Hiding in Plain Sight
Every evening, David Smith drives past North Lawndale, a neighborhood on the west side of Chicago, on his way home to the suburb of Western Springs, where the median income is more than five times that of Lawndale.
During his 20-mile commute, Smith has contemplated the privilege of his family’s position. The founder of Chicago-based consultancy Third Horizon Strategies, Smith thinks about his 7-year-old daughter and how her life is likely to unfold in very different ways from, say, a 7-year-old cohort now growing up in Lawndale. Statistically speaking, Smith says, the Lawndale child will live until she is 65, while his daughter will live until she’s 82. “That little girl will make $30,000 a year,” he says of the Lawndale child, “and my little girl will make $80,000 a year.”
As the girl in Lawndale ages, Smith says, she will be six times more likely to have Type 2 diabetes, chronic kidney disease, renal failure and hypertension. And she will be five times more likely to die in labor than his daughter.
“These are the same 7-year-old girls, with wildly different outcomes in their lives and wildly different demands on the healthcare system,” he says. “This is an enormous societal problem that we all have a citizen’s obligation to address.”
Our quality of life is often linked to access to education, healthcare, healthy food, affordable housing and social support networks.
One report found 53% of people who were uninsured or insured through public or individual plans were adversely impacted by such social determinants of health.
Within the industry today, there’s a growing awareness that improving social determinants can improve health and cut healthcare spending.
Smith’s observation underscores the role of social and economic conditions on our health and our earnings. Our overall quality of life is often linked to our access to education, healthcare, healthy food, affordable housing and social support networks. For more than a century, the public health sector has understood that the local hospital is not nearly as responsible for our well-being as are the communities in which we live, work and play. In fact, it’s estimated that a local healthcare system and insurance options account for about 20% of what drives health and mortality. Genetics accounts for about 30%, and the other half is an amalgam of an individual’s choice, environment and economics.
These factors, dubbed social determinants of health (SDoH), have long been scrutinized by public insurers and healthcare systems, and today there’s a small but burgeoning awareness among employers and private insurers that improving employees’ social determinants could not only improve their health but also cut their healthcare spending.
“It’s time to do something different,” says Dr. Bruce Sherman, chief medical officer at the National Alliance of Healthcare Purchaser Coalitions. “The burden is on the employer to identify issues in the workforce and start thinking about creating solutions. There really is an opportunity to be more thoughtful, use available evidence and create a systematic approach that is good for employees.”
The Case for SDoH
Experts tend to group social determinants of health into a handful of categories: economic stability, education (including literacy and graduation rates), physical environment (housing, water and transportation), food (access and hunger) and community (workplace conditions and isolation). A 2018 McKinsey & Co. survey of more than 2,000 people who were uninsured or insured through public or individual plans, not employer-based coverage, found that 53% were adversely impacted by at least one social determinant of health. The most common was food insecurity.
And while it may seem that these issues affect only poorer, uninsured populations, that is not the case.
Pamme Taylor is the senior vice president of social innovation at Solera Health, a Phoenix-based benefits network connecting payers and patients with community resources. Before working at Solera, Taylor ran a national call center for health plans that worked to help individuals with social needs. They captured 500 transactions each day. The center was made available to its own associates, and about 10% of the workforce needed SDoH assistance (including their executive team).
ProMedica, a healthcare organization headquartered in Toledo, Ohio, began screening for hunger in the community about six years ago as part of its diabetes work. Those efforts expanded into screening all patients for 10 social determinants. About 35% of commercially insured patients at ProMedica have some kind of unmet social need. “Something like isolation or behavioral health cuts across all income and demographic levels,” says Kate Sommerfeld, president of social determinants at ProMedica.
And unmet social needs directly relate to poorer health outcomes. Almost half of those in the McKinsey study who reported having high healthcare use or poor health also said they had more than one SDoH problem. People with food insecurity and transportation challenges were more than twice as likely to have multiple emergency room visits and to have an inpatient hospital visit over the past year. Those in unsafe communities were three times more likely to go to the ER over a year’s time.
HMS, a healthcare technology, analytics and engagement firm based in Irving, Texas, recently released a white paper on social determinants of health. The paper found that people with concerns about social challenges like food and shelter were five times more likely to report having poor health, more than twice as likely to say health negatively affected their work and eight times more likely to report high stress.
And because they impact health, these social issues affect healthcare costs. A 2018 article in Population Health Management, a public health journal, analyzed data from a managed care group’s call center and found that people with SDoH needs who were connected with social services reduced costs by $2,443 per member per year when compared with those not receiving help.
Solving food insecurity can lower healthcare costs for employers by 15%, according to Sommerfeld. Ensuring quality food has been shown to lower hospital readmissions, ER and primary care visits, she says.
