At World Health Care Congress, An Inspirational Interest in Better Understanding Social Determinants of Health

April 30, 2018
At the 15th annual World Health Care Congress, leaders of various organizations across the healthcare ecosystem stressed the importance of understanding and acting on social determinants of health so that outcomes could be improved and costs lowered.

At the 15th annual World Health Care Congress, leaders of various organizations across the healthcare ecosystem stressed the importance of understanding and acting on social determinants of health so that outcomes could be improved and costs lowered.

The panelists, speaking at the Marriott Wardman Park Hotel in Washington, D.C. on April 30, included Martin Otto, chief operating officer of San Antonio-based supermarket chain H-E-B; Akram Boutros, M.D., president and CEO at Cleveland-based MetroHealth; Harold Paz, M.D., executive vice president and chief medical officer, Aetna; and William Shrank, M.D., chief medical officer, UPMC Health Plan. The session was moderated by Ian Morrison, author, consultant and futurist.

Morrison opened up by noting how healthcare’s key players, namely hospitals and health plans, are becoming increasingly interested in how social determinants of health can help dictate care operations. He said that the growing interest in these critical health factors is due to the rising burden of chronic care, mounting research evidence, and the shift toward providers and payers taking on more risk. But above all there is one answer to the question of “Why are some people healthy and others not? The short answer is income; it’s the single biggest factor behind determining health,” Morrison attested.

The panelists were quick to point out that the amount of money the United States spends on healthcare—$3.3 trillion in 2016, or 18 percent of the GDP—is a trillion dollars in excess of where the nation ought to be in comparison to other countries. “But we aren’t getting the [desired] health outcomes given what we are spending,” said Otto, noting that healthcare access is a major challenge, as well, with so many people either underinsured or uninsured. “We are not spending enough on poverty-related [issues] or education, and this in turn breeds worse health outcomes, which in turn breeds more healthcare spending,” he said, referencing the “vicious cycle” that currently exists in this sector.

As such, provider organizations such as MetroHealth have taken to addressing social health factors in an effort to reverse these troubling trends. Just eight years ago, explained Boutros, MetroHealth senior executives realized that the system was close to going out of business due to providing a large amount of services on non-paying patients. “We had to figure out how to significantly lower costs while providing better healthcare,” said Boutros. What came from the brainstorming was the creation of a model that included collaborations with legal aid agencies, local foodbanks, and other community organizations to address some very basic issues such as providing patients transportation for their visits. MetroHealth, through these initiatives, was able to achieve savings far below its Medicaid benchmark, Boutros attested.

The organization has also been able to tie 50 percent of its contracts to risk—up from just 5 percent not too long ago. “I don’t think anyone in healthcare would run toward social determinants of health if not for this risk part,” Boutros said. “In healthcare, unambiguous and highly committed leadership is important. Our CEO not saying ‘both value and volume’ was [critical].” Instead, MetroHealth C-suite leaders understood that in its value-based care transition, the system might lose some money early on, but it would aim to reduce readmissions and figure out how to make up the money in other ways. Indeed, explained Boutros, the organization was able to reduce readmissions by 2,000 patients per year. “And our CEO was not working to counter that by saying that we need patients in the beds,” he added. 

Boutros also believes that patient engagement is critical when integrating social determinants of health into care processes. “Once you engage with patients, it’s not very difficult to solve the underlying problems,” he said. UPMC Health Plan’s Shrank agreed. “If you are taking risk and deeply engaged in the community, you would be crazy not to look hard at how social context is impacting the health and healthcare costs of the population you serve,” he said.

Shrank said that UPMC is working to foster a more rapid adoption of these determinants, with actionable data at the core of it. “These are vulnerable folks who we are trying to help, and capturing the right information from those patients can be challenging, since it’s [currently] being captured in an unstructured way. But we are working to create a registry using NLP [natural language processing] to capture information from unstructured notes so we can better understand the social determinant challenges that our members face,” he said.

Even more importantly, Shrank believes that there is currently a lack the evidence that will help healthcare organizations tie the right social services to the right people. As such, UPMC has taken to testing how interventions to address social determinants ultimately create value on the medical cost front. “We are seeing incredible momentum; we are increasingly partnering with everyone out there,” said Shrank, from retail pharmacies to urgent care clinics to a whole host of other community-based organizations. “There are so many opportunities to integrate data and work together to drive improvements. In a few years from now, the hope is that social determinants will be a central part of healthcare instead of on the fringe,” Shrank asserted.  

Aetna’s Paz agreed, adding that in order to move to the next curve of personalized health, greater interoperability and actionability of solutions will be necessary. “Today, we have a paternalistic system in which the doctor owns your health information. But why don’t you own it in a way so that you can understand what it means and act on it? That flips the paradigm to a personalized system,” he said.

What’s more, Aetna has taken other steps toward better understanding its members, including the recent launch of a well-being assessment about members’ purpose, character, financial status, emotional status, connectedness and physical health, said Paz. Aetna has also recently showcased its Cultivating Healthy Communities project in which investments have been made to support organizations working to address social determinants of health, like access to healthy food and expanding access to spaces that promote active living and healthy eating.

The idea, said Paz, is to identify what some cities and communities are doing to address social determinants of health, and then identify what the ingredients of success within these projects are. In one community, for instance, asthma alliances have been created, and in another, efforts to fight food deserts are underway. “This won’t solve every community’s problem, but they are examples of how to have an impact in a single community, showcase it and then scale it,” Paz said.

In the end, the panelists believe that repurposing the money that is currently going to waste—about one-third of healthcare dollars spent—can help pay for many of these initiatives. But before that happens, the experts attested that patient engagement on a personalized level must take place. “There is no magic bullet or single solution to address homelessness or food insecurity,” says Shrank. The key feature is getting close to patients and hearing from them to address those personal challenges that they face.”

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