Timothy Kelley

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For decades there have been lamentations in the United States about the sorry state of primary care, traditionally a patient’s first and most consistent contact with the healthcare system. “Are there enough primary care doctors?” asked the National Academy of Medicine’s (then called the Institute of Medicine) Committee on the Future of Primary Care in 1996. “Are they merely gatekeepers? Is the traditional relationship between patient and doctor outmoded?”

Since then, the alarm bells ringing in those questions have only grown louder. In 2006 the American College of Physicians (ACP) declared that primary care, “the backbone of the nation’s healthcare system, is at grave risk of collapse.” That year, in a landmark 

 article, Thomas Bodenheimer, M.D., M.P.H., a professor at the University of California, San Francisco (UCSF) and founding director of its Center for Excellence in Primary Care, identified “a confluence of factors that could spell disaster.” Patients are increasingly dissatisfied with their care, he wrote, and primary care physicians are unhappy with their jobs. “The quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field,” says the Bodenheimer jeremiad.

Indeed, the field seemed stuck in a vicious cycle. Physicians suffering from burnout and deserting primary care left their remaining colleagues with larger panel sizes, increasing dissatisfaction on all sides. Payers remained stingy with reimbursement. Graduating medical students shunned primary care in droves for more lucrative specialties. ACP figures cited by Bodenheimer showed that between 1997 and 2005 the number of U.S. students entering family practice residencies dropped by half.

The demand side also looked rather bleak. From 2008 to 2016, visits to primary care physicians (PCPs) fell by 6% to 25% in five sets of survey data representing commercial, Medicare and nationally representative samples. A 2021 study attributed the declines to “fewer contacts per patient.” Perhaps that’s no surprise, given the profusion of walk-in urgent-care clinics, telehealth services and quick-care drugstore clinics. Patients had been voting with their feet against primary care docs even before the pandemic kept millions at home and telehealth took off.

Yet primary care “remains the foundation upon which a high-performance, cost-effective health care system must be built,” insists the Purchaser Business Group on Health, an employer group that focuses on healthcare costs and quality. The purchaser group says healthcare costs are 33% lower for U.S. adults who regularly visit a PCP and their chances of dying prematurely are 19% lower than those who rely on specialists alone.

Other countries seem to get it even if the U.S. doesn’t. Study after study has shown that other wealthy countries outperform the U.S. on almost any healthcare metric you might imagine while devoting a far smaller share of their gross domestic product to healthcare. One explanation: They put more emphasis on primary care. When a 2020 Commonwealth Fund survey asked in 11 advanced Western nations how many people had a regular doctor “or place to go for care,” only Sweden ranked behind the U.S. When the question was how many had a primary care provider relationship of five years’ standing or more, Sweden slipped ahead, leaving the U.S. dead last.

There’s also trouble among those providing the care. “We have a real workforce crisis,” Bodenheimer warned in 2017. Asked by 

® in a recent interview whether this situation had improved or deteriorated in the years since, Bodenheimer replied: “Let’s just say it’s still bad.” Like others, he’s been preaching the gospel of team-based care: physician assistants, nurse practitioners, medical assistants and others working in concert with PCPs and, to some extent, taking on the tasks and responsibilities that used to belong only to those with M.D. or D.O. next to their names.

But even Bodenheimer says teams aren’t the full answer, noting that the total number of all primary care providers who can bill for their services, be they doctors or not, is slowly going down as a percentage of the population.

Primary care delivery, in some places and by some groups, has become more efficient. There’s an analogy to climate change — Bodenheimer didn’t volunteer it, but when it was offered, he embraced it. “You do a little bit for climate change,” he said, “but the climate’s getting worse much faster than what we’re doing to help it, and it’s sort of a similar thing with primary care.”

That’s not to say Bodenheimer is all doom and gloom. He’s been a hopeful evangelist for team-based care for at least 15 years. And there really should be two teams in primary care, he explains: the core teams consisting of clinicians and their medical and other kinds of assistants and the interprofessional teams that include physicians collaborating with other professionals — pharmacists, physical therapists and social workers as well as nurse practitioners and physician assistants.

With an extra medical assistant on the core team working as a scribe, says Bodenheimer, physicians can see more patients because they’re relieved of many of the documentation tasks that overwhelm their days and that they often take home to work on after a long workday is over. The nonphysician members of interprofessional teams, he says, can save physicians even more time by seeing some patients themselves “if you let them do what they’re capable of doing,” he says. Some studies have shown that pharmacists can do a better job of taking care of people with diabetes than physicians and that physical therapists can do the same for people with musculoskeletal problems, says Bodenheimer.

Team-based care can be seen as an unavoidable adaptation to mounting pressures, a positive change or both. One booster of the team approach is Megan Mahoney, M.D., MBA, who recently left Stanford and is now chair of UCSF’s Department of Family and Community Medicine and a colleague of Bodenheimer’s (she calls him “the father of all of us.”). The old approach of every patient seeing a doctor for every visit has become unaffordable, says Mahoney — and isn’t necessary for quality care.

