As much as 80% of health outcomes are determined by circumstances and factors outside of clinical care. Individuals’ physical environment and access to healthy food, stable housing, reliable transportation, education, and income play as much (or more of) a role in determining outcomes as the care and procedures clinicians deliver in physician offices and hospitals.
Intuitively, we believe that influencing these nonclinical environmental elements will result in lower healthcare costs and better outcomes. Despite our convictions, however, there is not much concrete evidence to help us understand which social health interventions are most effective, and under which circumstances.
Which, among the many possible programs a health system may consider to influence social determinants of health, should be prioritized? Is it more important to provide weekly deliveries of fresh food, or is it better to sponsor programs that teach financial literacy and how to create a budget? Is it better to invest in affordable housing or to build programs that create social connections for those who may be socially isolated? Although healthy, fresh food may seem the more obvious solution, financial counseling programs, housing investments, and programs that encourage connections among people have also been shown to drive positive health outcomes.
In each of these cases, small studies and pilot programs with specific populations show promise, but there is little evidence that these programs can be delivered at scale to achieve the same results. Healthcare organizations increasingly have to weigh where and how to invest scarce dollars, and how to prioritize investments in social health programs versus investments in case/care management or other more traditional clinical programs that have been proven to improve outcomes.
Providers and payers facing these questions find themselves in very much the same position they were a quarter century or so ago when they were asked to invest in quality improvement. The intuitive case for improving quality was there, but the evidence for which investments would measurably reduce costs and improve outcomes at scale wasn’t. Organizations had to “take it on faith” that the investments would show some return, and that they would see the benefit of their investments. And for providers in a fee-for-service environment, improved outcomes may not have always resulted in obviously improved finances.
The same might be said today when it comes to investments in social health.
In the case of quality, payment models and incentives evolved to support the hypothesis (and hope) that better quality could drive better outcomes and better financial performance. Medicare began paying bonuses for higher quality through Medicare Advantage’s star rating program and levied penalties for poorer quality (for example, hospital readmissions).
Today, we are at the early stages of a similar evolution of social health. To date, CMS has published a roadmap for states to address social determinants of health in Medicaid and the Children’s Health Insurance Program, has begun to drive collection of data related to social determinants of health through the skilled nursing facility prospective payment program, and has adopted a framework for equity that considers the effect of social factors on health and health outcomes.
National and regional health plans and providers are increasingly investing in programs to address the social needs of their members and patients, and states like North Carolina and health plans and providers in Hawaii are building statewide networks of community-based organizations to address citizens’ social needs and to improve health equity. Momentum is growing.
The challenge, and the opportunity, for all healthcare organizations today is to take the lessons learned on the quality journey and apply them to this new journey of social health: develop deliberate strategies, prioritize focus based on local needs and conditions, track and measure outcomes to help build an industrywide understanding of what works, and continue to push and evolve payment models to support and reward these investments.
The mission of healthcare organizations is to improve the health of their patients, members, and communities. Improvements in social health hold enormous promise. But we are still in the early stages of the journey, and pursuing it will require the courage of our conviction that we are heading in the right direction, a structured approach to testing, and an openness to discovering new and unexpected ways to reach our destination.
In future blogs, I will offer deeper looks at specific approaches to social health.
