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Keeping Pace with Social Determinants of Health

A recent survey found 75 percent of payers and providers feel at least somewhat prepared to address social determinants of health, but experts believe opportunities to focus on areas of greater impact remain.

Payers and providers overwhelmingly recognize the impact social determinants of health models have on managing chronic disease, but more than half say budgetary challenges and lack of reimbursement impede their ability to effectively address the determinants that most affect member health, according to a survey by Modern Healthcare Custom Media.

Nearly 600 payers and providers participated in the survey, conducted on behalf of Envolve Health. Asked to choose the top five issues affecting patient and member outcomes, they cited income and income distribution (59 percent), addiction (50 percent), family structure/social support (48 percent), and health literacy (48 percent), and access to care (41 percent).

But their level of confidence in their ability to address social determinants of health seemed surprisingly high to some experts who reviewed the survey results, especially given research1 that shows hospitals spend the least amount of their community benefits dollars on addressing a social determinants of health model reflecting their patient's challenges.

What Social Issues Are Affecting Your Organization’s Patient/Member Outcomes the Most?

Graph of Social issues affecting organizations. Information in preceding text.

Seventy-five percent of respondents stated they are somewhat prepared, well prepared, or very well prepared to address their community’s future health needs as they relate to social determinants of health. Meanwhile, 49 percent agree or strongly agree that their clinicians and staff are well-equipped to identify and assist members with their social determinants of health needs.

How Prepared Do You Consider Your Organization to Be to Address Your Community’s Future Needs as They Relate to Social Determinants of Health?

Graph on organization preparedness. Information in preceding text.

“There are a number of analyses that indicate hospitals that prepare community benefit reports have extraordinarily limited information about the social determinants of health needs in their communities,” says Matthew W. Kreuter, PhD, MPH, faculty director for the Envolve Center for Health Behavior Change, a research collaboration between Brown School at Washington University in St. Louis, The Center for Advanced Hindsight at Duke University and Centene Corporation. “That doesn’t align with the sense that more than half of respondents believe they have a good sense of what social determinants of health to address and how to do so.”

“I suspect our members would not be as confident,” agrees Francis Rienzo, vice president of advocacy and government relations and interim CEO, of Medicaid Health Plans of America (MHPA). “Populationally, there are still a lot of issues to address to make a significant impact on social determinants of health.”

Taking a Closer Look

The survey results shed light on the social determinants of health that are of greatest focus for payers and providers and the investments being made to address them.

Ranking social determinants of health. Among the social issues survey respondents say most impact members’ health, access to transportation—which can include lack of vehicle access or affordable transportation as well as long wait times for transportation—ranked seventh on the list (37 percent). Social exclusion ranked last, at just 10 percent.

“I expected social isolation to rank higher,” says Rashi Venkataraman, executive director of prevention and population health, America’s Health Insurance Plans (AHIP). For example, recent research2 points to the impact social isolation can have on seniors’ health, including disrupted sleep, abnormal immune responses, and accelerated cognitive decline. “As Baby Boomers continue to age, we’re starting to see the early pieces of the impact of social isolation on health, especially as families become smaller and more spread out, geographically.”

Much has been written about the link between transportation and health outcomes. According to the American Hospital Association (AHA), 3.6 million people forgo medical care each year due to lack of transportation. Members who face challenges with transportation often accumulate higher healthcare costs and experience poor health outcomes.

“All of our association’s members will tell you transportation is a key way to address social determinants of health,” Rienzo says. “It’s impossible to manage Medicaid enrollees if they can’t get to their provider.”

“Our Clinicians and Staff Are Well-Equipped to Assist Patients/Members and Discuss Social Determinants of Health.”

Graph on staff assisting in social determinants of health. Information in following text.

Top areas of investment. Initiatives most frequently deployed to address social determinants of health include care coordination for low-income or geriatric members (56 percent), nutrition education (56 percent), lobbying of government officials, whether locally or through trade associations (47 percent), substance abuse support (46 percent), and prenatal and early childhood resources (45 percent).

“Determining how best to address the social determinants of health is really an evolving strategy for many of our members,” Venkataraman says. “We’ve seen efforts by payers to operationalize social determinants into their everyday business, whether it’s training people who answer call lines to ask about social determinants of health, leveraging care coordinators to explore these issues with members, or hiring people to support affordable housing initiatives.”

One area where payers and providers may wish to invest more heavily is community partnerships. Collaboration with community resources, such as local schools (an area of focus for 29 percent of respondents), faith-based organizations (27 percent), housing authorities and other community organizations (24 percent), and law enforcement (20 percent), offers the potential to make a deeper impact on health than a focus on health-specific education and programming alone.

“We know that access to safe, affordable housing and food services are two of the biggest challenges to managing health,” Rienzo says. “If I’m worried about where I’m going to sleep tonight or how I’m going to get food, it’s very hard to stick to a medication schedule.”

A limited number of survey respondents also are exploring rewards and incentives for members who take care of their health, such as loyalty/rewards cards that can be used for food, clothing, or other needs (5 percent). For example, in Minnesota, UCare, a not-for-profit health plan, offers rewards such as $25 gift cards for women who get mammograms, $75 gift cards for regular prenatal visits and a $50 gift card for a qualifying colon cancer screening. Meanwhile, California’s Medicaid program offers movie tickets to parents who keep up with their children’s well-child visits.

