Road to value begins with addressing social determinants of health

For many Americans, social determinants of health (SDoH) reflect unyielding circumstances that keep them from living healthy lives and accessing the essential preventive healthcare services that could help them avoid developing chronic conditions, requiring costly hospitalizations or facing premature nursing home placements.

The clear and considerable challenges and opportunities posed by SDoH are what make it a bipartisan issue, according to Lance Robertson, a director in the healthcare practice of Guidehouse in Washington, D.C., and former U.S. Assistant Secretary for Aging at the U.S. Department of Health and Human Services Administration for Community Living (August 2017-January 2021)

“Keeping people healthy and in the community is a win-win,” Robertson told HFMA. “So if you’re a member of Congress, that speaks to you. It’s not just a specific health policy kind of discussion. It applies across anything that is common sense in trying to address and bend the healthcare cost curve in America.”

The best way to tackle the problems posed by social determinants of health 
is through low-cost, high-impact interventions, Lance Robertson says.

Q

It seems clear that our nation must deal with the problems posed by SDoH if it is to have any hope of achieving the goals of value-based care. So from your experience, where do you think the healthcare industry and our nation overall is on the path toward meaningfully addressing this issue and achieving true cost effectiveness of health for Americans?

Robertson

SDoH has been a core area for me over the past 10 years or so, and recently in my work in the federal space, which I also have transitioned into my work with Guidehouse. And from that experience, I can say your initial comment is spot on.

Healthcare in the United States, as we all know, still generally remains far too complex and costly, particularly in comparison to healthcare in other leading countries, so we have work to do. The conversations about cost effectiveness were front and center in the work that we did at HHS when I was a leader there. The issue was always in front of the policy-setting team when it came to healthcare conversations, regardless of what part of agencies within HHS were involved.

As you know, there are 11 major agencies within HHS. So whether it was the CDC or CMS or the office of health or wherever it was at, being able to work alongside physicians and really talk through the federal response was encouraging. I think the watermark level of support is the highest it’s been, and I’m really encouraged by what we’re seeing — again, acknowledging that there’s always work to do. I would say the momentum and the support for really valuing social determinants is the best it’s ever been. And that didn’t happen by chance; we’ve been working at this for a long time. One example is the caucus on social determinants of health Congress created in 2021. I point that out as one example of where I think things are in a much better position than they’ve ever been, because Congress, our key federal partner, is paying attention.

Today, I can tell you it’s exciting to see states, payers, hospitals, advocates, national associations, health systems and the federal government all be part of the conversation.

When I was championing this issue at the federal level, my goal was to keep it simple. I always framed it in terms of low-cost, high-impact interventions. And the members of Congress I worked with started to pick up on that because because the message is powerful yet simple to understand and support.

Q

What are some examples of low-cost, high-impact solutions that we really need to focus on now?

Robertson

One that I am a big advocate of and that gained a lot of attention in meetings at the federal level — whether it was with HHS Secretary Alex Azar or members of Congress or others — was falls prevention, because falls are simply taking too many lives prematurely. A fall can lead to an exacerbated health condition from a broken hip or broken arm, for example — something that requires some sort of rehab that either doesn’t go well or just leads to further health issues. The fact is that falls prevention is probably one of the smallest funded evidence-based programs we have. Yet with more investment, the number of falls that we could prevent can be enormous, and the associated economic and health impacts could just be unbelievable.

Every 16 11 seconds, a senior falls in America, and one in four of those 65+ fall each year. A lot of people have personal experiences with this problem.  I lost my paternal grandmother to a fall just a few years ago.

A second one is addressing food insecurity. Those $6 or $7 meals that we offer through publicly funded programs like the Older Americans Act honestly keep people out of nursing homes,  because food insecurity is a major nonaccident-related factor that’s responsible for putting older adults out of their homes. Too many older adults are food insecure, and the cost to remedy that problem is small compared to the health ramifications if we don’t do anything.

Q

What are some of the ways of effectively addressing those types of problems? For example, when you’re talking about falls, that’s a tricky one, especially where you have an isolated senior who doesn’t have easy access to healthcare. What role can hospitals and health systems play in helping to address that issue?

