Social Determinants of Health- Are They Still Relevant?

Aug. 17, 2015 / By Steve Delaronde

What is the impact of the social determinants of health, such as income, education and occupation, as U.S. health care moves from volume to value-based care with a focus on population health management? Providers of health care have been well-trained to focus on the clinical manifestation and treatment of disease, but often struggle with the environmental and social context within which they occur.

The treatment and management of health conditions has typically been a one-size-fits-all approach when it comes to socio-economic status (SES). Conditions that are most amenable to population health management are typically chronic and often require frequent visits to a physician, lab, or outpatient facility, multiple medications, lifestyle modifications, treatment plan adherence and costly out-of-pocket expenses. All of these issues are challenging, particularly for those patients in lower SES groups.

The social factors that influence health play a major role in who gets sick in the first place, and remain important factors in the maintenance and restoration of health. While access to medical care is an important component, simply providing universal access to health care does not eliminate disparities across SES groups according to a 2008 study comparing SES status across 22 European countries. Thus, policy decisions that affect a population’s health not only pertain to the availability, quality and cost of health care, but include larger issues related to poverty, unequal educational opportunities and racial discrimination.

Poverty leads to poor health status and presents challenges in maintaining positive health behaviors. For example, substandard housing exposes its occupants to lead paint that can cause cognitive delays and household allergens can exacerbate asthma in children. Neighborhoods that do not offer safe places to exercise, convenient access to nutritious food, and public transportation can make it challenging to fulfill treatment plans that require regular exercise, special diets and frequent healthcare visits.

People with lower educational attainment are more likely to hold jobs that do not offer flexibility to attend frequent medical visits, allow paid time off to care for sick family members, provide gym membership or other fitness opportunities and may include physical demands that make a person more susceptible to injury. Finally, a low income means that patients may not be able to afford the medications and treatment that is required, since they may be in plans with higher deductibles or copays.

The health care system can begin to address the disparities in health associated with SES differences the following ways:

1. During medical visits, collect information related to patient’s social history and living situation, such as the neighborhood where they live, outdoor exercise options, social support systems, financial situation, occupation, and environmental stressors. This information should then be used when developing a treatment plan.
2. Consider the cost to the patient of the treatment that is being rendered and recommended, including medications, and help the patient determine whether these present a barrier to treatment. If yes, then work with the patient to identify less expensive treatment options.
3. When evaluating physician’s using performance and outcome measures, consider using risk-adjustment methods that factor key social determinants of health. This will incentivize, or at least not penalize, physicians and health systems that treat a greater proportion of low-SES patients.
4. Advocate for changes in the social circumstances of populations that are likely to lead to poor health outcomes, such as poverty reduction, safe neighborhoods, availability of fresh and nutritious food and high-quality education.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.

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