Improving Health, Outcomes by Addressing Social Determinants of Health

By Patrick Johnson, PharmD
Emtiro Health

As a pharmacist, I keep updated on all the new medications that hit the market. In many cases, they offer, at best, a modest clinical benefit over current therapies and come with a price tag that can be hundreds, if not thousands, more than a generic alternative. Well, what if I told you the FDA was about to approve a drug that increased life expectancy by 10 years, halved the infant mortality rate, and substantially decreased hospital admissions and emergency department use, while at the same time saving our health system $1 trillion per year? Now that I have your attention, I’ll admit that I am not talking about a new wonder-drug, but the significant impact that Social Determinants of Health (SDoH) have on a person’s health outcomes and on our health care budget. 

The social, behavioral, and environmental factors unrelated to the medical care that a patient receives truly drive health care outcomes. The disparities within our population as it relates to these factors can account for dramatic differences in life expectancy, child mortality, prevalence of chronic diseases, and hospital/Emergency Department (ED) utilization to name just a few. While the United States continues to spend more than any other country on health care, the relative investment in social services lags far behind, which has contributed significantly to our overall poor health outcomes. As our country’s health care system shifts from fee-for-service to a pay-for-performance model, the quadruple aim of improved outcomes, decreased cost, and increased patient/provider satisfaction can be achieved through the integration of a universal screening and referral system based on SDoH.

Improved Outcomes

SDoH have and will continue to become increasingly important as quality metrics begin to drive practice, as evidenced by Medicare’s MACRA/MIPS, Medicare Star Ratings, Medicare Accountable Care Organizations (ACO), and Medicaid Reform. Outcomes data, particularly in high-need populations, now demonstrates the substantial effect that interventions such as those related to housing, nutrition, education, neighborhood conditions, income support, and care management/coordination have on health outcomes. Because of these results, payers across the nation, including insurers, states, and employers, have begun to incentivize outcomes based on SDoH, independent of medical outcomes. Therefore, it has become an absolute requirement to not only uniformly gather this information from patients via a screening mechanism, but to then provide linkage to social service agencies based on the results of that screening to remove and address previously unknown barriers to optimal health care.

Decreased Cost

Much like with health care outcomes, we now have numerous program examples that have shown decreased cost through a focus on SDoH within capitated and/or shared savings environments. This level of savings has been accomplished through decreased ED visits, hospitalizations, and hospital readmissions, which are largely influenced by care coordination with community organizations to address barriers related to housing, finances, employment, transportation, education, and more. Implementation of systems that increase staff capacity to address these areas, through care models such as Patient Centered Medical Homes (PCMH) on the outpatient side and discharge coordination/follow-up post-hospitalization, will help determine which health care entities make up our landscape moving forward. 

Increased Patient Satisfaction

When patients feel that their health care team cares about them as a person enough to ask and address their social, behavioral, and environmental needs rather than solely speaking to them about the numbers they need to meet, a lifelong relationship can be formed. As patient satisfaction increases, so too does adherence to a medical plan and overall outcomes. In a pay-for-performance model, health care can only go so far if patients do not buy-in. 

Increased Provider Satisfaction

In recent years, the Triple Aim has progressed to the Quadruple Aim as the importance of provider satisfaction has become evident. Many providers feel that they are unable to provide quality care to their patients because they do not have the tools to adequately address SDoH-related needs and they realize that medical care is just one component. As SDoH are integrated into the practice, provider satisfaction increases alongside quality of care and the providers themselves find they have more time to resolve medical issues when a team is in place to address nonmedical barriers.

At Emtiro Health, experience has taught us that our patients do not often simply choose to be non-adherent to the plan of care that they have helped create with their health care team. They want to eat better and lose weight, but healthy foods prove too costly or they do not have a grocery store nearby. They want to control their child’s asthma, but their housing or neighborhood environment contains allergen triggers. They want to take their diabetes medication to lower their A1c, but they have to take two buses to get to the doctor’s office or pharmacy and are turned away when they cannot afford the copay. Through universal screening for SDoH, you’ll find out— like we did— just how much these needs are underestimated. The essential next step for those patients that screen positive is referral to appropriate community resources based on their needs. For this to optimally occur, we have found it is necessary to build and maintain a network of community referral agencies that have proven track records. Once you have integrated these services into your health care model to better understand your patient’s barriers, you will be well on your way to breaking through them together. Through our clinical and community integration work and our care management program, Emtiro Health can help community providers implement these capabilities.


Sarah Dohl