Robertson

I think there’s a role for everybody. The roles vary slightly, but there’s obviously the direct approach, which involves funding intervention programs that make a difference.

With falls, you have to understand most of them happen at home, and often in the bathroom. So finally, we are starting to recognize during home assessments that a $30 grab bar in the bathroom would absolutely contribute to reducing falls.

We also look at possible tripping hazards within the home environment.

But one thing we can just never do enough, honestly, is public education. We just have to make people, particularly family caregivers, more aware that if you have an older loved one, you need to spend the time to make sure that you’re helping them be safe. The public education component is something we can all embrace, including hospitals and health systems.

There’s a lot that can be done just with hospital discharge planners. When I was in Oklahoma, we would often provide a checklist when a senior was discharged. We would encourage the family saying, “Hey, here’s kind of a very simple punch list of things we want to encourage you to take a strong look at when you get home.”  These proactive conversations can make a big difference.

Whether it’s through direct action or programming or advocacy, there’s just a lot that we need to do as a society to pay more attention to all of this and focus on getting further upstream. And that’s where we can bend the cost curve: If we can get upstream and prevent falls, prevent food insecurity and remedy health inequity, whether it’s transportation or access or so many other low-cost high-impact things, we would save a lot of money on the back end.

Q

You also mentioned food insecurity. How can hospitals and health systems begin to tackle that issue?

Robertson

The struggle we often see across America with older adults is, of course, limited income and having to make choices about where money’s going to go. So often, because of the high cost of prescriptions, the food budget gets whittled down, because it’s often considered secondary, believe it or not. The thinking goes: “I have to make sure I have heat in the house or air conditioning. And then I have to pay for my medications.” And only then do you get to food. This is where I think there’s a huge opportunity for faith-based organizations to partner with community organizations and with hospitals and health systems to rally around tackling food insecurity, which is actually a simple issue to solve when you just consider the mechanics.

We do have pockets across the country where you’re starting to see a lot more food banks and other entities that are doing significant work to addressing hunger and doing it in a nutritionally appropriate way.

That’s where I think some communities are being serious about the balance that’s needed there, making sure that there’s access to fresh fruits and vegetables and also looking at how food is packaged and delivered.

Through the Old Americans Act, we serve 9 million meals a day across the country, and those meals are critical nutritionally and socially.  It’s more than meal because the associated wellness check is so valuable.  During the pandemic, the congregate sites shut down, but many are reopening now and that’s a great thing.   

Q

How should hospitals and health systems get involved in things like that? And how do you think a progressive hospital CFO might view supporting such efforts through community partnerships?

Robertson

Hospitals should find out whether there are food banks or organizations like that in their communities, and look for ways to partner with and support them.

My experience has been that hospitals are often civically minded because, let’s be honest, they want to see only the people who need to be there. And if they have a preventable incident, the hospital administrator looks at that and says, “What can we do to help prevent that from happening?” And it’s not just the economics of it. It’s also the social responsibility. They’re inclined to say, “ Hey, let’s all work together to eliminate these hospital admissions that are preventable so we can save capacity and be focused on conditions that do need that sort of skilled medical capabilities we have to offer.”

That’s true for the hospitals that I’ve have had the honor to work with, particularly around Oklahoma. Those hospitals have really stepped up into the role of being a champion for ensuring these issues are being addressed so that they don’t have food insecure or injured seniors arriving on their doorstep for a three-day stay that costs the taxpayers $80,000, which could have been prevented if a $6 meal had been delivered consistently or a $30 grab bar had been installed and prevented a fall.

Why falls prevention and food insecurity are key issue impeding cost effectiveness of health

Statistics underscore the importance of a national focus on reducing falls and improving nutrition for seniors. Consider that:

• Falls are the leading cause of fatal and non-fatal injuries for seniors.
• The total cost of falls may exceed $101 billion dollars by 2030. 
• Inexpensive falls prevention programs have a return on investment between 64% to 509% and reduce falls by 30% to 55%.
• The disease-associated cost of senior malnutrition is staggering, estimated to exceed $51 billion annually.
• An estimated 65% of hospitalized older adults are at risk of facing malnutrition