Overcome the Stigma of Social Determinants of Health
Identify environmental and socioeconomic factors in health to improve the overall care of the patient population.
At a local Blue Cross carrier conference I recently attended, J. Nwando Olayiwola, MD, chief clinical transformation officer at RubiconMD, spoke eloquently about the challenges of identifying social determinants of health (SDOH) — a term we should all start to recognize. Here’s what you should know about SDOH as a professional on the revenue management side of healthcare.
Become Aware of Environmental Health Challenges
The World Health Organization (WHO) explains SDOH as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”
What we do in clinic represents, at most, 10 percent of the patient’s life, according to Dr. Olayiwola; the other 90 percent of the time, people are fighting their own environmental challenges. These environmental challenges frequently work against those of us trying to improve our patients’ overall health. For example, low-income patients increasingly are faced with having to choose between food, paying the electric bill, or filling their prescriptions. Medication is usually last on the list and food options (when there are options) are typically the low-cost, low-nutrition types.
HEALTHCON 2019 keynote speaker Karen DeSalvo, MD, MPH, MS, former acting assistant secretary for health at the U.S. Department of Health and Human Services (HHS), also talked about SDOH. She spoke passionately about the impact of SDOH on the U.S. population.
In looking at the overall cost of healthcare in the United Sates, DeSalvo said, about 5 percent of the population drives over 50 percent of total healthcare costs. Sick patients are remaining sick and using healthcare resources at an alarming rate. According to the Centers for Medicare & Medicaid Services (CMS), at the current rate of spending, the hospital insurance trust fund (Medicare Part A) will be depleted by 2026.
This explains the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the push to gain better control over healthcare expenditures. We are moving rapidly towards a “reimbursement for quality performance” model under which providers are paid to keep patients healthy rather than a “reimbursement for volume” model under which providers are paid a fee for service.
The overarching question posed to practitioners and staff is: How do we identify patients’ needs so we can recommend the needed resources?
The Reality of SDOH
I work with hundreds of providers, and many of our patients reside in depressed socioeconomic areas. My team and I spend countless hours each week discussing how to identify and reach patients who need preventative services and who are at increased risk of morbidity and mortality. We discuss how to avoid unnecessary hospitalizations and how to help the offices with outreach for patients who are homeless or underinsured. We have initiated discussions with two local agencies about partnering with our providers to send social workers and registered nurses into patients’ homes or onto the streets to find these patients and identify the many issues they face. These agencies provide a variety of services such as:
- Arrange transportation
- Procure links to food resources
- Help complete paperwork for emergency assistance
- Explain the complicated medical jargon used by doctors and pharmacists
- Find housing resources
- Coordinate medical appointments
The problem continues to be how to identify the patients. How do we identify and keep track of all patients who face uphill battles between their healthcare and their socioeconomic environment? Identifying patients with SDOH after repeated hospitalizations is too late. Unfortunately, it is the model we have been following, until recently.
Identifying SDOH Is Key to Better Patient Care
The Journal of the American Medical Association (JAMA) in May 2013 identified using the Patient Centered Medical Home model as a prime method to address SDOH. Humana, UnitedHealthcare, Blue Cross Blue Shield, and numerous other carriers are all recognizing that identifying issues such as housing instability, transportation issues, social isolation, violence, illiteracy, and food insufficiency are just as important to a patient’s health outcome as taking care of the patient’s physical conditions.
Dr. DeSalvo referenced numerous studies that identified food insecurity and social isolation as the two greatest risks of morbidity and mortality in our older population. Possible solutions you can implement in your practice to lessen the risk:
- Maintain a food pantry at your physician practice to ensure patients are going home with nutritious meals.
- Partner with a community clinic with a core mission of patient wellness for uninsured and underinsured patients.
For example, my employer partners with HUDA Clinic in Detroit, Michigan, that provides a full range of medical, mental health, dental, podiatric, and ophthalmologic services for patients who would not otherwise be able to afford these services. Their mission statement is, “(W)e seek to provide medical services not just to treat your symptoms but to address core problems with our patients to create a healthier community. We focus on educating our clients on important lifestyle interventions, vital health and nutritional information, while working with the community through health fairs and local events which allows us to bring this information to more people.”
