In a recent interview, Karen DeSalvo, MD, stated a truth that has been known for decades in health care: what happens in a primary physician’s office, hospital or clinic is just the tip of the iceberg when it comes to efficient healthcare delivery. Dr. DeSalvo, Professor of Population Health at the University Texas at Austin, said there’s a reason why five percent of patients can account for up to 50 percent of healthcare costs.
“These people are not just medically complicated but socially complicated,” she said at a social determinants of health (SDoH) conference last November. “These are people not only with chronic conditions, but who tend to be older, with less income and less formal education, and they tend to be on Medicare or Medicaid and have fewer resources … It’s just a clinical reality we’ve all been knowing.”
SDoH is defined by the Department of Health and Human Services (HHS) as: “…conditions in the environments in which 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…”
With the advent of CMS rules that decline payments to hospitals and their medical staffs for Medicare readmissions within 30 days of hospitals, what happens to a patient when they return home is now of concern to all caregivers. With just about half of primary care physicians (family and internal medicine) employed by health systems, SDoH centered care is evolving as a whole person care standard. Hospitals are forging ever increasing community care coordination relationships to provide a wide array of social support. This includes addressing such quality of health factors as housing and food shortages, transportation, and access to medications and primary care physicians.
In the emerging era of value-based healthcare that stresses outcomes over volume, there is financial incentive to keep people out of hospitals by paying attention to SDoH. CMS incorporated “Z-Codes” in ICDN-10 overhaul a few years ago to help collect SDoH data on patients. The entire hospital team – ranging from nurses and behavioral health manager to case managers, community health workers, and discharge planners – now have a data-rich tool to get patients the community care coordination they need to stay healthy. A 2018 study found that SDoH strategies pays off: “There is increasing traction within the medical field for improving social history taking and integrating more regular screening for social determinants of health within clinical practice. There is also a growing number of high-quality, evidence-based reviews that identify interventions that are effective in promoting health equity at the individual patient level, and at broader community and structural levels.”
SDoH solutions, to be successful, cannot place an undue burden on physicians in their day-to-day practice of medicine. This is key in putting SDOH to work for doctors and their patients, which still in its early stages. According to a survey conducted last fall, 60 percent of patients at high risk for high SDoH risk have never discussed the matter with their provider or insurance company.
For a successful SDoH strategy, a data-driven platform is essential.
“Without that information, providers are just seeing that this individual is not compliant or is not seeking the care they need. They don’t know the reason why,” said Sanket Shah, Clinical Assistant Professor at the University of Illinois a science. He is a health informatics expert who develops artificial intelligence and machine learning to assist in SDoH delivery.
A 2016 study found that “states with a higher ratio of social spending had significantly better subsequent health outcomes” for seven measure. These included adult obesity; asthma; mentally unhealthy days; days with activity limitations; and mortality rates for lung cancer, acute myocardial infarction, and type 2 diabetes.
SDoH still has a way to go, but HHS, which administers Medicare and Medicaid under CMS, is taking action. The agency now allows Medicare Advantage Plans, which are modeled on whole person care, to pay for SDoH health-related benefits such as transportation and home health visits.
Health system primary care physician leaders also see SDoH delivery strategies as a viable solution to value-based healthcare delivery.
“We spend 90 percent of our dollars on hospitals and clinics, and that only contributes about 10 percent to the overall health of the population; that doesn’t make any sense,” Marc Harrison, MD, President and CEO of Intermountain Healthcare in Utah said. “We need to change up our game, and we need to do it fast.”