What Role Should the Healthcare Delivery System Have in Addressing Social Determinants of Health?

Bruce Sherman, MD, FCCP, FACOEM, is the medical director for Population Health Management for the RightOpt private exchange offering for Buck Consultants, A Xerox Company, and he is the consulting medical director for Employers Health Coalition, Inc. Previously he served as consulting corporate medical director for Wal-Mart Stores, Inc, Whirlpool Corporation, and The Goodyear Tire
With growing demand for practitioner accountability and a transition from fee-for-service to value-based care, there is now a compelling case to be made for healthcare delivery team support to address these social determinants of health.
Collectively, we are rapidly approaching a defining moment when it comes to the health and well-being of residents in the United States.
 
A confluence of factors is creating what may be the perfect storm. The middle class is shrinking with 51% of American adults now earning less than $30,000 per year, according to the Social Security Administration.1 The cost of healthcare continues to rise, particularly so for these low-wage earners who are faced with the unfortunate choice of either paying for healthcare or basic necessities such as housing and food. Stress levels in the general population continue to rise with financial stress at the top of many population-based surveys.
 
In 1948, the World Health Organization defined health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Unfortunately, many healthcare entities have seemingly focused exclusively on the physical component of this definition. A number of factors understandably contribute to (if not necessitate) this approach—a focus of medical school training on the increasingly complex field of medical care and expanding healthcare process and outcomes compliance reporting demands from clinical personnel, as well as narrowing revenue margins and the push to increase patient throughput, among others.
 
This physical health focus has represented a significant priority for low-income individuals, where treatment compliance challenges have been well documented, particularly among those enrolled in government insurance programs. Specific care management issues have characterized issues with gaps in care, medication adherence, and appointment follow-up, among others. While many might argue that the patient is to blame, another perspective is that these data highlight shortcomings of the narrow and clinically focused medical treatment model, despite well-intentioned practitioners.
 
With growing demand for practitioner accountability and a transition from fee-for-service to value-based care, there is now a compelling case to be made for healthcare delivery team support to address these social determinants of health. At greatest risk are accountable care organizations (ACOs), which may miss performance goals if they’re unable to achieve desired clinical outcomes.
 
In their insightful book, The American Health Care Paradox, Elizabeth Bradley and Lauren Taylor have chronicled the history of the separation between the healthcare delivery system and social service programs in the US, and how the US differs from that of other countries in that regard.2 While the authors acknowledge that an expanded government welfare state and cooperation among groups with fundamentally opposing viewpoints are unlikely to occur anytime soon, they present some selected examples of successful, community-level integration of medical and social services and their beneficial outcomes.
 


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