Social Determinants of Health

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

By M2|2018-06-15T19:32:48+00:00June 15th, 2018|Health Care Trends, Health Disparities, Health Information Technology, Health Reform, Innovation, Public Health, Social Determinants of Health, Uncategorized|

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

Here at M2, we spend a lot of time thinking about the social determinants of health (SDH), or the nonmedical factors that can affect a person’s overall health and health outcomes. We have blogged recently about this issue, and . The issue is gaining momentum and we are seeing more articles and studies addressing how to better incorporate SDH into programs and technologies; for example, former CMS administrator Andy Slavitt recently announced his new venture capital firm will focus on companies in this area. Another recent article highlights the opportunities for technology entrepreneurs as adoption rates for SDH technologies are projected to increase over the next ten years. Today we are taking a close look at a recent position paper from the American College of Physicians (ACP).

SDH are defined as “the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life”. In other words, “where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy,” the ACP notes in its recent paper.

SDH are “responsible for most health inequalities,” the ACP says; the paper examines the complex issues involved and provides recommendations on “better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.”

The paper was drafted by the ACP’s Health and Public Policy Committee, and the ACP notes that it is charged with addressing “issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties.”

“Understanding and addressing social factors that affect health outcomes is a pressing issue for physicians and medical professionals,” the ACP says. The group is issuing a set of recommendations “to empower stakeholders to advocate for policies aimed at eliminating disparities and establishing health equity among all persons.”

The paper features nine policy recommendations. Most notably, these include: integrating SDH into medical education at all levels; adequately funding federal, state, tribal, and local agencies in their efforts to address social determinants of health; developing best practices for utilizing electronic health record (EHR) systems as a tool to improve health without adding to the administrative burden on physicians; and adjusting quality payment models and performance measurement assessments to reflect the “increased risk associated with caring for disadvantaged patient populations.”

Expanding on one of the recommendations above – the importance of EHRs and collecting data – the paper notes that in 2014, a National Academies of Science committee identified 12 social determinants to be included in EHRs as part of meaningful use stage 3, and issued recommendations on standardizing collection of measures of these social determinants. Several behavioral and social domains are currently collected: tobacco use; alcohol use; race/ethnicity; and residential address, which is geocoded.

The report says that in terms of racism and health equity, the ACP’s policy on racial and ethnic health disparities “acknowledges that addressing social determinants of health is a key component to increasing health equity among racial and ethnic populations.”

Social determinants “can exacerbate health care disparities among racial or ethnic groups,” the paper says. “Socioeconomic status, race, and ethnicity are connected in a complex, multidimensional way and may affect a person’s health independently or in combination.” As an example, the ACP notes that Latina women experience a greater incidence of cervical cancer and higher mortality rates than non–Latina women. Access to care for Latina women is also affected, as they are more likely to lack health insurance than white non-Latina women.

SDH has been a bit of a buzzword for a while in public health circles, but it may finally be time for SDH to influence policy, as seen by ACP’s efforts. “Why now?” many are wondering. As proof points pile up, and more people gain an understanding of what SDH are, the concept is gaining momentum and being included in more discussions.

For example, it’s interesting that one of the largest physician groups has developed policy positions on SDH. This may be an indication that physicians in general are realizing the significant role that SDH play in individuals’ health. Incorporating an understanding of SDH into not only the practice of medicine, but also into the tools and incentives that drive patient care, would be welcome steps in helping to reduce the negative health outcomes related to SDH.

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Proof Point: Addressing Social Determinants of Health Reduces ED and Hospital Visits, and Reduces Costs

By M2|2018-05-23T16:53:35+00:00May 23rd, 2018|Evidence-Based Medicine, Health Care Trends, Hospitals, Providers, Social Determinants of Health, Uncategorized, What do we pay for and why|

Proof Point: Addressing Social Determinants of Health Reduces ED and Hospital Visits, and Reduces Costs

Just a couple weeks ago, I about social determinants of health (SDH), so I was intrigued to come across this recent study in Health Affairs showing that improved access to care and a consideration of SDH can lower emergency room use and inpatient hospitalizations, and reduce costs.

A health clinic in Dallas, the Baylor Scott & White Health and Wellness Center (we’ve also highlighted before), partnered with the Dallas Parks and Recreation Department to create a primary care clinic in a rec center in an underserved Dallas community. The public-private partnership offers clinical services such as routine primary care, regardless of the person’s ability to pay. But it also offers access to other health-supporting interventions. For example, the partnership provides access to programs that help community members participate in physical activity and get healthy food.

