In 2019, over a quarter of the nearly $200M in CMS reimbursement to hospitals for high quality performance was awarded to just 14% of US hospitals. To qualify for a reimbursement, a hospital must report on several measures that demonstrate a high quality of care for patients while reducing overall cost. Accounting for 25% of the overall score are patient satisfaction surveys.
The Yelp of healthcare, HCAHPS, is a national survey of patients’ experiences in a hospital setting. In order to break into the top quartile cohort of “high performing facilities,” only 57% of a hospital’s patients need to report they understood their care when they left the hospital.
What does it mean that nearly half of patients are leaving hospitals reporting they do not fully understand their care? I imagine it has less to do with the clinical details of their diagnosis and treatment plans than it does how they will manage their health within the context of their life.
- How many of the 30 million diabetics diagnosed last year wonder how they will manage treatment on breaks at work?
- How many of the 1 million kidney disease patients on dialysis worry about how they will get to and from appointments?
- Of the 75 million patients with hypertension, how many have the resources to manage a proper diet, reduce stress, lose weight, and increase physical activity?
Half of patients leaving a hospital do not understand their care when they leave the hospital and this is rewarded as quality.
The whole person is greater than the sum of their diagnoses
When a person is diagnosed with a condition of any acuity, it is important to consider the whole person’s identity. A holistic understanding of how a person navigates their social world can help healthcare providers treat their patients and also better enable pharmaceutical and medical device companies to develop therapies to address the specific needs of patients.
Forbes’ Reenita Das predicts that social determinants of health (SDOH) will play a larger role in health outcomes than medical care determinants. She writes that close to 40% of US health systems and commercial payers will leverage SDOH data to engage patients and improve the quality of care, health outcomes, and optimize the overall cost of care.
What is a social determinant of health?
Social determinants of health are the social and cultural factors that influence a person’s access to and quality of healthcare. When a healthcare provider makes a diagnosis or prescribes a treatment plan, they must also consider the influence of their patient’s physical and social environments. While family history and genetic predisposition can certainly affect a person’s health outcome, the diagnosis is experienced and managed by patients differently in the context of their cultural and physical worlds.
One of the most extensively researched examples of SDOH for population health focuses on patients with diabetes. If an oversimplified plan for Type 2 diabetes is to eat healthier and exercise regularly, we must consider a patient’s ability to access this treatment. Providers should be asking questions such as:
- Can patients afford gym memberships? If not, do they live in safe neighborhoods that allow for outdoor exercise?
- Are there grocery stores or restaurants with affordable and healthy options nearby?
- Can they afford the cost of regular visits with their health care provider?
- Do they have the ability to take time off from work to visit their doctor?
According to the Center for Disease Control, a person’s socioeconomic status is one of the more prevalent social indicators for health. Poverty severely limits not only one person’s access to healthcare and treatment, but also disenfranchises whole communities from accessing job opportunities to afford their healthcare, education to navigate healthcare systems, or time to engage with healthcare providers.
While socioeconomic status is a key social indicator, consider how else people move through their day. Women, people of color, individuals with multiple physical or mental disabilities, religious minorities, those for whom English is not a native language, and other identities influence a person’s engagement with their health and healthcare providers.
Social identities and health outcomes
Where does your target patient population live, work, play, travel? What is their race, class, gender, religion, age, language fluency? How does this engagement with their social world promote or prevent health outcomes?
I recently read an article about a CPR "manikin" outfitted with a neoprene breast vest (NPR’s Rachel Treismanto) that trains first responders and bystanders how to perform life-saving techniques on all body shapes. She writes that the Womanikin was developed to close the gender gap in who survives CPR during a cardiac emergency. Rachel references a 2017 study in which only 39% of women received CPR from strangers compared to 45% of men.
Think of your last CPR training. Training material predominantly featured male actors; training manikins are predominantly flat chested and of a typically able bodied dummy; symptoms predominantly highlight those experienced by men. Folks who are trained in basic CPR have limited exposure to body diversity: black bodies, bodies with breasts, tattoos, scars or piercings, obese bodies, or bodies with physical disabilities are rarely, if ever, represented in basic first responder training programs. A person’s body and the way we engage with diversity puts these populations at a much higher risk of mortality.
Screening for social determinants of health
As we learn more about the social lives of diverse populations, healthcare providers and companies that develop therapies must continue to engage with patients where they live, work, and play. Those providing therapeutic and diagnostic care for patients can ask, among other questions:
Who does this treatment benefit?
- Consider who is featured in marketing and educational material for treatment and if patients see themselves represented.
Who may have difficulty adhering to this treatment plan?
- Religious practices may prevent adherence to elements of a care plan (for example, a Jehovah’s Witness will refuse blood transfusion).
What barriers exist to accessing treatment?
- A foreign language interpreter may be linguistically fluent but lack the cultural competency to interpret non-verbal nuances between the patient and healthcare provider.
What resources must a person have for a successful outcome?
- A person earning below the poverty line may not be able to afford the therapies required for their diagnosis.
How does this patient define their quality of life?
- A Deaf person may not see a cochlear implant as a solution, whereas a late deafened adult with no cultural ties to the Deaf community may find an improvement in their quality of life with a hearing aid or cochlear implant.
How we diagnose and treat patients must consider their social identities and determinants of health or we risk prescribing inaccessible and ineffective care solutions.