Breaking Down Barriers: Understanding the Impact of Social Determinants of Health (Part 1)

Ryan Bosch, MD, President and Chief Health Information Officer, Socially Determined

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more. 

Bosch: My name is Ryan Bosch. I'm an internal medicine doctor by training. I currently am the founder of Socially Determined. We are a health care social analytics technology company headquartered in Washington DC. I mentioned I'm an internal medicine physician, and my background is deep in both population health and technology.

Interviewer: All right, excellent. And also I don't know if it's your time in Texas but your accent reminds me so much of Matthew McConaughey. 

Bosch: Well, that's nice to hear. There was some time that I was in Texas, and that maybe brings me to a story of how I got involved in social determinants. You know, when I started my career in medicine, I was fortunate enough to be on an Air Force scholarship. So the Air Force paid my way through medical school. So I come from a deep population health background, caring for folks that are in general quite healthy, but need community care, particularly around a base and around a mission.

My scholarship sent me to San Antonio, Texas, where I did my residency and got heavily involved in technology at that time as well. And it was there with a larger group of patients and a senior doctor that I learned about social determinants of health. And so to kind of leap forward to a story that got me involved in the social terms of health, and gives me an opportunity to maybe share my why statement here as a physician who got involved in technology who started a company.

My why statement began in San Antonio, Texas. Maybe where that accident began, as you said. And it was while caring for a patient and I came back to the attending room to present to my attending an outpatient that had come in with a couple of medical problems that needed some follow-up and indeed, in my mind as a young doctor, needed to start at a new medicine. And so my attending listened to my summary delivered in the most summarized medical perspective that I could deliver. And he asked me what percent of the time was this patient going to take the medicine that I prescribed? And I struggled a little bit because I didn't quite know what he was asking. And he said well what percent of the prescriptions that you write are they going to take? And I hesitated for a minute again and, “So, well I think all of them.” And so my naivete shined through and he paused and he said, “Well, does he have 3 hots and a cot?” And I said, "Three hots and a cot?" And I remembered with my father, being an Air Force pilot, the saying in reference to being deployed and having 3 hot meals in a place to sleep. And I didn't know how to apply that to being compliant on a medical therapy or compliant with medications. But my attending doctor took me into a small oration on the non-specific health care determinants that indeed affect a community, how well that we can receive social clinical care around us and how that indeed affects population health. And so if an individual or community is not getting adequate food, transportation, health literacy, social connectedness, then they're indeed not able often to be compliant about specifics around their own individual health care journey, all the way to being adherent on a medication.

And fast forward, we know today in the social determinants of health, quite often both communities and patients are faced with the substitution challenge where they have a focused amount of resources, we'll call it dollars, that could go towards rent or utilities or housing, transportation, prescriptions, childcare, and each of those decisions are subject to that substitution rule. What month will I use which part for which thing? And whether or not I need to control my diabetes, my heart disease, or my asthma, it is affected by these non-specific health care determinants. So as a young doctor that learned an awful lot from my older colleagues and how to care for patients and populations, that's where it began for me, Hannah.

Interviewer: I love that. That was a beautiful way to enter into our discussion here. Yeah, it really takes that learning out of the textbook context into the very complicated real world, doesn't it? Would you like to provide any more examples or context on how they influence health care costs and outcomes? 

Bosch: Absolutely. So the way that social terms of health influence health care costs and outcomes is multifactorial. And maybe just a second more to talk about my personal background to give the audience a vantage point of the scope of some of my opinions and expertise, I was fortunate enough after finishing my residency in the Air Force to then go on into real-time military practice. And because military practice is a single payer system, you aren't often afforded to have as much knowledge of what costs are. Costs are often measured in health and health outcomes, very different in health care in the civilian world, where costs are measured in utilization counts, number of appointments, and also measured in resources in terms of total cost of dollars spent for outpatient or pharmacy or inpatient care. So the social determinants of health, as I watched that evolution in my career as both a military physician and then a civilian physician. I moved over to George Washington University in DC, ran their division of general internal medicine, became an academic doctor and patient and outpatient, but stayed very close to my roots around technology.

