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In Depth: Social Determinants of Health: Is There a Return on Investment?

An article on the NPR (sited frequently below) started me on an exploration of the question of whether the considerable investment in supporting social determinants of health (SDOH) is producing the outcomes anticipated and expected.
The short answer seems to be “no”, at least not yet.
We will start with a definition.

What are social determinants of health?

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

SDOH can be grouped into 5 domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context

The NPR article is sourced, in part on this study, a meta-analysis: 

Can Social Policies Improve Health? A Systematic Review and Meta‐Analysis of 38 Randomized Trials

Key findings:

  • Social policies might not only improve economic well‐being, but also health. Health policy experts have therefore advocated for investments in social policies both to improve population health and potentially reduce health system costs.
  • Since the 1960s, a large number of social policies have been experimentally evaluated in the United States. Some of these experiments include health outcomes, providing a unique opportunity to inform evidence‐based policymaking.
  • Our comprehensive review and meta‐analysis of these experiments find suggestive evidence of health benefits associated with investments in early life, income support, and health insurance interventions. However, most studies were underpowered to detect health outcomes.

Conclusions: Early life, income, and health insurance interventions have the potential to improve health. However, many of the included studies were underpowered to detect health effects and were at high or moderate risk of bias. Future social policy experiments should be better designed to measure the association between interventions and health outcomes.

So, the outcomes might be there, but the studies weren’t designed in a manner to capture the outcomes. Somewhat charitable, but it makes sense.

Now we arrive a the NPR post I mentioned. This passage sets the stage for the discussion, explaining the theory and implementation of a plan to alter outcomes by investments in SFOH. 

In Health Care, More Money Is Being Spent On Patients’ Social Needs. Is It Working?

The move to address social needs is gaining steam nationally because, after nearly a dozen years focused on expanding insurance under the Affordable Care Act, many experts and policymakers agree that simply increasing access to health care is not nearly enough to improve patients’ health.

That’s because people don’t just need access to doctors, hospitals and drugs to be healthy, they also need healthy homes, healthy food, adequate transportation and education, a steady income, safe neighborhoods and a home life free from domestic violence — things hospitals and doctors can’t provide, but that in the long run are as meaningful as an antibiotic or an annual physical.

Researchers have known for decades that social problems such as unstable housing and lack of access to healthy foods can significantly affect a patient’s health, but efforts by the health industry to take on these challenges didn’t really take off until 2010 with the passage of the ACA. The law spurred changes in how insurers pay health providers — moving them away from receiving a set fee for each medical service, to payments based on value and patient outcomes.

As a result, hospitals now have a financial incentive to help patients with nonclinical problems — such as housing and food insecurity — that can affect health.

How much money has been invested? A lot.

Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19

The past decade has seen a growing recognition of the importance of social determinants of health for health outcomes. However, the degree to which US health systems are directly investing in community programs to address social determinants of health as opposed to screening and referral is uncertain. We searched for all public announcements of new programs involving direct financial investments in social determinants of health by US health systems from January 1, 2017, to November 30, 2019. We identified seventy-eight unique programs involving fifty-seven health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in fifty-two programs was specifically committed to housing-focused interventions. Additional focus areas were employment (twenty-eight programs, $1.1 billion), education (fourteen programs, $476.4 million), food security (twenty-five programs, $294.2 million), social and community context (thirteen programs, $253.1 million), and transportation (six programs, $32 million). Health systems are making sizable investments in social determinants of health.

More from the NPR article; this time focusing on studying for the effect on outcomes. It’s here that it becomes more explicit that the initiative does not appear to have a solid, verifiable  Return on Investment (ROI). Nevertheless, the SDOH theory is persuasive, and there’s an impulse to lay the blame on the study not capturing the ROI, and to continue the initiatives.

In the past decade, dozens of studies funded by state and federal governments, private hospitals, insurers and philanthropic organizations have looked into whether addressing patients’ social needs improves health and lowers medical costs.

But so far it’s unclear which of these strategies, focused on so-called social determinants of health, are most effective or feasible, according to several recent academic reports that evaluated existing research on the interventions. The reports were produced by experts at Columbia, Duke and the University of California-San Francisco.

The new reports found that even when such interventions show promising results, they usually serve only a small number of patients. Another challenge is that several studies did not go on long enough to detect an impact, or they did not evaluate health outcomes or health costs.

“We are probably at a peak of inflated expectations, and it is incumbent on us to find the innovations that really work,” says Dr. Laura Gottlieb, director of the UCSF Social Interventions Research and Evaluation Network. “Yes, there’s a lot of hype, and not all of these interventions will have staying power.”

I really like the NPR article’s closing argument, based on a criticism of the status quo, the nobility of trying something new, and the presumed benefits of approaching Social determinants of health as a means to improve health.

“We need to pay for health not just health care,” said Elena Marks, CEO of the Houston-based Episcopal Health Foundation, which provides grants to community clinics and organizations to help address the social needs of vulnerable populations.

The nationwide push to spend more on social services is driven first by the recognition that social and economic forces have a greater impact on health than do clinical services like doctor visits, Marks says. A second factor is that the U.S. spends far less on social services per capita compared with other large, industrialized nations.

“This is a new and emerging field,” Marks says, after reviewing the meta-evaluations of the many studies of social needs interventions. “The evidence is weak for some, mixed for some, and strong for a few areas.”

But despite incomplete evidence, Marks adds, the status quo isn’t working either: Americans generally have poorer health than their counterparts in other industrialized countries with more robust social services.

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Paul Hudson, FACHE
Chief Operating Officer