If an employee’s child has asthma, it makes sense to send someone to examine the employee’s home for mold or other air-quality issues, says Randy Oostra, ProMedica’s CEO. That’s less costly than having the child end up in the emergency room a handful of times over a year.
“An investment in these things keeps people out of healthcare facilities, which is costing businesses a fortune,” he says. As the head of a healthcare organization, Oostra says he isn’t blind to the fact that health systems make money only when people go to hospitals, not by keeping patients away from them. “I think there’s a real intervention model that can be built with companies to take better care of employees,” he says. “It’s going to fundamentally reduce costs, but it’s not going to be driven by healthcare organizations. It’s going to have to be done by employers.”
Most of employees’ healthcare cost-cutting efforts have focused on changing benefits designs or raising deductibles. But with the increasing understanding that most costs are driven by other factors, the path needs to be changed, says Dr. Karen DeSalvo, a co-convener of the National Alliance to Impact the Social Determinants of Health.
“The pendulum swinging to think about a person’s whole health is somewhat driven by reducing costs,” DeSalvo says. “We are now in a place where the system is saying there is more to this story.”
Most Vulnerable Hit Hardest
Though experts agree that social challenges cross class boundaries, poorer people do tend to bear the brunt. And much of what is known about SDoH is because of research done among this population.
The HMS white paper found that lower-income groups were more apt to miss preventive care visits and maintenance, such as screenings for blood pressure, cancer and diabetes. The authors hypothesize these patients—particularly those making $25,000 or less a year—sometimes have to choose between necessities such as food and housing over healthcare.
In 2017, Sherman wrote a paper that found almost one third of the nation’s civilian workforce with employer-sponsored insurance earned less than $30,000 a year. Another 13% earned between $30,000 and $40,000. A follow-up study that Sherman published a year later in the Journal of Occupational and Environmental Medicine found lower-wage workers may cost employers about the same as higher-wage ones because they use the healthcare system in more reactive, and thus less efficient, ways.
Sherman and his colleagues analyzed the healthcare activity of more than 40,000 employees from four employers enrolled in a health insurance plan through a self-insured private exchange. The researchers found that, for lower-income employees, deductibles accounted for 10% of total wages as opposed to 1% among higher-wage workers. Low-income employees had greater incidence of chronic illness and mental health conditions. These workers also used half the amount of preventive care that higher-wage earners did and had almost twice the hospital admissions, more than four times the number of avoidable admissions and three times greater use of the ER.
In 2017, Aetna analyzed its commercial group-plan customers and came to similar findings: low-wage workers had a higher incidence of preventable conditions; diagnosis and treatment of illnesses occurred later; and they more often received treatment in higher-cost settings, such as the ER.
DeSalvo says she has seen a lot of discussion about social determinants among large employers and those with low-wage workers—but scarce action. To date, much of the impetus has been on the healthcare system to make change. But DeSalvo says employers are beginning to consider if they should be more involved in remedying these unmet needs.
Every group of employees is going to have different unmet social needs, depending upon their circumstances. But data are available, some at employers’ fingertips, to help identify them.
At a base level, internal, human resource records can be used to tease out social factors that might be impacting healthcare. For instance, a ZIP code can show crime data, income levels and the presence of food deserts (places where access to fresh, healthy food is scarce). Other SDoH factors such as education levels, wage status, work hours and the adoption of health insurance and wellness programs can also help create an individual’s health profile.
After a profile is created, an employer can make certain assumptions. As DeSalvo says, even “guessing isn’t necessarily bad.” For instance, food tends to be a priority for most groups, regardless of their socioeconomic status. In lower-wage groups, housing tends to top the list. If there are a lot of diabetics in an organization, food or exercise is likely an issue. If asthma is prevalent, housing is often the culprit. And people living in rural areas tend to be more likely to struggle with transportation.
Age-related assumptions can be made as well. According to Taylor, a self-insured employer will typically have about 5% of its staff nearing retirement but not yet switched to Medicare. Falling is a risk that has been identified for that group. Knowing that, an organization could design a fall-prevention model and connect people in that age group to tai chi classes or balance programs or send someone to their homes to check for fall risks. People who receive this assistance could then be monitored to see if the program was effective compared with employees who didn’t take part.
Then there’s claims data. Dr. Rishi Manchanda, CEO of Burbank, California-based Health Begins, says his organization uses claims data from insurance companies to help pinpoint issues that might be in any population. One analytics solution, known as risk intelligence, rates people based on their barriers to care by identifying factors such as missed healthcare appointments, prescription adherence, or absence of preventive care visits. Manchanda says insurers and vendors are commonly doing this, though it may be harder, but not impossible, for employers to get this data.
