Patient Engagement

Social Determinants of Health: How Much Do We Understand?

Interview · September 27, 2016

Addressing patients’ social needs is critical to improving their health outcomes. But if we know this is important, why aren’t we collectively doing better?

“A lot of why we’re not doing better with the social determinants of health is because even though we know they’re important, we don’t really understand them,” says Damon Francis, Chief Medical Officer for the social enterprise Health Leads.

Francis sat down with NEJM Catalyst’s Clinical Editor, Namita Mohta, to discuss the barriers, key stakeholders, interventions that would make a difference, and the progress we’ve made thus far.

“We intervene often at the individual level in clinics and in the health care system — [but] the social determinants of health are social.” But what’s hard, he adds, is figuring out what we can do that has a high level of efficacy and doesn’t cost a lot of money to actually intervene against these social causes.

“It’s incumbent upon all of us to fan the flame of public health and grow its importance,” says Francis. “[As] health care system and health care providers, we need to conceive of ourselves as a branch of public health, rather than thinking of it as our baby brother over there whom we ignore a lot of the time.”

Read or listen to the interview below.



Namita Mohta: This is Namita Mohta for NEJM Catalyst. I’m speaking today with Damon Francis, Chief Medical Officer of the social enterprise Health Leads, who has spent his career working in hospitals and communities of care focusing on the health challenges facing those living in concentrated poverty. Let’s start, Damon, talking about social determinants of health. Most of us know and accept that addressing patient’s social circumstances is critical to improve health outcomes. If we know it’s important, why aren’t we collectively doing better?

Damon Francis: A lot of why we’re not doing better with the social determinants of health is because even though we know they’re important, we don’t really understand them. Even the phrase itself is a little bit complex: social determinants of health. I’m not sure we understand them as the social causes of good and bad health. It’s sort of like the weather sometimes when you’re a clinician. You know it’s going to rain but you don’t necessarily know why, or what to do about the rain. We know that it’s important that our patient doesn’t have enough food or doesn’t have a secure place to live, but we don’t exactly know what to do about it, and that makes it hard for us to collectively do anything.

Mohta: So is it a fair statement to say that the biggest barrier is because we don’t know what to do, we don’t do anything?

Francis: I think that’s a lot of what’s happening. We intervene often at the individual level in clinics and in the health care system — [but] the social determinants of health are social. The interventions are often collective.

So if you look at the roots of public health — John Snow and the cholera epidemic — we’re responding as a health care system primarily to a bunch of people with cholera by navigating those people to other pumps, which is critical work. If I’m responsible for taking care of a family living in a neighborhood with cholera and I say, “that pump over there is bad, go to this other pump,” that’s a great intervention. But we’re still working to figure out in the health care system, how do we shut down the pump? How do we take the handle off, the way that John Snow did, around some of these social causes? What’s hard is figuring out what we can really do that has that level of efficacy that doesn’t cost a lot of money, to actually intervene against these social causes.

Mohta: Let’s take a step back for a moment and define the term. When you say, or when we talk about social determinants of health, what is it that you think of? How do you encapsulate that into a concept that people can understand and grasp on to?

Francis: I like the WHO definition, which is “the conditions in which [people] are born, grow, live, work, and age.” Then it goes on to talk about the structures in society at all levels that shape the distribution of power, also shape those conditions. The other key concept is that they actually do cause health. The reason that someone lives a long time, or lives well or lives poorly, is in large part because of those conditions. That’s the frame that I use when I think about the social determinants of health.

Mohta: What are some other barriers, other than not knowing what to do about it so we, clinicians, don’t necessarily do anything about it? What are some of the other barriers that are preventing us from collectively doing better?

Francis: The way that our work is structured is also a barrier. We have these units of work that we do in health care that are a visit, a medicine, a procedure, a hospital stay, and those aren’t really units of health. They’re units of work. So the things we’re managing in health care systems are visits and stays and procedures. But if we add all those up, they don’t add up to health, even for an individual — let alone for a community. Figuring out a way to move toward a systematic understanding of units that end up as health is something that we’re going to need to do in health care.

This is wrapped up with a lot of the payment reform that’s going on. Thinking about a healing relationship as a unit and how we measure the number of healing relationships we have, the quality and depth of those relationships, and how we act on those relationships and pay for those relationships. Moving in directions like that is going to help us be better at understanding and seeing the social causes for what they are.

Mohta: We spent some time talking about providers and their relationship with their patients, as you just mentioned, in terms of being a building block on which to start addressing social determinants of health. Who are some of the other key stakeholders in this conversation, and what are their respective responsibilities?

Francis: The public health community, the people working in governments, the people working in nonprofit organizations who have a concept of the public’s health and have a vocabulary and a set of frameworks to think about the health of the public — they’re a key stakeholder that’s not empowered enough right now to lift up these issues to the level where they deserve to be addressed. Then it’s incumbent upon all of us to fan the flame of public health and grow its importance. So governments need to fund public health better. They need to fund interventions that are targeted at groups of people, rather than individuals, on the basis of health outcomes, not just on the basis of economic outcomes, for example.

[As] health care system and health care providers, we need to conceive of ourselves as a branch of public health, rather than thinking of it as our baby brother over there whom we ignore a lot of the time.

Mohta: You raised a lot of interesting points. Other than giving them more money, how else can we make the public health community more empowered?

