The Critical Role Social Determinant of Health Data Can Play in Population Health

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:

With the majority of adults reporting social needs, it stands to reason that identifying and mitigating social determinants of health will improve population health.

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. One good example is Geisinger Health System’s Fresh Food Farmacy program, which 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.

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.

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, demonstrated, “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.”

Social Determinants of Health in Action

The research demonstrates the United States is in the midst of a diabetes epidemic as well as the connection between diabetes and food insecurity. That means identifying the populations at risk of diabetes who also have difficulty 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. 

There is no doubt about the critical role SDoH data can and are playing in improving population health. Given the prevalence of chronic illness 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. For organizations that are not yet ready to invest in an analytics and insights platform, research shows even a one-minute patient survey can reveal important social determinant information.

For more information about using social determinant data to improve population health, download Social Determinants of Health: From Insights to Action.

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