Social determinants, despite their intangible origins, have very tangible effects. For example, according to an article in the Atlantic, there is a 20-year life expectancy gap between wealthy and poor areas of Baltimore, Maryland, and other race- and class-segregated communities across America. This is an outrage, particularly in one of the wealthiest countries on earth.
What if poverty was treated like a disease?
In June 2011, Sandro Galea and colleagues writing in The American Journal of Public Health posed an interesting question.
if we treated poverty as a disease and tracked its effects on the population, how many deaths would it be responsible for?
At the time, the discussion surrounding the social determinants of health (the economic, social and environmental factors that affect a person’s health and wellness) was taking off. Dr. Galea and his team isolated attributes like low-income, limited education, and a lack of social support. Then they conducted a meta-analysis to estimate their effects on the American public.
The results revealed a large blind spot in clinical care. In 2000, 133,000 deaths were attributable to individual-level poverty, higher than the 122,000 deaths attributed to chronic respiratory diseases that year. While the latter came with concrete treatment plans and dedicated specialists, the former was rarely even talked about. Since then, a slew of similar studies have confirmed the growing impacts of social determinants on wellness and predicted lifespan.
Social determinants are now viewed as key to costs
Now, approaching ten years after Galea’s study, the medical industry is looking to social determinants as a critical piece of America’s healthcare spending problems.
It’s a familiar cycle—unaddressed social needs cause illness, and people seek relief from the symptoms of those illnesses in clinical care. But, because physicians cannot fully address the root causes, those patients will return sooner rather than later, costing themselves, their caregivers and their insurance companies money each time.
This cycle has contributed greatly to America’s distressing healthcare spending figures: the country spends a whopping 17.8 percent of gross domestic product (GDP) on healthcare, far ahead of the Organisation for Economic Co-operation and Development’s (OECD) average of 11.5 percent. When combined with our below-average allocation of 16.7 percent for social spending, it seems that the amount of money is sufficient, but the distribution is all wrong—the U.S. is the only country to have a healthcare to spending ratio less than 1.
Physicians have the responsibility, but no tools
In this current climate, physicians are left with the responsibility of addressing social problems without being equipped with the tools necessary to bring about lasting change. Even though physicians report 88 percent of their patients are affected by social determinants in some way, intake forms and electronic health records (EHR) systems do not collect or analyze health-related social information that provides useful context to a patient’s clinical history.
Physicians often cannot address social needs rooted in the outside world, such as sending diabetic patients home with refrigerators, stopping tobacco companies from advertising near schools and in poor neighborhoods, or writing prescriptions for safe, stable jobs. Influence in the clinical environment simply does not translate to the outside world, and the social safety nets meant to assist with housing and food, especially in rural areas, are often under-resourced partners.
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Unfortunately for physicians dedicated to serving those battling the effects of social determinants in rural and inner-city communities, financial incentives are often misaligned. In fact, they may even be penalized.
Typically, value-based payment models judge success as an improvement from a baseline. This approach does not take into consideration that some patients started well behind the baseline. For those patients, simply reaching the baseline is an achievement.
For providers working in health systems focused on metrics and standardization, the compounding effects of social determinants can make results hard to assess. Our current healthcare system is not designed to facilitate the careful, individualized clinical approach needed to unravel the ways in which zip codes conspire with genes and behavior to affect health. This approach would take time—time to build trust, to listen and learn the contours of a community. And most importantly, time to design reasonable and creative treatment plans.
Impact on physicians
Understandably, physicians in these communities might be at a higher risk for burnout. Despite taking all the appropriate clinical steps to address a patient’s pathological needs, the patient may not improve due to these social determinants. Discouraged by their inability to deliver long-lasting wellness, physicians might begin to question their own effectiveness.
Physicians are responding to this pressure by limiting the number of Medicare and Medicaid patients they see, taking time off and seeking non-clinical work. All of these trends contribute to the physician shortage that will further jeopardize these already at-risk populations.
Where do we go from here?
Payors and providers are already seeing that money spent providing basic needs has dramatic impacts on health and incredible returns. A housing program at Montefiore Health System in the Bronx, New York reported a 300 percent return on investment, mainly due to a reduction in repeat visits. Another at Northwell Health in Long Island, New York tackled food insecurity, much to the appreciation of program participants.
In the face of these successes, physicians are asking where the boundary of their responsibilities lie in the expanding definition of healthcare. Despite finding joy in restoring health to their patients, using highly-skilled physicians to address the effects of social inequality seems like the wrong tool for the job, particularly for specialists. And, as burnout continues to bear down, physicians frankly can’t handle much more.
To cope, physicians are banding together in their state and local medical societies to identify ways to alleviate the effects of social determinants in their communities and amplify their voices for change. Physician leadership in the healthcare space allows for patient-focused solutions informed by real clinical experiences that account for today’s realities and tomorrow’s possibilities.
Joseph Valenti, M.D.
Joseph Valenti, MD, is a board member of the Physicians Foundation. He is a board-certified Obstetrician and Gynecologist with 17 years of private practice experience. He is the founding senior partner of Caring for Women, PA in Denton, TX. Dr. Valenti is a DaVinci robotic minimally invasive gynecologic and pelvic reconstruction surgeon and a DaVinci national proctor. He is a Center of Excellence certified Minimally Invasive Gynecologic Surgeon and an expert in women’s health and health technology issues. Dr. Valenti joined the Physicians Foundation board in 2007 and is the chairman of the Council on Socioeconomics as well as past chairman of the Committee on Constitution and Bylaws for the Texas Medical Association. He is a Fellow of the American College of Obstetrics and Gynecology. Previously, Dr. Valenti served as chairperson of the Texas Medical Association Committee on Maternal / Prenatal Health and chairperson of the Medical Society of the State of New York Resident Physician Section. He is the recipient of the Buffalo Gynecologic and Obstetric Society Award for Academic and Clinical Excellence and the Medical Society of the State of New York Community Service Award. He is the former Chief of Staff of North Texas Hospital. Dr. Valenti completed three years of cancer research in immunology and bone marrow transplant while at the Roswell Park Cancer Institute in Buffalo. He earned his medical degree from the State University of New York at Buffalo and completed his residency in Obstetrics and Gynecology at Children’s Hospital of Buffalo.