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The Business Case for Social Determinants

December 2019 Vol 12, No 8 - Editorial
David B. Nash, MD, MBA
Editor-in-Chief, American Health & Drug Benefits
Founding Dean Emeritus, Jefferson College of Population Health, Philadelphia, PA
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Ryan Daniels and his colleagues at William Blair, an equity research company based in Chicago, IL, are no strangers to population health. They follow our industry carefully. Their most recent report, Healthcare Mosaic Report: The Growing Importance of Social Determinants of Health in the Future of U.S. Healthcare Delivery,1 grabbed my attention. Below I discuss the highlights of this report and draw connections between that report, our work at the Jefferson College of Population Health, and the articles published in American Health & Drug Benefits.

I’m confident that by now most of our regular readers are well-aware of the uncomfortable fact that despite spending 18% of our gross domestic product on healthcare expenditures, our country does not yet rank in the top 10 countries for health outcomes among the world’s developed nations. In addition, the United States is one of only a few countries that spend more on the delivery of health services than on social care, such as housing, food, daycare, and related social support systems.

Our readers also know that the environment in which people are born, live, work, play, and worship has a much greater impact on their health than the actual delivery of healthcare services. None of this information is new, but it is certainly attracting a great deal of new attention. To put it in context, experts note that of the 68,000 total International Classification of Diseases, Tenth Revision (ICD-10) codes currently used in our healthcare system, only approximately 11 ICD-10 codes refer to any aspect of a person’s social determinants.1 In other words, the current healthcare system is still characterized by the notion that, “the more we do, the more we get paid.”

Daniels and his colleagues do a good job of summarizing the recent literature on the importance of social determinants, so I won’t repeat that here. In all, I was not familiar with 1 or 2 take-home messages in that report. Let’s take nutrition, for example. Sadly, as the authors note, “with more than 28 million adults (11.5% of U.S. population) and almost 13 million children (17.5% of children) living in food-insecure households in America as of 2016, health insurers and providers…are beginning to recognize the importance of addressing diet and nutrition.”1 It does indeed make sense for health insurers and other providers, as well as government health plans, to recognize the importance of diet and nutrition in the prevention of treatment of health conditions before they become more expensive.

Daniels and colleagues give some very specific examples of for-profit companies within the healthcare sector that are making some headway in tackling these social determinants. The list is too long to repeat here, but it is indeed impressive. For example, Tivity Health (especially after their acquisition of Nutrisystem in March 2019) can now focus on food insecurity and can promote health and exercise through their SilverSneakers program. We know that seniors specifically suffer disproportionately from loneliness, which can lead to depression and, subsequently, dementia. Suddenly, we have a market incentive to tackle upstream problems to prevent downstream events.

I was particularly intrigued by the one aspect of the report that is dealing with housing. Surely, we know, especially here in Philadelphia, that housing uncertainty can contribute to dangerous health conditions and increased expenses. “Moreover, people between the ages of 25 and 44 experiencing homelessness face an all-cause mortality risk that is 8.9 times higher than the general populations (and 4.5 times higher for those age 45 to 64).”1

I was surprised to learn how many cities, and different providers in those cities, are actively tackling housing as part of their battle to improve the social determinants. From the University of Illinois Hospital in Chicago, to 5 hospitals in Portland, OR, and 1 large provider in Orlando, FL, these disparate towns have recognized the direct connection between homelessness and an increase in healthcare expenditures. It is remarkable that UnitedHealthcare, the largest for-profit payer in the nation, has now invested more than $400 million in affordable housing to help mitigate health problems associated with homelessness.1

Nutrition, housing, and even transportation play a role in the social determinants that predict health. The authors provide disturbing statistics regarding the impact of transportation on healthcare. “It is estimated that 4 million medical appointments are missed or delayed every year because patients cannot get to their appointments as a result of transportation issues. This equates to an estimated $150 billion in excess costs to the healthcare system each year that are unnecessary. Payers, providers, and third-party companies, such as ride-sharing giants Uber Technologies and Lyft, are beginning to take notice and are coming up with ways to address this glaring issue.”1

However, it was vexing to me that despite the clearheaded approach to tackling nutrition, housing, and transportation in the report, there is no consensus on how information technology can play a role in tackling these social determinants. We lack the national will for a coordinated attack. For example, there are 3 widely recognized social determinants of health screening tools in the United States, including the National Academy of Medicine (NAM)’s set of social and behavioral measures; the National Association of Community Health Centers (NACHC) Protocol for Responding to Assessing Patients’ Assets, Risks, and Experience (PRAPARE) tool; and the Centers for Medicare & Medicaid Services’ (CMS) Accountable Health Communities tool.1 Once again, information technology poses a potential solution to organizing the data that are critical to tackling the social determinants, and we need to find a way to sort out these tools from NAM, NACHC, and CMS.

Daniels and colleagues conclude their report with some market reconnaissance. Although they fall short on making specific investment recommendations, they list a series of companies that have put a stake in the ground in terms of social determinants. As a result, I believe our readers should pay attention to companies such as Landmark Health, Welltok, Omada Health, and Castlight Health. I’m particularly taken with Solera Holdings, Folia, and Socially Determined.

In a nutshell, I believe we are seeing the emergence of a new business case for social determinants. Given the way our system is structured, this is likely to result in innovative solutions to gather data, analyze them, and distill important new insights.

As always, I am interested in your views about the business case for the social determinants. You can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

David B. Nash, MD, MBA, is Editor-in-Chief, American Health & Drug Benefits, and Founding Dean Emeritus, Jefferson College of Population Health, Philadelphia, PA.

Reference

  1. Daniels R, Garro J, Spiekhout N, Haase J. Healthcare Mosaic Report: The Growing Importance of Social Determinants of Health in the Future of U.S. Healthcare Delivery. William Blair Equity Research; July 24, 2019.
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