This topic was the focus of a breakout session at Outcomes+ 2022.
The United States has some of the biggest health disparities in the world. The unequal impact of the COVID-19 pandemic on certain communities highlighted these deep divides and the devastating effects of health inequities.
That said, health inequities aren’t new and are caused by Social Determinants of Health (SDoH) like gender, race, education, income and zip code, among others. These factors shouldn’t dictate a person’s health. The hopeful news is that using a tool like a geographic Social Vulnerability Index can identify at-risk individuals and actionable insights for plan sponsors to focus resources and interventions that will reduce health disparities, improve health outcomes and lower health care costs.
What are Social Determinants of Health?
Social determinants of health are underlying factors that contribute to an individual’s ability to be in good health. In fact, socioeconomic status, education, employment, social support networks and neighborhood characteristics have a greater impact on population health than factors like biology, behavior and health care. Other social determinants of health can include:
- Safe housing, transportation and neighborhoods
- Racism, discrimination and violence
- Education, job opportunities and income
- Access to nutritious foods and physical activity opportunities
- Polluted air and water
- Language and literacy skills
The costs of health inequity
Social determinants of health affect more than 80% of health outcomes. This means that a majority of health outcomes are determined by behaviors and the environment in which people live, work and play – none of which will show up in prescription, medical or lab data. Care teams are missing life-altering information when treating patients. Individuals with unmet social needs are more likely to have chronic conditions, double the rate of emergency room visits, nearly double the rate of depression, and have a 60% greater prevalence of diabetes1. In aggregate, disparities are estimated to amount to $93 billion in excess medical care costs and $42 billion in lost productivity per year2.
With most individuals spending the majority of their time outside of the health care setting, plan sponsors need to provide more support outside of the health care setting, like ensuring individuals have access to food, housing, etc. Consider how likely someone will be to focus on the clinical aspects of their life if they don’t know where their next meal will come from.
How a Social Vulnerability index can help
An index with a geographic-based score can help plan sponsors identify where there are problems, and what they specifically are. From there they can ensure that the right resources and interventions that solve for health inequities in their populations with the highest needs are being deployed. For example, by connecting individuals with doctors they trust and who understand their environments and how those environments might be affecting their health. Such tactics, strategically deployed, can improve health, reduce inequities and save lives. Several Evernorth pilots that used an index to guide their work have demonstrated their effectiveness.
For example, one pilot sent providers to rural work sites to provide health services like physicals and vaccines; allowed 90-day supply conversions on maintenance medications to promote adherence; and had pharmacists collaborate with other providers to optimize patient outcomes. These engagements resulted in increased medication compliance and 3 percent average decrease in diabetes patient A1C, enabling savings of $282,000 to $963,000 per year.
An index should factor in multiple measures in order to identify where disparities exist in a population and reach actionable insights. The CDC/ATSDR (Geospatial Research, Analysis & Services Program (GRASP) Social Vulnerability Index uses U.S. Census data to determine the social vulnerability of every census tract. It then ranks each tract on 15 social factors and groups them in four related themes:
- Socioeconomic status
- Household composition
Evernorth thinks it’s important to incorporate additional factors into an index to reveal at risk individuals. These include the share of population more than one mile from a supermarket in a city or 10 miles in rural areas, a neighborhood’s walkability score, and businesses per capita. Also key are improving health literacy and helping members find providers they trust, who understand their circumstances.
There’s a lot of work to be done to address SDoH and reduce health inequities. The purpose of an index is to help plan sponsors prevent the snowball effect among their members by addressing health inequities where they begin. Results will vary by population, person by person. But it’s critical work that starts with the commitment to understanding the factors at play.
1. Health Payer Intelligence: Addressing the Real Implications of Social Determinants of Health, Addressing the Real Implications of Social Determinants of Health
2. Berkowitz, et al. BMJ Quality and Safety 25(3), 164–172)