Community health workers are also a component of the approach. Patients often need help navigating both the health care system and support programs, for example, free exercise classes at the rec center. Community health workers assist patients with that navigation in a culturally relevant way for the Dallas center. Local churches – more than 25 of them – provide an additional level of support by increasing awareness of the health clinic/rec center offerings and availability of community health workers.

The clinic “exemplifies the integration of social determinants of health within a population health strategy,” according to the study by David Wesson, President, Baylor Scott & White Health and Wellness Center, and his colleagues.

While increasing access to both clinical health care services and health-supporting programs, such as those offered by rec centers, is worthy goal on its own, to health policy wonks the added proof point of cost savings due to a population based approach that integrates SDH is just as exciting.

The study examined emergency department (ED) and inpatient care use for 12 months after initiation of the program. People who used the center’s services experienced a reduction in ED use of 21.4% and a reduction in inpatient care use of 36.7%, with an average cost decrease of 34.5% and 54.4%, respectively. All of these are notable proof points: “These data support the use of population health strategies to reduce the use of emergency services,” the authors conclude.

The Baylor Scott White/Dallas Recreation Center partnership is a great example of how improving access to health care and addressing the social determinants of health can have a positive impact on both health outcomes as well as costs, by reducing expensive types of care such as emergency and inpatient services. We are still building the evidence-base, but this study shows taking a holistic approach to patient care, including addressing the social determinants of health such as culture and language, can help achieve what everyone wants: improved health and lower costs.

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Want to Fix the Opioid Crisis? First, Think Structurally

By M2|2018-05-17T16:49:16+00:00May 17th, 2018|Chronic pain, Evidence-Based Medicine, Insurance, Public Health, Social Determinants of Health, Uncategorized, What do we pay for and why|

Want to Fix the Opioid Crisis? First, Think Structurally

I am often asked to come up with creative ways to address various health care problems. When I was asked by a client a few years ago to come up with some ideas to address the opioid crisis, I dove in to the latest academic literature, news reports, and books (if you haven’t read it yet, and are interested in the bigger picture of opioids, check out Dreamland by Sam Quinones). Thousands of pages later, I came to what seemed an obvious conclusion: opioid misuse and abuse is not a singular crisis, but the effect of a huge set of policy decisions that have occurred over years.

In a recent commentary in the American Journal of Public Health, author Nabarun Dasgupta of the University of North Carolina, Chapel Hill, and colleagues are blunt – “The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Until we adopt this framework, we will continue to fail in our efforts to turn the tide of the opioid crisis.”

Using a structural framework to analyze causes of the opioid crisis generates “an alternate hypothesis…that an environment that increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality,” the authors point out. “Complex interconnections between obesity, disability, chronic pain, depression, and substance use have not been adequately explored.” Also, suicides “may be undercounted among overdose deaths,” they say. “Under both frameworks, social distress is a likely upstream explanatory factor.”

In order to “turn the tide” on the opioid crisis, the authors urge a focus on patient suffering, tied to things like social disadvantage, isolation, and pain. However, one of the challenges is that the U.S. health care system is “unprepared to meet the demands elucidated by a structural factors analysis.”

Again, seems obvious, but still bears repeating: the health care delivery system is not built to deal with structural problems.

Addressing these types of factors requires “meaningful clinical attention that is difficult to deliver in high-throughput primary care.” Indeed, the current “institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients,” the authors say.

Incorporating social determinants of health (SDH) into care plans also highlights the need to “integrate clinical care with efforts to improve patients’ structural environment,” the commentary says. While the commentary authors recommend, “Training health care providers in ‘structural competency’” as promising, as the system scales up “partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction,” I’m not as inclined to think health provider training alone will suffice. When I was first taught the basic premises of SDH and structural thinking as a young graduate student, the discipline was already decades old.

Knowing the importance of SDH is not enough. Until the evidence base is deeper, it is difficult to get payers to reimburse such as activities. (See next week’s blog for a great example though!)

Thinking structurally is not so difficult to learn, but acting structurally is extremely difficult. Still, the opioid crisis – like so many health care conundrums – can’t be solved without it. Let’s get to it.

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Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

By M2|2018-05-07T14:32:50+00:00May 4th, 2018|Health care spending, Health Care Trends, Medicare, Social Determinants of Health, Uncategorized, What do we pay for and why|

Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

CMS recently announced it will change its policy regarding Medicare Advantage plans and the scope of “supplemental benefits” these plans may offer. As of the 2019 plan year, CMS says it is reinterpreting existing law and expanding the options that Medicare Advantage plans may offer to enrollees.