At that time, value-based care was in its infancy, but value-based care brought this all together, particularly around the concept of risk. Who is at risk for the health or health care costs? Notice I distinguished those two. They are collinear, but health and health care costs are very different costs. And particularly social clinical susceptibility. So the unique susceptibility that certain groups and individuals have because of some of their diseases that indeed are made worse by social risk, social determinants like health risks, things like food insecurity, housing insecurity, economics, transportation, health literacy, digital access, social connectedness. Each one of these risks brings forth a unique individual and community weight, and that cost is not just in health care dollars, it's in the biggest cost to all of us, to our entire country: in health. Particularly our health, our productivity, our fulfillment, what we can do as individuals and groups. 
So I think the value-based care movement, the movement in health care today around health equity and social determinants of health, is precisely where we want it to be to be focused on cost. But it wouldn't be fair if I only let that be dollars. 

Interviewer: Right, I think that's a fantastic point. There's so much more in the ledger to take into consideration than just dollars. Let's explore so one of some of the reasons why social determinants of health have fallen into these blind spots of health care historically. Why is there that oversight and that need to turn our attention to them? 

Bosch: Hannah, I really like the optical analogy because we use that a lot and I found comfort in it. And we often talk about opening the aperture and what we mean by that is the keyhole of the data. We're at our root an analytics company, and I'm a chemistry major from college, so the scientific method gives me comfort. The specific data that we're analyzing that we have a plethora of is often just around claims. 

So think about it as the keyhole of one portion of that 360 degrees. This little 10-degree keyhole, this aperture is only what we can get from receipts, typically called UBs and HICFA 1500s. These are receipts for health care. The rest of the view is obstructed. The rest of the view is when the patient is not engaging or interacting with health care. Instead, they're out there living their lives when they're not in a visit or getting an x-ray or doing physical therapy or going to urgent care or getting a prescription. The rest of their life, that's when the social determinants of health affect their health. Not that health care, period. As you mentioned the blind spots, the blind spots that we have seen are when you apply analytics to a whole patient and a whole population, you start to look at those other period, I'd say 95% of an individual's life when they're not generating a health care receipt. And you start to look at what are their individual social risks for health literacy, for housing, for food insecurity, for social connectedness, and then what's going on in their community? What is the opacity of their community on these same risk parameters. So rather than just knowing one hour, and that's usually the average amount an individual is in front of a provider in a given year and has a health care receipt to document that, the remaining 99% of the time when they're out there living their lives is when we can get information about their risk, social clinical susceptibility information. And it's indeed that information that removes that blind spot. 

I think it's not just the epiphany that, "Oh, analytics companies can do this now when they couldn't do it before." Yes, there's some of that. But it's the unique process to go through and actually identify that risk within the population. To then quantify the opportunity, prioritize the match action. That action could be a food insecurity program in diabetics on Medicaid in Ward 7 in Washington, DC. You see how I did that? I narrowed that all the way down to that one group. But now I'm going to measure it, right? So I got a real nice scientific method, sort of a linear process where I'm identifying, quantifying the opportunity. Now I'm going to prioritize the actions, and then I'm going to measure it. So I'm humble enough to say, well, let's see if it works or not. Because I have at my tool bag the rinse and repeat. Just circle it right down with the arrow, and we'll tweak it, and we'll go right back. This process is, I believe, part of the innovation that the social analytics and health care movement has brought. It has allowed us to attack those blind spots. 

It also has allowed us to kind of get away from the optics of the feel-good social interventions, well, we delivered some food over Thanksgiving. Those feel good. I'm not against them at all. And in the setting of a physician-patient relationship or a larger philanthropic effort or foundational effort, they're powerful. But we need to be precise with our resources. We don't have unlimited resources in here. If anything, we're going the other direction. So, social analytics really gives us both innovation of risk and the innovation of the process. It's almost due to the old retail model. We probably all remember CRMs that come after us to buy shoes from one of the department stores that now online. It's that same model where we can actually identify who is at greatest risk. I gave the model of those diabetics that are ready for the food insecurity and food as medicine program that live in this geography that have these risks that are on Medicaid and they can match to a program of benefits that is already present. So I think it's not just a blind spot. I think it's a match of risk and process that is truly innovative.

Interviewer: When you lay it out like that it seems like such common sense, you know. Of course these things are connected, of course that this is the way you have to approach a solution to meet these needs. But I feel like that still is definitely a jump for a lot of providers. Do you have any recommendations or insight for people on this side of the health care equation to educate themselves more about social determinants of health and about solutions? 

