Social determinants of health (SDoH) is a phrase you’re likely hearing more lately. They are the conditions in the environments where people are born, educated, work, play, and go about their daily lives—and which greatly affect one’s access to healthcare, their health risk factors, and ultimately their medical outcomes.

 

Defining the social determinants of health

We’ve long known that the non-medical factors and conditions that comprise an individual’s or population’s SDoH set the stage for unequal access to healthcare and potentially poorer health results. For example, racial differences in mortality rates persist despite initiatives to correct inequalities. However, the shift underway from volume- to value-based payment in healthcare links reimbursement to outcomes. As a result, payers and provider organizations are being incentivized like never before to act on data related to SDoH. 

Population health, public health & SDoH: What's what?

  • Population health refers to the physical, mental, and social well-being of defined groups of individuals and the disparities in health between population groups. 

  • Public health is a society’s collective efforts to improve the health and well-being of the total population. Such efforts rely on participation from the government, the private sector, and the public to focus on the determinants of population health.

  • Social determinants of health within populations include direct/proximal factors (e.g., socioeconomic status, physical environment, living and working conditions, family and social network, lifestyle or behavior, and demographics), and indirect/distal influences (e.g., political, legal, institutional, and cultural). 

 

 

The five domains of SDoH​

Thousands of factors affect a person’s health. But to better study the contributing elements, the U.S. Department of Health & Human Services (HHS) and its major operating components (e.g., The Centers for Disease Control and Prevention, The Centers for Medicare & Medicaid, The Office of Disease Prevention and Health Promotion) established five domains into which SDoH factors fall

  1. Neighborhood and built environment
  2. Social and community context
  3. Education access and quality
  4. Economic stability
  5. Healthcare access and quality

 

Delve into those domains, and you can begin to see how negative circumstances affect people’s health. Examples include unsafe housing, lack of public transportation​, racism or other discrimination, violence​, lack of educational opportunity, income​ disparities, polluted air/water​, language barriers, illiteracy. And studies show that there’s a cascade effect of any one (or multiple) of these disparities. For example:

 

Patients’ view of SDoH

Patients, of course, don’t think about their risk factors for health outcomes in the same terms as healthcare organizations and regulatory bodies do. To them, SDoH are represented in day-to-day challenges, especially if they don’t have basic needs met. Astoundingly, 40% of people in the U.S. today do not have adequate access to:

  • Enough food to eat
  • Clean, running water
  • Heating/air at home
  • Money for prescriptions
  • Transportation
  • Phone/computer (Do I have one, and can I use it?)
  • Access to care (Do I live in a rural area?)

 

And many face challenges like these on top of lacking basic needs:

  • Illiteracy (Can I read medical labels/instructions?)
  • Socialization/loneliness (Do I have family/caregivers?)
  • Mental illness/depression

 

COVID-19, especially, has focused attention on SDoH. Many eyes were opened to the inequity of basic needs based on class, race, geography, and other factors.

A spotlight on quality

Improving the health of all citizens benefits everyone socially and economically. But a confluence of factors today is giving the government and the private sector special incentive to address SDoH and reduce health disparities. The issues cross quality, safety, and reimbursement, and include: 

  • The cost of healthcare continues to rise sharply, despite many initiatives to stem costs.
  • Our healthcare delivery and payment systems are posting insufficient return on investment for government and some provider organizations, and there is room for price gouging.​
  • Heightened awareness of social justice issues is leading more individuals and companies to act through demands or initiatives. ​
  • Healthcare reform requires payers and provider organizations to work more closely together. In managed care space, SDoH was always at the forefront!​
  • There are many more opportunities today for entities beyond government and healthcare to get involved in social inequity.

The changes we make in 2021 will affect quality and reimbursement for all healthcare organizations down the road. 

Barriers to addressing SDoH

It’s no easy task to address the structural issues that result in unequal access to healthcare and poorer health results among some Americans. For example,

  • Initiatives across education, housing, literacy, legal, etc. have not always connected to help those who face healthcare and other disadvantages. 
  • The data and technology needed to coordinate efforts are siloed in government and state agencies, healthcare organizations, commercial enterprises, and payer organizations such as MCOs.
  • Programs that have been successful within communities have been difficult to replicate at a larger scale.

 

But, there is progress among organizations whose goal it is to connect the dots, especially with regards to SDoH. For example, the Office of the National Coordinator for Health Information Technology, a part of the DHHS, is making strides. And there is slow but sure movement of corporations/CEOs who care about fiscal and social good (i.e., “do well and do good”) in their communities.

Simply put, today there is both more opportunity for shared accountability regarding healthcare inequities—and the future of value-based payment demands it.

Technology—and a dichotomy

Today’s technology can be used to screen, identify,  prioritize, connect, and support patients with SDoH needs, as well as identify and prevent risks. COVID-19 drove a 50–2,800 per month average increase in telehealth visits at healthcare organizations, and brought telemedicine to the forefront of healthcare, essentially overnight. 

Yet telemedicine also spotlights the work still to be done to address SDoH and inequities in healthcare. According to William Torkildsen, MD, Chair of the Valley Organized Physicians,

a TX-based independent physician association: “While virtual healthcare has gained a tremendous push recently, we’re finding telemedicine literacy is a challenge ... only 40% of our Medicare patients are 'virtually fluent’.”

Other challenges abound, again stressing the need that community resources must come together to address SDoH:

  • Patients spend only one hour per year spent annually in exam rooms.
  • Patient information/data is not always updated online, and exists in too many disparate places.
  • Despite HIPAA regulations, technology leaks personal patient information, leading to harm or distrust.
  • There will be an adjustment to patient perception of “caring” as physicians deliver more services online only.
 

The future is now with payers

It’s clear that payers’ and providers’ attention on SDoH will only increase going forward. For example, Patrick Conway, MD, now CEO of Care Solutions, Optum at UnitedHealth Group, has historically invested in SDoH at the healthcare organizations he leads. And he’s not alone. Kaiser Permanente has been addressing SDoH for years, even building affordable housing; and Cerner CommunityWorks offers free telehealth access for rural hospitals.

SDoH are not new, but they're now at the forefront of addressing healthcare inequities, and will remain there as one of healthcare’s many "new normals” post-COVID-19.

 

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