What primary care physicians need to know about social determinants of health

Social determinants of health are a difficult challenge for primary care physicians. If ignored, they can completely negate a course of care and patient conditions are less likely to improve. But most primary care doctors are already overburdened and don’t have the staff or monetary resources to help patients resolve their social issues in order to improve their health.

Medical Economics spoke with Michael Dulin, MD, a professor of health sciences at the University of North Carolina-Charlotte and the chief medical officer of Gray Matter Analytics, about what physicians can do to help their patients with social determinants.

(Responses have been edited for brevity and clarity)

Medical Economics: For primary care physicians, how big of a role do social determinants play in the overall health of the patient?

Michael Dulin: I'm a primary care physician and I was trained in a model where I thought clinical care delivery was kind of the end all and be all in terms of patient outcomes. But what we found is that clinical care only accounts for about 10 to 20% of patient outcomes. So the other 80% is influenced by things like behavior, social determinants in the environment, where he lives. So pretty much the majority of health care outcomes are actually driven by factors that are outside of the clinical care and the health care delivery environment.

ME: How can doctors find out what social determinants are impacting a patient's health?

MD: It's very difficult to do. Part of our training in the primary care space is to inquire more about some social circumstances. So for example, employment, other health behaviors like smoking or lack of regular exercise, but some of the key factors, things like your social network, who are the people around you, your access to transportation, your housing, there can be some stigma with those types of factors. And it's a little harder and not really part of the practice to start to inquire about that in a primary care setting. So one of the solutions is to think about primary care as instead of just being a doctor providing primary care services to think about a team-based approach to care delivery, where you do have members of your team that focus and better understand the social circumstances that influence a patient's outcomes. You start to have that team assist with collecting the data and using more comprehensive, holistic information about the patient, to think more deeply about how you deliver care and to take those factors into consideration.

ME: Are patients honest about what social determinants exist in their lives?

MD: It's often hard to determine that until you run into some type of circumstance that directly is related to a social circumstance or social outcome. There's definitely a stigma around some of the social determinants of health. Some patients are more forthcoming and more likely to reveal that, and others are not. I've had a patient that was illiterate in the past, and that was not forthcoming until we started to actually look at his medication. So it was embarrassingly quite a while after it started, having a relationship with this patient, that I began to understand that he had problems with illiteracy. It came down to a point where we were going through his medicines, and I think I handed him one and asked him how do you take this and what is this medication for? Then he revealed that he wasn't able to read the labels on his medication. I think the same often can be true for other factors. Who's living with you? What are your circumstances? Do you have housing insecurity and food insecurity, which are extremely important factors that drive an individual's health, and are often overlooked. As a primary care physician, sometimes our first approach is to start to escalate care delivery, to think about patients with high blood pressure and start a medication, have them come back, and their blood pressure isn't moving in the right direction, they're not getting control of the blood pressure. And then the knee jerk reaction is, well, the medication is not working, we need to escalate, add another medication or do something differently in terms of the medical care, rather than thinking through what's actually going on in their environment. Are they actually able to get the medications? Do they have access to a pharmacy? Were they able to comply with some of the changes that were recommended in terms of the diet and go for low sodium foods and things along those lines? So often those factors aren't readily apparent until you start to notice issues with the care delivery process itself or with the outcomes that you're hoping to achieve in terms of better health care.

ME: Are there situations where a patient is answering honestly, but their life experience is so different from the physician’s that in the physician’s view, they're having housing issues, but because the person's always lived in that particular area and always had difficulties with housing, that to them, it's not an issue. Do you run into situations where you're kind of working off of two different definitions of what you're asking?

MD: Absolutely, I think there's huge differences in that. There's a lot of maybe unconscious bias that happens in care delivery when there is this difference between the social situation or the cultural background. As physicians, we're kind of trained in one model, but not necessarily trained in this whole realm of cultural competency, or how to create these bridges and better understand the cultural factors that are driving health outcomes. It's also a lot more difficult to address social issues than it is to just write another prescription. For me, as a provider, I found that in my own behavior, sometimes you have a hammer, and everything looks like a nail. You know what the medication regimen is for high blood pressure, but you don't necessarily know how to overcome those social barriers that prevent access to healthy foods or exercise, or even access to the medications that are needed. And so it's easy for physicians to kind of slip down that pathway of clinical care, since we know it so well. The social circumstances and overcoming the social barriers are much more difficult and that's why it's important for us to start to think about primary care as a team-based delivery process. We have members of the team that better understand how to overcome social barriers or the social determinants of health. And we work together in tandem so the physician or clinical team better understands the clinical care pathway, but we have a member working right next to us that also understands how to deal with certain social circumstances and behaviors. Those can be much more difficult in some ways to overcome than the medical components of care.

ME: In your experience, what are the biggest social determinants that affect the patient's health?

