Examining SDOH in a Commercially Insured Health Care Workforce

Workers with commercial health insurance are impacted by social determinants of health (SDOH) in ways similar to those who are uninsured, according to an Aetna executive who spoke at the National Association of Managed Care Physicians Virtual Spring Managed Care Forum.

Steven Serra, MD, MPH, MSc, FACOEM, the executive director of Physician Consulting in Aetna’s Plan Sponsor Insights team, shared an analysis of an early pilot with a large, self-insured employer in a session about health equity.

Poor SDOH lowers employee productivity and raises plan costs by 5% or more, he said, so the insurer has begun using predictive analytics with their clients.

Aetna has created its own SDOH index, comprised of median household income, poverty, diversity, disability, education, physical inactivity, family structure, public transport, and employment. The dataset uses US Census tract data and CDC data.

Serra described the customer as one with about 20,000 employees; the majority of the employees (70%) were female, which he said was “not uncommon” for a health system. About half of the employees were physicians, nurses, and other health care workers.

Twenty percent of the workers lived in low-income neighborhoods, and the majority were female. The average age of workers in low-income neighborhoods was 43, about 2 years younger than those in high-income neighborhoods.

Risk scores were also assigned to the population, and those living in a low-income neighborhood had a retrospective risk score of 1.77, compared with 1.56 in high-income neighborhoods, meaning they were unhealthier and may have been using more costlier services.

By medical cost per member per month (PMPM), the low-income members of the plan spent more annually than high-income workers (a difference of $49). They spent more on specialty physicians, inpatient facilities, and ambulatory facilities. Notably, high-income workers spent considerably more on mental health ($18 compared with $8 for low-income workers).

Outcomes were also different:

• Low-income members had more potentially preventable chronic conditions—diabetes, hypertension, and obesity—than high-income members.
• They had more potentially avoidable care, such as emergency department visits or hospitalizations.
• They had higher 30-day readmission rates, but lower 90-day and 180-day readmission rates.

Interestingly, a reversal of these trends was seen when it came to behavioral health; although overall prevalence of issues related to behavioral health were similar across income groups, high-income employees had more outpatient visits as well as inpatient stays.

When looking at behavioral health and comorbidities, low-income workers had a higher incidence of comorbid cardiovascular issues and diabetes.

"So what can be done to remediate health care inequities?" Serra asked. "I think the answer is, a lot."

Serra said employers have a variety of options at their disposal to improve health equity and eliminate disparities:

• More flexible leave policies
• Reimbursement for education, since education is a factor of SDOH
• Creating a culture of health, such as promoting ergonomic workplaces and worker safety
• Extending health plan benefits to the entire workforce, including part-time workers
• Basing premiums and deductibles on salary
• Offering travel and lodging reimbursement for care sought at Aetna's Institutes of Quality and Excellence

He also said employers can ask their payer to implement programs that increase access to high-quality, low-cost care and use value-based benefit design. Serra also urged the audience to view prescription carve-outs and exclusions through the lens of health equity.

"Unless we force ourselves to look at these decisions though the lens of health equity, we are violating the Hippocratic oath," he said.