Social Determinants as Public Goods

Taking Social-Risk Adjustment Beyond Care Quality-and-Performance Metrics

In our May 2018 blog (Social Risk Adjustment for Provider Quality Measures), we addressed the need consider adjustments to healthcare-provider performance scores so that medical practices that serve disadvantaged populations don’t get penalized because diet, location, wealth, education level and environmental factors depress the wellness of these patients.

A recent paper published in the August 2018 issue of Health Affairs, Social Determinants as Public Goods, by Len M. Nichols and Lauren A. Taylor – takes this a step further: rather than only using Social Determinants to adjust measures and guide policies, it proposes to actually change the Social Determinants. And it provides a detailed roadmap and budgeting process for doing this.

This takes us back to the oversized impact of Social Determinants on someone’s health (see May blog, or the pie chart below): Healthcare contributes roughly 10%, whereas Social Determinants contribute approximately 50%. If a healthcare organization wants to improve the health of the community and reduce utilization of expensive services, the traditional approach might be to address; Care Management, Care Coordination, Care Education – all in the 10% bucket. This paper proposes: aim rather for the 50% – and impact transportation, education, food, exercise, environmental factors.

Pie Chart Image Illustrating Proportions

Social Conditions and Behaviors Contribute Over 50% Among Proportional Factors

Health-care organizations have traditionally hesitated to invest in upstream programs to improve social determinants because the direct benefits to their costs and profits are slippery, for several reasons;

  1. The difficulty in estimating those cost savings in advance.
  2. Doubts about whether the 3rd party services delivering the social services are competent.
  3. Possible losses due to plan-switching before the payoff can be realized.

Investments in social determinants, such as non-emergency medical transportation, have practical properties very similar to those of traditional public goods, according to the Health Affairs paper. As public goods, these proactive investments are susceptible to the free-rider or wrong-pocket problems (benefits accrue to a party that didn’t bear their fair share in project costs). A proposed integration between health plans, non-profits, county health agencies, hospitals and private practices could help by fairly and accurately distributing the costs—and benefits—of these public goods among these stakeholders.

The paper’s authors propose a step-by-step process to bring together these stakeholders, gather input, agree on data sources, determine unique community needs, select investment interventions, implement the program, and measure the results. Beyond providing transportation for healthcare appointments, the same concept could also be applied to jointly sponsoring community food stores with healthy food, exercise and workout opportunities, classes and coaching, supplemental infant nutrition, addiction treatment and prevention, and even neighborhood and household safety education.

Healthcare provider organizations may find some aspects of this concept out of scope, mission creep, or “not our job,” – I’m sure you have heard those arguments. However, these health-improving and cost-saving strategies make sense and can have a greater impact than many “in scope” initiatives we’re funding today. If we’re willing to spend on care management, and we’re finding that what really needs managing is social determinants, then why not?

Bottom line: we tend to think of Social Determinants as “Read Only” data – data about populations to include in healthcare analysis. But we should also consider that we can “Write, Modify, Edit” this data – to actively change the Social Determinants, for better health and improved healthcare. This case study shows how.

Please contact me for further discussion on ways to actively manage Social Determinants in your region.

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