In the past, CMS has not allowed an item or service to be eligible as a supplemental benefit – an additional benefit beyond the standard benefits under traditional Medicare – “if the primary purpose includes daily maintenance,” the agency says.

However, in the 2019 final Call Letter for Medicare Advantage, CMS says the policy change will “expand the scope of the primarily health-related supplemental benefit standard” to allow benefits used to “diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”

Items and services under this expanded scope could include things like “air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals,” a recent article in Kaiser Health News notes.

Transportation, different food options, and items such as grab bars in bathrooms might be covered options now. While a physician’s order or prescription is not necessary, the new benefits must still be “medically appropriate” and recommended by a licensed health care provider.

While public health types (me included) often focus on explaining what a social determinant of health is and how it could be addressed in order to improve health equity, this policy change is significant in that it attaches payment to interventions – even if they are not clinical – that could lead to improved health.

Separately, the most recent federal budget agreement lifts the annual caps on the amount Medicare pays for physical, occupational, or speech therapy, and streamlines the medical review process. This policy change will apply to both traditional Medicare and Medicare Advantage enrollees.

As of Jan. 1, Medicare beneficiaries will be eligible for therapy indefinitely as long as their provider confirms their need for therapy and they continue to meet other requirements. Also, under a 2013 court settlement, enrollees will not lose coverage “simply because they have a chronic disease that doesn’t get better,” KHN says.

In an interview with KHN, Judith Stein, executive director, Center for Medicare Advocacy, said, “Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient’s condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that.”

These are innovative moves on CMS’s part; they show the agency recognizes the need for a more holistic approach to health care for Medicare enrollees and that it’s willing to address the social determinants of health, such as the impact of the home environment on a patient’s health.

CMS is now moving beyond purely “medical” treatments for Medicare Advantage enrollees and addressing broader aspects of health. We get what we pay for, and by covering different types of care, CMS is encouraging actions that may lead to improved health outcomes and avoidance of some preventable health events for patients.

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An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

By M2|2018-04-10T19:27:24+00:00April 10th, 2018|Chronic pain, Evidence-Based Medicine, Health Disparities, Insurance, Social Determinants of Health, Uncategorized, What do we pay for and why|

An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

Pain is a common, yet difficult to treat condition; it is one of the top reasons people go to the doctor. Opioids are commonly prescribed to treat pain; opioids are quite effective but addictive. The use of cognitive behavioral therapy (CBT) is known to be efficacious in addressing chronic pain; however, its benefit in disadvantaged populations is not well understood.

To help shed light on this question, a team led by Beverly Thorn, University of Alabama, conducted a study to evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.

The randomized controlled trial enrolled 290 adults with chronic pain symptoms. Most had incomes at or below the poverty level, and about one-third read below a fifth grade level. Many participants were taking opioids at the beginning of the study.

Both the CBT and EDU were delivered in ten weekly 90-minute group sessions. Participants in all three groups reported their pain levels and physical functioning via questionnaires at baseline, ten weeks, and six months.

The study, funded by the Patient-Centered Outcomes Research Institute and published in the Annals of Internal Medicine, found that patients in the CBT and EDU groups had greater decreases in pain intensity scores between baseline and post-treatment than participants receiving usual care.

However, while treatment gains were still present in the EDU group at six-month follow-up, these gains were not maintained in the CBT group, Thorn, et al., say.

Regarding the secondary outcome of physical function, those in the CBT and EDU interventions had greater post-treatment improvement than patients who received usual care; this progress was maintained at six-month follow-up. Changes in depression, another secondary outcome, did not differ between either the CBT or EDU group and those receiving usual care, the researchers state.

This study highlights the fact that when done correctly, i.e., when materials are adjusted and tailored to a patient’s reading level, there are non-opioid interventions like behavioral therapy and education that work. While it is probably easier to prescribe opioids for pain, given the increasing severity of the opioid addiction epidemic, insurers really should consider these effective alternative treatments which positively impact pain. Why NOT prescribe effective, non-addictive treatment whenever possible?

