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.


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


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