In today’s America, people live in two distinctly different worlds. Dr. Garth Graham, President of the Aetna Foundation, points out that “life expectancy in New Orleans can vary as much as 25 years between neighborhoods just a few miles apart.” If a physician sees two patients, one from a well to do neighborhood in New Orleans and the other from one of the poorer neighborhoods, both of whom present with Type II diabetes due to overweight and a sedentary lifestyle, and that physician prescribed the exact medications and the exact lifestyle changes, will these two patients have the same outcome?
One of them, if she chose to, will be able to get a trainer to come to her home, and buy plenty of the best fresh produce, but the other will not. One will be able to arrange her schedule to arrive at work an hour later or leave an hour earlier to make it to her exercise class, whereas the other, an hourly employee, will not. And when the patient living in the poor neighborhood gets home, she won’t be able to go for a walk in her neighborhood because it might be too dangerous. There was a time when neighbors used to walk the sidewalks in poor neighborhoods, but now as crime has increased, residents are afraid to be outdoors. Actually, when Dr. Szapocznik asked mothers from an inner city neighborhood about their children’s play, they told him that after five in the afternoon, the mothers make sure that all the family is indoors because it is too dangerous to be outside.
We have named these factors that differ between the poor and the well to do and affect their health, social determinants of health. They are a set of individual, family, community and other social processes that affect the health of the poor. People living in poor neighborhoods, because of their lack of control about the jobs they do, because their inability to spend quality time with their families or have breathing space for themselves, because of crowded conditions at home, because of their economic and neighborhood conditions, may suffer from chronic stress that affects their health outcomes.
Our society has been sold a ‘bill of goods’: that healthcare is the most important factor in health, but it is not. In fact, according to Dr. Pascal Goldschmidt, Dean Emeritus of the University of Miami’s Miller School of Medicine, in the 20th Century our life expectancy increased by 25 years, of which five years we owe to medical advances and 20 years to public health innovations; innovations such as immunizations, workplace safety, improved lifestyle including reduced smoking, safer and healthier foods, and preventive care for mothers and babies.
A recent report from the National Academy of Sciences of the National Academy of Medicine concludes that “A growing body of research has demonstrated that social risk factors and health literacy may influence health outcomes as much -- or more than -- medical care does.” Thus in today’s value-based health care world we must ask ourselves, if social risk is an important determinant of health outcomes, how do health systems increase value for populations at high social risk?
We can look to Europe, where healthcare costs are lower but health outcomes - measured as longevity of the population - are better than in the US. Europeans have invested some of their erstwhile medical dollar on social services. It makes sense, doesn’t it? If what is preventing patients from having good outcomes are social processes, maybe social services can be as helpful as, or more helpful than, medical care alone. Whereas we spend 18 % of our Gross Domestic Product (GDP) in America on health, European Union countries tend to spend an average of 9% on health, with no country spending more than 12 %.
Those of us responsible for the health of patients who live in poor neighborhoods, can advocate for more jobs in these poor neighborhoods, we can advocate for more subsidized housing, but ultimately we must ask ourselves, what can we provide within our health systems? Can we move some of our healthcare dollars to social services?
What kinds of social services can deliver improved value? There is the misperception that while in medications and devices we should only use those that have sufficient scientific evidence to have been approved by the FDA, when it comes to social services, we propose services that feel good or make sense from a lay perspective. That is a mistake. We should be as uncompromising about what social services we choose as we are about what medications the FDA chooses. We must only use social services that have been scientifically proven to yield desired results. here are social service interventions that improve health outcomes among the poor such as patient navigators and case managers for patients with multiple chronic conditions. I am particularly interested in a set of interventions that have been found to have short and long term pay-off: parenting.
We know that the foundation of children’s wellbeing and healthy development is their experience within the family. From birth, children are learning and rely on parents and the other caregivers in their lives to protect and care for them. Parents help children build and refine their knowledge and skills, charting a trajectory for their health and well-being during childhood and beyond.
Under the best of conditions parenting is a very specialized set of skills. But, among the poor, scientists have found that parenting has to be quite precise- for example not too strict and not too lax; not too harsh and not too warm. As much as we might think that we should instinctively know how to be good parents, research shows over and over, that the children of parents who participate in parenting programs have better outcomes that parents that do not.
