Seth Joseph Contributor
I write about the intersection of health care, technology and policy
There’s no question that social determinants of health (SDoH) affect health outcomes. But amidst Covid-19, their significance is becoming even more clear and their drivers more apparent.
While policy discussions of healthcare spend have historically focused on medical spend, recent data suggests that the majority (up to 80%) of a person’s health may be driven by non-clinical factors. SDoH are a complex mix of these non-clinical factors that impact someone’s overall health status, including where people are born and live, socioeconomic status, race, education, and age. Data shows that, when taken together, health behaviors and SDoH have the greatest impact on both health and life expectancy, where a difference in life expectancy can be as close as a subway stop away.
For example, according to research from the RWJF Commission to Build a Healthier America program, life expectancy for babies born to mothers in New Orleans can vary by as much as 25 years across different neighborhoods. Similarly, those born to mothers in Maryland and Virginia counties surrounding D.C. can expect to live six to seven years longer than those born just a few Metro stops away in the District.
Mortality and mile markers are undoubtedly connected, reinforcing just how big of a role SDoH play in a person’s health status throughout their life. But health drivers and health spending are not always aligned.
As detailed by Intermountain Healthcare at the 2019 JP Morgan Healthcare Conference, while access to care accounts for 90% of healthcare spending, it only drives 6% of consumers’ health and well-being. On the flip side, health behaviors, which drive 37% of a person’s health and well-being, only account for about 9% of healthcare spending.
“There has traditionally been a separation between medical and social services, or non-medical care,” says Matt Sabbatino, managing director in L.E.K. Consulting’s Healthcare Services practice. “For instance, there have not been any CPT codes to bill a plan to address food insecurity or if an elderly patient needs an air conditioning unit,” says Sabbatino, speaking to some of the benefits design and reimbursement challenges associated with developing meaningful SDoH programs.
Fortunately, as the importance of SDoH has become more recognized and data has started to come in showing the returns on investment that programs to address SDoH can yield, plans are increasingly dedicating more resources to addressing them.
Doing so is not easy: there are challenges, for instance, to identify what social services are needed, how to build networks of providers, how to coordinate and share information between medical professionals, payers and social services, what metrics to track and report out on, and how financing and reimbursement should work.
Digital health platforms can play an important role, providing a common system to connect multiple different types of constituents – from hospitals to primary care providers, social services to food banks, mental health providers to payers – and help them identify non-medical needs and connect people with necessary services, and then track outcomes.
So while Covid-19 continues to exacerbate the severity and impact of SDoH, it has also served as a call to action for digital health companies using technology platforms to address and account for SDoH in care.
Platform Technology, Health Equity And The Need for Public Health Infrastructure
“The Covid-19 crisis and social justice movement have laid bare many social needs and inequities across our communities,” says Rachel Kohler, CEO of NowPow. NowPow’s personalized community referral platform connects patients with community-based resources and social services to address SDoH.
NowPow’s platform helps tackle health inequities by systematically connecting people to the resources of their community. The company uses evidenced-based condition algorithms to automatically match individuals to services based on their needs, demographics, and other information like risk scores and eligibility.
“We are building an infrastructure that takes care of whole people by allowing us to address their basic needs, caregiving needs, as well as needs stemming from managing a chronic health condition,” Kohler says, also noting that the geospatial data collected helps the company understand gaps in community care, “which can inform initiatives, investments and policies.” The platform has also been used to support contact tracing, extend care at Covid-19 field hospitals, and support quarantined patients being transitioned from hospital to hotel to home.
One person who both understands and has seen these gaps and disparities firsthand is former U.S. Army infantry officer Taylor Justice, co-founder and president at Unite Us. Based out of New York, Unite Us is an outcome-focused technology company that builds coordinated care networks of health and social service providers to fill gaps in community care.
“We had people in the justice system going over to the local prison and helping people figure out: once you get out, what do you need? Housing? A job? All these critical things. I was tracking it all on an Excel sheet, and the most vulnerable of these individuals in these families had co-occurring needs that had to be addressed simultaneously,” notes Justice, speaking about the opportunity he saw to improve how community health and SDoH are managed among vulnerable and disenfranchised populations.
“All the organizations providing care didn’t know about other service providers,” explains Justice. “There was this lack of connectivity and communication between all of these different sectors and all of these different industries. So we started Unite Us to fill that void.”
Though Unite Us initially focused on the veteran and military population, Justice and his co-founder, Dan Brillman, an Air Force reserve pilot who’s also in the Defense Innovation Unit at the Department of Defense, quickly realized that the challenges the veteran and military community face are not unique, and expanded their scope. “Our mission was to bring human and social services into the 21st century through a platform that connects everybody together,” he notes.
Covid-19 made that an even more critical mission.
