Health systems in the U.S. have been investing substantial amounts of money to address social determinants of health, but early efforts have found a number of obstacles, according to two recent studies.
Both studies were published in the February Health Affairs. The first quantified new direct financial investments in social determinants of health announced by U.S. health systems from Jan. 1, 2017, to Nov. 30, 2019. It found 78 unique programs involving 57 health systems with a total of 917 hospitals. The programs involved at least $2.5 billion in spending. Housing-related interventions were the most common focus, with $1.6 billion committed by 52 programs. Additional focus areas included employment (28 programs, $1.1 billion), education (14 programs, $476.4 million), food security (25 programs, $294.2 million), social and community context (13 programs, $253.1 million), and transportation (six programs, $32 million).
Researchers also looked at investment by hospital characteristics and found significant differences. “The clear predominance of sectarian and other nonprofit institutions in making these investments and the absence of for-profit institutions suggest that health systems may be driven to invest in social determinants more by mission and values than by the potential for direct financial returns. However, the fact that investments are disproportionately being made by systems that are in Medicaid expansion states, in the [Bundled Payments for Care Improvement] BPCI Initiative, or in an [accountable care organization] ACO suggests that business-case considerations may also be playing a role,” the authors said. They noted that an ongoing challenge to these projects is that the evidence that social interventions improve health outcomes “is thin.”
The second study identified additional obstacles to improving social determinants of health in an analysis of 22 ACOs that were working on initiatives to address social needs including transportation, housing, and food. It found that health systems often lacked data on both their patients' social needs and the capabilities of potential community partners. In addition, relationships with these partners were in the early stages of development and often driven by personal relationships. Despite these limitations, referral to social services was more common than direct provision of them by the health systems.
The results show that “the tools at ACOs' disposal to integrate social services are weak, relative to the challenges of deeply entrenched social inequalities, siloed medical care and social services, and the long period of time needed to realize benefits from this work,” the authors said. “Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.”