Doctors Talk About How Social Determinants Affect Their Work With Patients

A few days after releasing a call for action about social determinants of health (SDOH), the American College of Physicians (ACP), talked more about the topic as they began their Internal Medicine Meeting 2018. The briefing discussed ways to reduce inequalities in healthcare and how the ACP and other medical professionals can promote health equity.

On Monday, the ACP released a set of 9 recommendations about SDOH, to improve patient care and health outcomes that are negatively impacted by the conditions in the United States under which patients live, grow, and work.¹ However, in an accompanying editorial, 2 physicians wrote that they feared inequities that widen gaps in SDOH would worsen, citing last year’s tax law passed by President Trump and Congress, growing deficits, and the president’s own words and actions, which they called “intemperate.”²

“This is your zip code, not your gene code,” said Jack Ende, MD, MACP, president, ACP, during Thursday's briefing.

He was joined by Sarah Candler, MD, MPH, an internist in Houston, and and Karen DeSalvo, MD, MPH, MSc, president-elect, Society of General Internal Medicine (SGIM).

Doctors all work hard to keep patients healthy, Candler said, “But sometimes our toolbox of medicines and skills don’t get us there.” And the reason, she said, is because of SDOH factors.

All patients from all neighborhoods and all backgrounds should have the same opportunity to be healthy and make healthy choices, according to Candler.

Research has shown that where a person is born and the social circumstances they experience can have an impact on their health, the ACP said. Doctors should develop a broader understanding of how SDOH may affect a patient’s ability to adhere to a care plan, take a prescription, or follow a physician’s advice.

But doctors first need to be taught how to screen for SDOH risks and look for warning signs, and policymakers need to support interventions that encourage health, said Candler.

“I think that it’s my job as a doctor to look for those reasons that my patients may not be able to have the same opportunities for health,” she said.

The ACP also supports data collection about this issue, because as Calder put it, “I don’t know where to put my effort until I know how big of a problem it is.”

As a doctor, she tells all her patients she will help them be “as healthy as they want to be for as long as they want to be that way.”

However, she considers herself “lucky” to work for a healthcare system that addresses SDOH. For instance, she knows to ask if a patient is having transportation problems getting to or from medical appointments or obtaining prescribed medication. She has telehealth as an option. And she knows to ask about work conditions and the impact that will have if she prescribes, for example, a diabetes regimen that requires a patient to inject insulin 3 times a day at work. Will the workplace be conducive to that kind of regimen?

Meanwhile, DeSalvo, the incoming SGIM president, said there are a number of issues that she is concerned about.

One is creating the healthcare workforce that is needed for innovative care delivery solutions. Another is leveraging technology so that there are not stand-alone silos of data, so that information can flow freely, not only among the medical workforce but also among the social workforce and back and forth, so that patients can obtain services seamlessly.

Another is allowing for sustainable payment systems, and creating payment systems and a value proposition so that payers address SDOH.

“It’s the right thing to do if there are social challenges that our patients are facing,” she said. But there is also a business case to be made, she said, noting recent coverage in The American Journal of Managed Care^® (AJMC^®) about the insurer Humana measuring “healthy days” for its Medicare members in 4 locations and found that investments in population health improved its bottom line. Humana found that 1 unhealthy day costs $15.64 per person in monthly medical costs.

"Diseases of despair" are showing up in higher rates of substance use disorder, liver diseases, suicide, and people despondent over a lack of economic and educational opportunities, she said.

“Clinical excellence alone will not be enough to bring health and well-being to our patients,” said DeSalvo. “It’s crucial for physicians to understand that care plans for our patients must include understanding and addressing the social factors that have an impact on their health.”

References

1. Daniel H, Bornstein SS, Kane GC. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168(8):577-578. doi: 10.7326/M17-2441.

2. Himmelstein DU, Woolhandler S. Determined action needed on social determinants. Ann Intern Med. 2018;168(8):596-597. doi: 10.7326/M18-0335.