Evidence grows that these nonclinical factors have a large influence on patient outcomes. Here’s what hospitals and payers can do about it.
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.”
Individual health systems are looking for ways to create those opportunities through innovative research programs. With Medicare-related avoidable hospital readmission penalties on the rise, Kash and her colleagues at Houston Methodist and at the Texas Medical Center, a confederation of 60 medical institutions in the Houston area of which Houston Methodist is part, wanted to see how much social and environmental factors might influence the likelihood that different patients might be readmitted.
“Our ultimate goal is to close the disparity gap in hospital readmissions-because, unsurprisingly, there is a big gap. More disadvantaged populations are at a much higher risk of being readmitted to the hospital after a health issue,” she says.
To start, Kash and colleagues conducted a meta-analysis of studies that compared different readmission reduction strategies to see how they intersected with SDOH. They then took a detailed look at patient-level data regarding SDOH from EHRs and health information exchanges to get a better understanding about different patient populations and any correlated reasons for readmission. Then they used predictive modeling techniques, including their own data and data from the area deprivation index (ADI), which is census data that looks at common socioeconomic factors, to determine the factors that were most likely to predict an avoidable hospital readmission.
“We found that being a Medicaid patient is the best indicator of an avoidable readmission. Even with all the other ADI data, it seems to be a good proxy for disadvantaged populations,” Kash says. “The other factors included patients who are older than 45 years of age, patients who are discharged to a skilled nursing facility or discharge themselves against medical advice, patients who have a diagnosis of chronic obstructive pulmonary disease, and patients who have severe illness. But when it comes to reducing readmissions, it seems to come back that simple insurance status really is a predictor of outcomes.”
Kash hopes that studies like hers will encourage payer organizations to consider SDOH when calculating readmission penalties. But she also hopes that more healthcare systems will find ways to incorporate the findings into clinical care.
“We want this to result in some kind of actionable strategy,” she says. “And this is something that could be easily implemented with some kind of alert or reminder in the EHR. We recommend that patients who meet these criteria get more detailed and comprehensive discharge instructions, especially around self-care and symptom recognition and management. And we also recommend follow-up phone calls and home visits. They work-and they don’t cost all that much in the long run.”
While it would be easy to add a few checkboxes to a patient record on an EHR, Kash is quick to point out that every hospital and health system needs to develop their own approach to addressing SDOH.
“Each hospital really caters to a different type of patient population,” she says. “We’ve learned, if you really want to close these gaps, it’s important to come up with strategies that are very specific to your region and the needs of the patients within that region. And that means understanding, at the patient level, the SDOH that may interfere with positive outcomes.”
Kane agrees, using the community in Flint, Michigan, as an example. “They have very specific community issues that affect the health of all their residents,” he says. Because of infrastructure issues in that community, he explains, children in that area have a much greater chance of experiencing learning disabilities, of chronic kidney disease, and potential growth retardation-all because that community has struggled with providing basic human services like water, transportation, sewage, and safe housing to everyone. “Even the opioid epidemic, in some ways, could be considered a byproduct of SDOH, because of an environment with jobs with more physical demands that led to injuries, to higher rates of prescriptions, to targeted pharmaceutical advertising.”
Broader effort needed
Kane contributed to a position paper on SDOH for the American College of Physicians in April 2018, “Addressing Social Determinants to Improve Patient Care and Promote Health Equity.” In it, he and his colleagues called for “health in all policies.”
“Payers and providers can’t do this alone,” Kane says. “Legislators need to consider the health of the population when they implement policies in their city, state, or region. It really is an important first step,” he says.
Yet, he acknowledges that dealing with SDOH must be a team effort.
“We also believe there should be greater attention for SDOH among trainees in medicine. We can do a much better job of teaching our students so they know what to look for when caring for individual patients,” he says. “Healthcare systems need to think creatively about how to address all those little things that can influence care-how patients get transportation to their facilities for follow up, how the neighborhood may contribute to exacerbating an underlying condition, or how to make sure that patients have access to fresh fruits and vegetables. Payers should recognize that patients who are affected by a number of SDOH may require more time to treat, and reimbursement might need to be adjusted so we can deliver that care. It’s going to take a lot of different things, many of them little things that add up over time, to get the insights we need into how SDOH affect our patients and how we, across our communities, can effectively plan and deliver interventions that will address them.”
Kayt Sukel is a science and technology writer based outside Houston.