“There will be an important role for a primary care provider as the captain of care, coordinating the care, but I’m not sure that needs to be a physician,” she says. In Mahoney’s view, doctors can focus on assessment and diagnosis and then delegate much of the rest of the medical encounter — treatment advice, the details of care coordination — to other team members.

Although economics is forcing the change to this team approach, we shouldn’t regret it because it holds some advantages, says Mahoney. There are pluses, for instance, in having multiple clinical minds thinking about a patient, she says. “For a medically complex patient,” says Mahoney, “a team can get together on a regular basis and talk about all aspects of the care of that individual, from food security and social determinants of health to access to community resources, in addition to diet, exercise, and medical care.” True, the character of the patient-physician relationship may change, but Mahoney says that trust in providers can be transferred and distributed. Doctors can introduce other team members to patients as those they trust and referencing the team members’ area of expertise and potential benefits to the patient. “When people hear that,” says Mahoney, “they feel reassured.”

There’s still a lot to figure out, she says. And there’s also the obstacle of the way U.S. healthcare is paid for, notwithstanding the armada of value-based care models and programs that has been launched the past several years, says Mahoney: “The biggest barrier currently is the way (much) primary care is funded — by a fee-for-service model, which is contrary to what primary care is all about. It’s about prevention, not utilization of services.”

Sometimes physicians themselves are a barrier. As Bodenheimer remarked in a 2017 video interview: “Physicians are kind of crazy, in a way. On the one hand (they say), ‘I can’t do all this work; there’s too much work; I can’t stand it any longer.’ Well, you have this wonderful RN. Evidence shows that she could probably take care of half of your patients with diabetes without taking any of your time.” Here on the video he gestures frantically with both open hands, imitating the physician. “ ‘Oh, no, no, no! Can’t do that. Has to be me!’ ” Research, Bodenheimer continues, shows that nurses, pharmacists, behaviorists and physical therapists can in many cases take over some of a doctor’s workload with no compromise in quality. “Doctors have to learn how to share the care,” Bodenheimer says in the video.

Asked about this issue of the doctor’s ego, Randolph Gordon, M.D., M.P.H., is ready with an answer. “If one’s ego satisfaction is power in being an authoritarian ruler,” he says, then yes, there’s “ego diminution” when team-based care takes effect. “But,” he says, “if one enjoys working with other people, leading and learning from team members to provide better care and see better outcomes, then in my mind that’s ego enhancement.”

Gordon is managing director at Deloitte Consulting, which issued a report on the physician of the future two years ago based on interviews with 13 thought leaders and 680 physicians done just before the pandemic. Unlike Bodenheimer, Mahoney and many others, Gordon rejects the label “crisis” for the state of primary care. He prefers a milder, business-speak characterization: “a time of transformation.”

Gordon sees “a lot of hope on the horizon for practicing primary care,” and embraces a vision that “returns the joy of practicing medicine to physicians.” But his firm’s forecast of what PCP life will be like 10 years from now — based on those interviews — suggests that such hope and joy will need to stand up against some pretty drastic change.

“We envision a future where medicine will be a team sport, with humans and machines working together, and consumers playing an important role,” says the Deloitte report, conjuring a future “marked by technological breakthroughs in robotics, AI, nanotechnology, quantum computing, fifth-generation wireless technologies, 3D printing and material science.” In this dizzying new world, PCPs aided by tech will be sharing more of their work with physician assistants, nurse practitioners, medical assistants and others. Physician survey respondents (not just PCPs) estimated that 30% of their current work could be performed by nonphysicians and 18% could be automated.

The doctor’s role is already changing, and Deloitte’s survey predicts that it will change a lot more, quickly. “What we learned in medical school was memorizing — signs and symptoms, differential diagnoses and treatments,” says Gordon. “But as fast as medical knowledge is expanding, one individual cannot put all of that data into her brain. So the role needs to change from trying to memorize all the data and apply that to an individual’s health situation to coordinating the data and the care. And, if you’re my patient, I can coach you.”

But before PCPs breathe too big a sigh of relief over the arrival of the cavalry in the form of teams and tech, they should check out the long list of areas the Deloitte report says PCPs will need to master and understand: empathy, cultural sensitivity and storytelling, so they can relate better to both colleagues and patients; leadership skills; data handling, genetic information and how to interpret it; the economics of medicine; and the “direct and indirect costs from the perspective of the organization, the patient, and the healthcare system.” The daunting list went on.

And, oh, new kinds of specialization may be coming, too. “Future PCPs,” says the report, “may specialize in the types of patient populations they serve rather than in body systems: the young and healthy, adolescents, the elderly, patients with complex conditions, or those in specific communities.”

The upshot? “We need people in medicine who are really good at being human,” says Gordon.

It’s conceivable that new personality types will be attracted to primary care as it is redefined in coming years: tech-savvy young people, more favorably disposed to collaboration than to being the-doctor-knows-best authority figures.” I will postulate they’re not necessarily different people,” says Sterling Ransone, M.D., outgoing president of the American Academy of Family Physicians (AAFP). But they will almost certainly be educated and trained in a different way, in his view. They’ll be more adept at incorporating new tech tools into what they do. One example: “Right now,” says Ransone, “there’s technology I can hold up to a patient’s eye to take a photograph that can be downloaded into an AI (artificial intelligence) platform that will diagnose diabetic retinopathy with the accuracy of a fellowship-trained retinologist.” Lisa Howley, Ph.D., president of the Association of American Medical Colleges (AAMC), says curriculums are changing, so today’s med students are learning about data management, AI and “how to work within a very high-tech environment.”

