A study published last week confirms what doctors, nurses, and other hands-on caregivers have long-held relevant to whole-person care: the best medical care cannot fulfill severe deficiencies in the social determinants of health (SDoH). Recent research indicates that SDoH, rather than medical care, impact and determine about 80 percent of good health.
The study, “Health Care Hotspotting – A Randomized, Controlled Trial,” was published January 9 in The New England Journal of Medicine. According to NPR, which reported the results of a Camden, NJ study, when patients’ lives are so complicated by social factors like poverty and addiction—social determinants of health—their manageable medical conditions, such as diabetes and asthma, lead to “expensive, recurring hospital stays.”
The study concluded two groups of chronically and acutely ill patients—one cohort who received intensive medical and social attention and a second which was cared for under standard protocols—did not show significant differences in the use of medical resources. As a measurement, the study tracked emergency department (ED) visits and hospital stays. However, the study also concluded any shortcoming in SDoH performance was most likely due to a lack of assistance resources—“the larger social safety net”—such as housing, mental health services, and addiction treatment.
SDoH in the Spotlight
SDoH includes such factors as:
Health Behaviors (30%): Tobacco use, diet and exercise, alcohol and drug use, and sexual activity.
Social and Economic Factors (40%): Education, employment, income, family & social support (inversely, domestic violence), and community safety (inversely, social violence, and crime).
Physical Environment (10%): air and water quality, housing, and transportation.
The Camden study did not confirm SDoH cause and effect among acutely ill patients. However, other analyses of less severe patients indicate that finding the sweet spot between primary care management and reducing SDoH pressures is a worthy long-term strategy. For example, a 2018 survey by The Physician’s Foundation revealed that “88 percent of doctors reported that many or all of their patients have significant social/economic needs that pose a threat to their health,” according to Medical Economics. Further, a 2018 study found that addressing SDoH patient needs reduced healthcare spending by 11 percent.
Researchers Look to Close Evidence Gap in SDoH Measurements
The sometimes-contradictory study results indicate an evidence gap common to emerging healthcare delivery reform. In March last year, Health Affairs (HA) cited the need for more evidence in addressing SDoH factors. In citing “super-utilizers,” the authors found that just one percent of patients—this one percent consisting of patients with high SDoH needs—can account for 20 percent of healthcare expenditures. Such an association was even more pronounced in the Medicaid population—more than half of all expenditures were attributable to about 5% of Medicaid’s beneficiaries.
Both groups were found to be high utilizers of ED resources, which is the most expensive point of entry into the healthcare system, as well as the least effective in managing chronic conditions. The analysis also concluded that about a third of all deaths in the US are related to SDoH factors. HA cited inconsistencies in how primary care providers screen for SDoH. There was also a lack of standardization and validation in screening tools and metrics noted.
In a paper published in 2019, the nonprofit Center for Health Care Strategies (CHCS) confirmed several SDoH whole-person care need factors. These include identifying patient non-medical needs, partnering with social service agencies and community-based organizations, and testing new uses of technology to address patient needs. CHCS also presented several specific SDoH assessment platform identifiers linked to successful SDoH management. These included:
What assessment tool should be adopted or adapted to collect SDOH information?
How will the tool be administered and by whom?
How will the information collected inform clinical practice?
How will patients with identified needs be referred to community resources?
How will providers track whether patients’ needs are addressed?
HHS, which administers Medicaid, has cited three specific needs in utilizing SDoH management effectively. These include:
Defining and standardizing data on social determinants.
Supporting local and state-based decision-makers.
Creating a sustainable infrastructure for collecting data, including financial incentives for payers, providers, and community-based organizations.
Congress Interested in Addressing SDoH
The SDoH connection has come to the attention of Congress, and they are currently working to secure funding for further SDoH study and research. A bipartisan Senate bill, the Social Determinants Accelerator Act of 2019, was referred to the Senate Finance Committee at the end of December. The proposed legislation seeks $20 million in funding over five years. The act, if it becomes law, would establish an interagency council that would make recommendations on how best to coordinate funding and administration of federal programs that could be better improve SDoH whole-person care for Medicaid recipients.
It remains to be seen what kinds of recommendations would be made by the proposed interagency council. Already, across the country, agencies and local governments have found success utilizing care coordination platforms, such as Eccovia Solutions’ ClientTrack, to establish a central patient population database, coordinate funding, administer programs, and track and report on outcomes, and as such, deploying such a platform may well be one of the prime recommendations by the potential interagency council. Until that time, it will be crucial to pay close attention to the outcome of the Social Determinants Accelerator Act of 2019.