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ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

By M2|2017-12-07T01:22:04+00:00December 6th, 2017|Health Care Trends, Health Disparities, Insurance, Public Health, Retail Health, Social Determinants of Health, Uncategorized|

ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

Sunday, December 3, CVS Health announced it will acquire health insurer Aetna for $69 billion. Lowering the cost of care by enabling a broader range of treatment in retail clinic settings, of which CVS Health has more than 1,100 in 33 states, is one of the obvious rationales of the combination. But what struck me in the comments of the merging companies’ CEOs was how much they sound like public health professors. Social determinants of health? Health as a path to fulfillment? What have they done with the business people? In case you missed it…

Mark Bertolini Really Cares About the Whole Person

Aetna Chairman and CEO Mark T. Bertolini has been talking publicly for quite some time about the importance of thinking about people not as patients, but more holistically. In September, in an interview with Dennis Berman, the Wall Street Journal financial editor, he said, “We believe the only way to truly disrupt the cost of health care … is to go into the homes and meet the social determinants that are now driving as much as 60 percent of life expectancy of Americans.”

What Bertolini has had to say now that the merger is official is straight-up public health speak. On CNBC Monday morning, when explaining the vision of the merger, Bertolini sounded like a philosopher: “Most people,” he explained, “find their health is a barrier to the life they want to live.” Indeed.

Larry Merlo is Fixated on Unmet Need

Larry J. Merlo, President and CEO of CVS Health, reminded anyone who was paying attention something that we in public health have known for a long time, but surprised the CNBC reporters, “You look at chronic disease in this country today, about half of all Americans have at least one of those chronic diseases. It’s accounting for 80% of the health care costs.”

Merlo further explains, “there’s billions of dollars every year on unnecessary and avoidable spending because people are not following…care plans.” Merlo’s solution, to be executed in part with the announced merger, is to address the unmet need the traditional health care system is creating, but CVS Health knows first-hand because patients come through its doors with health care needs that aren’t being met.

We “lack the element of convenience and coordination…that is the unmet need we are talking about,” says Merlo.

We Are All Public Health

As a public health student, educator and professional, I am public health. This merger discussion shows we are all public health. Georges C. Benjamin, M.D. Executive Director, American Public Health Association wrote in 2015, “Today, the biggest threats to the health and longevity of Americans are preventable diseases. These are the diseases that are burying us in preventable suffering, as well as crippling our communities with mountains of avoidable medical bills. The root causes of many of these health threats are inextricably linked to the social determinants of health and the conditions that shape a person’s opportunity to attain good health and adopt healthy behaviors. These social determinants include access to safe housing, good jobs with living wages, quality education, affordable health care, nutritious foods, and safe places to be physically active. They also include racism, discrimination, and bias.”

To see such similar language from Mark Bertolini and Larry Merlo in the CVS-Aetna merger discussion to date shows that the leaders of what could become the largest health care company in the U.S. are thinking differently about the broken U.S. health care system. Near the end of the investor call about the merger, an analyst asked whether the combined entity planned to be a person’s primary care physician. Bertolini answered: “The real important part here is that you have to understand that almost 60% of Americans don’t have a regular doctor.”

When you connect these dots, you can really see the big picture come together. The CVS-AET vision is bigger than managing the pharmacy benefit.

Will it work? Hard to say at this early stage. Should consumers want it to work? Absolutely. A health care company with a public health lens that focuses on health well before a person shows up at the doctor and prioritizes convenience, coordination, and social determinants of health would be a welcome change for individuals, families, and employers. Score one for public health.

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Health disparities disproportionately drive hospital readmissions

By M2|2017-10-09T02:04:45+00:00December 6th, 2016|Health Disparities, Social Determinants of Health, Uncategorized|

Health disparities disproportionately drive hospital readmissions

Health disparities, as opposed to medical treatments, are disproportionately driving hospital readmission rates, resulting in higher penalties for safety net hospitals, according to a study published in the journal Surgery.

Elizabeth Hechenbleikner, MD, MedStar Georgetown University Hospital, et al., studied readmissions after colorectal surgery. The authors evaluated outcomes and patient factors in more than 168,000 colorectal surgery patients treated in 374 California hospitals from 2004-2011, using the State Inpatient Database and American Hospital Association Hospital Survey data. They performed sequential logistic regression analyses to determine the associations between minority-serving hospital status and readmissions.

As noted by MedPage Today, 30-day, 90-day, and repeated readmission rates in minority-serving/safety net hospitals were 13.6%, 20.1%, and 4%, respectively. In comparison, the overall readmission rates were 11.6%, 17.4%, and 3%, respectively.