Francis: We need to make sure that folks are at the table where we’re making decisions. People who have public health and epidemiological perspectives on the health problems that we’re facing within communities. Within health care institutions, making sure that geographic population health — not just populations as all of my patients, add[ing] up to a population once they come into clinic to see me, but actually the population of the community that I live in — that there’s someone involved in our planning discussions and our evaluation discussions who has the ability to understand and talk about the health of a population that’s there.

The same thing for people working in businesses or social services. Just making sure that people are present and involved in those conversations who can present those points of views and perspectives and help shape decisions that are made that affect the conditions in which we are born, grow, live, work, and age.

Mohta: What about payers? You mentioned the public health community, you mentioned government. What about the private sector? What about insurance companies? Do they have a role in this space, and if so, what would it be?

Francis: Payers have a critical role. I think the public understands that the money that we’re giving to the health care sector is for our health, and that 17 to 18 percent of our economy in the United States that we spend on health care is primarily going through public and private payers for health care. If we want that to be effective, it needs to address important causes of good and bad health.

Right now, a lot of payer strategies are focused on finding healthy populations, segmenting the markets, and segmenting populations in certain ways, avoiding costly procedures. [But] strategies that are more around intervening as groups of payers, around causes of health, are going to be really important strategies. CMS is promoting this with some of its payment reforms, for example. The Comprehensive Primary Care Plus program is targeted toward all payer initiatives in places and communities.

Those kinds of partnerships where we say, “We’re all here, we’re all paying for the health of these people here. Let’s figure out a way to do it smartly and together and enhance collaboration in the places where we know this is going to benefit all of us.” Payers need to be working more and more toward strategies like that.

Mohta: You mentioned earlier the role of specific interventions, assuming all the key stakeholders are in place. There’s enough funding, there’s enough political will and a burning platform. Assuming that that is true and present, what are the interventions that will make a difference?

Francis: That’s a great question. One of the key causes of poor health in the United States is concentrated poverty. So, not just being poor itself. Inequality and income has gotten a lot of attention. Inequality in wealth has probably gotten less attention, but also the idea of integrated communities.

People are able to achieve good health based not just on their income, but also on the social capital of the people they’re in relationships with. To the extent you have communities that have not been invested in, and where people are only surrounded by other people who are struggling as well, you’re going to have poor health outcomes. To the extent that you have communities that are integrated across income lines, integrated across racial lines, with good, collective social resources, we’re going to see communities that actually thrive. A lot of the interventions are around making sure everyone has enough housing, making sure everyone has enough money to meet their basic needs, and then making sure people are connected to one another in ways that allow them to creatively become the best humans that they can be.

Mohta: Toward this end, what is some of the key progress you’ve seen in this space over the last year? What are you optimistic about?

Francis: Well, I mentioned the Centers for Medicare and Medicaid Services before. I think they’re really demonstrating that they get the importance of the social determinants of health in a lot of their initiatives. So the Accountable Health Communities pilot where they’re supporting health systems to navigate patients to social resources, [and] on one of the tracks, Track 3, they’re supporting community-level partnerships around the types of things we just talked about — intervening in the landscape of resources that help people to be healthier by enabling partnerships between health systems and community partners. A lot of the payment reform initiatives like Comprehensive Primary Care Plus are also oriented toward social determinants in great ways. Then, of course, the Medicaid waivers. Here in California, where I’m most familiar, enabling new partnerships around housing in fairly specific ways demonstrates a real understanding of the importance of housing as a social determinant of health. I’m really excited about some of those initiatives.

On a different level, the Paris Agreement around climate change  represents, potentially, a longer term view of what health systems can do. One of our partners, Health Care Without Harm, has worked organizing health systems around the globe to participate in advocacy, saying a key determinant of health for our population is climate change. We all need to get together as public health people, as health care systems, and speak out and shape the approach to climate change in order to ensure that the people we are responsible for caring for are healthy for generations to come. So the Paris Agreement being signed in the last year and the role that Health Care Without Harm and other health care and public health organizations played in that is a strong demonstration of the importance of health systems thinking about social determinants in a big way.

Mohta: Let’s bring it back to provider systems for one minute. Climate change as a driver of health, particularly around social determinants of health, is a very noble and important goal. Provider systems cannot improve the changes we have in terms of the climate. What can and should leadership in provider organizations, hospitals, clinics, integrated delivery systems, what should they be focusing on in the next 2 to 3 years?

Francis: I want to just push back on the first part of that and say I think people can participate in large consortiums of advocacy to address climate change. That is one thing people can do. They can do it in a measured and small way, but if you add a bunch of voices — Health Care Without Harm has 1,700 organizations signed onto their platform and helping with the advocacy — that is a small thing they can do about a problem that’s coming at us over generations to come.

In terms of acting within local communities, health care is often an institution that is funded, whether that’s at the payer level or at the hospital system level, in ways that a lot of other social service–oriented institutions are not funded. Underwriting community efforts to improve health and participating in community collaboratives to improve health is something that health systems need to look at well. Not just orienting their community benefit program around that, but showing up in places where people are addressing housing or income or isolation, and looking creatively at what we can do with the health system. How can we apply our resources to these problems? Can we have hiring programs, for example, that make sure that we’re being part of the solution for underemployment in our community? Those kinds of interventions are going to be more and more important over the next few years.

Mohta: Damon, thank you so much for taking the time to speak with Catalyst this afternoon. We really appreciate it. Thank you.

Francis: Thank you for having me, Namita.


Disclosures: Namita Mohta is a Strategic and Clinical Advisor for Health Leads. Thomas H. Lee, MD, MSc, Founding Advisor for NEJM Catalyst, is a member of Health Leads’ Board of Directors.

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