“I think what Covid-19 has done is really highlight the second- and third-order effects of the clinical response, which is the lack of appropriate public health infrastructure.” said Justice, attributing unprecedented stress on the human and social service system today, in part, to people accessing public benefits for the very first time.
“One of the big things that we saw right out of the gate was 46% of community-based organizations either limited their programs or suspended programs altogether,” notes Justice. “So having that coordinated network where I can throttle referrals up or throttle referrals back based on the supply in the community is super, super important,” he says, in reference to Unite Us’ platform, which matches patients with the most appropriate, available community resources while also helping close the loop on those referrals for more coordinated care.
Non-Clinical and Clinical Care Are Intrinsically Related
Another company using platform technology to address health disparities and system-level healthcare inequities is Cityblock Health.
“At Cityblock, we see behavioral health, medical health, and social health as intrinsically related,” says Cityblock Health co-founder and chief product officer, Bay Gross. And each of these areas of care require different delivery strategies and professional role types, he added.
“Thoughtful technology products can bring these forces together, while maintaining order and clarity,” notes Gross, adding that the company is aligning incentives and addressing systemic barriers “while ensuring simplicity and coherency for our front-line teams.” These teams are across primary care services, behavioral health support, chronic disease management, and substance abuse treatment, as well as social services like transportation, housing, and healthy food access.
“By coordinating our social and medical care teams, and providing a low-friction series of 24/7 access points for members, our technology product increases access, reinforces model fidelity, and ultimately drives outcomes for member health,” explains Gross.
Access To Care Does Not Mean Equality Of Care
While care access is certainly a necessity for good health, it’s only a small factor in overall health and wellness, especially when considering the systemic racial inequalities and disparities in care that exist across the country.
“It’s about understanding that even if Black and Brown people have equal access to good quality medical care, they may lack access to resources and reliable information about resources that enable high-quality self care,” says Stacy Lindau, MD, MAPP, NowPow’s founder and chief innovation officer.
“If our goal is to eliminate health disparities, we have to turn serious attention to understanding and providing people high-quality connections to vital health-promoting resources in our communities,” explains Lindau. “By doing this in a systematic, digital, 21st century manner, we generate critical data that are a big missing part of the current approach to health equity,” she says.
“In other words, for the first time, we can see what is the scale and scope of people’s community resource needs and what is the quality and availability and capacity of communities to meet these needs,” Lindau continues, adding that this kind of supply/demand/quality data of community resources is what is required to address the true structural determinants of health and health disparities.
“Upstream” Investments in SDoH Reduce Downstream Medical Spend
Managing costs and improving the health of vulnerable populations are among the driving forces behind providers and both government and commercial plans adopting solutions to account for SDoH.
In a recent survey from the Deloitte Center for Health Solutions, of the 300 hospitals and health system respondents, 88% said they were committed to addressing SDoH and were already screening for social needs. And while 40% of hospitals also reported having no current capabilities to measure the outcomes of their activities, most said that demonstrating improved health and cost outcomes, and improved patient experience, were the goals underlying their SDoH strategies.
And in a 2018 study by WellCare Health Plans and the University of South Florida College of Public Health, Tampa — which looked at the impact of social services on healthcare costs (physician office visits, emergency department use, etc.) among Medicaid and Medicare Advantage members — there was an additional 10% reduction in healthcare costs, or more than $2,400 in annual savings per person, for people who were successfully connected to social services in comparison to a control group of members who were not.
These kinds of cost savings, paired with implications of the industry’s shift to value-based care, can make a big difference for plans and providers alike.
“For health plans administering government programs, investing in social determinants of health has been more straightforward, as their mindset is a dollar invested in social determinants will save two or three dollars in downstream medical expenses,” says L.E.K’s Sabbitino, who specializes in payer/provider integration and behavioral health.
Health plans, he explained — specifically those that administer Medicare and Medicaid plans — see the advantages and the upside of investing in SDoH. “This flows right through to their bottom line because they get capitated payments,” he notes, referencing the shift to value-based care and risk-sharing models that prioritize care quality and outcomes.
Having solutions or strategies in place to manage SDoH can also be a source of competitive advantage for plans, notes Sabbatino, like Medicaid plans trying to differentiate themselves to win coveted state-issued contracts, or commercial plans vying for employer-sponsored business with the promise of better population health and lower costs.
At Unite Us, Justice is also seeing an increased interest in SDoH at the state level from Medicaid plans. “States are getting ahead and using levers, specific to Medicaid, including social determinants of health, industry structure, and requirements in their rates for Medicaid managed care contracts or anybody that’s receiving Medicaid dollars from a plan perspective,” Justice explains, noting that the slight policy shift provides an infrastructure to then expand to other applicable populations.
“And that’s where we’re at right now,” says Justice, “building the appropriate public health infrastructure across the country, the operating system for social care.”