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There’s some skepticism as programs to address social determinants of health proliferate. Some data are being collected.
Reading is a struggling small city (population 88,000) in southeastern Pennsylvania with a poverty rate of about 35%. If healthcare providers and providers are to travel “upstream” to address the social determinants of health (SDOH), communities like Reading might be where those efforts would have the biggest effect — or falter because the determinants are deep-seated and intertwined.
Three years ago, Reading Hospital, the 714-bed flagship hospital of Tower Health, a regional nonprofit health system in southeastern Pennsylvania, received a $4.5 million grant from CMS to start a program that teams up community organizations with the hospital. Medicare and Medicaid patients who receive medical treatment at the hospital are asked about their social service needs and care navigators and community health workers help link them with services. Addressing these social needs has helped decrease emergency department visits, saving the hospital $1 million, according to a case study by Reading Hospital released in July.
“Working together has a much more powerful impact,” says Desha Dickson, the hospital’s associate vice president for community wellness.
SDOH is a hot ticket in American healthcare these days and the COVID-19 pandemic has made it even more so because of the health and healthcare disparities the pandemic has revealed. The appeal of dealing with the root causes of disease is strong and easy to grasp. But there are also some misgivings. Can the healthcare system realistically take on such big problems? Are the programs longer on public relations than on substance?
Brian Castrucci, president and of CEO of the de Beaumont Foundation in Bethesda, Maryland, which focuses on community health, said that while establishing a community food pantry, for example, may be greatly needed, “It only meets the individual patient’s needs for the moment.” Helping an individual address their social service needs by helping them obtain a job or secure housing “extends the treatment of the symptoms, not the treatment of the causes,” he says. “There’s not enough money in healthcare to mitigate these societal-level problems,” Castrucci says “Instead, American healthcare could be more effective using its power to push policymakers to address the social and economic conditions that impact the health of a community.”
Castrucci and the skeptics and critics may have a point. But it also seems reasonable when Dickson and others say SDOH programs take time to bear fruit because the problems they’re addressing — housing, employment, nutrition — are not minor. Besides, even if a program skims the surface or homes in on a fairly narrow problem, it could make a big difference in people’s health status. Granted, the numbers are a little squishy, but by some calculations, up to 80% of a person’s health is influenced by SDOH.
Measuring the effect
Insurers and providers now have enough experience with SDOH programs that they are beginning to amass data measuring the effects of their efforts. Starting in 2018, Humana launched pilot programs in several cities with Papa, a platform that provides “grandchildren on demand” by recruiting college students to spend time with lonely seniors. The students, who earn up to $15 an hour, help the seniors with such things as baking cookies or doing chores.
“There’s a laser focus on social isolation and loneliness,” says Caraline Coats, MHAS, vice president of Humana’s Bold Goal and Population Health Strategy programs. Using the CDC’s Healthy Days metric, which measures an individual’s physical and mental health, participants in Humana’s program with Papa reported they were physically healthy three more days per month and mentally healthy five more days per month, Coats said.
When the COVID-19 pandemic struck, Papa’s college students shifted to virtual visits with seniors, says Andrew Renda, M.D., associate vice president of population health at Humana.
Humana also used Papa to help address other social determinants of health when COVID-19 flared, Renda says. The students delivered groceries to those who had food insecurity, which allowed for brief social connections with the seniors.
“Social determinants existed before COVID-19, and they’ve been exacerbated by COVID-19,” Renda says. When the insurer surveyed 100,000 Medicare Advantage members after the pandemic began, it found that 40% were feeling a financial strain, about 30% were lonely, more than 25% were food insecure, and almost 10%t had insecure housing, Renda says.
In some cases, people who didn’t struggle with social determinants of health before the pandemic are grappling with them now, Renda says. Humana is working with the National Quality Forum, a nonprofit focused on improving healthcare, to develop qualitative measures of food insecurity.
“We’re trying to put solid study designs around it,” Renda says. That can help Humana measure outcomes, such as improving patient health and saving money on care. Humana also has started awarding value-based healthcare contracts, adding incentives for insurers to screen for social determinants of health, Coats says “They have a massive impact on health and health outcomes,” notes Renda.
No codes for that
Elizabeth Baca, M.D., MPA, a specialist leader at the consultancy Deloitte, says value-based care “changes the equation about how we think about health more holistically.” Baca, a physician who practiced medicine and taught at Stanford University, says healthcare traditionally does not have a way for physicians to bill for care that would address SDOH.
She recalls dealing with one immigrant family who lived in a garage. Their son had severe allergies and asthma and had been repeatedly admitted to the intensive care unit. Baca eventually called the California Health and Human Services Agency for help getting the family into a home in order to improve the son’s health. By addressing social determinants, “There’s so much potential to have a real impact for the patient,” Baca says.
More data are getting collected on SDOH. Onlife Health, which is part of GuideWell, the umbrella organization that owns and operates several Florida health insurers, is about to launch the Social Determinants of Health Community-Based Index, a mapping tool that identifies every community’s SDOH vulnerabilities.
The tool can be used by certain Blues health plans, such as Florida Blue, Health Care Service Corp., and BlueCross BlueShield of Tennessee, so they can “understand at community levels the vulnerabilities of that community,” says Catherine Bass, Ph.D., M.S., director of informatics at Onlife Health, which is headquartered in Brentwood, Tennessee. After collecting input from its health plan members on topics such as how stress affects their lives or on their eating habits, Onlife can pass the information on to the insurers. If an individual is dealing with food insecurity, for example, the insurer could help link the person to resources in their community that could help them access healthy food or provide them with information on how to eat healthy on a budget, Bass says.
Taking such an approach can help improve members’ health and help an insurer attract and retain members because it creates loyalty, as the insurers “know you in a way that feels very personal,” says Bass.
Susan Ladika is an independent journalist in Tampa, Florida, who writes about healthcare and business.