Why it’s time to improve the social determinants of health

It has been known for a long time that “health care” — all the stuff that we do, prescribe and provide — is a minor determinant of how “healthy” any of us is. Overall health, or more technically, the variability in health outcomes, is much more dependent on the combination of genetics, personal behavior (think smoking and seat belts), environmental factors and socioeconomic status than it is on health care.

I was thinking about that when I read in the New York Times about how some health care provider systems, driven by the need to cut costs, are starting to address some of the non-medical social needs of their patients. These kinds of innovative community-based interventions started to get traction after they were highlighted by an influential profile by Atul Gawande in the New Yorker. Their diffusion has been driven by the expansion of novel payment models that have started to reward providers for reducing utilization of services like ER visits and hospitalizations, the very services that they have traditionally been paid for.

From a society-wide perspective, all this makes perfect sense and is long overdue. No rational person would want to preserve the situation described the county health official quoted in the Times: “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.” That said, I see at least two big challenges to straightening this all out.

The first problem in ridding “the system” of the perversion of paying for amputations but not boots is that we don’t really have a health care “system.”  We have an unholy mess of independent actors and government agencies without any ability to make it rational from a society-wide perspective. Sure, there are pockets of integration and global oversight, like the Veterans Administration, or state governments, which are responsible for an array of social welfare and health benefits.

But even within these bureaucracies, it is a real challenge even for well-meaning individuals to work across the barriers of separate budget lines and programmatic responsibility. It is not a simple matter (and may even be illegal) to transfer funds from, say, a diabetes clinic to a homeless shelter, even if more services at the latter would improve the health of diabetics.

The action lately has largely been to start to hold health care providers accountable for health outcomes instead of compensating them for the provision of services. In general, I think that is a good thing, but it raises the second challenge: Health care providers may not be any good at providing the non-health care services that people need to be healthy. Why should we expect physician practices and hospitals, which have evolved over decades to become what they are now, to be able to morph into effective social welfare agencies?

Frankly, if I were paying the bills (and let’s not forget that as taxpayers, we are all paying part of it) I’d be inclined to pay us less for care and pay others more to improve the social determinants of health.

Ira Nash is a cardiologist who blogs at Auscultation.

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