The World Health Organization now considers social determinants of health to comprise the better part of healthcare. This is long overdue, but as pioneers of the population health movement, my colleagues and I consider this an understatement.
We estimate that 80 percent of individual health is due to non-medical factors, including crime, poverty, education and opioid abuse. The silver lining of Covid is that people are finally paying attention to the large-scale social, economic, and environmental issues that impact health outcomes of disparate groups of people — population health — but this is just a start.
An “engine of inequality”
In April of 2020, professors Anne Case and Angus Deaton wrote in The New York Times that the current healthcare system is an “engine of inequality.” Sadly, they got it exactly right. The pandemic exposed the primacy of social determinants in terms of who lives and who does not. Now, we in the healthcare business must ask some very tough questions that have been avoided for far too long. For example, how do we care for populations that may put us at economic risk? How do we stratify care among populations? How do we coordinate care between communities?
In the past, these were considered public health questions. They now fall under the “roof” of population health. The central pillar supporting this roof is composed of epidemiology, behavioral science, and the environment — all of the key tenets of the traditional public health approach. However, there are other pillars, including the quality and safety of the care we deliver, its cost, and public policy considerations.
During the height of the pandemic, the lines for food exceeded the lines for medical help here in Philadelphia. The inherent inequality in our system ensured that the death rate for people of color would be much higher than for others. Covid was a witches’ brew of catastrophe and increased mortality for minority populations.
While it is too late to declare victory over Covid — and, sadly, we already have another population health crisis on our hands — let’s not wait to recognize the scope and depth of the problems we face. Moreover, let’s address them with the appropriate tools. If our core business is improving health, then let’s reinforce all of those pillars in order to improve the roof over our heads. Of course, this begs yet another question: how are we going to get paid to implement these changes?
Healthcare is a $4 trillion business, and at least $1 trillion of this amount adds no value — except corporate profits. So, one idea could be to redirect those funds to actual healthcare.
Aside from a small minority, most doctors feel like outsiders victimized by the healthcare system. Almost 42% of physicians report symptoms of burnout, especially the physicians in critical care, emergency medicine, family medicine, internal medicine, neurology, and urology. I have a daughter who was on the frontlines of Covid as an attending physician. I get it; expecting doctors to heal themselves is simplistic during and after a pandemic.
In contrast, research says that we can reduce burnout if we give providers the opportunity to ameliorate social determinants. Why not allow doctors to write a prescription for food, connect patients to community organizations for help, and mandate behavioral consultations? If we can give providers the tools to help the underserved, burnout decreases. We know doctors aren’t social workers, but they can (and should) be leading the charge to implement the population health paradigm. All they need is a voice and the right tools.
For example, it’s critical that providers at a minimum have a unique and unified patient record. Especially as we adapt to telehealth and virtual care, organizations need to have a framework that can enable a swift exchange of data among members of care teams. Indeed, population health intelligence is another vital pillar, as well as an important subset of population health that subsumes predictive analytics, augmented intelligence, and artificial intelligence. We can and should be creating a registry of patients with Covid that protects privacy. From the tsunami of data gained, we would glean actionable information about at risk populations. I’m also hopeful that we’ll see digital healthcare that continues to reduce marginal costs. This will enable us to reach much larger populations at a lower cost than ever before.
Imagine if we could go upstream to shut off that faucet of disease, rather than constantly mopping up the floor. What if the population of Philadelphia had been healthier pre-Covid? If we had paid more attention to social determinants, we would have been far more proactive. The chance of reducing the unbelievable death rate in minority populations would have been far greater if we had paid attention to obesity, smoking, heart disease, exercise, nutrition, and other “soft” issues. Why didn’t we do this? No one was leading the way, probably because there was no profit incentive.
We know that healthcare is big business, but even more than that, it is the final common pathway to all social determinants. It is constantly reframing what it means to take good care of the population. I firmly believe that we can still establish an exemplary model of population health — a system that promotes inclusion of all factors associated with a patient’s health in order to provide as much comprehensive care as possible.
Photo: marchmeena29, Getty Images