When Gregory Kane, MD, chair of medicine at Thomas Jefferson University’s Sidney Kimmel School of Medicine, started his career in pulmonary medicine in Philadelphia 30 years ago, he quickly noticed that patient outcomes were not solely dictated by the patient’s medical condition. Two patients with similar cases, who were treated in comparable ways, could—and often did—respond to those treatments differently.
“Early on, I recognized that my patients’ neighborhood and their domicile was a major contributing factor to flares of their disease,” he says. “Those who work in healthcare understand that poverty level, access to healthcare insurance, and social situation contributes to disease and outcomes. We see it every day.”
With the passing of the ACA in 2010, and a greater focus by payers and providers on value-based care, such social determinants of health (SDOH)—defined by the World Health Organization as “the conditions in which people are born, grow, live, work, and age”—have become a major public health concern.
Julia Andrieni, MD, vice president of Population Health and Primary Care at Houston Methodist, an eight-hospital health system with more than 6,700 physicians, in Houston, says research shows that SDOH-related inequities don’t just impact access to care—but overall health outcomes. In fact, according to Healthy People 2020, a report put out by the CDC, social and economic factors play an integral role in whether a patient can or will engage in behaviors known to promote health or follow a doctor’s recommendations or treatments after being diagnosed with a chronic condition.
“Social determinants of health affect every aspect of healthcare, says Andrieni. “We’re learning that we have to address not only clinical factors that affect a patient’s health but also the nonclinical ones if we are going to successfully treat patients. Patients may have the same conditions, but they are not the same. If you have one patient with diabetes who has a good education and predictable income, and another who has food insecurity, an inability to pay for medicine, and a lack of transportation, there are disparities there that require more than a prescription to address. This is a major public health concern.”
Across the United States, a growing number of programs and initiatives are tracking SDOH—and exploring how it can inform effective, evidence-based patient care. While it’s not easy, it’s important, says Bita Kash, PhD, director of the Center for Outcomes Research at Houston Methodist Hospital.
“The overall goal is to achieve the same outcomes for every patient regardless of their income, where they live, or education level,” she says. “The problems that arise from these factors are often manageable—if we understand them and their effect on care—and healthcare payers and providers should be able to come up with pertinent interventions to reduce variations and outcome disparities due to socioeconomic factors.”
It’s well known that the United States’ healthcare spend greatly surpasses other first-world nations. Yet, despite spending 17.8% of its gross domestic product on healthcare, patient outcomes are no better—and, in fact, are often poorer—than other high-income countries. As noted by a recent Commonwealth Fund report, “Health Care Spending in the United States and Other High-Income Countries,” lower rates of insurance coverage and mixed levels of population health programs likely play a role.
A lack of investment in social services that could help mitigate many of the SDOH that negatively impact health—and, as a consequence, drive up healthcare costs—also need to be tackled, says Krista Drobac, chairwoman of Aligning for Health, a payer coalition that advocates for better integration of social service programs into the healthcare system.
“We’re spending a lot of money on clinical care that would be better spent if we invested it upfront to help deal with these inequities,” she says. “There’s been a lot of research about how SDOH impact healthcare. It’s well-documented at this point. But they don’t answer the really critical question: What is the next step? What is it that we have to do to actually integrate SDOH into patient care in a robust and meaningful way?”
Aligning for Health believes it starts by breaking down funding silos in federal programs and testing community pilot programs that address specific SDOH issues. As a federal advocacy organization, the coalition is lobbying the federal government to allow for “lending and breeding of funding” across different departments like the United States Department of Agriculture, Housing and Urban Development, and HHS.
“Right now, there isn’t transfer or waiver authority across programs,” says Drobac. “We’re trying to create county level pilots that would be able to get across all of these different departments and really address the whole patient—because that’s what’s needed to really address these disparities.”
To do so, the coalition is relying on data from payers and providers about SDOH, as well as other federal or community programs that patients may be utilizing. But that data can only take them so far, says Drobac. Without the right connections between healthcare and community problems to address these issues, healthcare costs will continue to rise and patient outcomes will continue to decline.
“Providers are collecting data about whether or not a patient has adequate nutrition or lives in a safe home but often they just don’t know what to do with it,” says Drobac. “Unless that provider has the ability to actively refer the patient to a program, the data really just sits there—we can’t reduce costs and we can’t improve care. We need more opportunities for providers to take action on SDOH so patients can be connected with the social services they need.”