Dr Hennessey relates her past personal experience with cancer care delivery when her mother was receiving chemotherapy for lung cancer, where an issue with care access could have significantly altered her mother’s life span. This experience inspired her career and prompts an exploratory discussion of how social determinants of health (SDOH) are currently addressed in health care today. Authors discuss definitions of social determinants of health, survey results of how organizations currently integrate SDOH, and insights on how to make better use of SDOH for more value-based care.
Several decades ago, as a health care professional in training, I personally and powerfully experienced the impact social determinants wield upon health. My mother was receiving chemotherapy for lung cancer and contending with severe nausea and vomiting as a result. At the time, remedies for nausea were so ineffectual that she would reflexively feel nauseous when she saw her chemotherapy nurse in the local supermarket! My fiercely tenacious mother was ready to give up and lamented, “If I could just lie in bed at home and not move, I wouldn’t get so sick on the chemo.” Access to in-home infusions was rare in our community, but fortunately, a social worker gave me the name of an oncologist with a grant for a mobile chemo van, and he gave my mother infusions in bed at home. My mom, with an anticipated life expectancy of 6 months, lived another 7 years and saw the birth of her first grandchild, my sister’s high school graduation, my doctoral graduation, and other precious family milestones.
Personally grateful, I found myself reflecting broadly and professionally on the impact of access to care on patients’ opportunities for life and quality of life. What would have happened if that oncologist had not provided in-home infusions? What if the social worker had not known, taken time, or been willing to share his name? How many people unnecessarily suffer or die due to poor care access? After graduate school, I took those lessons to heart when I began a career as a managed care executive tackling escalating and avoidable hospitalization and readmission rates among populations in rural, suburban, and urban areas that included the most impoverished and wealthiest American communities. These experiences offered opportunities to deploy analytics and leverage social and clinical networks. This work then encouraged innovations that led to models of subsidized patient transportation, in-home care programs, and telehealth outreach. The networking that took place around these programs reduced the impact of adverse social determinants to attain better clinical outcomes through improved care access and more efficient resource use.
As my experience testifies, although addressing social determinants of health (SDOH; also called social risk factors) has occurred inconsistently for decades among health plans, delivery systems, and subpopulations, they are now emergent factors to be systemically addressed to improve population health and better deliver value-based care. This article will define and describe SDOH.1,2 Further, it will comment on reasons for their growing importance and will share select insights from Precision for Value’s 2019 SDOH Survey regarding organizations’ approaches to SDOH. The article will also offer observations on ways that health care entities are addressing SDOH and conclude with a summary of opportunities for collaboration to accelerate effective action to address SDOH.
Definition of SDOH and Their Expanding Importance
While multiple definitions exist for describing SDOH, the Centers for Disease Control (CDC) and World Health Organization have provided some of the more commonly used descriptions. “Social determinants of health are economic and social conditions that influence the health of people and communities. These conditions are shaped by the amount of money, power, and resources that people have, all of which are influenced by policy choices.”3 Examples of SDOH include: access to quality health care, discrimination, education, employment, food security, income, safe housing, and social support.4
Given CDC estimates that SDOH account for 75% of population health,4 combined with findings that the United States spends far more than other high-income countries on health care (but falls comparatively lower on health care quality outcomes5), it is unsurprising that SDOH are receiving expanded focus among US health care entities. Plans, integrated delivery networks (IDNs), and quality organizations are among the entities increasingly recognizing that systemic assessment and intervention with SDOH offers opportunities for attainment of the Triple Aim: better care, healthier people, and smarter spending.6
At the 2019 National Quality Forum conference, Kate Goodrich, MD, MHS, of the Centers for Medicare & Medicaid Services (CMS) noted that SDOH or social risk factors are integral to CMS Strategic Priorities for 2019 and discussed ways CMS is embedding a focus on health equity within its programs.7
The Population Health Alliance has also weighed in on the importance of addressing SDOH. In a 2018 white paper, it declared that the emergence of value-based health care creates a United States imperative for multistakeholders to forge alliances to reduce the impact of SDOH on our population’s health.8 Yet another quality organization, the Pharmacy Quality Alliance (PQA), has commented on the importance of medication access within value-based care and noted that difficulty accessing needed medications substantially impacts population health. PQA recently authored a report describing a Medication Access Conceptual Framework with SDOH integrated within this framework.9 Finally, as an additional indicator of the urgency of systemically addressing SDOH, two highly influential organizations, United HealthCare and the American Medical Association, have joined forces to standardize how ICD-10 data is collected, processed, and integrated to assess and address SDOH, with the purpose of improving health care access and outcomes.10
The health care ecosystem is evolving from volume-based reimbursement models to value-based reimbursement paradigms with incentives and penalties linked to quality performance and cost management. Both payers and providers—seeking to gain revenue, attract and retain members and patients, and avoid financial penalties—are transforming their systems to offer better health outcomes, enhanced patient experience, and more efficient cost management consistent with the Triple Aim. Many are developing population health management infrastructures to accelerate this process.11 This transformation will continue as more entities reach a tipping point with payer and provider delivery systems merging and IDNs contracting to assume more financial risk for costs and quality of care. Precision for Value sought to gain insights into diverse health care stakeholders’ approaches to SDOH as they evolve to value-based care; summaries of select survey results follow.