Focusing on social determinants of health could improve outcomes

Our health care system is highly effective at treating us when we are sick, but it is not set up to keep us healthy. The sector, however, is undergoing a transformational change where there will be more emphasis health and prevention and less on treatment. This is an exciting moment for our industry as we embark on the future of health—but to get there, industry leaders will need to consider investments in what we see as the underlying social and economic conditions that drive health outcomes.

While stakeholders and government entities continue to invest in treating disease, there tends to be far less focus on the drivers of health, which could help people avoid illness in the first place. Improving the health of a population requires health systems, health plans, not-for-profit health organizations, and government payers to come together in impactful ways to develop strategies and investment approaches that address the drivers of health (also known as social determinants). Increased emphasis on factors that keep us healthy could mean fewer resources need to be devoted to care.

Treating an illness often doesn’t address any of the social and contextual factors that caused it (e.g., limited access to nutritious food, lack of exercise, unsafe or unstable living conditions, poor air quality). A growing number of health care stakeholders (including hospitals and health plans) are beginning to pay closer attention to these drivers of health and their connection to health outcomes. This shift in focus could help drive meaningful, sustainable change that impacts the health of individuals and their communities.

What do consumers want from the health system? In 2018, Rebecca Onie and Rocco Perla, leaders of a venture called The Health Initiative (THI), commissioned a series of research that asked consumers how they would invest their own health care dollars. For every $100, participants said they would spend about $30 on hospitals and clinics. The remaining $70 would be split across various drivers of health (e.g., good-paying jobs, healthy food, affordable housing, childcare, and transportation). The results were similar regardless of race, gender, socioeconomic status, or political leanings.¹

There appears to be a philosophical shift occurring among some stakeholders in the health sector. Rather than referring to the care continuum, I’m hearing more conversations around the health continuum. At the same time, we are seeing a vertical shift among some health systems and health plans. Instead of focusing solely on patients or members, they appear to be taking a broader view of health and are placing greater emphasis on communities.

Consider some of the recent investments being made by stakeholders in North Carolina:

• Blue Cross and Blue Shield of North Carolina: The Blues plan recently said it had invested $2.6 million to help non-profit groups fight hunger across the state.² Long-term food insecurity is linked to poor health outcomes and higher incidence of chronic illness.³
• Atrium Health: The health system recently committed $10 million to affordable housing. In a prepared statement June 4, Atrium explained that inadequate housing can have a direct and lasting negative impact on a person's health.⁴
• Healthy Opportunities: Section 1115 Medicaid demonstration waivers allow states to test approaches to Medicaid that are outside federal rules. Last October, the US Centers for Medicare and Medicaid Services approved funding for North Carolina's Healthy Opportunities Pilots, which will invest in health drivers including housing, transportation, and access to health for high-need Medicaid beneficiaries. Over the course of the demonstration, the state must incorporate value-based payments for pilot services, which will gradually link payments for new services to health outcomes.⁵
• NCCARE360: This statewide resource and referral network, which began rolling out early this year, seeks to electronically connect people to community resources and allow for a feedback loop on the outcome of that connection.⁶ The idea is to make it easier for community-based organization, health plans, health systems, and other groups to connect to needed resources. The program is the result of a partnership between the NC Department of Health and Human Services and the Foundation for Health Leadership and Innovation.⁷
   

Data and analytics can play a key role in the ability to successfully address the drivers of health. Stakeholders should consider looking at ways to collaborate with each other to identify needs and determine where investments could have the most impact. Creating a meaningful impact, however, requires a collaborative and coordinated effort—in addition to rethinking and reframing the competition that has traditionally existed between stakeholders.

For example, health systems that now compete for patients in a region might find a way to collaborate to keep community members healthy and out of the hospital. Hospital leaders might invest more in virtual care technologies rather than expanding their physical footprint. Health plan leaders might decide to develop new coverage models that emphasize health and wellness rather than provider networks. Some health plans might build community organizations to meet social needs.

Earlier this year, the Deloitte Center for Government Insights and the Deloitte Center for Health Solutions interviewed executives from Medicaid managed care organizations and Medicare Advantage plans. We also interviewed leaders from four states to learn how states are directly addressing the drivers of health. This project builds on a previous study by the Deloitte Center for Health Solutions that surveyed a nationally representative sample of hospitals and health systems.

Some health plans or health systems might be large enough to lead such an effort without help from the state or federal government. Given the typical time-horizon constraints—and without a clear return on investment (ROI)—securing investments to address the drivers of health can be challenging. It might take longer to reap a return on investment when compared to more targeted efforts such as securing transportation for disease-specific at-risk members. Moreover, stakeholders typically have different motivations and priorities.

Efforts to address the drivers of health are often focused on assessing the social needs of individuals and connecting them to existing community-based resources. While this is an important step, such efforts can fall short if they fail to address the deeper, structural forces that underlie the social needs that impact health and well-being. In a value-based system that is rapidly shifting financial incentives toward prevention and maintaining well-being, there is financial imperative for all stakeholders to invest in the drivers of health.

Josh Lee is a principal with Deloitte Consulting LLP, and leads the firm's Health Care Provider Strategy Practice. He holds extensive experience in strategy formulation, large-scale transformation, operations, and organization strategy in the global health care industry.
 

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