BY, MSW, ACSW, LCSW, CCM, CCTP, CMHIMP, CRP, DBH-C
The social determinants of health (SDoH) are embedded in the fibers of society. They are a major factor to precipitate care disparities, while emphasizing social stratification of society. The SDoH are the conditions by which persons are born, live, socialize, go to school, work, age and ultimately die. They involve physical and behavioral health conditions that invoke stress, foster helplessness and make patients feel more susceptible to illness and premature death. The impact is intergenerational in scope and yields a lion’s share of priorities for population health and case management across every age and practice setting.
WHERE IT STARTED
Sir Michael Marmot first coined the term Social Determinants of Health toward the end of the 20th century. Robust data validated how poor populations lived shorter lives and were more prone to illness, compared to persons with greater financial wealth; the longer people lived in stressful economic and social circumstances, the greater psychological wear and tear with increased morbidity and mortality. The Solid Facts (Marmot & Wilkinson, 2003) were crafted to enhance understanding of the SDoH for the workforce, displayed in Box 1. Yet, despite a global mandate to address health disparities through emerging data, the connection to return on investment for the health was not yet made. As every case manager knows, fiscal imperatives (and outcomes) are what drive organizations to prioritize populations, programs and their staffing.
The Hospital Readmissions Reduction program (HRRP) hit our healthcare scene in October 2012 (fiscal year 2013) with an explicit goal: “encourage hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions” (CMS, 2020); one might think over $280 million in penalties would accomplish that task, but not necessarily.
Once studies identified how over 50% of readmissions were due to the SDoH, the game was afoot. Every organization prioritized funding and initiatives to bridge the disparities gaps and plug the quickly draining fiscal faucet. However, there is limited progress in resolving the readmission quagmire. In the tenth year of the HRRP, over 2,500 facilities (83%) were penalized for readmission of Medicare patients within 30 days: original treatment for heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement and coronary artery bypass graft surgery. National Health Expenditures (NHE) for 2019 were over $3.8 trillion dollars, or $11,582 per person with Medicare and Medicaid spending at 6.7% and 2.9% respectively (CMS, 2021). The industry is quick to blame an array of issues, from escalating SDoH-related costs to insufficient primary and specialty care for chronic illnesses and co-occuring health and behavioral health conditions.
HOW IT’S GOING
The five domains of the social determinants of health (SDoH) were recently updated for Healthy People 2030 (HP 2030) (U.S. Department of Health and Human Services, 2020):
- Economic stability
- Education access and quality
- Health access and quality
- Neighborhood and built environment, and
- Social and community content
These domains now cut across almost every demographic group. Increasing populations are at risk of being added to a roster that includes growing numbers of homeless veterans, victims of human trafficking, families struggling to manage high co-pays, deductibles and other types of medical debt, persons with chronic illnesses, victims of domestic violence, a generation of the workforce forced out of jobs due to harassment claims; let’s also add over 40 million unemployed from pandemic-related employment furloughs, layoffs and other shifts.
The changes to HP 2030 are critical to advance how the SDoH are managed across the industry. The presence of quality education and healthcare in any community are essential. However, disparities easily become embedded within every practice setting. Limits to reimbursement, as well as provider and industry stigma create obstacles to care. These obstacles impede a patient’s ability to obtain necessary appointments and treatment reflective of cultural needs and preferences. Quality of care deteriorates as providers become overburdened by grossly expanded caseloads and inadequate time to render care. Reimbursement pales in comparison to what it should be. Clinical and fiscal outcomes fail to meet established thresholds. The industry can and must do better, but how?
WHAT THE FUTURE MANDATES
The growth of populations at risk for the SDoH translates to a horizon full of innovative program and population health mandates. These opportunities encompass funding, robust informatics, rising numbers of dual eligibles, mental health disparities and a wider lens for professional case management to address care.
Healthcare organizations are positioning themselves for success through community investment and development. These efforts address rising costs associated with the SDoH, especially for hospitals. The Federal Reserve Bank of Philadelphia’s annual report, Hospital Community Development and Investment (Savage & Divringi, 2020), reveal how nonprofit hospitals in the United States spend an average of $67.9 billion annually on community benefits with more than half of these expenditures spent on patient care: 41.2% for unreimbursed care, 20.9% for charity care.
Nonprofit hospitals face major obstacles in achieving the Quadruple Aim, rendering the right population health, at the right cost, right time and by persons who embrace the work. These obstacles include rising utilization and costs associated with high rates of uncompensated care. This rate has risen steadily since the $17.4 billion reported by the American Hospital Association (AHA) in 1995; the amount hit a high of $41.3 billion for 2019 (AHA, 2020). The numbers are expected to rise exponentially in 2020 and beyond from COVID-related costs and loss of revenue from canceled surgeries, procedures and other service shifts. Hospitals must define fresh ways to mitigate these fiscal care gaps, implement new spending priorities and engage in strategic investments that bridge gaps in funding. The list of community-based investment options appears in Box 2.
