Social determinants of health: Pushing the boundaries of healthcare

• Addressing social determinants of health (SDOH) is vital to improving health outcomes.
• As a society, we are just starting to come to terms with the implications of SDOH.
• Meaningful improvement in SDOH will require new levels of collaboration among all stakeholders.

Health outcomes are not a function of healthcare alone. In fact, healthcare accounts for just 20% of the factors that contribute to an individual’s health status. Genetics explains another 20%. The biggest influencer — 60% — is social determinants of health (SDOH), which include security of all kinds (e.g., food, employment, domestic relationships, neighborhood); other environmental factors; and behavioral factors.

Yet our country allocates the vast majority of national health expenditures to healthcare, with relatively little going to SDOH. Research supports the premise that a low ratio of social service spending to healthcare spending is associated with poor population health outcomes. If disproportionately high healthcare spending in the United States is a result of underinvestment in social services, spending more on healthcare digs the spending-growth hole even deeper.

Scoping the challenge of SDOH

Although this isn’t news, many healthcare stakeholders are only starting to process it as they take on greater accountability for health outcomes and costs under value-based payment. Many questions are emerging for stakeholders as they take a deeper dive into SDOH and their potential roles in addressing these issues.

Which SDOH have the greatest impact on healthcare for particular populations? What are the barriers to addressing SDOH, and how can they be overcome? What predictive analytics are best for guiding wise investments and interventions? Who should bear the primary responsibility for addressing SDOH through the healthcare system? Despite evidence of a significant return on SDOH investments, in both financial and quality-of-life terms, no single group is clamoring to take the lead.

HFMA dedicated its October 2019 Thought Leadership Retreat to an in-depth discussion of SDOH-related issues, with presentations by experts and leading practitioners catalyzing small-group discussions. Participants agreed that our nation’s efforts to address SDOH are sorely lacking. When asked to characterize these efforts in one word, the most popular choices were fragmented, lacking and inadequate.

Yet, there was no consensus about who should take the lead on SDOH initiatives. Options discussed included hospitals, clinicians and health plans; local, state and federal government agencies; community service providers; and, of course, the affected individuals themselves. More than 40% of retreat participants chose government as the entity that should have primary responsibility for addressing SDOH. Another 28% said individuals/patients bear primary responsibility. (Perhaps this dichotomy reflects differences in participants’ core beliefs about the role of government vs. personal responsibility.)

Hospitals, clinicians and health plans were tagged by just 15% of participants in our informal poll, but discussion revealed that many felt responsibility would default to these stakeholders in the absence of either funding or political will for government to take on these responsibilities.

Charting a path to address SDOH

So, how should our society move forward? (And it is a societal question,) The scope and magnitude of SDOH needs are nearly limitless, while resources available to healthcare stakeholders for these purposes are extremely limited.

When it comes to healthcare stakeholder involvement, the key may lie in targeting SDOH efforts to the specific needs of their communities or members. As most healthcare leaders know, 5% of the population, composed of people with multiple chronic conditions, accounts for 50% of healthcare spending. With regard to SDOH, a small minority of people with identifiable SDOH needs, which may lead to or exacerbate chronic conditions, is likely to account for a disproportionately large share of healthcare spending in a community.

This group would include, for example, the elderly person living with congestive heart failure who lacks air conditioning and the child living with asthma who needs a cleaner indoor environment. It also includes people struggling with homelessness, mental health or addiction. SDOH, like healthcare overall, is local.  

As a society, we doubtless will continue to explore how best to address SDOH needs across the lifespan. The benefits of improving the full range of SDOH extend far beyond healthcare. But healthcare providers, practitioners and health plans can and should begin to focus on those SDOH that are linked to the specific chronic conditions that are most prevalent and problematic in their respective populations, because chronic conditions are a key driver of healthcare spending.

The ROI on such SDOH investments can be substantial, and demonstrating an ROI is key to sustainability. However, hospitals and health systems won’t realize the return unless they are taking on population health risk.

Meaningful improvement in SDOH will require new levels of cooperation among all stakeholders, as Thought Leadership Retreat participants pointed out during the concluding session. As is the case with delivering improved value to consumers and other healthcare purchasers, it all comes back to collaboration. No one group can solve this alone.