Over 50 parenting interventions have been scientifically proven to be effective. One of them, for example, the Nurse-Family Partnership has demonstrated improved prenatal health, fewer childhood injuries, fewer subsequent pregnancies, increased maternal employment, improved school readiness, and reduced delinquency in the children through age 21. With parenting programs we can prevent many of the social (health) scourges of our time such as delinquency (and eventually crime and incarceration), violence, school drop outs, drug abuse and addiction, risky sexual behavior, and even possibly having children drafted into the roles of victim and perpetrators in human trafficking.
We are not advocating that we abdicate our societal responsibility to address social inequities by improving the social determinants of health. Rather our intention is to point out that among the poor, health systems can achieve improved health outcomes by providing more than medical services.
How Do Health Systems Manage Care?
Given the transition of the US healthcare system from a fee-for-service system to one involving payment for quality and cost-effectiveness, how do individual health systems, particularly those financially responsible, all or in part, for a specific population, manage their care effectively, when one's zip code is the best predictor of one's health. It is, hopefully, not by "cherry picking" patients that are in the well to do neighborhoods, nor "lemon dropping" those patients who are in the poor neighborhoods.
As more and more persons are covered or have the potential to be covered by health insurance, it stands to reason that many of them will live in zip codes where they experience less desirable health outcomes because they are affected by the negative social determinants of health. If such persons are in individual health systems which do not address the social determinants of health, their healthcare costs will undoubtedly be greater and it will not be cost-effective to have them part of such entities, possibly even when they receive adjustments related to social risk. Thus, the negative health outcomes of these people will adversely affect the profitability of the individual health system. As a result, those responsible for the viability of such health systems will want to start introducing cost-effective interventions that reduce the health impact of social determinants on the patients for whom they are financially responsible.
They can introduce patient navigators and social workers not only assist patients in navigating the entire healthcare system, including inpatient, outpatient, home health, and social services (e.g. locating housing free of mold for an asthma patients), but also in managing complex care. Many of these patients have not had a regular physician and might not even know that they need to make an appointment to visit with a clinician. In addition, health systems can introduce pharmacists to actively manage patients with multiple conditions taking numerous pharmaceuticals through medication therapy management. Although health systems might not now believe they are in a position to plant trees in certain zip codes (which has been shown to reduce obesity-related chronic disease), some health systems have facilitated a truck selling reasonably priced fresh fruit and vegetables, coming into such neighborhoods.
Health systems will have to develop more innovative means to reduce health disparities to ensure that people who reside in zip codes with less desirable health outcomes not only can have their care managed more effectively, but reduce the negative health impact of patient’s social conditions. Health systems need not only look to existing scientific research to determine what social service interventions they might employ, but also initiate their own research because what works for their patients may be unique to their community. Given that healthcare is generally seen as local and that populations differ, it will be important for such health systems to prioritize the social interventions they might employ in a manner that seeks to achieve the best, yet most cost-effective health outcomes.
Although many value-based purchasing, bundled payment, shared savings, and payment for quality and cost-effectiveness initiatives may be a good start to revised payment mechanisms, insurers will increasingly focus on health outcomes. We cannot implement such new payment mechanisms in a way that only exacerbates the health disparities, we already have. We must find ways to level the playing field and incentivize health systems to strive to ensure better health outcomes for all, including for patients who live in zip codes with the least desirable health outcomes. Not only is doing so the right thing, but from an economic perspective we cannot afford to do anything less.
We are going to have to employ public private partnerships at a community level. We are going to have to recognize that the many tenets of public health are important in population health management. There is much health systems can do to ensure that the populations for which they are responsible are healthier and have better health outcomes. It starts one step at a time, by introducing cost-effective interventions that reduce the impact of social determinants on the patients for whom they are financially responsible. The initial challenge will be to identify and employ the most efficient interventions that that can be implemented in the shortest period of time, while moving forward with the more expensive and complicated interventions as the positive effects of these earlier interventions are realized. We do this in public health, e.g. providing mosquito nets to people in areas where malaria may be prevalent, when we cannot rid the community of malaria-carrying mosquitoes.
Whoever is the next president will have quite a challenge to redesign current health system policies in ways that will work for all, creating a system of incentives for health systems introducing cost-effective interventions that reduce the impact of social determinants on the patients for whom they are financially responsible and to be paid for the value of health outcomes. Whoever she or he might be, the timely actions that they employ are critical at this juncture, less we face a possible implosion of our healthcare system. We cannot afford to go from healthcare expenditures of 18% of GDP to 20% to 22%. If we merely reconfigure the value-based purchasing initiatives and not tackle the underlying social determinants of health that exist in many zip codes, we will not achieve a quality and cost-effective healthcare system for all.