing, safety, or nutrition.³⁵
• Harvard Pilgrim launched a program to reduce racial and ethnic disparities in colorectal screening with a focus on low-health literacy groups.³⁵
• Kaiser Permanente’s partnership with Project Access Now focuses on supporting low-income diabetes patients.³⁶

Disease and population management

• Anthem: Take Action for Health, with the National Urban League, City of Hope, and Pfizer, is aimed at improving the quality of heart disease and breast cancer care among African American communities across the United States.³⁷
• Anthem: Digital Incubator is focusing on health literacy, food insecurity, and medication adherence.
• The Merced County Department of Public Health and the Dignity Health/St. Joseph’s Medical Center are working to prevent and address cardiovascular disease, diabetes, and associated depression early.³⁸

Virtual health

• The payer CareOregon and its health care providers have offered flip phones and smart phones to patients who may not have one in order to encourage patients to continue connecting with their providers during the pandemic.³⁹

Pharmaceutical Industry

Almost 90% of people with chronic conditions take medications, therefore, partnerships with the makers of these therapies could be incredibly beneficial in closing health disparities and improving patient outcomes.⁴⁰ As manufacturers bring new therapies to market, they leverage SDOH as part of the marketing strategy to increase providers, patients, and payers’ awareness to disparities to optimize patient therapy outcomes. Dr Sachin Jain, CEO of SCAN Group and Health Plan, stated that “Biopharma has a huge opportunity and imperative [in the SDOH space]. You can produce medicines that will change lives, but if you don’t have the living conditions to support effective use of those medicines, we’re missing an opportunity to improve human health.”⁴¹

Similar to results from a 2019 PRECISIONvalue survey,²⁵ a 2021 PRECISIONvalue survey found that more than 80% of respondents indicated their organizations were engaged in, planning to, or willing to consider collaborations with pharmaceutical and device manufacturers on an array of initiatives to address SDOH, including access to affordable medications and health care services, access to digital therapeutics and telehealth, support of health literacy, and health care provider education on SDOH.⁴²

Examples of payer-pharma collaborations include:

• The Gilead Compass Initiative: a partnership program with local community organizations and stakeholders to facilitate access to prevention, treatment, and care services for people with HIV/AIDS⁴³ 
• The cross-sectional collaboration between Anthem, Inc, Beckman Research Institute of City of Hope, Golden State Medical Association, National Urban League, Pfizer Inc, and 100 Black Men of America, Inc on the Take Action for Health program to eliminate health disparities in the African American/Black community, with an emphasis on cancer, heart health, prediabetes, kidney care, and emotional health⁴⁴ 
• Roche’s collaboration on the SisterPact project that aims to reduce disparities in breast cancer outcomes in African American women⁴⁵
• These partnerships help close disparity gaps in care “by improving access to medications and devices; facilitating better clinical and medication management outcomes; reinforcing patient trust and loyalty by collaborative manufacturer, payer, and provider goodwill; and enhancing a manufacturer’s brand through comprehensive, centralized patient services offerings.”⁴⁶

Next Step: Health Care Ecosystem Activation

This article has summarized key chronic condition health disparities and four elements that can serve as accelerators of holistic care provision for individuals and populations living with chronic conditions. Life science companies are recognizing that their payer and health system customers are transforming their networks of care to deliver better clinical and financial outcomes aligned with value-based care models. This necessitates closing health disparity gaps, in part through mitigating the impact of adverse SDOH. The next step is accelerated action for impact. Leveraging key insights, landscape analyses, tools and resources, PRECISIONvalue is supporting and partnering with life science companies and payers to bring SDOH to life in the following ways:

The Patient Journey 

• Surveys and in-depth interviews to identify alignment of SDOH needs and interests relevant to pharmaceutical manufacturers, customer segments, and therapeutic areas
• Integration of social strategies within market access planning, prior, during, and after launch

Infodemiology: The Surgeon General’s Call for a “Whole-of-Society Effort” to Combat Misinformation Threats

• Social listening and psychographic development (surpassing standard demographic profiles) to develop a more psychosocially nuanced understanding of population health segments, relevant health messages and messengers, and targeted omnimedia use⁴⁷
• Multistakeholder roundtable collaborations with third-party quality entities to forge consensus on relevant strategies (eg, delivery models and policies) to advance select topics within population health, and white papers and publications to address current and future threats and amplify consensus 

Enablers 

• Landscape overviews and briefings for clients, C and D level customers, and health care providers, summarizing barriers and facilitators impacting health care and therapeutic access within the context of SDOH and associated health disparities relevant to their therapeutic areas 
• Webinars and forums with multiple stakeholders (eg, academicians, clinicians, patient advocates, payers, pharmaceutical manufacturers, and quality/population health professionals) to advance consensus on best practices and policies to address adverse SDOH and advance health equity

Multicross-Sector Partnerships 

• Value-based Alliance Playbooks, customized for our clients, adapting a design thinking process for a step-by-step roadmap for ideating and implementing multistakeholder alliances and partnerships, supported by templates, tools, and tips for success
• Value and Access Insights Forum sessions with key customers to facilitate co-design of resources to support SDOH initiatives 
• Development of tools, resources, and guides to support payer, clinician, and health system initiatives (eg, SDOH screening tools; evidence-based medication adherence training and tools on topics such as health literacy, motivational interviewing, and shared-decision making) to address adverse SDOH

Conclusion

COVID-19 has exacerbated and highlighted glaring adverse SDOH, such as educational attainment, geography, health literacy, housing security, income, and misinformation, that affect chronic disease management and engagement. As health care stakeholders continue to recognize the outsized role they play in population and social health, it will be critical for stakeholders to understand the areas in which they potentially have the biggest impact. Meaningful chronic disease management is a key aspect of value-based health care. After all, a sizeable portion of health care spending can be attributed to a small share of the nation’s sickest patients, underscoring the need to manage illness.

But with this shift comes a growing realization that care management is more than just medical practice; it’s an acknowledgment that the SDOH impact chronic disease. Thus, addressing both the social and clinical factors of health will be crucial to truly make a palpable difference in improving the health and well-being of all communities. These factors will determine a patient’s ability to obtain wellness, engage in healthy behaviors, access health care and therapies, and keep their disease state symptoms under control. 

For patients with chronic conditions, strengthening linkages between clinical and social services to support screening, referrals, and programs to align health and social interventions has never been more neccesary for health care ecosystem transformation to mitigate SDOH contributing to health inequities. Therefore, payers, providers, policies and politics, pharma, patients, and current and new entrants into the health care systems must integrate and weave SDOH into all aspects of care across the health continuum. It is only then that the quest for value-based care and the Quintuple Aim (better care; healthier people; smarter spending; care team well-being; and health equity) become a reality for all.⁴⁸  

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Author Information

Authors: Elizabeth Oyekan, PharmD, FCSHP, CPHQ; Maureen Hennessey, PhD, CPCC; Dominic Galante, PhD, CPCC; Cynthia Miller, MD, MPH, FACP; Jorge Font, MPH

Affiliation: PRECISIONvalue

Disclosures: The authors have no disclosures to report.