The Tipping Point for Social Determinants of Health - Are We There Yet?

I am a native New Yorker now living in Hermosa Beach, California. The demographic shift has no doubt shaped who I am. I believe everything you say is likely bull but will dedicate my life to joining you in a just cause. I'll sit with you in deep meditation so we can cleanse our chi, but won't sit too close...because I saw you eyeing my watch. As such I am highly qualified to work in healthcare reform; a deeply cynical...optimist. So when I think about the new emphasis on social determinants of health I am at the same time skeptical and hopeful.

I've run hundreds of events on public health, population health, Medicare, Medicaid, and now Social Determinants of Health. Every time, I think now is the time when public and private sector healthcare will come together to combat long-held beliefs that poverty is beyond the scope of healthcare. As a New Yorker, I'm not a big fan of admitting I am wrong, but sadly I was. Have there been important shifts in the last twenty years. Yes. But are public and private health still worlds apart? Yes. So to say I'm skeptical of the healthcare industry's recent focus on social determinants is putting it mildly. However, in the last year, executives in the C-Suite of major health systems and health plans are yielding to the notion that healthcare spending is a bottomless pit if social factors are not addressed. Motivated by shared savings and readmission penalties they have finally started to invest in programs that address social determinants in their communities. Short of throwing money at social programs, the question is what does a system that supports the integration between disparate social and community programs look like and how do we get there when healthcare organizations will barely share data within the walls of their own closed systems?

Dr. Roy Beveridge, Chief Medical Officer at Humana wrote a thoughtful post on Forbes where he shared a vision for a path forward that requires that clinicians both get the tools they need to prescribe community services to their patients with ease and that they are compensated for these services. He speaks from experience as Humana was first out of the gates with the launch of their Bold Goal Initiative in 2015. Their goal - to improve the health of their communities 20% by 2020. They knew they needed to address social determinants like homelessness, food security, and loneliness to create this type of impact. You can read their recently released progress report here.


Another is perspective offered by HealthIMPACT SDoH Summit Co-Chair, president and founder of Accountable Health, LLC, and chair of the Board of Directors, Population Health Alliance is Fred Goldstein

We don’t need new billing codes, it’s the 30% waste in the system that’s redirected to fund the social services. If we got rid of Fee for Service payments which reward excess, and moved to bundled or capitated one’s, the providers would do even better by taking out the waste and keeping people healthy. In this scenario providers could use the majority of the estimated $1 trillion dollars of waste to fund the needed social services.”

Since the advent of ACOs, Fred has been working to shift the focus from accountable care to Accountable Health. In his 2014 paper on the topic, Fred and population health luminary Dr. David Nash point out that 

“True success in the United States will not come from an ACO, which places an overwhelming majority of its efforts on the provider system and the care they provide, but rather from an AHO that includes the patient and the broader community as an active and necessary partner in the structure, management and indeed financial rewards and penalties required to make this work.”

They go on to explain that an “Accountable Health Organization” will require the integration of the additional components: the patient and their communities.


This month Kaiser announced plans to invest $200 million to address homelessness in the communities it serves. Kaiser and Humana are not alone. Several major health systems are implementing initiatives to impact their communities. Last year, Northwell Health hired seasoned public health executive and former health system CEO, Dr. Ram Raju to head up their efforts to leverage social determinants for population health strategies. In addition efforts across the industry to create standards for the capture of social determinants in patients' EHRs are finally coming together.


So the will is there, however as with everything in healthcare, the incentives must be aligned across all stakeholders. Leavitt Partners' recent white paper revealed that the majority of physicians surveyed don't believe that addressing SDoH factors is within their realm of responsibility or even influence.


With the launch of Town Hall Ventures, Former Medicare Chief, Andy Slavitt is no doubt going to bring a lot of attention to the need for technologies and innovations that address food insecurity, homelessness, social isolation, and that is a great next step.

It, however, reminds me of an important observation from Esther Dyson, Executive Founder of Way to Wellville and digital and population health pioneer.

The biggest challenge in everything is to think long term instead of short term. Whether it’s kids who take the first marshmallow without the grit and self-determination to wait a little longer and get two or three marshmallows, to governments and companies who are not willing to invest in the long term and want to be reelected right now, or have a high profit this year, or, frankly, communities who keep doing pilot after pilot, rather than sitting down and saying, “We’re going to scale something and grow it so that we can reach all the pre-diabetics in our community.” It’s that thinking long term that, ultimately, leads to success. Short-term thinking is addiction. Long-term thinking is purpose .”

Esther is right. The healthcare industry has an addiction. We are addicted to the next shiny object, the magic bullet cure, the moon shot, the thrill of the ride on the innovation hype cycle. We are guilty of exactly what we accuse patients of doing. We know the treatment plan needs to run its course, but we are quick to drop it as soon as we don’t see the immediate results.


Dr. Amy Sheon is the SDoH Summit Co-Chair and Executive Director of the Urban Health Initiative at Case Western Reserve University where they are actively pioneering methods of universally screening patients for their digital skills and connectivity, referring those in need to community partners who are equipped to help people gain digital skills and access low-cost equipment and connectivity, and then to train patients to use health technology. She points out that,

When one has been living with an ever-present smartphone for a decade or more, it becomes impossible to remember life without it. Yet for up to one-half of individuals from low-income households, with high school education only, who are over age 60, who live in rural areas, or who live in low-income urban areas, these online resources will be of little value. Those lacking digital equipment and skills will not avail.” 

As the healthcare industry continues to pour money into technology, this digital divide has the potential to exacerbate healthcare’s lack of influence on social factors. So while we design these programs to help it is essential that we do not leave behind those who are dependent on mobile devices for internet access as they are triply disadvantaged.  

The integration of the patient and their communities is not a problem of technology or even the slow rate of change in healthcare. Which is not to say that AI and machine learning can't be applied to identify patients at risk or that the directory of community services can't live on the blockchain. It is to say that what is truly required is the time, money, and tools for clinicians or the appropriate care professionals to help the healthy and the sick take accountability for their health.


The good news is that the momentum is building and we are delighted to be a part of it. We launched HealthINSIGHTS last year with a focus on the business case for social determinants of health. Now we are bringing it back as part of our flagship HealthIMPACT East event July 18-20th in Washington, DC.


If you are part of a team working to address food insecurity, loneliness, social isolation, and other risk factors that when managed create measurable improvements in health and outcomes, please reach out and let me know. As we do at every HealthIMPACT event, we want to elevate the successes and share the failures so that we as an industry can accelerate meaningful change and innovations in this incredibly important area that has always been at the heart of how healthcare professionals impact and improve population health.


Acknowledgments

Thank you to Amy Sheon and Fred Goldstein for their input on this article and for their participation at HealthIMPACT East SDoH Summit July 18th in Washington, DC.


References

HealthIMPACT East July 18-20, 2018

Humana to Address Social Determinants of Health in New MA Benefits

Most physicians say addressing social determinants of health isn't their job

Social Determinants of Health Dashboard Expands to 500 Cities

We Can Do Better — Improving the Health of the American People

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