This article originally appeared in Population Health News.
Physicians and nurses have long known what has become increasingly obvious to hospitals, health systems and health plans - social determinants of health (SDoH) have an outsized impact on health outcomes. In fact, research suggests that medical care accounts for only 10 – 20 percent of health outcomes while the other 80 – 90 percent are attributed to demographic, environmental and socioeconomic factors.
It’s tempting to think that the impact of social determinants – food insecurity, transportation, financial literacy, loneliness and more – is concentrated within at-risk populations such as Medicaid recipients. Yet, at least two studies challenge this idea:
- 68 percent of patients have at least one social determinant of health challenge, according to a study of 500 random patients; 57 percent have a moderate-to-high risk for financial insecurity, isolation, housing insecurity, transportation, food insecurity and/or health literacy.
- A national study commissioned by Kaiser Permanente found 68 percent of adults had at least one unmet social need, and these needs span income levels. Not surprisingly, 91 percent of those with income of less than $25,000 report an unmet social need. More than half (54 percent) of adults with $100,000 - $124,000 in annual income report the same as do 40 percent of adults with annual earnings of $125,000 - $150,000 and $150,000+. Likewise, unaddressed SDoH impact all age groups; more than 80 percent of Generation Z (Gen Z) and Millennials, 74 percent of Generation X (Gen X), 53 percent of Baby Boomers and 43 percent of the Silent/Greatest generation say they have at least one unmet social need.
With the majority of adults reporting social needs, it stands to reason that identifying and mitigating social determinants of health will improve population health. The evolution to value-based care payment models – expected to account for 59 percent of healthcare payments by 2020– has brought with it greater alignment between physicians and healthcare delivery organizations and expected outcomes, and more impetus for healthcare organizations of all types – health plans, providers, hospitals and even employers – to increasingly incorporate SDoH data to improve healthcare quality, cost and patient satisfaction.
The Surprising Connection Between Physician Burnout and Social Determinants of Health
In many ways, improving population health depends on the engagement and activation of physicians, who by objective measures are increasingly burned out and frustrated by the increasing administrative demands of medicine. Interestingly, there’s reason to believe addressing patients’ social determinants may also reduce physician burnout.
Numerous studies have documented staggering levels of physician burnout. As but one example, a national survey conducted in July 2018 by Geneia found:
- 80 percent of physicians say they are personally at risk for burnout at some point in their career.
- 96 percent of physicians say the amount of time spent on data input and reporting has increased in the last 10 years.
- 86 percent agree that “the heightened demand for data reporting to support quality metrics and the business-side of healthcare has diminished my joy in practicing medicine.”
Research published in Health Affairs showed that the average physician practice dedicated 15.1 hours each week per physician in 2014 – or 785 hours a year – to processing quality metrics. Most of these hours were logged by staff, but the same study showed physicians spent 2.6 hours a week on quality metrics, time that could be used to care for nine additional patients, which is why most chose to become doctors.
That’s why it is so encouraging to learn that mitigating patient social needs also benefits the physicians who treat them. The January-February 2019 issue of the Journal of the American Board of Family Medicine reported “improving clinical capacity to respond to patients’ social needs may reduce primary care physician burnout.” The national study of 1,298 family physicians found burnout was less likely to be reported by those “with a high perception of their clinic’s ability to meet patients’ social needs,” suggesting that addressing patients’ social determinant challenges may help reverse epidemic levels of physician burnout.
Physicians: ‘Surely, someone else is better positioned to address SDoH’
It is critical to note that physicians understand the importance of addressing unmet social needs but also fundamentally believe it is not their responsibility to address social determinants. A study by the Leavitt Partners, Social Determinants Matter, But Who is Responsible? 2017 Physician Survey on Social Determinants of Health, showed the majority of physicians believe SDoH matter for their patients and SDoH assistance would help their patients:
- Transportation: 66 percent of physicians believe assistance arranging healthcare transportation helps patients
- Housing: 45 percent say affordable housing aids patients
- Food: 48 percent believe getting sufficient food benefits patients
- Income: 54 percent consider income assistance a help to patients
- Healthcare pricing: 75 percent say patients benefit from information about the price of healthcare and health insurance
The study also showed that physicians felt someone outside the office or practice is best-positioned to help patients. For example, nearly half of physicians believe housing assistance would help their patients, and at the same time, 91 percent do not see themselves or health plans as responsible for helping.
Addressing Social Determinants of Health
Given the profound impact social determinants have on patient health outcomes, it makes perfect sense that addressing a patient’s housing, transportation and food needs reduces health spending. Research has shown this to be true.
Payers, in particular, lead the way with pilots and research studies demonstrating the effectiveness of managing patient social determinants:
- A 2016 study by the Robert Wood Johnson Foundation reported a 17 percent decrease in emergency department use, a 26 percent reduction in emergency spending, a 53 percent decrease in inpatient spending and a 23 percent decrease in outpatient spending as the result of referring 33,000 people to 106,000 community-based programs and services.
