Should Care Management Be Expanded To Include Impacting Social Determinants of Health?

Introduction

Social Determinants of Health (SDOH) were highlighted in a 2008 report published by the World Health Organization.¹ Several initiatives have been developed since then to create social and physical environments that promote good health for all. SDOH are conditions in the environment that have a potentially significant impact on health. This includes social, economic and physical conditions. Fundamental to understanding the impact of SDOH is the relationship of “place” to health. For example, SDOH include availability of resources to meet health care needs and the access to them. It could also include availability to transportation and transportation options. The list is lengthy. The physical determinants could include the natural environment and exposure to toxic substances. The premise is that as we work to establish policies that positively influence social and economic issues which in turn support changes in individual behavior, we can more effectively improve the health for large numbers of people.

The looming question is what role should or could providers and health plans play in trying to impact this developing area of information.

The looming question is what role should or could providers and health plans play in trying to impact this developing area of information. It is clear that actions to date have been limited. Is this a public health issue? Is it a private sector issue?

What Is It?

The Healthy People 2020 initiative highlights five key areas or determinants with multiple components within each:

• Economic stability: employment, food insecurity, housing instability and poverty
• Education: early childhood education and development, enrollment in higher education, high school graduation, language and literacy
• Social and community context: civic participation, discrimination, incarceration, and social cohesion
• Health and health care: access to health care, access to primary care, and health literacy
• Neighborhood and built environment: access to foods that support healthy eating patterns, crime and violence, environmental conditions, and quality of housing.

The above categories provide a useful framework to establish objectives to improve health. This framework has also been used to identify additional resources and examples of how policy might be established, or solutions developed.

What’s Going On?

Several strategies and tools are emerging to help with this situation and pursue solutions to resolve concern areas.

These include:

• Health Impact Assessment tools
• “Health in all policies” strategy to introduce improved health and reduced health gaps

Some health care plans are pursuing actions in this area.²

• Anthem launched a partnership program — Take Action for Health — with the National Urban League, City of Hope, and Pfizer to improve breast cancer and heart disease care in African American communities nationwide.
• Humana launched an initiative to build community trust, establish behavior change, lower costs, and improve health in seven communities. By 2020, the Bold Goal initiative plans to improve health in these communities by 20 percent.
• Kaiser Permanente is advancing a “Total Health” framework to address the social determinants of health in neighborhood and school settings that focus on health-promoting policy, system, and environmental changes. To accomplish this, Kaiser Permanente is screening patients for unmet social needs to refer them to relevant resources in their communities. Data shows that 78 percent of those screened have one or more unmet social needs.
• Harvard Pilgrim launched a program to reduce racial and ethnic disparities in colorectal screening, reducing the screening gap between low-health literacy groups and their general patient population from 11 to 4 percent in four years.
• UnitedHealthcare Community Plan of WI invested $25,000 in four different community programs that were designed to improve financial independence or interpersonal disability care. The payer also used demographic data to improve the distribution of healthy food to local communities by 87 percent in 2016.
• Using geospatial data, California-based Health Net reduced postpartum care disparities by 40 percent and increased postpartum visits for African American women in Los Angeles from 17 to 33 percent.
• CareSource launched a pilot program in three states to help members get and keep jobs that can improve their lives. Among other activities, the program addresses education and skill gaps and links members with employer partners and life coaches.
• UPMC Health Plan partnered with the Pittsburgh-based Community Human Services to secure permanent supportive housing and provide care coordination for homeless individuals. Those who gained housing saw an average annual health savings of $6,384.
• L.A. Care Health Plan committed $20 million over five years to fund an initiative to secure permanent supportive housing for homeless individuals in Los Angeles County.
• Molina Healthcare opened a resource center for homeless members to avoid emergency department use for nonmedical needs. The payer also purchased two behavioral health subsidiaries of Providence Service Corporation to “focus on social determinants of health,” and launched a clinical setting — WellRx pilot in New Mexico — to screen patients for nonmedical social needs.

As additional results emerge from these types of programs it is highly likely other health care organizations will invest in other activities.

How Does This Fit in With Care Management?

Care management generally has been limited to impacting how care is delivered. The broad definition of this includes disease management where patients are encouraged to proactively improve their health status (i.e., diabetes management, encourage smoking cessation programs, etc.) and avoid unnecessary future health costs. It also includes alternative forms of care (i.e., sub-acute vs. acute care) to reduce the cost of care. It has also included provision of special equipment to more efficiently care for patients (i.e., special wheelchairs or devices). It has included remodeling people’s home to make them safer for the patient (i.e., ramps to enter or exit the home).

The transition to also include SDOH is natural. It is just stepping back from the cost of care provided to some of the contributing causes of higher than normal health care. For example, is the living environment causing an issue which leads to higher health care? Are the needs of some individuals greater than normal because of related circumstances (i.e., one of the parents is incarcerated)? Is the child’s success rate at school negatively impacted by a language barrier? Is health care not being pursued at the right time because of an unnecessary barrier that should be removed?

It is the author’s opinion that a fresh look at all of these issues will lead to more solutions to improve the health care crisis we have here in the United States.

Summary

Although a relatively new topic, SDOH is clearly an important one that deserves much more attention within the health care sector, in public policy, and by society itself. This is not just another additional cost to health care but rather an additional solution to solving our health care problem. Smart money invested wisely will help all of us.

¹ “Closing the gap in a generation: Health equity through action on the social determinants of health”, https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf;jsessionid=5235B03E514A6D50AA82732C1BB988AF?sequence=1

² https://www.healthedge.com/blog-social-determinants-health-what-are-payers-doing

David Axene, FSA, FCA, CERA, MAAA, is the President and Founding Partner of Axene Health Partners, LLC and is based in AHP’s Temecula, CA office.