MD: It's highly variable, but some of the things that I've seen, and in particular I think is really important, is the social network. If somebody has a social network that reinforces some negative health behaviors, for example, tobacco use, often runs in families. The parent will smoke, the kid will smoke, a spouse or significant other will smoke, others in the network use tobacco, and it makes it extremely difficult to change behavior. It's a very hard behavior to address anyway because of the addictive nature of nicotine, but then if it's also in your social network, it's going to be extremely difficult to overcome. The other ones I've seen are issues with transportation. I've worked in clinical care environments where the clinic is located two bus stops away from where an individual lives. It takes a lot of additional effort, particularly with patients that have young families or kids that need access to daycare or have a job that doesn't allow them to take time off. And then often the health care setting is not very accommodating for those that have transportation issues. So, you've come in, you've had to take two buses, find daycare take time off from your job, and you're 15 minutes late for the appointment. Then the primary care setting has a rule that you know, if you're 15 minutes late, you have to reschedule or you get some sort of penalty or if you don't have your copay when you arrive, then you don't receive care. Sometimes that makes it a lot easier to go to an emergency department that's in your neighborhood that doesn't have those same types of barriers.

Food access is also extremely difficult. A lot of people, particularly my community, in Charlotte, North Carolina, we have some communities where there's not ready access to healthy foods. If you have a combination of a transportation barrier and you live in a food desert, and there's a fast food restaurant around the corner, or a corner market that sells low quality food that's inexpensive, it's much easier just to grab something on the on the way home, particularly if you've had a stressful hard day. You don't want to have to think about going out of your way to another community to purchase the foods that you need to maintain a healthy diet and have that better health outcome.

ME: What should primary care physicians do with the social determinant data once they've collected it from their patients?

MD: It’s tough building that trusting relationship so that you can overcome those stigmas, and you have to manage that data in a way that the patient's aware of it and sharing it in a way that the patient has control of it, so that you don't break that trust. I think that could be one of the worst situations, as you collect this really important data about social determinants, and then somehow it's used in a way that doesn't align with how the patient thinks it's going to be used. The other component of it is to try to act on it in some way. Even if you work in a care setting where you don't have a team, a social worker, or someone else that can understand how to address that, starting to use some of these new tools that allow us to refer people into community-based services and being engaged in the community, understanding what those services are, where they're at, I think it's extremely important.

Now, it's going to become more and more important as we really move into more value-based systems of care delivery. The other component is that the primary care doctor’s job is extremely difficult already, and you have to become the care navigator, helping to interact with care systems, hospital systems, specialists, and other pathways. Finding new electronic analytic tools that allow us to digitally collect the data, and then use it in a way that helps us distribute resources more effectively to the people that need them the most, is going to be extremely important. But that technology is still emerging at this point. It's not necessarily there yet. So you have to continue to push for that as a solution to help us to do our jobs more effectively.

ME: Many small practices don't have the resources to address social determinants themselves. They can't afford the extra staffing or whatever they would need. What can they do to make a difference?

MD: Often the small practices are also in communities where people can directly access them, and so I think that's going to become more and more important. We’re going to have to think more kind of policy level — how do we reinforce the need to address social determinants in a small practice and provide changes and funding mechanisms? We're starting to see that. The Medicaid and Medicare Innovation Group is starting to recognize that as you build these accountable care organizations and want to try to help the practice to actually achieve better health outcomes, that you have to pay them for this type of work. There are some of the Medicaid solutions where they pay practices directly to manage populations. And as the more commercial payers move into this space, as well, I think they're going to have to proactively understand the burden that social determinants plays on a community or practice, and then reimburse appropriately so that those practices can get the additional resources that they need to address the social determinants of health.

ME: Are there advantages to practice in collecting and analyzing social determinant data besides improving patient health?

MD: Well, number one is to drive improvement in patient outcomes, but absolutely, there are others. Often, practice design is more of a patient-driven experience. I think in the U.S., we look at patients as consumers of health care, and we often create systems that are driven by the patients themselves. If you think about your own care, you probably had to call the doctor, make an appointment, and come in in a timely manner. But I think that model can be flipped and make more practices more efficient, by helping to surface back to the practice the patients that have more resource needs, or have additional care needs, and almost do it in reverse. So reach out, engage the patients that are in need of more care, and ensure that the resources are applied appropriately. One interesting example we have locally, we had some issues with health disparities for minority populations, particularly for kids with asthma, and we kind of flipped that model. Here we're delivering care using another model called shared decision-making, but it's an active outreach to people that are high risk or kids that are high risk because of their asthma. We use this additional layer of intervention to try to engage with those patients and their families to provide better care for their asthma. And I think that's really how the care model is going to have to go where we use this type of data to deploy resources in a way that helps improve health equity and directly address health disparities.

ME: Are there any other things you'd like to mention about social determinants?

MD: We estimate over $300 billion every year is spent directly on issues that could have been dealt with if we had better health equity, and we didn't have health disparities in our country. And the Kaiser Family Foundation, I think, found about a third of deaths are directly driven by social determinants of health. So there's a huge upside. We've unfortunately, in the US, we've seen diminished, you know, life expectancy because of a number of different factors. Obviously, the pandemic, opioid misuse, obesity, and health disparities underlie that as well. So as we think more globally about how we do a better job with delivering care, we really need to think through how do we address social determinants, and I think primary care is a great place to do it. But at the same time, we have to be careful not to overwhelm our primary care physicians, we already have issues with so much paperwork and bureaucracy and you know, all the interactions with a broader health system. So we have to do it in a way that makes it healthcare easier to deliver and better, and clearly shows improved health outcomes. And I think that is a way of engaging primary care physicians if we can see that our work is clearly making a difference, addressing health disparities and improving, but real patient-oriented outcomes that will help us maintain our engagement and be excited about the work that we're doing.