The World Health Organization (WHO) defines “social determinants of health” (SDOH) as “…the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.” The WHO further specifies that social determinants are factors that give rise to disparities in health outcomes, particularly those that are inequitable and produce avoidable outcome differences within and between countries.
The Centers for Disease Control and Prevention (CDC) provides an expansion on the WHO definition: “The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.” The CDC further breaks down SDOH into five discrete components: 1) biology and genetics, 2) individual behavior, 3) social environment, 4) physical environment, and 5) health services.
Third-party payors take notice
Until recently, SDOH was a topic for academics, analysts and legislators. The academic study of SDOH began with the famous Whitehall studies of Sir Michael Marmot. Those studies found that the health of a British civil servant correlated strongly with his social rank. Realizing the importance of social metrics of health, healthcare organizations are beginning to address SDOH in an effort to provide high-quality, low-cost healthcare to their members.
A 2018 study showed that 80% of American payors agreed that attention to SDOH would be an important goal of their provision of services going forward. Several payors have already implemented programs aimed at eliminating disparities in health outcomes attributable to SDOH. Many such programs have begun to publish preliminary data.
In 2017, Anthem, Inc. collaborated with the National Urban League and Pfizer Corp. to carry out a pilot project designed to reduce disparities in health outcomes in African-American communities in three American cities. The study included 290 participants who were administered a questionnaire that assessed their willingness to undergo screening for various conditions. The intervention consisted of a web-based tool that also encouraged participants to attend in-person seminars. The preliminary results showed that the educational intervention caused significant increases in professed desire to undergo screening tests.
Humana, Inc. launched its Bold Goal initiative in 2015. The objective of the project is to generate a 20% increase in a CDC-developed metric called “healthy days” among all its members by 2020. A specific focus of Bold Goal was SDOH. Humana’s 2018 progress report indicated that their community outreach program is achieving results. For example, in Knoxville, TN, Humana members experienced a 5.4% increase in the number of Healthy Days among all plan members.
In 2017, focusing on people with disabilities, UnitedHealthcare of Wisconsin awarded over $100,000 in grants to four non-profits in the state with the mandate to improve access to health services for this vulnerable population. Preliminary results of the project are expected sometime in the near future.
Also in 2017, Health Net won recognition for an innovative project using geospatial mapping to improve postpartum visit rates among African-American women in Los Angeles. The project successfully increased postpartum visits from 17% to 33% and decreased disparities in utilization by 40%.
The majority of efforts put forward by third-party payors to date have involved time-delimited projects such as those highlighted above. There does not appear to be much evidence yet that payors have incorporated consideration of SDOH into their plan benefit structures. Nevertheless, these pilot studies may be seen as so many experiments in management of SDOH. The successful projects will be those that reduce total medical expenses while narrowing the gaps in social disparities.