And if technology is on the syllabus, so are teams. In 2009 the AAMC and five other groups became founding members of the Interprofessional Education Collaborative, which seeks “to help prepare future health professionals for enhanced team-based care of patients and improved population health outcomes.” (Today there are 21 member groups.) “We’ve actually made quite a bit of progress in understanding the new science of teaming,” says Howley, but “we still have a long way to go.”

Howley agrees that a higher proportion of medical school graduates should be choosing primary care disciplines. In the 2022 National Resident Matching Program, her academy reports, just 15.7% of the positions filled were in primary care.

Bodenheimer says a primary care program at the University of Colorado is a model of effectiveness that can and should be replicated. There are two medical assistants for every primary care physician. One takes a patient’s history before a clinician comes into the room, and the other serves as a scribe. The approach reduces physician burnout from 50% to 20%, says Bodenheimer.

Why don’t more primary care practices emulate the Colorado approach? Bodenheimer ticks off three reasons: physicians’ lack of trust that medical assistants can perform all the tasks assigned to them; state laws and regulations that don’t permit nurses and pharmacists to get paid for some of the things they can easily do for patients; and shortsighted chief financial officers (CFOs) who insist that revenues must exceed expenditures every month. Those CFOs should take a longer-term view, he says. The Colorado-style team approach lets physicians “see an extra patient or two a day, and under fee-for-service that’s enough to pay for an extra medical assistant. They can increase market share, and actually make more money in the long run.” Also, “when burnout goes down, fewer physicians leave the practice,” he says. “And we know it takes something like $1 million to hire a new physician to take the place of someone who’s left, and then your productivity’s going to be down for quite a while.”

Also shortsighted, in Bodenheimer’s opinion, is the AAFP’s opposition to independent prescribing authority for nurse practitioners. “It’s the craziest thing I’ve ever seen,” he says. “They feel nurse practitioners are competing with them, but they desperately need nurse practitioners to help them take care of these huge panels.”

Nevertheless, there has been some good news for primary care. Medicare’s system of relative value units has been adjusted to “redistribute payments from procedural to non-procedural physician services in a meaningful way,” as John D. Goodson and co-authors reported in 

 in 2021. For both specialists and PCPs, CMS has changed coding for levels of office visits to more accurately reflect medical decision-making.

However, recent innovations such as the accountable care organization (ACOs) and the patient-centered medical home (PCMH) have failed to transform primary care as many had envisioned (although ACOs have plenty of proponents and some positive results to brag about).

PCMHs, in particular, get low marks from Bodenheimer: “They’ve been pretty much a flop.” The patient panels were too big, the doctors too busy and the practices didn’t have the enough money to create a strong team, he says. “You can get recognition to be a PCMH all you want, and nothing changes.”

Of course, it’s entirely possible that things will change — that enough good efforts in enough places at the right time will cause a new, self-perpetuating virtuous cycle that spins in the opposite direction from vicious one that has been the driving force in U.S. primary care. Bodenheimer notes that annual U.S. healthcare expenditures totaled more than
$4 trillion in 2020, with just 5% of that spending going to primary care compared with 12% in European countries. “Primary care really should get 10% of the healthcare dollar rather than 5%,” he says. “If we do that, we’ll have enough money to hire the people — the nurses and pharmacists and physical therapists, for example — to be on teams that can help the physicians take care of their overly large panels and make life a lot better for the physician. And that would attract more medical students to go into primary care and could reverse the whole downward trend.”

So there it is. Just move $200 billion around, and you’ll get many more physicians eager to embrace what is arguably U.S. healthcare’s most crucial, most problematic — and potentially most rewarding — challenge.

Timothy Kelley is a healthcare journalist in New York City.

Articles

Its physicians are overworked, and patients are going elsewhere for care. Experts say help is on its way for primary care in the United States — but so is an onslaught of new demands.

Primary Care in Critical Condition

You didn’t hear it here first. The role of the primary care physician (PCP) is changing — and in some vexing ways. Long gone, of course, is the all-knowing, black-bag-carrying (middle-aged White male) Marcus Welby of two generations ago. But the gatekeepers of the 1990s and early 2000s also seem to have left the building. What’s left is a beleaguered, dwindling profession facing too many patients, too much paperwork and not enough pay — or minutes in the day.

Why, then, do two leading PCPs asked about this crisis — while no Pollyannas — sound unexpectedly hopeful?

Ishani Ganguli, M.D., M.P.H., of Harvard Medical School and Brigham and Women’s Hospital, and co-authors sounded an alarm in an article published in the 

 in 2019. They noted that five national surveys had shown declines of 6% to 25% in primary care visits from 2008 to 2016. They cited ways that the Affordable Care Act and other reform efforts have tried to bolster PCPs’ role, increasing reimbursement and promoting such innovations as the accountable care organization and the patient-centered medical home. “The decline,” they wrote dryly, “implies they have fallen short.”