What New Programs or Initiatives Would You/Your Organization Like to Administer in the Future that Aren't Already in Place? 

Graph on future program. Information in following text.

Future areas of focus where respondents say they’d like to invest more include free or low-cost mental health services (27 percent), partnerships with housing authorities or other community organizations (24 percent), transportation to and from medical appointments (24 percent), care coordination for low-income or geriatric members (23 percent), and mobile health vans (21 percent).

Barriers to addressing social determinants of health. Budgetary constraints and lack of reimbursement overwhelmingly top payer and provider challenges in addressing social determinants of health at 55 percent. Difficulty in proving return on investment (ROI) ranked second at 15 percent. Research by George Mason University and Harvard Business School3 found providers would be more likely to invest in social determinants of health initiatives if they could count on ROI from their efforts. “We’ve got to be able to demonstrate that if you address these social needs, you get cost improvements and improved health outcomes,” Kreuter says. “As providers and health systems move into an era of addressing social determinants, they need really strong plans for determining and evaluating the impact of those efforts so initiatives are based on evidence.”

Action Steps for Payers and Providers

Erasing the impact of social determinants on the health of member populations is complex work that has the potential for big dividends. There are four steps payers and providers should consider in elevating their approach.

  • Share the lessons gained through social determinants initiatives. As payers and providers gain greater experience in managing the impact of social determinants on members’ health, disseminating evidence-based strategies for improvement will be critical to gaining momentum on a wider scale. “More and more, we’re seeing examples of providers and health plans that are trying to create a social-determinants-of-health identity,” Kreuter says. “As the results of their efforts are reported, we’ll end up learning more about approaches that are effective and those that are not.”
  • Don’t focus solely on the health impacts of social determinants in determining where to invest. "If you only view social determinants of health from the perspective of healthcare alone, that’s too limited a view,” Rienzo says. For example, look for ways to partner with government agencies in decreasing exposure to crime and violence and improving public safety.
  • Don’t go at it alone. “Partnerships matter—and partnerships with different sectors matter,” Kreuter says. “Consider joining forces with law enforcement, schools, and community service agencies that are highly familiar with the social determinants that most impact your community. Continually seek ways to leverage their lessons learned and their expertise in addressing social determinants of health.”
  • Understand there is no one-size-fits-all approach. “There’s not a magical strategy that is going to work for every community,” Venkataraman says. “Each community has its own set of challenges it is trying to work through.”

About This Survey

Modern Healthcare Custom Media, on behalf of Envolve Health, commissioned Signet Research, Inc., an independent company, to conduct a survey of healthcare professionals. The objective of this study was to gain insights on social determinants of health and any actions organizations may be taking to address their impact on patient/member outcomes.

On Aug. 3, Modern Healthcare Custom Media sent a broadcast email to a sample of 57,590 healthcare executives who subscribe to Modern Healthcare, asking them to participate in a survey, followed by a series of two reminders to certain readers. By Aug. 9, 2018, 579 returns had been received. The base used is the total number of respondents answering each question. Survey findings may be considered accurate to a 95 percent confidence level, with a sampling tolerance of approximately +/- 4.1 percent.



Responsibilities/Roles of Survey Respondents

Graph on Responsibilities of Respondents. Key and information in following text.

 19% - Senior Management (CEO, President, Administrator)

 12% - Operations Management (COO, Executive, Vice President, Business Manager, Assistant Administrator)

 9% - Financial Management (CFO, Vice President/Director of Finance, Controller, Business Manager)

 3% - Information Management (CIO, Information Systems Manager, Vice President of MIS, Chief Technology Officer, Medical Records Administration)

 23% - Clinical Management (Chief Medical Officer, Chief Medical Information Officer, Vice President/Director of Medical Affairs, Chief of Staff, Chief Pharmacist, Chief Nursing Officer, Director of Health Services)

 2% - Materials Management (Chief Purchasing Officer, Vice President/Director of Materials Management)

 11% - General Administration (Director of Planning and Development, Vice President/Director of Marketing, Public Relations, Human Resources, Facilities Engineering)

 13% - Case Management (Risk Manager, Compliance Officer, Director of Quality/Managed Care)

 8% - Other (e.g., Board Member, Consultant, Attorney)


Institutions Represented

 61% - Hospital (Academic Medical Center, Children’s, General/Acute, Rehabilitation, Women’s/Maternity, Behavioral/Psychiatric, Specialty, Multi-Hospital System, Long-Term Care)

 19% - Medical Clinics/Groups and Nursing Homes (Ambulatory Surgery Center, Medical Group/Clinic, Nursing Homes)

 10% - Payers (HMO, PPO, Managed Care)

 9% - Other (e.g., Board Member, Consultant, Attorney)

Graph on Institutions represented. Key and information in the preceding text

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Sources: 1Clary, A., “States Work to Hold Hospitals Accountable for Community Benefits Spending,” NASHP, May 8, 2018. 2Brody, J.E., “The Surprising Effects of Loneliness on Health,” The New York Times, Dec. 11, 2017. 3Nichols, L.M., and Taylor, L.A., “Social Determinants As Public Goods: A New Approach To Financing Key Investments In Healthy Communities,” Health Affairs, August 2018.