Social determinants and their impact on value, better outcomes

All stakeholders—especially payers and consumers—are pressing for value-based payment (VBP) models that emphasize outcome over cost. To achieve it, the focus must swing to prevention, more efficient use of resources and evidence-based changes to models of care.

For this to occur, data is core. And that data must be complete, comprehensive, accessible and consumable for efficient staff utilization and more effective delivery of healthcare. With analytics and AI providing insights, coupled with collaborative and communication tools, data will allow organizations to create value change across the continuum of care.

This complete data set must include healthcare data from clinical care, patient-generated and patient life data, and data on social (personal) determinants of health.

It’s that last category—social determinants—that provides an exciting challenge for healthcare stakeholders.

There is little doubt that social factors are powerful determinants of health and significantly impact health outcomes. What’s less known is the best way to leverage understanding about the importance of social determinants.

Let’s examine it from through a prism of past mistakes, and how electing to not look at social determinants in a siloed way can benefit to the individual (patient) and to healthcare systems.

About two-thirds of disease burden is impacted by lifestyle and life choices. To improve quality and lower cost, it is critical to address factors that contribute to higher cost. Clinical care does not occur in isolation; perhaps we have not been very accurate in using the label “non-compliance.” What was the factor or factors that result in non-compliance in the specific patient?

We see parallels with population health and disease management. Improving population health requires more than just having data on the population. It requires more than just having the health data from the EHR that you use. It requires having the complete, comprehensive set of healthcare data related to each patient, as well as data about the person, including that provided by the patient. And it requires tools to analyze and make data actionable for the healthcare team and the patient.

That data must also be made available and actionable to the patient, so they are sufficiently engaged. Preventive health services and any disease treatment program such as diabetes management have failed as success is not limited to clinical care team actions. IT and care model initiatives in these areas have also failed to deliver promised value, because they were treated as silos. We have databases and tools for both.

We should not think social determinant data is somehow more unique or sensitive than other patient data. Patients are increasingly willing to share information about themselves. We in healthcare delivery also should get past the belief that social determinants are some limited, specific list of data elements—for example, race, economic status or zip codes.

Many life factors are critical in influencing a given patient’s outcomes. Every facet of an individual’s life contributes to his or her ability to successfully manage health, and to deal with disease and healthcare. Let’s acknowledge this and support data collection and discovery in a broader approach to person-centric care. Otherwise, we will lose the ability to discover insights in care support and population health that can positively impact clinical care and the evolution of healthcare transformation.

In my next blog, I’ll explore more of the how, and the why, of using social information to guide healthcare that leads to superior value and better outcomes.

In the meantime, here are key points to consider:

• Social determinants impact significant parts of healthcare outcomes as well as the larger driver of healthcare cost—a patient’s personal choices.
• Data-driven insights are critical to leveraging social determinants and overlap other initiatives that also need similar data and data analytics.
• Data collection without communication, collaboration and patient engagement will likely result in increased cost—not a change in outcomes.
• Remember to address the needs of the person, not the zip code. Personalized medicine is a key to all of it.