“There is clear evidence,” says Ganguli, “that burnout rates are higher among primary care clinicians compared to other specialties.”

But pressure on PCPs shouldn’t be confused with a lessening need for primary care. Megan Ruth Mahoney, M.D., MBA, chief of staff at Stanford Health Care and a Stanford professor, says the way to solve today’s primary care crisis is to apply more fully the “team” model already used in many offices.

Asked what care will look like 20 years from now, she predicts that “higher-risk, medically complex patients” will see doctors for assessment, diagnosis and conditions involving multiple organ systems. But other patients, says Mahoney, will likely be managed by other health professionals, including advanced practice providers (nurse practitioners and physician assistants), but also pharmacists, nutritionists, nurses, behavioral health specialists and even medical assistants. The PCP will play an important role as “the captain of care, coordinating care. But I’m not sure that needs to be a physician,” says Mahoney.

Both physicians believe in the team approach, but they admit its downside: the potential “dilution,” as Ganguli puts it, of the personal trust between patient and physician that has long been considered vital to adherence and quality care.

Mahoney agrees. The big hurdle, she says, is the change patients face when they encounter the team. “Trust obviously is foundational,” she says, but her group has succeeded “in transferring that trust to an entire team.” And seeing more individuals for care means more people — potentially — to bond with. “I have patients who love the nurse I work with,” says Ganguli. “They see us as a unit.”

The team approach is also good for health equity, Mahoney contends. A team of providers increases the likelihood that patients will find someone in the office with a similar cultural background. Moreover, she says, a care team can convene to discuss all aspects of a patient’s health: food security, social access to community resources, drug-drug interactions. “Longitudinally, it’s better when you have more minds thinking about the patient.”

Teams are no panacea. Ganguli sees an urgent need for a payment system that better reflects what primary care providers — doctors or not, in teams or not — actually do. “It’s a misconception that primary care is easier than specialty care,” she stresses.

Timothy Kelley is an independent journalist in New York.

Are Primary Care Physicians an Endangered Species?

Editor's Note: This arrticle was published in our May issue along with 

"Traveling Upstream to the Social Determinants of Health"

"Positive Outcomes for SDOH Interventions: A Q&A With Kate Sommerfeld." 

Not every U.S. county was bold enough in 2012 to make a 13½-minute video titled “Framing Social Determinants of Health” challenging itself to do a better job of addressing the wellsprings of health disparities. But this home of Grand Rapids did. “We must measure our success by impact,” declared one community leader on the video, citing the need for improvements in rates of diabetes and high blood pressure among Black and Latino residents. Added the leader, “Shame on us if we’re having this conversation a year from now.”

A decade later, the nation has learned humility about the complex task of addressing SDOH — and so has Kent. Although survey numbers aren’t available for the number of patients with hypertension, the rate of self-reported diabetes did decline among Black adults in the county between 2014 and 2020, from 18.9% to 15.9%. But disparities lived on (the comparable figures for White adults: 8.5% to 7.6%) despite many initiatives, including improvements to local parks and a partnership with the YMCA’s “Veggie Van,” a mobile farmers’ market that provides produce to stores in food-desert areas.

Kent County is still waging the SDOH fight by, for example, putting CDC grant money to work addressing needs identified by the community. A neighborhood group, Seeds of Promise, advised the county to focus on housing and a program was shaped accordingly.

Asked what advice she’d offer other counties with high-need populations, Teresa Branson, chief diversity, equity and inclusion officer for the county’s Health Department (and narrator of that video in 2012), says it’s vital to build trust with sometimes skeptical community residents.

“Don’t plan anything without the community,” she says.

“We’ve been guilty of doing that for years in public health,” Branson adds. “We think we have the answers, and a lot of times we don’t.”

You can say “ACCESS” when you speak of the 40-year-old agency that administers the Arizona’s Medicaid program, but you don’t spell it that way. It’s AHCCCS, or Arizona Health Care Cost Containment System. Medicaid expansion dollars under the ACA have made possible “exciting partnerships” to address social determinants of health, says Blythe FitzHarris, Ph.D., LCSW. She’s the chief clinical officer at Mercy Care, a nonprofit health plan that serves people eligible for AHCCCS benefits.

Although transportation to doctor visits is a Medicaid-covered benefit, the funding also permits the plan to contract with providers to expand services not directly covered, such as meal deliveries to pregnant women or transportation to a support-group meeting. “We work with our cities and counties to ‘braid’ funding,” FitzHarris explains. “We say to them, ‘If you can partner with us and deliver a subsidy, then we can deliver the service supports,’ recognizing that most of these folks who are receiving county assistance also likely qualify for Medicaid.”

When experts say it’s not yet clear what mix of SDOH interventions is ideal, they get no argument from FitzHarris. But she’s happy to share some numbers from Maricopa County, where Phoenix is. They’re not new — they come from a January 2018 report — but they show the kind of things Mercy Care has been doing. For a certain high-need population, healthcare costs were approximately $20,000 per member, per quarter, before a housing subsidy initiative was implemented. The program cut the total cost of care by 24% (per member, per quarter), the cost of behavioral health professional services by 23% and behavioral health facility costs by 46%.

