Health plans, providers and policymakers have finally come around to thinking about how “social determinants” impact individuals’ healthcare. This somewhat academic terminology refers to the notion that social factors such as housing, food, transportation, education, income, wealth, zip code and race—all indicators of social status—are fundamental determinants of one’s health.
Academics and public health researchers have long understood this. More recently, however, insurers and providers have begun examining what they can do to address the persistent social gaps that have historically contributed mightily to health inequity.
This is a positive development in our efforts to address poor outcomes and high costs. But, in a healthcare ecosystem prone to fads, we cannot afford for social determinants of health to become just another issue of the day we quickly abandon when misguided efforts bear little fruit.
Social factors are multilayered, challenging and often difficult for many to acknowledge when they are not directly exposed. Consequently, any interventions to address these social challenges must be open-minded and iterative. We must also be willing to fail in the process of getting them right.
Not long ago, quality improvement programs such as Plan-Do-Study-Act, LEAN Six Sigma and other tools were touted as the panacea to solve all healthcare problems. Organizations poured resources into these efforts. There was often anemic buy-in from clinicians, and staff tasked with implementing various initiatives had little support or direction.
More recently, employee wellness programs were all the rage, with insurers pouring millions into various programs. Yet plan enrollees were often unaware of or disinterested in wellness incentives being thrown at them by their health insurer. These initiatives were well-intentioned, but the gulf between understanding the problems and how to address them loomed large in the success of these programs.
This brings us to how to avoid losing steam in our interest in addressing social determinants of health. There are many resources and frameworks policymakers can tap when addressing social determinants of health. Still, two points are worth emphasizing: First, engage the community and primary stakeholders when defining the problem, and tackle the right problem. Second, use a robust amount of data and information to make decisions.
I was recently in a meeting with large, reputable organizations interested in delving deeper into their populations’ social determinants of health, and they were certain community input would not be needed to design the solutions.
This is an easy mistake to avoid: In healthcare, we must expand our Rolodex and talk to community stakeholders whose voices have been missing from the discussion for too long. They may give difficult, infeasible or conflicting information, but we must be patient enough to listen and sort through the problems and possible solution set.
Let’s take transportation as an example. This is usually an obvious problem, so we provide everyone with ride-share credits. However, further engagement might reveal that while people may have a ride, childcare for children not allowed at prenatal visits is the real impediment—which is not solved with the credits. Therefore, ride-share credits and a short-term childcare solution to address prenatal care visits could help improve maternal and birth outcomes.
Additionally, use data to dig deeply and glean information, then leverage the information to drive decision-making. Having data that contain no meaningful information is unhelpful and wasteful. Healthcare organizations interested in cracking social determinants of health must have information on the socioeconomic details including location, economic disposition, race, sex, age and other characteristics that paint a clear picture of the social determinants at play.
Interventions designed for one community may not be applicable in another, or it may need to evolve over time in the same community. We have the problem of not having many interventions tested at scale. This might be the nature of the problem of social determinants because community-level solutions may not apply at scale. Access to nutritious food in a “food desert” area, for example, may be a specific problem for one county, but in another county the problem is entirely different.
It is hard to overstate how positive this movement is toward addressing social factors in health. We are a long way from my work about 10 years ago, when I was brusquely informed by a health system CEO that demographic data were unnecessary. I suggested that without such reliably collected data, it would be impossible to do rudimentary subgroup analysis to determine how patients and customers fare when they use the health system. The CEO’s response was: “We treat everyone the same here, and they all do just fine for the most part.”
We knew then, and we know now, that not everyone does “just fine” in every health system. Indeed, it may be that everyone should not be treated the same, because some people need more attention or assistance to prevent further catastrophe.
Social factors affect us all eventually, whether it’s a baby born to a stressed, poor and badly treated new mother or an older adult suffering from loneliness and declining health. Addressing social factors thoughtfully and thinking through a provider’s return on investment given their payer mix and financial pressures is necessary to avoid this being yet another health care fad we abandon.
Adaeze Enekwechi is vice president at McDermott+Consulting, a wholly owned subsidiary of McDermott Will and Emery. Previously, she served as the associate director for health programs at the White House Office of Management and Budget under President Barack Obama.