Solera also uses claims data to identify SDoH needs among populations. Working directly with payers, Solera will look at a population’s claims, take member-level data, run it through a “social propensity model” and identify people who are at risk due to, for example, a lack of healthy food. Then Solera determines the risk for diabetes and helps set up a disease-management program that might include home-delivered meals or health education through a local grocery store. Solera also works with employers directly using biometric data or online screening to identify employees at risk.
“Interventions can be sculpted to a population and its needs,” Taylor says. “What is put together would be different for an aging population, low-income or an executive population, but all have social needs.”
Solera’s program also features an important link in the chain to developing and standardizing healthcare programs around SDoH—reimbursement. This has traditionally been a challenge for treating social determinants, because there hasn’t been a way for insurers to pay for things like providing healthy food or remediating mold from a home.
Solera began its work by creating a model that supported the Diabetes Prevention Program for employers and health insurance companies. The Diabetes Prevention Program has created partnerships between public and private organizations to offer evidence-based, cost-effective interventions that help prevent Type 2 diabetes. The Centers for Medicare & Medicaid Services (CMS) allows health plans to pay for diabetes prevention. Taylor says providers get reimbursed using CPT codes for preventive measures and targeted diabetes interventions under the category of health education.
Also working on codes is insurer UnitedHealthcare, which has recently partnered with the American Medical Association to help create a new set of ICD-10 codes. These codes are used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses and help standardize everything from processing health insurance claims to tracking disease epidemics and compiling worldwide mortality statistics. Using medical data in combination with patients’ self-reported SDoH information, the codes would identify people with unmet needs and prompt referrals to local social agencies.
Assessments and individual interviews round out the data-gathering opportunities for employers. Assessments are a useful tool and, like the one used at ProMedica, can be as simple as seven questions answered on an iPad. These allow insurers and employers to directly understand employees’ needs.
AmeriHealth Caritas District of Columbia formed a relationship with Lyft in 2017 to provide on-demand transportation to its members. Members can call into AmeriHealth’s outreach team, which books rides to and from health promotions, education and other related services. If members need a ride to medical treatment, they call into a non-emergency transportation number.
The organization analyzed claims data from six months before the program began and again for the same members six months after implementation. They found that members taking part had higher healthcare compliance and reduced inpatient stays, emergency room visits and ambulance transportation.
A recent report from Anthem Public Policy Institute underscores the importance of getting information directly from individuals. Working with Quid, a software analysis company, Anthem was able to analyze news, academic papers, and personal posts and comments on health forums with the goal of distinguishing how social determinants were perceived by people dealing with them versus the general public.
When asked about needs, individuals’ top healthcare challenge was navigating the system itself, followed by social support, food, economic stability, neighborhood and education. Researchers and the media, however, focus more on education, then economic stability, the healthcare system, neighborhood, social support and food. The authors estimated the difference might be partly due to researchers’ ability to measure factors such as educational attainment and income as opposed to a factor such as isolation. A major concern raised by the media and researchers—access to culturally sensitive care—did not appear on any of the public’s posts.
The Gravity Project is a collaborative of public organizations working to identify and standardize data on SDoH. The project is headed by the Social Interventions Research & Evaluation Network out of the University of California San Francisco and EMI Advisors, with funding from the Robert Wood Johnson Foundation.The goal is to build the data support system needed to better understand and effectively treat SDoH problems. The Gravity Project supports everything from screening and treatment to CPT codes for payment to interoperable electronic health information exchange using Fast Health Interoperability Resources (FHIR, pronounced “fire”), which is quickly becoming the industry standard API for data sharing.
Following Healthcare’s Lead
Most employers making grand steps in social determinants are healthcare organizations at this point. They have been able to take what they see among their patients and translate that internally. For many other employers, however, putting social determinant programs into benefit packages is still fringe thinking.
“They have a long way to go to understand the issue deeply,” says Manchanda, CEO of Health Begins. “They need to get in the mix and figure out what it might mean for them, or they will be playing catch-up. It behooves employers and brokers to start to do a deep dive and understand what the value proposition is and how they can experiment with their budgets.”
Allotting money to fix someone’s home or investing in early childhood education without a guarantee of return on investment may seem like an obscure idea for executives. But Manchanda says the public health space offers plenty of evidence.
According to him, there is at least 30 years of evidence in the healthcare sector showing that assessing and addressing social needs across a population is the best model of care.
“What’s new is people’s understanding of the term social determinants,” he says. “What hasn’t been shown is how to take it and put it into different spaces like employer-based health insurance. And that is a challenge—but a good one.”
The goal is to find ways to reach individuals for assessment, help them get treatment in the healthcare system or through other services, and share that information with the employer or insurer for evaluation. “You need to have a closed-loop process to tell where a patient ended up going or that affirms there was some resolution to their needs,” Smith, of Third Horizon Strategies, says.