Patient-level factors, such as race, income, and insurance status accounted for up to 65% of the increase in odds for readmission at minority-serving hospitals.

On the other hand, hospital-level factors, such as procedure volume and procedure type, accounted for up to 40% of the increase. Notably, inpatient mortality was also significantly higher at minority-serving hospitals (4.9%) compared to non-minority-serving hospitals (3.8%).

Study co-author Waddah B. Al-Refaie, MD, also of MedStar Georgetown University Hospital, said in an accompanying statement that CMS holds all hospitals to the same readmission standard.

CMS established the Hospital Readmission Reduction Program (HRRP) in 2012 in an attempt to reduce higher-than-expected readmission rates for six conditions: heart attacks, heart failure, pneumonia, COPD, and hip and knee replacement. “To date, it has penalized more than half of the nation’s hospitals for failing to meet expectations, imposing more than $500 million in fines,” Al-Refaie says.

“These findings suggest that CMS should account for patient socio-economic factors when they compare readmission rates,” he says. If patient-level factors “are not balanced out, we fear minority-serving hospitals will face substantial, crippling financial penalties, and may end up being selective about the patients they admit.”

In addition, the study authors highlight the need for addressing patient-level factors in order to “shape quality improvement interventions to decrease readmissions.”

Indeed, some part of the system has to be concerned about addressing these social determinants of health. Instead of pointing to “unfair” fines for safety net hospitals, these hospitals would serve patients better by addressing the readmissions themselves.

For example, hospitals could partner with local community health organizations to help address these patients’ socioeconomic factors and work to find ways to ensure patients are actually recovering well from surgery, and therefore do not need to be readmitted.

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Cardiac Rehab Programs: Yet Another Evidence-Based Intervention That Isn’t Paid For

By M2|2017-10-09T02:07:38+00:00November 7th, 2016|Evidence-Based Medicine, Social Determinants of Health, Uncategorized, What do we pay for and why|

Cardiac Rehab Programs: Yet Another Evidence-Based Intervention That Isn’t Paid For

Evidence shows cardiac rehabilitation programs –which teach patients who have had a cardiac event about exercise, diet and prescription drugs – substantially cut the risk of dying from another cardiac problem; they also improve quality of life and lower costs. But as Kaiser Health News notes, fewer than one-third of patients whose conditions qualify for cardiac rehab actually participate.

One of the main reasons for the low participation rate is cost; patients must generally pay a co-pay to participate in such programs – about $20 per session for regular Medicare beneficiaries, and anywhere from zero to over $60 per session for Medicare Advantage enrollees and those who are privately insured.

Aside from cost, other barriers include distance/travel time to the facility, lack of referrals at the time of hospital discharge, and capacity of existing cardiac rehab programs. This is particularly troubling because in spite of the increased likelihood of death within five years of a first heart attack, certain populations are less likely to be referred for cardiac rehabilitation, including women, minority populations and patients of lower education levels of socioeconomic status.

[Note to readers: I am a bit obsessed about the evidence for cardiac rehab, as well as the social determinants of health that prevent it from being routinely recommended and included it as Case 17 in the textbook I co-edited, Essential Case Studies in Public Health: Putting Public Health into Practice, published by Jones and Bartlett.]

What do we pay for, and why?
In considering innovation and value, there are frequently situations in which patients are receiving a health care service that runs counter to recommendations based on the latest evidence- clearly a waste, but politically difficult to stop, especially if it runs counter to patient or provider preferences. However, this is an example of where the evidence clearly supports reimbursing for the intervention, but the service is underutilized considering its value to the patient and the system.

As noted, this low participation rate in cardiac rehab is due in part to patients’ reactions to time requirements, but can also be blamed on health insurer cost-sharing requirements that discourage use of a valuable intervention. To be clear, studies show 25% reduction in all-cause mortality rates and 31% reduction in hospital readmissions, translating into millions in annual savings.

Medicare is inching forward with its Cardiac Rehabilitation (CR) Incentive Payment Model which pays hospitals incentive payments based on total cardiac rehabilitation use for patients in their care after a heart attack or bypass surgery. Hospitals can receive $25 per cardiac rehabilitation service for the first 11 services they provide and the payment increases to $175 per service after those first 11 services.

If the evidence shows significant reductions in adverse events and cost of care for those who participate, is it time for payers to reflect that increased value in lower co-pays? And perhaps more importantly, is it time for payers to require providers to recommend cardiac rehab for everyone who could benefit, regardless of their gender, race or income?

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