Public health experts have been studying the “social determinants of health,” which the Centers for Disease Control and Prevention defines as “conditions in the places where people live, learn, work and play affect a wide range of health risks and outcomes,” for decades.
The greater healthcare system has slept on addressing these factors for a long time, but it started to wake up in 2018. Newly launched initiatives, as well as studies reinforcing the need for such initiatives, made 2018 social determinants’ biggest year yet.
Housing: Kaiser Permanente launched a $200 million initiative to improve access to affordable housing in May. At its announcement, CEO Bernard Tyson said “this is not a giveaway; this is an investment.” The University of Pittsburgh Medical Center’s health plan touted its success finding housing for homeless members with high healthcare expenditures at the America’s Health Insurance Plans (AHIP) Conference on Medicaid this year. Fellow speaker Jasmine Leimaile Ho encouraged Medicaid plans to build on efforts like these by working with affected communities, which tend to have a high population of racial minorities, in a culturally competent way, and by encouraging Congress to invest in affordable housing and other social services for Medicaid beneficiaries.
Rideshares: Lacking reliable transportation, many patients with high health needs forego care or miss their appointments. In addition to harming those individuals’ health, missed appointments are a major drain on the healthcare system financially. Rideshare company Uber launched a “health dashboard” this year for patients to request and plan free rides, which is accessible online, by text message, and via landline for patients who don’t own a smartphone. There is limited evidence that this program has been effective so far, but the company is working with physicians and payers to determine ways to reach and help patients more effectively.
Food assistance: A study in the New England Journal of Medicine found Geisinger Health System’s “Fresh Food Farmacy” cut costs among diabetic patients between $48,000 and $240,000 per member. The risk of death or serious complications among these patients dropped by 40%. Another study, in Health Affairs, found providing dual-eligibles meals tailored to their medical needs can cut costs by hundreds of dollars per patient.
Personal finances: This month, Cigna said it would begin offering group members financial planning services. Cigna president Bill Smith said this is a sensible investment because financial stress “can take a toll on a person’s health and well-being.”
All of these efforts represent major steps toward a healthier America, but equity doesn’t exist yet; there are many miles left to go. For instance, physicians say social determinants aren’t their problem. On one hand, they can only do so much right now, but on the other, they are capable of doing much more, as one New England Journal of Medicine series explains.
On the payer side, Department of Health and Human Services (HHS) Secretary Alex Azar recently encouraged Medicare Advantage plans to cover everyday services that can keep seniors out of the hospital, such as home modifications to prevent dangerous falls.
Medicaid managed care plans can cover social services for the highest-need individuals, tie social interventions to quality measures, and more, according to a list of recommendations from the Commonwealth Fund. Some state Medicaid agencies are already doing this. Take a look at Minnesota, where providers help patients in need apply for Social Security disability payments and food stamps. The Centers for Medicare and Medicaid Services could increase its impact by partnering with other agencies, such as the Department of Housing and Urban Development and the Department of Transportation.
The most cutting-edge Medicaid plans, however, should consider using the latest technology to help patients. Startups typically don’t bring their products to the Medicaid population right away, even though they stand the most to benefit. HealthTech4Medicaid, which launched this year, is working to change that. The combination of social determinants and digital health sounds like a recipe for innovation going into 2019—and beyond.
As Adaeze Enekwechi told us this year, too many people's health is at risk for social determinants to be just a fad.