Mercy Care’s SDOH work can get pretty granular, as one summertime experience showed. “In our (emergency department) reports, we had someone who was continually going in,” FitzHarris says. It turned out that “the individual’s air conditioner didn’t work. He had some physical ailments. But we’re in Phoenix — it’s 120 (degrees)!” Mercy Care worked with local utilities to fix the electrical problem in his home. “And, lo and behold, he stopped going to the emergency (department) so much,” FitzHarris says.

Social determinants of health (SDOH) have been on the minds of local, county and state governments for years. These two jurisdictions have been conspicuously active in pioneering innovative programs addressing SDOH. 

A Tale of Two Counties Tackling the Social Determinants of Health

Proograms to address social determinants of health (SDOH) have shown striking success, one executive says. Now the task is to apply them more broadly.

Kate Sommerfeld is president of the Social Determinants of Health Institute and vice president of community relations and social investment for ProMedica in Toledo, Ohio, which has a dozen nonprofit hospitals in its region plus a health insurance division and a senior care division that serves 28 states. Its 3-year-old Social Determinants of Health Institute helps nonprofit health systems and payers across the country do SDOH interventions. Recently she spoke with 

ProMedica has done ambitious work in Toledo’s UpTown neighborhood, yes?

Yes. Seven years ago, in what was once a food desert, we opened a grocery that has served 58,000 customers. We’ve helped (approximately)
200 homeless individuals connect to services and get housed. We’ve connected 5,000 individuals to jobs and support and provided financial coaching to more than 800 people, increasing their average monthly income by $352 and helping them raise their credit scores by an average 79 points. And among 1,753 participants in our food clinic, we’ve seen a 20% reduction in (emergency department) visits (compared with a 12% decline for similar patients not enrolled in the program), with $6,400 in savings.

Can you prove your success with statistics on health status itself?

That’s difficult; health outcomes are the last piece to measure. But across the country we’ve seen some very small pilot programs where we’re able to measure health outcomes. Where we see that most is in our work in maternal health. We’re scaling a program that connects high-risk expectant moms with community health workers, and it has shown improved birth outcomes and decreases in NICU (neonatal intensive care unit) stays.

Isn’t addressing SDOH mostly a matter for Medicaid?

That’s one of the myths. Actually, a great many Medicare patients and almost 50% of the commercial patients who come through our doors (have) some type of need. Social and economic factors really span across populations and demographics.

What have you learned from your experience with SDOH?

One, that this work is all interconnected and it really takes a village — the integration of payers and providers, community members, nonprofit organizations, even employers. Two, we’ve been able to use teleservices, especially during the pandemic. For example, we’re now providing financial coaching across the country virtually. Three, it’s critical to engage the people we’re serving in the decision-making process. No longer can we in healthcare sit in our office buildings and hospitals and create solutions by ourselves.

Is healthcare still struggling to get a grip on SDOH?

Especially in the aging population, we’ve seen an uptick in social isolation, which COVID-19 has exacerbated. That’s an area where we’re still really testing and piloting. From an industry perspective, we’re trying to understand what moves the needle. I’d also cite the need for scalability. Many initiatives in individual markets are working, but we’ve got to figure out, Can you get those to scale? Can you do them across markets?

Part of our work is focused on ROI (return on investment). That’s our north star at the end of the day — to be able to prove which interventions are effective. So we use data analytics. We partner with the startup tech firm Socially Determined (based in Washington, D.C.), which braids together our intervention data with EMR (electronic medical record) and claims data sets to understand what drives value.

We see patients for a very limited time, so we’ve been focused on creating seamless, no-touch workflows integrated into the EMR. As more providers get into this space, those who were going in a different direction come back to this approach from an efficiency and effectiveness perspective.

We’re starting to use a proactive approach, not waiting until someone comes into our doctors’ offices or hospitals but targeting individuals and populations that may not be getting care today but have a social determinant need.

Despite everything you’re doing, is the SDOH effort is still just getting off the ground nationally?

I’m a little more optimistic than that. Payers are now starting to fund different social and economic supports. We closed 2021 with eight different contracts with payers who are providing food funding and financial coaching. And CMS is offering innovation grants to fund things like this. I think we’re starting to see the momentum shift.

Kate Sommerfeld, president of the Social Determinants of Health Institute, spoke about efforts to address social determinants of health (SDOH) gaining traction, taking an interconnected approach and using data analytics to understand the value of the efforts to address SDOH.

Positive Outcomes for SDOH Interventions: A Q&A With Kate Sommerfeld

How is this for a medical scenario? Through her stethoscope, a doctor hears a rattle in Mr. Rodriguez’s chest. “Urban-air congestion!” she declares, flinging the window open and aiming a magic spray at the polluted outdoors. “Two spritzes each morning for a week,” she says, handing her patient the bottle, “and you — and the neighborhood — should be fine.” Ms. Jackson has diabetes of the lives-too-far-from-veggies variety; her doctor gives her a wand she can wave to instantly transform her paved yard into a luxuriant garden with tomatoes, basil, beets and Brussels sprouts. Then there’s Mr. Diefenbaker, whose home is on a remote dirt road. His chronic conditions are worsening because he has trouble coming in for office visits — he can’t afford a car, there’s no bus line nearby and the neighbor who gives him rides is undependable. “Stat!” the doctor calls to her assistant, who pecks notes on a digital tablet. “Get a new light-rail transit system going past Mr. Diefenbaker’s house!”

