Reducing Health Disparities Through a Whole-Person, Whole-Population Approach

That a health outcome is determined by more than medical care alone is well understood — or at least, well documented. But despite a wealth of scientific evidence, years of discourse and efforts to incorporate social determinants of health (SDoH) into care models, health disparities remain a stark reality in the U.S.

In recent months, these disparities have been thrust into the spotlight in a profound and devastating way, as the COVID-19 pandemic has disproportionately affected low-income communities and communities of color. The New York Times reported that in New York City, eight of the 10 ZIP codes with the highest COVID-19 death rates are predominantly black or Hispanic. Adjusting for age, the Centers for Disease Control and Prevention analyzed COVID-19 hospitalization rates among ethnic and racial minorities, finding that:


  • The hospitalization rate for non-Hispanic black persons is approximately five times that of non-Hispanic white persons.
  • The hospitalization rate for Non-Hispanic American Indian or Alaska Native persons is approximately five times that of non-Hispanic white persons.
  • The hospitalization rate for Hispanic or Latino persons is approximately four times that of non-Hispanic white persons.

By no measure should it have taken a pandemic to call attention to the health and social inequities that have long existed in the U.S. But what this crisis has raised is the need to fundamentally change the approach. In a world where a person’s ZIP code determines their life expectancy, it’s time to start looking beyond the symptoms to get to the root of the illness.   


SDoH: At the Crux of Population Health

The World Health Organization defines SDoH as “the conditions in which people are born, grow, live, work and age.” Broadly, SDoH are all the non-clinical aspects of health, such as income, food and housing security, transportation access, proximity to green space, health literacy and many others. It is estimated that SDoH are responsible for the majority of a health outcome and that medical care accounts for less than 30%.

Yet, our healthcare infrastructure has been built largely around that 10–20%. As Dr. Maia Dorsett, Assistant Professor of Emergency Medicine at the University of Rochester Medical Center, notes in a recent Science Advances editorial, “U.S. healthcare is incentivized to react to sickness rather than proactively focus on health maintenance.” Fee-for-service, the traditional healthcare delivery model in the U.S., reimburses providers based on volume of services rendered, regardless of outcome.

Efforts have been made to change this. Value-based healthcare delivery models that prioritize quality over quantity incentivize a more proactive and coordinated approach, paying providers not for services, but for outcomes — a measure of the overall efficiency and effectiveness of care. Value-based programs advance the Centers for Medicare and Medicaid Services’ aim of better care for individuals, better health for populations and lower cost.


Population health management, the function that deals with improving the health outcomes of populations, is central to the shift to value-based care. By identifying high or rising risk individuals early on in the care continuum, and considering the social determinants contributing to that risk, providers and care teams can make more effective interventions, helping to avoid negative outcomes and closing gaps in care.


Effecting Change at Population Scale

Improving population health and eradicating health disparities hinges on understanding and proactively addressing the wide-ranging factors that contribute to health outcomes. On a personal level, it’s using data, analytics and technology to identify, engage and manage at-risk individuals and empower them with the tools to take action on their health. On a much broader scale, it’s bringing to the surface the issues and injustices that are embedded in the fabric of society — those that place entire populations at an inherent disadvantage — and building systems and policies that address them in a meaningful and sustainable way.

Although COVID-19 provides a glaring and sobering case study in the need to incorporate SDoH as part of standard healthcare practice, it is questionable as to whether the pandemic will be a catalyst for change. Experts are hopeful, yet skeptical.

The responsibility to drive change lies with the system’s stakeholders — those who deliver and manage care, those who regulate care and those who develop the solutions that help to facilitate care. HMS takes this responsibility seriously. Healthcare is about people, and we are committed to providing solutions and advocating for policies that enable healthcare access for all who need it. Change is incremental, but we are determined to be part of the solution.


To learn more about our whole-person approach to population health management, visit