What Role Should the Healthcare Delivery System Have in Addressing 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.
As the authors note, ACOs have positioned themselves well with outcomes-based payment models to address a more holistic view of health for their contracted populations. However, to date, it appears that the resource demands of medical care appear to limit ACO focus to largely clinical services, with social supports remaining subordinate in terms of both scope and funding. Unfortunately, this is occurring despite the fact that 40% of an individual’s health status has been attributed to social determinants, according to the Robert Wood Johnson Foundation.
Yet there is some good news. Awareness of the role of social determinants of health in relation to health status of individuals and populations is growing. Recent analyses have characterized the barriers to accessing healthcare intrinsic to low-income populations.3 Increasing mention of the phrase “social determinants of health” in the peer-reviewed medical literature (PubMed) has been steadily increasing, from 147 articles in 2010 to 734 in 2015, with likely more in 2016. Included in the current year are some excellent perspectives, including a review summarizing the importance of understanding and addressing social determinants of health during patient care,4 a commentary addressing the potential concerns of provider screening for social determinants of health,5 and another providing a viewpoint regarding the opportunity represented by the recently funded CMS Accountable Health Communities model.6
Even in commercially insured populations, the rapid growth of the low-wage worker population has prompted closer scrutiny of the healthcare utilization of this subgroup, 7 likely having not dissimilar social service needs as broader, population level analyses. The growing recognition of the pervasiveness and severity of financial stress among low-wage workers illustrates the challenges this subpopulation faces with making ends meet—and the need for enhanced resources to address these foundational personal concerns.
As the medical field strives for improvements in quality, efficiency, and clinical and cost outcomes, acknowledgement of and attention to social determinants of health may help to substantially improve overall results. Practical tools, including validated social needs assessments, as well as use of low cost resources to connect individuals with community-based resources may not require as great an investment as perhaps might be believed. Furthermore, collaborations between public health researchers and healthcare entities may lead to better understanding of the significance that social needs have when managing individual clinical concerns.
After all, for patients, these social needs are symptoms, too.
1. Wage Statistics for 2014. Social Security Administration. October 26, 2015. https://www.ssa.gov/cgi-bin/netcomp.cgi?year=2014. Accessed December 21, 2015.
2. Bradley E, Taylor L. The American Health Care Paradox. New York, NY: Public Affairs; 2013.
3. Jacob R, Arnold L, Hunleth J, Greiner K, James A. Daily Hassles' Role in Health Seeking Behavior among Low-income Populations. Am J Health Behav. 2014;38(2):297-306.
4. Nesbitt S, Palomarez R. Review: Increasing Awareness and Education on Health Disparities for Health Care Providers. Ethnic Dis. 2016;26(2):181-190.
5. Garg A, Boynton-Jarrett R, Dworkin P. Avoiding the Unintended Consequences of Screening for Social Determinants of Health. JAMA. June 2016:E1-E2.
6. Alley D, Asomugha C, Conway P, Sanghavi D. Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid. New Engl J Med. 2016;374(1):8-11.
7. Sherman B, Lynch W, Addy C. Lost in translation: Healthcare utilization by low-wage earners receiving employer-sponsored health insurance.. Am J Manag Care. 2016;22:268-290.
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