GROWING MANAGED MEDICARE AND MEDICAID POPULATIONS
Of the almost 62 million Medicare beneficiaries, over 24 million (or 40%) are enrolled in Medicare Advantage plans; by 2030, experts predict the rate to be over 50% (Freed et al., 2021). These numbers speak volumes about rising numbers of low income seniors mandating greater service provision to maintain their health and wellness. Yet, these numbers also speak to opportunities for the case management workforce, particularly as the industry’s top managed Medicare providers expand their national footprint and programs (Blue Cross Blue Shield Affiliates, Centene, Cigna, CVS Health, Humana, Kaiser Permanente, United Healthcare) (Freed et al., 2021).
Organizations are more focused on the SDoH than ever with emphasis on gathering and culling various data types and ensuring its proper integration within the care continuum. In response, a new dimension of social informatics has emerged. This innovative field homes in on collection, linkage, storage and retrieval of information associated with the SDoH. Through this effort, the data is accessible to inform healthcare organizations of patient and population barriers to care, local social service and other community resource gaps, and potentially organizational workflows. Social informatics fosters a unique view of care to incorporate a wholistic health triad of pathophysiology, psychopathology and psychosocial needs (Fink-Samnick, 2020). This perspective will leverage case management’s goal toward enhancing individual and population health equity.
SOCIAL DETERMINANTS OF MENTAL HEALTH
Growing mental health needs across society are mandating attention to the social determinants of mental health (SDoMH), prompted by the same socioeconomic and psychosocial factors associated with health disparities. These mental health gaps are exacerbated by long-standing issues with inadequate funding and reimbursement. Case managers may need to advocate on behalf of patients with providers who reject insurances, typically accessed by those persons in lower socioeconomic groups (e.g., Medicaid, Medicare Advantage). There may be disincentives for providers to accept these forms of payments (e.g., delays in or appeals to access accurate reimbursement, rigorous administrative processes and oversight). A domino effect ensues: Persons who are unemployed or in low-income or part-time jobs may be less likely to access mental health, are forced to use community mental health more frequently and are more likely to obtain care on an emergent basis from EDs and hospital admissions (Fink-Samnick, 2020). These realities result in care that reflect short-term Band-Aid fixes versus formal and sustainable treatment options.
Psychiatrist deserts exist across the U.S. and yield horrendous delays in care even if a provider is available. High numbers of patients with mental illness rely on public insurance, whether Medicaid or Medicare Advantage, with too few providers accepting these payor options. In Massachusetts, barely 33% of practitioners accept Medicaid managed care plans, while 95% are paneled with other private commercial group insurance plans. When individuals are unable to obtain the appropriate and timely mental health treatment, their stabilization and prescription management are grossly compromised (Fink-Samnick, 2020).
The pandemic has further fueled mental health challenges for society, especially among the most socially disadvantaged groups. Too many individuals face increased mental health exacerbation or onset of new behavioral health issues, deal with substance use and abuse, as well as succumb to overdoses and suicides. Mental health has become the largest driver of unnecessary emergency department visits: costs for patients with behavioral health needs upwards of $2,264 per visit (Schall et al., 2020). More of society’s “haves” are now “have-nots,” those previously marginalized populations at greater risk of succumbing to severe forms of mental health exacerbation (e.g., persons of color, members of the LGBTQ+ community, persons with disabilities, immigrants).
It took centuries for the SDoH to be recognized as a fiscal and clinical disruptor of care. The complex nature of patient needs mandates the expertise of each discipline that comprises our interprofessional hood. As a result, it will take time, as well as concerted and strategic efforts by the entire industry to address them. This translates to unparalleled opportunities for case management’s diverse professional workforce.
American Hospital Association (AHA) (2021). Fact sheet: uncompensated hospital care cost, Retrieved from https://www.aha.org/fact-sheets/2020-01-06-fact-sheet-uncompensated-hospital-care-cost
Centers for Medicare & Medicaid Services (CMS) (2020). Hospital readmissions reduction program (HRRP). Acute inpatient PPS. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
Centers for Medicare & Medicaid Services (CMS). (2021). National Health Expenditures Fact Sheet, Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet
Fink-Samnick, E. (2020). Mental health, Chapter 8, End of life care for case management, HCPro
Freed, M., Damico, A. & Neuman, T. (2021, January 13). A dozen facts about medicare advantage in 2020; Kaiser Family Foundation. Retrieved from https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/
Marmot, M & Wilkinson R. (2003). Social determinants of health: the solid facts.: World Health Organization Savage, H. & Divringi. (2020). Exploring hospital investments in community development. The federal reserve bank of Philadelphia, October 2020; Retrieved from https://www.philadelphiafed.org/community-development/exploring-hospital-investments-in-community-development
U.S. Department of Health and Human Services (2020) Social determinants of health, Healthy People 2030. Office of Disease Prevention and Health Promotion; Retrieved from https://health.gov/healthypeop…-determinants-health