These are fantasies, of course. We don’t live in such a magical healthcare world, but we do enjoy the next best thing: the widespread understanding that the origins of health or illness extend way beyond the proximal effect of a clogged artery, swollen tissue or genetically damaged cancerous cells. In healthcare there is agreement that our health status reflects not just what our bodies and brains are doing but also how the social determinants of health (SDOH) have affected it.

The government gets it. The rather lumpy definition of SDOH by HHS is “the conditions in the environments where 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.” But we’ve been hearing about SDOH for some years now, and it’s fair to ask: How much good has understanding and acknowledging the concept actually done?

There’s no doubt that SDOH have become prominent in healthcare policies and discourse. “In the past decade,” says Laura Gottlieb, M.D., M.P.H., a professor of family and community medicine at the University of California, San Francisco, “things have moved from people understanding the impact of social determinants to an acceptance that there’s a role for delivery systems and payers to do something about them to improve equity in
health outcomes.”

® editorial advisory board and CEO of the Association for Community Affiliated Plans (ACAP), a trade association representing
78 nonprofit health plans, says her group was studying SDOH “before it was cool.” SDOH are “baked into the DNA” of its members, health plans that were started by federally qualified community health centers, local governments and children’s hospitals, she says. She points to member-plan initiatives such as a job-support program at CareSource in Ohio and “food as medicine” campaigns aimed at food-insecure areas by CareOregon and Geisinger Health of Pennsylvania. In many cases, Murray says, plans are paying for these efforts themselves. Because such an approach isn’t sustainable in the long run, ACAP has proposed an SDOH rebate add-on, which, as Murray explains, “would be a way of giving plans some extra money to help with the social determinants of their beneficiaries who are enrolled in D-SNPs” — that is, dual-eligible special-needs plans for people entitled to both Medicare and Medicaid.

Recognition that circumstance impinges on biology does not belong solely to the 21st century. The ancient Romans noticed that there were higher death rates near marshes and swamps. Rudolf Virchow, a 19th- century German physician, writer and politician, is renowned for his theory of cellular pathology, which helped lay the foundation for modern medicine. But he’s also considered the founder of social medicine, famous for insisting that “medicine is a social science, and politics is nothing else but medicine on a large scale.”

Fast-forward to 20th-century Britain, where Thomas McKeown was named a professor of social medicine at the University of Birmingham in 1945. He studied Western societies’ increases in life expectancy, and in the 1970s he argued that these were due less to medicine’s advances than to economic growth and the improved nutrition it brought. Critics complained that McKeown slighted the role of public health policies such as those aimed at cleaning up drinking water and ending bovine tuberculosis, but the spotlight he’d shone on social factors remained bright.

Then there is Sir Michael Marmot, whose renowned Whitehall studies, which started in the 1960s, tracked a cohort of British civil servants. The Whitehall results defied the expectation that top executives facing the presumably heaviest stress would have the greatest cardiac risk. They showed that heart attacks — along with many other ills — actually increased as one went down the “social gradient.” It’s not clear who coined the term SDOH, but in 1999 the World Health Organization (WHO) published 

Social Determinants of Health: The Solid Facts

, a report (co-edited by Marmot) that listed 10 areas in which social conditions influenced health.

“Poor social and economic circumstances affect health throughout life,” the report stated — that part wasn’t surprising. People who couldn’t afford medical care or healthy food or a safe home were clearly at extra risk. But those British bureaucrats at the bottom of Marmot’s studies weren’t poor; they had stable paychecks and presumably could buy the basics needed for good health maintenance. Yet the document insisted: “Even junior office staff tend to suffer much more disease and earlier death than more senior staff.” Who knew — besides WHO — that health so closely tracked wealth?

In the past decade or so, says Damon Francis, M.D., medical director of Homeless Health Center at Alameda Health in California, “healthcare has become aware of the social determinants of health as an explanatory model for why some people are healthy and others aren’t.”

Francis is also chief medical officer for Health Leads, a national nonprofit aimed at addressing health inequities. And although social determinants affect everyone, most conversations about SDOH quickly segue into the related topic of health equity.

For example, take air quality and our hypothetical Mr. Rodriguez. A study published in March 2022 in 

Environmental Science & Technology Letters

 showed that although the discriminatory home lending practice of redlining was banned in the U.S. more than 50 years ago, it’s still affecting people’s health. According to an article in 

, researchers examined air-quality data for 202 cities where redlining had been practiced and found nitrogen dioxide levels markedly higher in neighborhoods that had been tagged in the 1930s as undesirable for mortgage lending. Because zoning officials often used redlining-based grades when deciding where to place highways or industrial plants, minority neighborhoods such as Boyle Heights in Los Angeles ended up being encircled by major freeways with heavy, pollutant-spewing diesel truck traffic. Thus its residents were and still are disproportionately exposed, as the

reported, to pollutants that can “inflame human airways, reduce lung function, trigger asthma attacks and … damage the heart and cause strokes.”

