Mary Jane Osmick, MD
Vice President/Medical Director Medical Services Department American Specialty Health
Chair, Quality and Research SDH Task Force Population Health Alliance
Imagine you are a case manager working with a 54-year old patient recently discharged from the hospital with heart failure. It is the patient’s third hospitalization in 10 weeks for a similar diagnosis. Although she has been successfully treated at each hospital visit and appears stable on discharge, she returns to the emergency department within a few weeks. It’s your job to figure out what is going wrong, and find ways to help her keep her heart failure in control. In talking with her, you note she has changed her address in the last three weeks, and on further questioning, you learn she is sleeping on a neighbor’s couch having recently lost her house to foreclosure. You also learn that her company has decreased her work hours from full time to 30 hours a week because of recent client losses.
I’ve been considering a thought-provoking question from an attendee at the October 2018 Population Health Alliance Capitol Caucus who asked, “Is it ethical to screen patients for risks from social determinants of healthi if you can’t do anything about them?” Such a simple question, yet fraught with complexity.
This question reminds us of other clinical issues and national recommendations that some have interpreted as, “don’t ask unless you can do something”. For example, regarding depression screening, the United States Preventive Services Task Force (USPSTF) makes a Grade “B” recommendationii stating, “The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment and appropriate follow-up.”
Participating in discussions on depression screening, it can be surprising when individuals use the “adequate systems” phrase to state, “See, we don’t have to screen for depression because we’re not set up to respond if screening is positive.”
The same could be said about social determinants of health. Over the last two plus decades, global research has revealed that the health care an individual receives predicts only 10 – 20% of health outcomes, 20 – 30% from genetics, while 50 – 60% are based on individual health behaviors related to social and environmental factors. It is increasingly clear that treating a persons’ diseases and health risks without also knowing and responding to who they are, where they come from, and their daily challenges sidesteps patient-centric, whole person care, while assuring poorer health outcomes. It cries out for organizations to develop collaborative systems of care that are able to respond to the social and environmental challenges experienced by many individuals.
In our 2018 PHA White Paper “Social Determinants of Health and Health Disparities – Taking Action”iii, we reviewed available research, and sought to help organizations gain an understanding of, and consider how, where, and when to respond to social determinant challenges. Through our work, it is clear that being “off the hook” is no longer an option. Organizational success in the waning fee-for-service and growing value-based care environments requires organizations to systematize consistent, reasonable responses to identified social determinant risks in their populations. To be successful, they must identify and collaborate with new partners whose capabilities and resources extend beyond their own. They must integrate, share data, and communicate as never before, seeking to overcome the key social drivers of poor health outcomes. And they must support updated payment structures and policy changes that will assure fair compensation for their collaboration.
Managing the health of populations requires organizations to know about and design, implement, measure, and continuously improve systems to respond when they identify social determinants that drive poor health outcomes.
Comments?
I The World Health Organization (WHO) defines social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life”. WHO also defines health inequities (or health disparities) as “the unfair and avoidable differences in health between groups of people within and between countries which stem from social determinants of health resulting in stark differences in health and health outcomes”.
ii Grade B Recommendation – The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Suggestions for practice – Offer or provide this service.
iii Access to the Population Health Alliance White Paper can be found at www.populationhealthalliance.org
Ms. Polak is a senior director based in Washington, D.C. In her role, she provides policy counsel and analysis to clients with matters involving regu-lations, legislation, and business implications. Anne Marie’s experience includes developing strategic messages and policy positions for Capitol Hill, administration, trade associations, and corporate audiences. Prior to joining Leavitt Partners, Anne Marie was a vice president for Faegre BD Consulting in the firm’s health and biosciences group. She also spent five years with the Podesta Group in Washington, D.C., while completing her law degree in the evenings at the George Mason University School of Law, graduating cum laude in 2010. Anne Marie also worked in the government and legal affairs office of Novo Nordisk in Washington, D.C., and as a congressional aide to Rep. Michael Ferguson of New Jersey.
Dr. Fabius has recently returned to his start up. HealthNEXT, a company dedicated to the development of organizational cultures of health — after serving as Chief Medical Officer of Truven Health Analytics (formerly the healthcare business of Thomson Reuters), the world’s leading source of intelligent information for business and professionals. In this capacity he is charged with developing and deepening relationships with customers, advising on product development, and providing counsel to the leadership on business strategy and medical issues. Formerly, Dr. Fabius served as strategic advisor to the President of Walgreens Health & Wellness Division. This organization will coordinate over 1,000 workplace health centers and 10,000 pharmacies, many with retail clinics, into a seamless primary care network across the country within the next five years. In the not too distant future, it will be possible to offer large employers medical and fitness services on-site as well as episodic illness care, health coaching and disease management monitoring at the employee’s nearest Walgreens pharmacy.
