By Robyn Alie, Manager, MMS Policy and Public Health
Sofia has poorly controlled diabetes and asthma, obesity, osteoarthritis, and dependency on opioids. At 45 years old, she’s on multiple medications. She is intelligent and industrious, but her life circumstances have limited her academic, employment, and financial opportunities and led to serious health issues. Growing up, she had limited access to nutritious food, physical activity, and school enrichment programs.
This anecdote opens a new book, Well, by Sandro Galea, MD, MPH, DrPH, dean of the Boston University School of Public Health. The book looks at the factors that make us healthy — or not. “Our health is not defined by things like seeing doctors or taking medicines or getting in our 5,000 steps a day,” writes Dr. Galea. “Rather, it’s defined by the full spectrum of our life circumstances, from the families we come from to the neighborhoods where we live to the people we see and the choices we make.”
These life circumstances that influence health, or social determinants of health (SDOH), have become a focus of discussions about health care outcomes and costs in Massachusetts and across the nation. Social determinants, defined by the World Health Organization as “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness,” refer to factors such as the availability of healthful foods, safe and affordable housing, access to education and job opportunities, transportation options, social support, and exposure to crime, poverty, and discrimination.
How SDOH Affect Health
Social determinants are responsible for 80–90 percent of modifiable contributors to health outcomes, with medical care claiming only 10–20 percent. For example, lack of stable housing contributes to higher rates of tuberculosis, hypertension, asthma, diabetes, and HIV/AIDS, and more frequent hospitalizations. Children who are food insecure are more
likely to have impaired brain development, more hospitalizations, iron-deficiency anemia, and behavioral disorders.
Patients across the Commonwealth
Physicians see the effects of these nonmedical factors every day. According to the 2018 Survey of America’s Physicians, almost 90 percent of physicians say that “some,” “many,” or “all” of their patients are affected by a social condition that presents a serious impediment to their health. “Social determinants of health affect all persons regardless of type of insurance coverage,” said MMS President
Maryanne C. Bombaugh, MD, MSc, MBA, FACOG. Payers are increasingly exploring how to address SDOH as a way to control skyrocketing health care costs. MassHealth is at the forefront of this effort (see MassHealth ACOs Beginning to Address Food, Shelter, and Safety as Part of Health Care Delivery.)
The AMA and United Healthcare recently announced a collaboration to standardize data collection of social determinants of health to help address individuals’ unique needs. They’re supporting the creation of 23 new ICD-10 codes to capture, among other things, patients’ access to nutritious food, adequate and safe housing, and transportation as well as their ability to pay for medications and utilities. The codes would trigger referrals to social service organizations and other community resources.
The Physician’s Role
But is assessing patients’ SDOH really the physician’s role? Many physicians find themselves already overburdened, unable to spend as much time with patients as they would like and lacking the resources to identify, let alone address, these social challenges. In reality, many physicians are already trying to address SDOH with patients, finding alternate solutions, for example, when patients cannot afford their medications or have no transportation to fill a prescription.
Resources are ramping up across the state to support patients. Boston Medical Center has committed $6.5 million to initiatives to help patients find and maintain affordable housing. Physician organizations like Atrius Health employ care facilitators and community health workers to link patients to social services. Hospitals, the state, and community organizations are providing web- and app-based tools to help patients and providers find community resources to address nonmedical needs.
Advocating for Social Policy Solutions
However, these health care system-based tools don’t solve the larger problems. In a January Health Affairs blog, Brian Castrucci of the de Beaumont Foundation and John Auerbach of Trust for America’s Health wrote that while “health providers’ efforts to meet individuals’ nonmedical needs are praiseworthy and potentially life-saving,” policy changes that get at the root causes are needed. “Health care navigators and similar enhancements to health care can’t actually change the availability of resources in the community. They can’t raise the minimum wage, increase the availability of paid sick leave, or improve the quality of our educational system. These are the systemic changes that are necessary to truly address the root causes of poor health.”
Physicians can play an important role in helping to effect systemic change, according to Dr. Bombaugh. “I view advocacy as a form of patient care. These social determinants have a profound effect on health, so addressing them is in our lane. We have a voice, we can influence decisions,we can make change
happen through advocacy. We can offer the medical expertise regarding the effects of these social determinants of health.”
She added, “How do we accomplish the most we can? We do that by taking a holistic view of what it means to have health, to have well-being. Clinical care is important, but if we want to truly impact the health and well-being of patients, we need to consider everything that may be affecting them.”