Racism is an inescapable part of the SDOH story. And the fatal knee restraint that Derek Chauvin put on George Floyd’s neck in May 2020 challenged complacent acceptance of the impartiality of public institutions when it comes to race. Having already hired its first chief health equity officer in 2019, the American Medical Association adopted a policy in November 2020 recognizing racism as “an urgent public health threat” and calling for best practices to combat it “considering that studies show historically marginalized populations in the U.S. have shorter lifespans, greater physical and mental illness burden, earlier onset and aggressive progression of disease, higher maternal and infant mortality, and less access to healthcare.”

After Floyd’s death, the phrase “abolition medicine” began to appear in the literature, building on recent social criticism that linked this century’s patterns of incarceration and policing to the legacy of slavery. According to an article in the July 2020 edition of 

t, abolition medicine “means challenging race-based diagnostic tools and treatment guidelines that reinforce antiquated and scientifically inaccurate notions of biological race.”

In March 2022, Gottlieb and two co-authors urged that abolition be added to the “five A’s” — awareness, adjustment, assistance, alignment and advocacy — suggested by the National Academies of Science, Engineering and Medicine in 2019 as the recipe for remediating SDOH. The addition was warranted, they argued, because even the best-intentioned interventions can fall short and become part of the problem. “Inattention to structural and systemic racism as fundamental causes of individuals’ socioeconomic risks,” they warned in 

, “means that healthcare’s social care practices will prove insufficient for improving health outcomes for marginalized patients.”

Gottlieb explains that the complex structural barriers facing those who would address SDOH in marginalized communities defy easy comprehension. “I personally haven’t been able to really, fully understand why social care is so hard,” she says.

The murder of George Floyd and the Black Lives Matter movement thrust SDOH and health equity issues into the consciousness of U.S. healthcare. But so has the COVID-19 pandemic with its disproportionate impacts on Black Americans. “There are more and more people who havesocial needs now,” says Therese Wetterman, M.P.H., a former Health Leads director who is director of network success for Aledade, a health services company that supports private practices.

Wetterman believes the widely noted pandemic-induced increase in wealth disparities in the past two years, both in the U.S. and abroad, is bound to result in adverse in health outcomes. The COVID-19 pandemic has forced a reconsideration of many healthcare issues.

“I work with a lot of primary care practices,” Wetterman says, “and I think the impact of the pandemic on primary care has created significant capacity constraints that make it really difficult for practices to add on addressing social needs as well.” ACAP’s Murray says one thing the industry has learned from the pandemic is that “the states don’t collect good data on race and ethnicity, which makes it harder to target your work.”

Still, one of the most heartening developments in recent years, Gottlieb says, is the way government at all levels has heard the message about SDOH. She notes that Alex Azar, HHS secretary during much of the Trump administration, saw that SDOH helped shape health inequities and that greater flexibility was needed to pay for services that addressed them. The Biden administration has made health equity a priority. In November 2021, CMS Innovation Center issued a “refresh” white paper that outlined its objectives for the next decade. Acknowledging that the ACA had authorized CMS to test payment and delivery models, it quoted Daniel Tsai, director of the Center for Medicaid and CHIP Services, that henceforth “health equity will be at the forefront of all policy decisions for Medicaid, not an afterthought.” One of the Innovation Center’s declared goals is to “develop new models and modify existing models to address health equity and social determinants of health,” according to the white paper.

“CMS is considering various incentives to encourage and sustain participation, such as upfront payments, social risk adjustment, benchmark considerations and payment incentives for reducing disparities or screening for SDOH,” Janet C. Walker, senior counsel at Crowell & Moring LLP’s Health Care Group, and two co-authors wrote recently. Some states — notably Oregon and New York — are doing interesting things with Section 1115 waivers that allow special demonstration projects. Oregon aims ambitiously at eliminating healthcare inequities by 2030 with SDOH services and infrastructure improvements; New York proposes creating new organizations to drive referral networks and facilitate interventions.

Growing use of value-based contracting should theoretically afford providers the flexibility to use funds for initiatives that can reduce healthcare costs even though they’re not medical interventions. The Biden administration recently dropped the directing contracting program and launched the Accountable Care Organization Realizing Equity, Access and Community Health, or ACO REACH. The ACO REACH program adds the element of implementing “initiatives to measurably reduce health disparities.” 

Increasing use of Z codes — introduced in 2015 as part of changes to the medical billing code system and used for nonmedical conditions such as homelessness or the death or disappearance of a spouse — reflects today’s broader understanding of the health consequences of social ills. For the nearly half million Medicare fee-for-service beneficiaries with Z-code claims in 2017, the top two chronic conditions were hypertension (72%) and depression (53%).

In July 2021, a formal bipartisan Congressional Social Determinants of Health Caucus was formed in the U.S. House of Representatives, chaired by Democratic Rep. Cheri Bustos of Illinois. The relevant issues fall under the domain of many different federal departments and agencies; caucus members hope legislative efforts can be more focused and effective when they’re looked at through an SDOH frame.