Because the solutions in the business world are newer, employers and brokers do have to make sure they are doing more than just throwing solutions at the wall to see what sticks.
“There’s lots of wasteful spending out there,” Manchanda says. “It’s time to become smart purchasers.”
Smith agrees. Employers and brokers, he says, will need to vet these programs effectively to find which are best for their insured populations. Progress in this area is encouraging, but because the industry is growing so rapidly, “it’s noisy right now,” he says.
Another challenge for employers looking to integrate social determinant solutions into a benefits plan is that most programs are underwritten for a year. It’s difficult to realize the fruits of SDoH work in that amount of time, one reason insurers frequently opt to provide SDoH solutions that work in short-term cycles, such as transportation to fill a prescription or see a doctor.
An example of this is ProMedica’s food prescriptions for patients dealing with food scarcity. The scripts can be taken to a food pharmacy or food clinic with which ProMedica partners. The system also has a grocery store where employees can get food and a mobile grocer that travels to its different sites. These prescriptions help fill an immediate need for someone lacking food.
Manchanda said short-term solutions like food and housing are often seen as a good investment because they garner “early wins” that can be seen in one budget cycle. “But we are not seeing employers or insurers figuring out how to do things with longer-term social returns, like early childhood education,” he says.
Businesses could learn from healthcare organizations and insurers that have done more outreach and been intimately involved in improving the health of their communities. Along with advocating for early childhood education, businesses can work to pass smoking bans, create walkable neighborhoods, improve public transportation, and increase the amount of safe, affordable housing. ProMedica created a financial opportunity center that assists employees with financial wellness. These efforts are more challenging to get involved in because they take longer-term efforts, payoffs aren’t immediate and they don’t always directly impact employees.
Kaiser Permanente has done this near its Oakland, California, headquarters. The organization recently invested more than $5 million to purchase and upgrade a 41-unit housing complex that will be retained as affordable housing. The company also invested $50 million in loan funds to create and preserve low-income rentals for people living in Kaiser’s service areas.
Taylor, the senior vice president at Solera, says employers that understand the importance of work in the SDoH space should be working with insurance plans that “get it.” Some are doing a lot more work in this space than others. Insurers and vendors should be able to demonstrate how they are coordinating holistic delivery programs rather than just offering isolated solutions, she says.
“One health plan may say, ‘We have a great transportation benefit and have added extra trips,’” she says. “They should say, ‘We know getting to a doctor and getting access to healthy food is a transportation issue, so here are ways to make transport easier.’ They should look for groups that see the bigger picture.”
About three years ago, Cottage Health, a healthcare system based in Santa Barbara, California, created its population health department. The company wanted to take a deeper dive toward understanding what makes area residents healthy. To find out, Cottage Health performed a health needs assessment combined with a listening tour, interviewing its own staff as well as 250 community, religious and nonprofit leaders.
It created a screening tool with seven questions including whether people have lacked money for food, if they were concerned about their housing stability, if a lack of transportation had kept them from work or health visits, and if they had mental health issues like depression or stress. The company decided to test the tool on its own employees as well, during their visit to get a required tuberculosis shot.
What it found was unexpected. Even in a higher-income area like Santa Barbara, a large number of Cottage Health employees were struggling. Of the 2,445 employees who have taken the survey to date, 25% have screened positive for at least one unmet social need. The largest was behavioral health at 11.2%; next was food disparity at 9.4%. Housing came in at 7.8% and transportation at 4%.
“Everyone was really surprised,” says Katy Bazylewicz the organization’s vice president of population health. “These are the indicators that lead to poorer health, so we really wanted to look at how to improve those in the workplace.”
With the support of the CEO and board, Bazylewicz says, Cottage Health immediately raised the salaries of all staff. Cottage Health already offered an abundance of housing resources, including mortgage assistance and reduced-rate rental housing for employees, which might explain why the company didn’t see more challenges with housing.
The company started looking at other options, and Bazylewicz decided to use data-driven programs to tackle the issue of hunger. Employees who indicated they were at risk for food insecurity were provided with resources in the community to help. They also determined an easy and anonymous way to reduce need would be to load money on the employees’ badges. They had 17 employees accept $50 uploads that could be used at the system’s cafés, farmers market or cafeteria.
The organization learned a couple of good lessons during its efforts in this space. First, people appreciated their employer’s making this kind of effort.
“From talking about it at forums…people said that, for us to understand and help employees, they were incredibly proud and thankful and appreciative,” Bazylewicz says.
Second, connecting people to resources can be a challenge. Though they offered money to everyone who identified as food insecure, not everyone accepted. When employees self-identified with needs and Cottage offered to link them with a community resource navigator, not everyone was interested.
The health system’s next order of business is to work in the space of behavioral health. Cottage Health is in the process of looking at options and understanding how it can best provide assistance to employees with mental health challenges.