For better health care, look beyond medicine

Expanding our view of health may reverse unhealthy trends.

The United States needs to realize it will take more than drugs and doctors to reset the country’s health.

We spend $3.5 trillion a year on health care — 18 percent of the country’s gross domestic product.¹ This figure is projected to rise by 5.5 percent annually, which means by 2026 our yearly bill of health costs could ring up to $5.7 trillion.²

And we aren’t getting any healthier because of it. Lower life expectancy and increasing rates of chronic disease are just two telltale examples of our declining well-being.^3,4

While there is no quick fix, many experts are taking a stand to slow the unhealthy trend. It will require looking at all the factors that affect health, not just the medical ones.

A health care model that considers social factors holds potential to guide us toward improved quality of life and a sustainable health care system.

·         See text version of infographic 

·         See text version of infographic 

Mind — and begin to mend – the gap

Trying to improve the health of a population without addressing social determinants of health (SDOH) is like expecting crops to thrive in poor soil simply by adding more water. While necessary, the hydration can’t completely compensate for the underlying soil condition.

“What we’re doing now — ignoring social determinants and over-medicalizing health — doesn’t work,” said Ethan Berke, MD, MPH, a family physician and current chief medical officer of population health solutions and vice president of clinical innovation for Optum.

Several research efforts estimate that medical care accounts for only 10 to 20 percent of health outcomes.⁵ Other factors include biology and genetics, individual behavior, social and physical environment and government policy.⁶

“If we’re being held accountable for improving health and not health care, why would we rely on a tool that’s only 10 percent effective? So, as we move into a value-focused system, and step away from volume, finding every lever at our disposal is critical to be successful,” Dr. Berke said.

Defining social determinants and their value

The World Health Organization defines social determinants of health as the “conditions in which we live, work, play and age as well as the forces that ultimately shape those conditions.”⁷

The U.S. Department of Health and Human Services defines determinants of health as the “range of personal, social, economic and environmental factors that influence health status.”⁸

Think of our well-being as a web. The social determinants are influences that weave together to sustain and foster holistic health. Food security, housing, safety, access to transportation, economic stability, education and social support systems all affect our ability to live long, healthy lives.⁹

It’s important to understand SDOH as they impact the health of individuals, but also the health of populations, which can vary by geographic region, social status and race.¹⁰

Jeffrey Brenner, MD, senior vice president of clinical redesign at UnitedHealthcare Community & State, explained that the social determinants model requires a macro view of the health landscape.

“Ultimately, we’re working to provide better care at a lower cost in the most judicious way to the most individuals,” Dr. Brenner said.

“We need a broader lens. And we need to understand people’s health problems more deeply. By thoughtfully examining why we use health care, how we use health care and the structural services available to meet patients’ needs, we can unlock better care at a lower cost, accessible to more people.”

SDOH: New emphasis, not new concept

The notion of improving health by addressing social determinants is not entirely new.

“People are starting to realize pharmaceuticals and surgical interventions are not the only route to health care,” Dr. Berke said.

“Social determinants serve as the base for how many of us have practiced for decades. And, when you look around the world, it’s not a new concept in terms of the decisions other countries make on how to balance medical and social spending to impact health outcomes.”

John Selig, vice president of public sector programs at Optum, saw a growing interest in social determinants while he was Arkansas’ director of Health and Human Services.

During that time, the 2013 book “The American Health Care Paradox, Why Spending More Is Getting Us Less” was published.

The writers compared spending on health care and on social programs, such as child care, food security and transportation, in 30 industrialized countries.

Their research revealed that while the United States spends a great deal per capita on health care, it spends relatively little on social supports.

Moreover, they found a strong correlation between a country’s ratio of social to health spending and its health outcomes. Countries that put more emphasis on social programs had better results.

·         See text version of infographic 

“That study had an impact on people throughout the health field,” Selig noted. “It made the case that we should consider shifting some of our focus away from health care spending to social services.”

On Yale University’s “The MacMillan Report,” one of the book’s authors summarized their findings on Scandinavian countries as compared to the United States.¹¹

Author and global health scholar Elizabeth Bradley said the Scandinavian countries have a longer life expectancy and half the infant mortality rate of the United States.

While the United States spends 18 percent of its GDP on health care, the number in Scandinavia is closer to 10 percent. For social services, spending is 10 percent of GDP in the United States and 20 percent in Scandinavia.

Bradley’s point: Taking a more comprehensive approach, coordinating medical care and social services, appears to lead to better outcomes at a lower price.

The path forward

Many public and private efforts to address SDOH are now underway.

For example, the Louisiana Permanent Supportive Housing program provides affordable rental housing and support services needed to retain that housing for people with severe and complex disabilities.

The program, began after Hurricanes Katrina and Rita, has served more than 2,000 households.

UnitedHealthcare began a community-based, data-driven housing and social service solution in 2016 for people who use the health care system most. The solution, called myConnections, addresses non-medical factors from housing to employment and financial stability.

The people served have become more medically stable and use fewer health care services than before, and many are now living independently in their own homes.

Selig and other experts note that we must continue to test programs such as these and research the most effective and efficient ways to build social determinants into our health infrastructure.

“Integration of social determinants will take time because we want to understand what works,” he said.

“We don’t necessarily want to spend more, but rather to see how to shift the dollars to improve outcomes. This is a relatively new field, and it will take some trial and error to find the best approaches. The potential is high enough that it’s worth the investment.”

Dr. Berke sees the model accelerating positive outcomes in public health, where engagement and relationships can play a leading role to make health care sustainable. Applying a bio-psycho-social model to a patient creates a holistic model unique to a person’s specific needs.

“We don’t throw the medical away. But there’s an important sequence to engaging patients, building trust, forging relationships and instilling confidence,” he said.

“We think about how to get patients activated and to feel confident, so they can be a part of their own health and health care. That empowerment is an important concept because the ultimate goal is better health. Health care is a tool to get there. Instead of focusing on the disease, we focus on the person.”

Dr. Berke said Optum is redesigning many of its population health management programs to remove the barriers that hinder an individual from managing their own care.

“How could I possibly expect you to check your blood sugar, purchase a new medication, stand on this Internet-connected scale and jump through other hoops when you don’t have housing and food?” asked Dr. Berke.

“So, starting with what people worry about, what they feel they cannot achieve on their own, we have the opportunity to help remove barriers and guide them to a place where they feel they can better manage their condition,” he said.

“From there, we can be more effective with medical care because we will have removed those factors impeding their ability to engage.”

https://www.optum.com/health-insights/social-determinants-of-health.html