- For some common chronic conditions such as diabetes, hypertension, diabetes and coronary artery disease, a Moody’s Analytics study for the Blue Cross Blue Shield Association showed social determinants drive larger differences in health impacts.
- Geisinger Health System’s Fresh Food Farmacy program provides 15 hours of education about diabetes and healthier living, followed by 10 free nutritious meals a week for diabetics and their families. It costs $2,400 per patient per year to operate the program, and early research shows an 80 percent reduction in overall health costs: from an average of $240,000 per diabetic member per year to $48,000.
Success stories such as those listed above suggest it is, in fact, possible to help patients mitigate their social determinant challenges.
Diabetes and Social Determinants
It is illustrative to look at the epidemic of prediabetes and diabetes and the role social determinant data could play. First, the numbers:
- 1+ in 3 Adults with prediabetes
- 90% Prediabetic adults who don’t know they have it
- 70% Prediabetic adults who will develop diabetes
- 30+ million American adults and children with diabetes
- $327 billion Annual costs of diagnosed diabetics
- $1 of every $7 Healthcare spend on diabetes and complications such as amputations, strokes and kidney failure
Let’s also dive deeper into the issue of food insecurity. The Kaiser Permanente study found 48 percent of adults reported problems with food security in the past year. As one might expect, the incidence is even greater among people with lower incomes: 74 percent of those with annual incomes below $25,000 and 57 percent of people with annual income between $25,000 and $49,000 experience difficulty paying for food.
At the same time, research shows food insecurity increases the prevalence of diabetes as well as impairs the ability of diabetics to manage their disease and glycemic levels. Research published in Current Nutrition Reports, The Intersection Between Food Insecurity and Diabetes: A Review, “Food insecurity in North America is consistently more prevalent among households with a person living with diabetes, and similarly, diabetes is also more prevalent in food-insecure households.” The review also reported,
Food-insecure adults are two to three times more likely to have diabetes than adults who are food-secure, even after controlling for important risk factors such as income, employment status, physical measures, and lifestyle factors.
Food-insecure diabetics have higher A1c levels than food-secure diabetics and are at increased risk for poorer glycemic control (A1c levels higher than 7%).
Among food-insecure diabetics, far more hypoglycemic episodes are attributed to the inability to afford food, than among food-secure diabetics (43.2 percent vs. 6.8 percent.)
A report authored by Hilary K. Seligman, MD, MAS, Food Insecurity and Diabetes Prevention and Control in California, referenced her earlier research showing the prevalence of diabetes rises with increasing severity of food insecurity reaching
…16.6 percent in very low food secure households. After accounting for differences in socioeconomic status, risk of diabetes is about 2.5 times higher in very low food secure households compared to food secure households, and after additionally accounting for differences in obesity, risk of diabetes is almost 3 times higher.
Social Determinants of Health in Action
The research shows the United States is in the midst of a diabetes epidemic that shows no signs of abating as well as the connection between diabetes and food insecurity. That means identifying the populations at risk of diabetes who also have difficultly paying for balanced meals can enable healthcare organizations to intervene earlier and target resources to these groups of patients.
Combining artificial intelligence (AI) models with social determinant data offers the distinct possibility that healthcare delivery organizations can do just that.
Increasingly, analytics companies are using innovative data science techniques to create models that identify who among the population without type 2 diabetes is likely to develop it in the next 12 months. Analytics and insights platforms are able to ingest this kind of output from AI models, combine it with population and patient-level data including food insecurity, housing, transportation and more, and integrate this information directly into the patient record. In other words, analytics plus technology enables healthcare organizations and their care managers to prioritize and work to engage the populations of patients who are food-insecure and at high risk of becoming diabetic in the near future.
A patient record that integrates claims, clinical and social determinant data in real-time can help a care manager identify, validate and work to mitigate social barriers. For example, the care manager responsible for a patient who is at risk for type 2 diabetes and has social determinant indicators for food insecurity and transportation could contact her to confirm she is, in fact, food-insecure and does not have access to a car. The availability of social determinant data within the patient record can also reveal insights about the patient’s neighborhood such as the prevalence of sidewalks and parks. This information enables the care manager to talk with the patient about the importance of physical activity for diabetes prevention and discuss options such as walking in a nearby city park or taking advantage of a health plan discount at a gym in her neighborhood. Then, within the patient record, the care manager could arrange for healthy meals to be sent to the patient’s home as well as create a referral to a social services organization that offers healthy cooking classes.
As Americans become older and sicker, there is no doubt about the critical role SDoH data can and are playing in improving population health. Given the prevalence of chronic illness – about 50 percent of adult Americans have at least one chronic condition and 25 percent have two or more – and social determinants of health, it is encouraging to know health plans, hospitals and physicians increasingly have timely access to pertinent information about patient social barriers and the ability to use technology to scale the mitigation of these needs. Even for organizations that are not yet ready to invest in analytics and insights platforms that make it easier to access and act on patient demographic, environmental and socioeconomic data, there is research showing even a one-minute patient survey can reveal important social determinant information.