Why take social determinants of health into account in health care payment?

April 21, 2021 / By L. Gordon Moore, MD

Imagine I have two patients with diabetes. Person A has very mild disease and does well with a treatment plan of self-directed diet and exercise. Person B has more severe diabetes and needs pills plus insulin, so requires more intensive medical resources due to their burden of illness. It would be wrong to provide the same treatment to Person A and Person B.

Now let’s imagine Person C, identical to Person B in terms of illness burden, but Person C (unlike B) has a long walk to the bus, is not permitted to take time from work to go to the doctor, doesn’t have access to a refrigerator at work for their insulin, can afford fast food meals but not the time or money it takes to obtain and prepare fresh fruits and vegetables (nearest grocery store is an extra 30 minutes on the bus). In contrast to Person C, Person B has a personal trainer at their gym, can afford the out-of-pocket copays for health coaching, etc.

If I want all three people to have the best possible outcomes, I need to prescribe a lot more medicine, testing, and follow up care to Person B, and Person C will need all of that plus I would want to get her access to nutritious foods, easier access to appointments with me, her physician, as well as health coaching to support Person C’s lifestyle and behavior change journey.

Some exemplary medical practices that serve many Person Cs have installed food banks in their clinics, invested in phone as well as video visits and expanded hours to accommodate challenging schedules. They also have hired staff to screen for the non-medical factors that get between people and their optimal health and wellness, have staff who connect with community-based organizations (housing, job training, prescription support, etc), and hired staff who work out in the community (e.g., community health workers) to connect with people who may struggle to engage with the health delivery system.

When practices bring these resources to bear on the issues facing Person C, health outcomes improve (reductions in unnecessary emergency room visits, hospitalization, readmissions) and people report improved quality of life.  A practice doing this work would be an example of high performing primary care.

For the most part, this work is not part of health care financing and it is very costly to the practices. We put 4-7 percent of health care dollars towards primary care in the U.S., while OECD countries range from a 15-20 percent spend on primary care.

If we want to reduce the inequities in health care delivery, we should provide primary care practices with the resources they need to meet the needs of the people they serve. One way to do that would be to adjust payments based on social determinants of health—more resources to meet the intensity of work for people with greater needs.  We adjust payment for burden of illness; maybe it’s time to additionally adjust for SDoH.

Come hear an excellent discussion of SDoH with an expert researcher in the field:  Robert Phillips, MD, MSPH, Vice President for Research and Policy, The American Board of Family Medicine, our guest on the Inside Angle podcast.

Dr. Gordon Moore is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.