Preventing a problem is always better than fixing it, especially when it comes to health. Yet, in the healthcare industry treating medical conditions still dominates their prevention. In part, this situation is rooted in patients’ data (un)availability, and particularly socioeconomic data. Clinicians often deal only with information regarding a specific complaint while deeper issues, such as a person’s living conditions, their lifestyle and such, remain uncovered.
Even
when enquiries about social factors take place, they are usually limited to diet
preferences, physical activity, alcohol and tobacco consumption and other socially-influenced
behaviours while the factors that initiate such behaviours are left out (Moscrop
et al. 2019). This is a major drawback on the path of creating efficient
value-based care, which negates the chances of a patient to stay healthy post-treatment.
Moreover, as many as 43% health consumers take the responsibility for
addressing the behavioural, social and economic factors contributing to their
health (PwC 2019). But it does not equals to them doing anything about it, or even
knowing what to do. Thus, it is obvious that both payers and providers need to embrace
and act upon relevant socioeconomic data.
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Healthcare leaders across the world increasingly recognise the importance of
social determinants in shaping population health. The US Department of Health
and Human Services emphasises this in their 10-year agenda for improving the nation’s
health, Healthy People (HealthyPeople.gov). The UK Department of Health and
Social Care does the same in its green paper Advancing our health: preventionin the 2020s, outlining a new multi-layered approach for the health and care system with prevention at the centre of decision-making. It suggests that ‘health is a shared responsibility’, and that the government, health
and care system, individuals and communities must all work together and play
their part.
Social Determinants of Health: Role and Cost
According to the World Health Organization, social determinants are ‘the circumstances in which people are born, grow up,
live, work, and age and the systems put in place to deal with illness’ defined by
the money, power and resources distribution, such as housing and environmental
conditions, education and employment, economic factors, socialisation, etc.
More than half of a person’s overall health is determined by various socioeconomic and behavioural factors, while the healthcare shapes only a quarter, or even less, of that (the rest is up to biology/genetic endowment and physical environment) (Department of Health and Social Care 2019). However, the healthcare spending, which has been growing steadily around the world (PwC 2019) seems to be structured in the opposite way.
In
the UK, healthcare expenditure has grown, both in total and per person, each
year between 2013 and 2017 (last available data). Total healthcare expenditure
in 2017 was £197.4 billion (+3.3% yoy), and real healthcare expenditure per
person grew by 0.5% (Office for National Statistics 2019). Similar
trends are observed in the U.S. where healthcare expenditures in 2017 reached
$3.5 trillion (+3.9% yoy), in line with average growth from 2008 to 2013 (Centers
for Medicare and Medicaid services 2018). Of those, 88% are treatment costs
while socioeconomic and behavioural interventions take up around 4% (Sigmond 2019).
This is an impressive disproportion that calls for expansion of the socioeconomic
data usage in order to maximise population health.
To outlinethe
full picture of a person’s health, eg to understand if a person is capable of picking up prescriptions or following
up appointments, external factors are invaluable. Information on shopping preferences,
social integration, vehicle ownership, commuting patterns would help clinicians
to most effectively address a person’s needs and to determine the risk of
future health complications.
A
recent study (Kanzaria et al. 2019) that included integrated medical, behavioural
and social service data, showed that those who visited emergency department often
and very often were sicker
than infrequent patients and sought a wide range of medical and social services
in San Francisco. Thus, the authors’ conclusion was that care
coordination and communication across multiple sectors, such as behavioural
health, medical health and social services, is urgently needed. Senior author, Maria
C. Raven, associate professor and chief of the UCSF Department of Emergency
Medicine, indicated the need for policymakers ‘to prioritise improvements in
data sharing and the development of integrated medical, behavioural and social
care systems’ (as quoted by EurekAlert.org).
The Difficulty of Asking Questions
However,
obtaining external information about the patient is not an easy task. Moscrop
et al. (2019) conducted a literature study on reasons for and against asking
patients about their socioeconomic contexts.
Among the reasons for asking patients about their socioeconomic circumstances, they identified those relating to:
- individual healthcare encounters (among others, clinicians can refer patients to social resources, engage directly with patients’ social needs, acknowledge risk of disease or better understand non-adherence to management plans)
- health service provision and organisation (better monitoring of healthcare use, more targeted healthcare resources allocation, etc.)
- population-level research and policies (improvements in health research, public health policies and health and social care).
There are, however, cases when experts see asking patients
about their socioeconomic circumstances as inappropriate. For example,socioeconomic enquiries may conflict
with clinical tasks, overburden clinicians or foster patient distrust; or the
quality of data collected and its sources cannot be guaranteed. In addition,
the authors did not find any consensus on who should ask a patient such
questions.
Recommendations for Organisations
Addressing non-clinical factors may help to ensure a patient remains healthy
and to reduce costs against overall population health improvement. While this requires
concerted efforts on national and even global levels (Alcaraz et al. 2019), in
the meantime organisations should plan for incorporating a social determinants
approach in their strategy. PwC’s Health Research Institute (PwC 2019) five-step
guideline may be a good start:
Step 1. Build
the collective will rather than acting alone. More than one-third of PwC’s
respondents indicated they had not discussed the social, economic, behavioural
and environmental factors affecting their health with anyone in the healthcare
industry. 43% had such discussions, but for pharmacists, therapists, nurses and
other health specialists this parameter is much lower.
Step 2.
Develop standard but adaptable frameworks
to successfully engage in coalitions
with partners, because consumers expect better integration of healthcare and
social services. Thus, there is a need for clear roles, common vocabulary,
goals, definition of value and decision-making protocols.
Step 3.
Generate data insights to inform decision
making. With predictive analytics the volumes of time and money wasted on
ineffective interventions can be radically decreased.
Step 4.
Engage and reflect the community.
The first three steps must be supported with consideration of a targeted
community’s response which, in turn, in necessary in building trust in the
population.
Step 5.
Measure and redeploy. Continuous
assessment of social determinants and
refinement of health efforts are needed. Feedback indicates weak spots
in capabilities or processes enabling the development of improved strategies.
Today, the pace and scale of innovations in healthcare is staggering, but for the level of human health to improve, treatment alone is not enough unless all other factors are taken into consideration and the root causes of disease are addressed. This requires efforts on the highest level, but organisations and patients themselves may start working in this direction, viewing ‘health as a shared responsibility’.
References
Alcaraz KI, Wiedt TL, Daniels EC et al. (2019) Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. CA A Cancer J Clin 0:1–16. Available from https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21586
Centers
for Medicare and Medicaid services (2018) National Health Expenditures 2017
Highlights. Available from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf
Department of Health and Social Care (2019) Advancing our
health: prevention in the 2020s – consultation document. Available from https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document
(2019) Frequent Emergency Department Users: Focusing Solely On Medical Utilization Misses The Whole Person.
Moscrop A, Ziebland S, Roberts N. et al(2019) A systematic review of reasons for and
against asking patients about their socioeconomic contexts. Int J Equity
Health18(112). Available
from https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-019-1014-2
Office for National Statistics (2019) Healthcare
expenditure, UK Health Accounts: 2017. Statistical bulletin.
Available from https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2017
PwC (2019) Action required. The urgency of addressing social
determinants of health. Available from https://www.pwc.com/gx/en/healthcare/pdf/pwc-social-determinants-of-health.pdf
Sigmond S (2019) The Missing Data Holding Back Value-Based
Care. Hospital & Healthcare Management. Available from https://www.hhmglobal.com/knowledge-bank/articles/the-missing-data-holding-back-value-based-care
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