Bosch: The first thing I think about to educate more the marketplace is to recognize some of the opportunities and health equity is an extremely important movement. We've seen the benefit of being more diverse, thoughtful, inclusive around all aspects of medicine. We've got an awful lot of work to do, period. But we've seen the benefits around whether it's clinical trials, whether it's measuring disease and disease outcomes, or measuring utilization. And I think when folks ask what around the social determinants of health are new and how should I get involved with them or what can I do differently, most of my response and those that I work next to is really to flip the lens back to value-based care. Value-based care and its movement creates an alignment around risk.

And why that's so important is because our industry, my industry, is often divided into payers, providers, government, physicians, or clinicians, and those are all fair. But where they all have a common alignment is who and where they are at risk. The government is arguably the greatest insurance company around here, period. Between Medicare and Medicaid, they have the greatest risk. They are at risk. With the value-based care movement, we're putting risk on providers, health systems, doctors, and groups of doctors, so that it's not just the payers that have risk. And so, I really like to, social determinants 101, really focus on risk, so that then our value of recite lift towards vulnerable populations breaks down the barrier of Medicaid, Medicare, commercial. Is it a payer plan? Is it a provider plan? Is it a government plan? 

Ultimately for our health care model to transcend from a thief or service model where you're ordering X number of visits or X number of pharmacies or X number of CT scans, to a model of value-based care where it's a proactive model, the core of that is the at risk. Who's the at-risk entity? And so first of all, for solution orientation and common ground around the table, that often creates a collegialism that breaks the barrier between some of the payer-provider antics and some of the government push on compliance around Medicaid or Medicare, and really focusing on what are we trying to do to promote better health and ideally promote less health care costs. Those are linked but different definitions. And so I usually began when folks are interested in the social determinants of health by bringing up that background and then using some analogies around retail sales and the retail market that we've used already because it usually resonates with folks. 

A couple more things about solutions that I think are really helpful in the marketplace, and I would say in the last 10 years they have a lot to do with the technology advancements, and I don't mean just AI and the things that are getting all the hot press right now. I mean the ability to have both scale and stamina around information. I didn't say data, we've got plenty of data. And to have scale and stamina around information means discipline to the structure of the data, how the data is shared, who owns the data, and respecting the data consent and the equity of the data.

This is maturing with lightning speed, sometimes too fast as we work on that, and states are weighing in on privacy laws and other challenges. But, Hannah, it's all going the right direction. I bring this up as a solution comment, because this becomes an obstacle at times, because individual investments, whether they're by any of the groups I've mentioned, payers, providers, government, sometimes they're more about the optics in the short term. I use hyperbole here. We gave out 50 turkeys at Thanksgiving. We feel good about ourselves. There's absolutely nothing wrong with that. But if we have several zeros after the end of our revenue line then that's probably not a program probably not a program that deserves much probably even done at an individual level could be done anonymously or could be done with a couple “atta boys” and “atta girls”. So I think some of our solution challenges are we still think very much in a short-term fix for 12 individuals with this program. 

And again, permission to use some hyperbole here: somebody's hungry. Let's feed them. This is a lot different than just having hunger. It's about the collinear nature of social clinical risk. So the fact that food insecurity is collinear to housing risk and often sits right next to social connectedness and often affects our older generation more than our younger. And so I think the solution challenges are an awareness that we can't just do quick wins and we need to open up our mind to the perspective and myths that are around us. 

Quite often when you talk about the health related social needs or social determinants of health, folks will think it's just the impoverished and the infirmed. Yes, having not as much discretionary income, having medical illness, those are dramatic impacts to your health. However, from my experience, from what I've learned with others from what I've seen in a decade more of being in this business and having 50 million lives that we've been able to look at over time. And in our data set, there's 280 million Americans that we create individual risk for. Hannah, what we're seeing that it is very consistent to probably what we've all seen in our families and our communities, that it isn't directly proportional to income or status or race or gender, it has a lot to do with community, it has a lot to do with health literacy and some of my patients that don't navigate health care well, they are older and have means and of the majority and have similar challenges navigating health care, have challenges with health literacy, have challenge with social connectedness and frankly don't utilize health care in a way that is to their best benefit. 

So it's not just that individual that doesn't have a primary care doc that's spending an awful lot of time in the emergency room that has Medicaid and has had 5 different insurance plans in the past year. So I think it's really important to open our mind up to social determinants affecting all of us, because when the day is done, we're social humans. And quite often the humanness is what aligns us. 

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