Mr. Buettner is an explorer, National Geographic Fellow, award-winning journalist and producer, and a New York Timesbestselling author. He discovered the five places in the world—dubbed Blue Zones—where people live the longest, healthiest lives. His articles about these places in The New York Times Magazine and National Geographic are two of the most popular for both publications.
Ms. Cooney provides strategic direction for the Centers three Pillars of Population Health – Clinical to Community Connections, Health Equity and the Social Determinants of Health, and Public Health Data Analytics and Informatics. Mary Ann previously worked for 14 years at the New Hampshire Department of Health and Human Services where she was Deputy Commissioner for the Department and Director of Public Health.
Mr. Scully is a General Partner in the Healthcare Group, having joined WCAS in 2004. Before joining WCAS, he was the Administrator of the Centers for Medicare and Medicaid Services (CMS) for three years and the President and CEO of the Federation of American Hospitals for six years. He also served as the Deputy Assistant to the President and as the Associate Director of OMB under President GHW Bush from 1989 to 1993, and has practiced law at Alston and Bird; Patton Boggs; and Akin, Gump, Strauss Hauer and Feld. He is a Principal at the Lincoln Policy Group.
Dr. Don Wright has served as the Deputy Assistant Secretary for Health and Director of the Office of Disease Prevention and Health Promotion (ODPHP) since January 2012. In this capacity, he leads coordination and policy development for public health and prevention activities within the Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services. He is also currently the acting Executive Director of the President’s Council on Fitness, Sports & Nutrition.
Dr. Sidorov is a board-certified in general internal medicine physician with more than 25 years of experience in primary care, inpatient care, medical education and evidence-based practice. Jaan believes physician leadership throughout the continuum of care is the bedrock of value-based care delivery. He received his medical degree from Pennsylvania State University College of Medicine, and completed his internship and residency at the Dartmouth Hitchcock Medical Center in Hanover, New Hampshire. Jaan also served as a Chief Resident at Reading Hospital in Reading, Pennsylvania.
Dr. Ostrovsky is a practicing physician, social entrepreneur, and health policy expert who specializes in human-centered design, lean manage-ment, quality improvement, population health, and digital health. Dr. Ostrovsky was most recently the Chief Medical Officer for the Center for Medicaid and CHIP Services (CMCS), the nation’s largest insurer covering over 74 million people, annually.
Dr. Choice is vice president and medical director for physical medicine services at American Specialty Health (ASH). Dr. Choice oversees the Rehabilitation Services Clinical Quality Evaluation program and leads the content development, training and clinical quality processes for ASH’s musculoskeletal health and pain management products.
Ms. Forte is responsible for leading Tufts Health Public Plans expansion efforts. Prior to her current position, she was vice president of care management for all Public Plans members.
As Director of Strategic Initiatives, Ms. Bowman oversees new social needs intervention initiatives among our clinical partners — including program design, resource database build-outs, and integration of Health Leads’ signature technology, Reach. Elise brings 10 years of direct service experience to her role, having previously served as a Health Leads program manager, a case manager for adults struggling with mental illness and homelessness, and in developing parent engagement initiatives in public education settings.
Mr. Johnson leads the Sage Consulting’s work for a number of public sector, corporate, non-profit and multi-employer clients. David brings particular expertise in evidence-based workplace wellness programs and leveraging Behavioral Economics principles in Human Resources Management. He is also an Adjunct Professor in the Department of Psychology at Towson University.
Dr. Wadhwa is a leader in building population health programs for vulnerable populations. He serves as the senior vice president of market innovation and is the chief health officer for Solera Health where he is focused on scaling the Diabetes Prevention Program as well as health-related, social support interventions. Previously, Sandeep held population health leadership positions with 3M and McKesson. He also served as the State Medicaid Director for Colorado under its former Governor. While there, he oversaw a $4 billion program and led the effort to implement an accountable care collaborative. Sandeep also serves on the board of Reinvestment Fund, a $1 billion non-profit, financial institute devoted to revitalizing low-income neighborhoods. Sandeep continues to see patients at the Seniors Clinic at the University of Colorado Hospital where he serves as associate clinical professor in the division of Geriatric Medicine.
Focused on the intersection of information technology, informatics, clinical medicine and innovation, Dr. Jain is VP and Chief Health Informatics Officer at IBM Watson Health. He was Co-Founder, Senior VP and Chief Medical Officer of Explorys, Inc. formed in 2009 based on innovations that he developed while at the Cleveland Clinic. In April 2015, Explorys was acquired by IBM as an integral component of the newly formed Watson Health business unit. In 2017, he was appointed by Congress to the Federal Health IT Advisory Committee established by the 21st Century Cures Act.
Ms. Maljanian is an accomplished senior executive with more than 25 years of experience in the health care industry. Rose’s leadership experience
John Haughton MD, MS