Q1 2018 Newsletter - Rise of Social Determinants of Health (SDOH) in Population Health Management

by Teddy Shah, MS, MBA, CPHIMS, PMP, 6s, Vice President – Optum Advisory Services

There are three fundamental forces driving higher managed cost of care:

  1. CHRONIC CONDITIONS - According to the CDC, 170M Americans have one chronic condition and 60M will have at least two.
  2. DISPROPORTIONATE SPEND – According to an article in USA today, 80% of the Medicare and Medicaid spend goes towards top 20% of high risk patients while 94% of Medicare spend is on patients with at least two chronic conditions.
  3. SOCIAL DETERMINANTS - 80% of factors that impact health are non-clinical as per a study conducted at the Population Health Institute at the University of Wisconsin.

According to a study done by the Institute of Medicine in 2012, approximately $8,086 is spent on medical care per person per year and only $251 is spent per person on public health measures that prevent medical conditions before they occur.  This highly disproportionate spend on social determinants of health results in one of the worst health outcomes of any developing country.

By 2030, 20% of Americans will be over the age of 65 and health care is under immense pressure to control costs and improve quality as the current trajectory is unsustainable.  Employers, states and the federal government purchasing healthcare for their constituents are all demanding payment reform, lower costs and better outcomes thereby putting the onus on providers to find new avenues of mitigating cost, while successfully managing the health of their patient populations. Healthcare organizations that are not prepared to manage higher levels of risk will likely be acquired or cease business.

More than 94% of Medicare fee-for-service money spent on seniors is spent on patients with at least two chronic conditions.  In 2012, the sickest 4M represented 15% of Medicare’s senior population, but accounted for more than half the spending on that group.  Chronic diseases are the leading cause of death and disability (in 2010 heart disease and cancer accounted for nearly 48% of all deaths) despite accounting for the most spend (more than $300B). 

However a typical high-risk patient case profile consists of not only someone with chronic illnesses and psychological needs, but it invariably includes non-clinical needs such as lack of transportation.  Providers know all too well how to focus on wide range of clinical interventions, and for the most part they are able to include behavioral help with the clinical.  The lack of focus on non-clinical is something that most providers are just starting to grapple with. 

Some providers are focusing on high tech solutions to manage chronic illnesses by monitoring and measuring every single activity of the patient, these solutions are perceived by many patients as akin to being in a monitored jail.  Few providers are beginning to understand that high touch solutions are truly what patients need across the 16 domains of care.  Ability to provide help within their community with safety and social support to reduce isolation and address behavioral change provides better outcomes. 

Everyone knows that a doctor can nudge you to eat more spinach and go to aerobics till he’s blue in the face.  But if your friend offers to come to your house and cook dinner one night or suggest going to a Zumba class together, you’ll be making that vegetarian lasagna and learning to dance.   No amount of formal medical training or well-meaning advice can trump the impact of relationship based “wellness” coach. 

According to a study by The Commonwealth Fund, providing social support reduces care costs for at risk and relatively healthy populations.  Therefore the focus by health systems to help entire communities stay healthy and population health management will soar in importance this year.  Taking on an even broader platform, the social determinants of health – including access to care and services, reliable transportation, housing, education, and nutrition – will become the focus of many more health care systems and social service providers. 

For those providers truly committed to improving population health, we'll see more partnerships that involve care management, housing (especially for the homeless), and peer to peer based community services. More emphasis will also be placed on the measurable outcomes achieved through these important alliances.

A comprehensive population health model must segment patients by complexity and not just by disease.   Healthcare administrators must be prepared to lead a hospital without walls if they want to deliver on the whole patient. Organizations should therefore end the concept of accepting and/or discharging a patient, because caring for a patient in the new world is not an episodic event but a continuum where they nurture relationships for wellness. Eventually crowdsourced population health management, that enables delivery of well-managed and cost-effective health outcomes, will become Health Management!

Teddy Shah is the VP of Provider Consulting at Optum.  He has 25+ years of experience that spans a diverse view having worked for a multi-facility health system, healthcare vendor and served several healthcare organizations.  Teddy has lead Delivery, Sales and Solution teams giving him an unparalleled 360 degree perspective across the healthcare continuum.  His area of expertise include strategy, business transformation, performance improvement, value based care and large system implementation initiatives.  Teddy recently helped develop a Population Health Management (PHM) framework focused on developing value-based care transformational strategies as a member of the National HIMSS Task Force on Population Health Management. Teddy also has considerable experience with Clinical Application Services covering the entire spectrum of EMR (Epic, Cerner and McKesson) and its related needs. Teddy has a PMP, CPHIMS and Green Belt Six Sigma (6s) certifications.  Prior to joining Optum, he worked for Ernst & Young, IBM Global Services, McKesson Provider Technologies and Dell Healthcare Services.

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