Physicians and nurses, of course, are too busy already. They don’t have much time to spend on new SDOH initiatives, even in the role of simply collaborating with the community service organizations that work with payer and provider organizations to meet social needs. That, experts say, is why there’s a need for people specially trained to provide culturally competent care — to screen for SDOH needs and arrange interventions with sensitivity and without patronizing or stigmatizing assumptions. In an era when it’s difficult to find workers in many parts of the economy, this promises to be another SDOH challenge.

But Gottlieb insists that clinicians can’t be let off the hook. “If I’m prescribing a medicine a patient can’t afford and there are cheaper alternatives, that’s just bad medicine,” she says. “Doctors need to know a patient’s insurance status, what’s covered, what’s not. They need to know if a medication must be taken with food and the patient doesn’t have enough food, or if it needs to be refrigerated and the patient doesn’t have a refrigerator. We’re setting patients up for failure when we don’t have social risk data at hand.” Gottlieb knows she is asking a lot, given what she calls “our fragmented, inefficient, very expensive healthcare sector.”

Indeed, the cacophony of different business relationships complicates the questions of how to structure incentives and pay the costs of addressing SDOH. Homeless Health Center’s Francis acknowledges, “Even the same payer and the same provider may have multiple different relationships with each other, some of which are adversarial, some collaborative.”

In recent years there’s been a spate of studies and papers about making the business case for SDOH, exploring how an organization can prove to itself or its stakeholders that investing in these interventions is worthwhile. Among the most recent is an issue brief published by The Commonwealth Fund in January and written by Wetterman and Lea Tompsett, Aledade’s vice president of network success. Its title is neither brief nor catchy, but it gets the point across: “Capturing Value in Social Health: Lessons in Developing the Business Case for Social Health Integration in Primary Care.”

The authors argue that many SDOH interventions have been just pilot programs and that long-term funding is required to integrate these services into primary care — for example, to pay the salaries of the new community health workers or navigators who start out being a cost center rather than a revenue generator. Wetterman and Tompsett mention a pilot project by the Collaborative to Advance Social Health Integration, which folded in social health interventions into primary care in a range of settings in varying stages of evolution toward value-based payment.

“I think what our paper highlighted was that you 

 make the business case for addressing social needs in a variety of different payment environments,” says Wetterman. “But it takes strong evaluation structures that are aligned with financial modeling to really show the value. That was new for a lot of the practices we worked with.”

Francis admires the study but would prefer the plural — business 

— because of the central issue of who is making the case — and to whom and about what. Does the payer, for example, reap all of the savings?

“Over the past three or four years, the innovation that’s happening in communities around this issue has exploded,” Francis says. “But we’re still very early in understanding which of these things we’re going to be able to replicate across a bunch of different places. We’re far away from the place where the executive can say, ‘I want to buy three of those social determinants interventions, plug-and-play, and they’re going to work for our community.’ I think people want that really desperately. But we’re not there.”

How much good has the SDOH concept done? It has undoubtedly stimulated thinking in healthcare and promising demonstration projects. But Gottlieb has concerns. “I sometimes worry that the enthusiasm around identifying and intervening with social determinants is being pushed without the strength of evidence that would lead to sustainability and effectiveness,” she says.

“The data about where the financial savings are and where you need to direct the social programs — which ones give you the biggest bang for the buck — are kind of all over the place,” she continues. “If I were a Medicaid managed care organization, it’s not totally obvious to me how comprehensive my social needs program would be. Do I target only the sickest of the sick? Or the ‘rising risk’ — people who aren’t yet super sick but seem likely to become so? Or everyone? How big a dose, for which patient and when? On those questions I wouldn’t put my money down yet.”

Francis, too, strikes a cautionary note. “I would advocate clearer thinking about mechanisms that improve public health,” he says, “and less breathless promotion of interventions that are expensive, modestly effective and possibly inequitable in the distribution of their outcomes.” He agrees that Gottlieb’s “How big a dose …” trio of questions haven’t yet been answered. But he also says that even when they are, these SDOH interventions won’t make a difference relative to changes in public policy. Citing the example of smoking, he argues that all the smoking-cessation tools in the world — brochures, counseling, nicotine gum — didn’t change things on the level that raising cigarette taxes and banning smoking in restaurants did.

“How do the ways healthcare systems address individual health-related social needs drivesocietalawareness around what we need to do for SDOH?” Francis asks. “That’s the most interesting question for me.”

Amid studies, pilot programs and widespread excitement, SDOH hasn’t yet reached what was once called “the end of the beginning.” “The difficulty with measuring ROI (return on investment) is that people’s lives are multifactorial,” says Enrique Martinez-Vidal, M.P.P., vice president for quality and operations at ACAP. “They’re complicated.”

That complexity is not stopping his health-plan trade group from unveiling a Center for Social Determinants of Health Innovations in summer 2022. The goal is to share ideas and thus spare member plans the proverbial reinvention of the wheel. For SDOH, however, nothing quite so elegant as the wheel has been invented.

There’s a long history to recognizing that social factors shape people’s health. But the social determinants of health are getting more attention than ever. Will that attention turn into action and lasting change?