Social determinants of health: The time has come

January 31st, 2020 / By Steve Delaronde

The realization that income, education and zip code have a significant impact on the health of a population has evolved over the past ten years and is now widely accepted. The challenge for the next decade is to make changes in the U.S. healthcare system that effectively use and address social determinants of health (SDoH) to create better health outcomes for the patient.

Population health is the intersection of biology, behavior, social environment, physical environment and health care. For example, children with asthma have a biological condition exacerbated by the social and physical environment, such as substandard housing, outdoor air pollution, secondhand smoke and stress. Effective interventions that prevent and treat asthma symptoms extend beyond prescribing controller and rescue medications, and address social determinants such as housing, transportation, racial discrimination and poverty.

Most healthcare providers do not have methods to identify or address risk factors that are related to social determinants of health. Laboratory tests, diagnostic tools and prescription pads are part of a provider’s traditional armamentarium; not smoking cessation, old carpet removal, arranging transportation to medical appointments and improved housing conditions.

Social service agencies, also referred to as community-based organizations (CBOs), are experts in addressing social issues. Community services are available to address health challenges associated with social issues, such as substandard housing, food insecurity and unemployment. A recent study by the Commonwealth Fund identifies some of the challenges faced by primary care physicians when coordinating patient care with social services. 

Lack of a social services referral system, inadequate physician office staffing and the lack of follow-up from social service providers were cited by approximately one-third of U.S. primary care physicians as barriers to linking patients to social services. Primary care physicians in Germany and the United States were equally likely to cite these challenges, however, only 40 percent of U.S. physicians indicated they frequently coordinated with social services or other community providers compared to 74 percent in Germany.

The Alliance for Better Health, funded by New York State, is one of 25 Performing Provider Systems (PPS) incented by New York’s Delivery System Reform Incentive Payment (DSRIP) program to reduce potentially preventable hospital admissions and readmissions. This organization is also addressing the issue of referrals between medical and social service providers in the Albany area by co-investing in the Healthy Alliance Independent Practice Association (IPA) with 30 social service providers. This network of social service providers is based on the physician IPA and physician hospital organization (PHO) concept, but is exclusively focused on the collective value offered by CBOs.

The New York DSRIP program hopes to build upon its success in reducing potentially preventable hospital admissions and readmissions with a continued focus on social determinants of health. The renewal request submitted in November 2019 proposes an expansion of the CBO IPA model by creating regionally-based Social Determinants of Health Networks (SDHNs) across the entire state. SDHNs would link social services to payers and providers within the community they serve.

New York managed care organizations (MCOs) have already launched initiatives that impact SDoH. MVP Health Plan is investing in the Healthy Alliance IPA to assist members with emergency housing, food, domestic violence, employment and caregiving services. CDPHP, the largest Medicaid managed care organization in the Albany area, partners with St. Catherine’s Center for Children to offer housing support and services to at-risk members with chronic conditions. The Alliance also funds a partnership between Ellis Medicine and Catholic Charities to address food insecurity and poor nutrition through food planning and preparation support.

Addressing social determinants is not only important to Medicaid MCOs. Commercial payers are also prepared to make investments that will return better health outcomes for their members. Some are doing this through expanding funding for non-clinical support services, such as Florida Blue’s hiring of social workers to help members connect with social services in their community.

While local initiatives represent positive steps for addressing social determinants of health in a community, large-scale social change requires broad cross-sector coordination. This type of coordination is beginning in places like New York state, where providers, MCOs and CBOs will be collectively responsible for making decisions about how funds are used to improve health in the state. Aligning incentives across multiple organizations in the pursuit of population health is the goal. Success will be achieved when access and utilization of healthcare services is viewed as one component of health and not the other way around.

Steve Delaronde is director of consulting for Payer and Population Health Services at 3M Health Information Systems.