Deliver medically appropriate meals to patients. This has proven to decrease hospital visits and admissions. Dr. DeSalvo noted a small study recently released that showed a 16 percent drop in readmissions by delivering medically-appropriate meals to the most chronic, frequently hospitalized patients. Physicians can accomplish this same task by coordinating with local food pantries.
In some practices with more “at risk” patients, questionnaires, such as the one shown in Table A on the next page, are used by ancillary staff to identify potential external insecurities. Patients seem more willing to discuss these issues with ancillary staff, rather than with physicians. In some of the practices I work with, for example, patients do not want to admit to their physician that they are taking their medication every other day to extend the life of the prescription, but they will admit it to the ancillary staff. Implementing into your practice ambulatory clinical pharmacists who can work with patients to find lower cost alternatives to their medications is an invaluable resource in many of these populations.
Table A: Example questionnaire
|As your patient-centered medical home, we are happy to partner with you, to help you and your family in your time of need. From the answers below, we maintain a list of trusted community resources that care about you as much as we do.|
|Food Security||Sometimes True||Often True||Does Not Apply|
|Within the past 12 months we were worried whether our food would run out before we got money to buy more.|
|Housing Instability||Sometimes True||Often True||Does Not Apply|
|I am worried that in the next 2 months I may not have stable housing that I own, rent, or stay in as part of a household.|
|Utility Needs||Sometimes True||Often True||Does Not Apply|
|In the past year, the utility company shut off my service for not paying my bills.|
|Financial Resource Strain||Sometimes True||Often True||Does Not Apply|
|In the last 12 months, I skipped medications to save money.|
|Transportation||Sometimes True||Often True||Does Not Apply|
|In the last 6 months, I have gone without healthcare because I didn’t have a way to get there.|
|Childcare||Sometimes True||Often True||Does Not Apply|
|I have problems getting childcare, so it is difficult to work or study.|
|Elderly Care||Sometimes True||Often True||Does Not Apply|
|I have problems getting elderly care, so it is difficult to work or study.|
|Literacy||Sometimes True||Often True||Does Not Apply|
|I have trouble understanding/reading my provider’s written instructions.|
Use ICD-10-CM to Better Identify Patients with SDOH
When thinking about how to help identify and quantify patients living with socioeconomic disparities, turn to ICD-10-CM. 2019 ICD-10-CM Expert, Guideline I.B.14, Documentation by Clinicians Other than the Patient’s Provider, states (underline added for emphasis):
Code assignment is based on the documentation by patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). There are a few exceptions, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.
For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.
This new guideline allows documentation from medical assistants to be used to identify patients in need of social services. The codes are not new, but the update to the guideline serves as both permission for ancillary staff documentation to be used, as well as a reminder that these codes exist and should be used accordingly. Insurance carriers use these codes for social service outreach to their membership and rely on the medical community to identify patients’ needs. Some of the codes in this section are:
Z59.1 Inadequate housing
Z59.2 Discord with neighbors, lodgers and landlord
Z59.3 Problems related to living in residential institution
Z59.4 Lack of adequate food and safe drinking water
Z59.5 Extreme poverty
Z59.6 Low income
Z59.7 Insufficient social insurance and welfare support
Unfortunately, the taboo, shame, and stigma around literacy issues, social isolation, and financial hardships continue to work against us. We need to bring these challenges into the open and talk to our patients about them if we have any chance of improving the overall health of our patients. As Dr. DeSalvo stated in her closing remarks, we are looking to the medical community to be a partner in addressing SDOH to improve the overall health of the population.
World Health Organization, About Social Determinants of Health:
JAMA Network, “Addressing the Social Determinants of Health Within the
Patient-Centered Medical Home,” May 15, 2013: https://jamanetwork.com/journals/jama/article-abstract/1681306?resultClick=1
2019 ICD-10-CM Expert, page 6: www.aapc.com/medical-coding-books/icd-10-books.aspx
- Overcome the Stigma of Social Determinants of Health - July 8, 2019