Social Determinants of Health-Have we Figured Out the Why?

Social Determinants of Health (SDOH)—Have We Figured Out the Why?

SDOH has been defined by the Centers for Disease Control and Protection (CDC) as those conditions in the environments “where people are born, grow, live, work, and age, as well as the complex, interrelated social structures, and economic systems that shape these conditions.” They can have a major impact on a person’s ability to access healthcare, wellness programs, and overall quality of life. Addressing SDOH is an enormous undertaking.  They are key drivers of health inequities and have a greater influence on health than genetics or access.  A greater influence than genetics?!  That’s crazy!

In fact, when the United States spends 4.3 trillion dollars on healthcare, it becomes difficult to explain the juxtaposition of this high expenditure and our poor health outcomes. Social determinants of health can provide some justification for this illogical coupling. Seema Verma, a former CMS administrator said it best: “The evidence is clear: social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on people’s well-being.”  

The National Academy of Medicine reported that 20% of the nation’s health is the result of medical care and over 50% of the nation’s health is determined by social determinants of health.” Looking at the overall US population and the reported 582,462 homeless in 2022 (National Alliance to End Homelessness) perhaps we would have a true reflection of the impact on the nation’s health if we changed the trajectory of our focus. Moving away from if a chronic condition should risk adjust and hold a certain weight in the HCC realm, but rather, what the cause of this disease is and why it continues to accelerate in the disease process.

WHO (World Health Organization) needs more focus on the overall impact that SDOH has on our nation as a whole and add HCC value to the SDOH ICD-10 codes to reflect the true reason behind the health status of our nation and why there is this seemingly unjustifiable gap between our Nation’s health status and health expenditure.

In fact, healthcare expenses are growing at such an enormous rate, that it appears unstainable.  20% of Americans do not have the means to access healthcare and one in four people avoid going to the doctor altogether simply because of cost.  It seems that the healthcare industry is at a tipping point.

As a result of the growing impact on healthcare costs, there has been an increased focus on strategies that recognize these needs.  Individual organizations are emerging to assist the healthcare industry drive advancement.  SDOH was included as a part of the Healthy People objectives.  Developed in 1980, the Health People initiative developed by the US Department of Health and Human Services (HHS) has set measurable objectives to improve the overall health of US residents.

Healthy People Groups SDOH into Five Categories:

  • Healthcare access and quality
  • Education access and quality
  • Social and community context
  • Economic stability
  • Neighborhood and built environment

To demonstrate the importance of SDOH data collection, compare the patients below. Which Patient has a chance for a better outcome? Which will likely consume more resources?

Patient 1 Patient 2
Age
80
80
Location
Rural Ohio
Columbus, Ohio
Living Accommodations
Homeless
Lives at home with his spouse
Caregivers
Children, but has been a victim of elder neglect
Wife, two sons, and one daughter
Activity
Some
Walks two miles a day
Medication
Noncompliance due to financial constraints
Compliant
Diagnosis
Parkinson's Disease
Parkinson's Disease
Diagnosis
Prostate Cancer
Prostate Cancer
Diagnosis
Hypertension
Hypertension
Diagnosis
Hyperlipidemia
Hyperlipidemia

SDOH can dramatically impact a patient’s overall health as well as the cost and resources needed to care for the patient.  For organizations and providers to demonstrate the impact of SDOH they must accurately capture the correct coded data.  According to the Centers for Medicare and Medicaid Services (CMS) any member of a patient’s care team can collect SDOH data.  Once documented, coding professionals assign all relevant Z codes to support future quality improvement organizational activities.

To capture coded data, coding professionals should follow the ICD-10-CM Official Guidelines for Coding and Reporting.  The information documented in a patient’s record should be coded. In some cases, this information does not need to be established by a physician or other provider type since the data represents social information rather than medical diagnosis (for example, front desk personnel have documented that the patient is homeless). 

Addressing SDOH is the primary approach to reaching health equity.  Meaning that every person should have the opportunity to attain their full healthcare potential and there are no longer disadvantages due to social positions or circumstances.  Documentation and code assignment is crucial to assist care providers across the continuum quantify the social needs of their patient population and thus, provide a better quality of care to those recipients. 

Currently, the US spends more on health care than almost every other country, accounting for approximately 18% of our gross national product.  CMS has recently disclosed that Medicaid now has the largest beneficiary compensation with over 93 million covered lives.  Let’s think about that for a minute.  Medicaid is a state-level health coverage program for low-income individuals.  If Medicaid is the largest insurance provider, does it stand to reason that SDOH are a fundamental part of patient care today?

While healthcare spending has had a slight decline in the past two years (likely due to a decrease in COVID-19 costs) the overall cost continues to be a source of concern.  The success of current initiatives such as population health and value-based reimbursement in decreasing overall expenditures hinges on accurately coded data.  Understanding SDOH’s impact on patient care is a critical factor in that success. Some experts estimate that SDOH are responsible for as much as 40% of a patient’s overall healthcare status.

The only way to accurately track and trend SDOH is through coded data.  Making coding professionals today an integral part of the solution.  It will be through the accuracy of coded data that the impact of SDOH will be measured.  It will be through the accuracy of coded data that immediate needs can be identified.   Now is the time to begin data mining your coded data to determine how you can mitigate risk. 

Lou Ann Wiedemann

Lou Ann Wiedemann

MS, RHIA, CHDA, CDIP, FAHIMA

Valentina Gallegos

Valentina Gallegos

BA, CPC, CRC

Resources:

2021 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec. DISPARITIES IN HEALTHCARE.Available from: https://www.ncbi.nlm.nih.gov/books/NBK578532/

Burns, A., Rudowitz, R., Hinton, E., & Mohamed, M. (2023, June 30). 10 things to know about Medicaid. KFF. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/

CDC. (2022, December 8). Social Determinants of Health at CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/about/sdoh/index.html

Deye, M., & Ogilvie, J. (2022, October 31). Social Determinants of Health Archives. National Academy of Medicine. https://nam.edu/tag/social-determinants-of-health/

LaPointe, J. (2019, March 14). How addressing social determinants of health cuts healthcare costs. RevCycleIntelligence. 

McGough, M., Telesford, I., Rakshit, S., Twitter, E. W., Twitter, K. A., & Twitter, C. C. (2023, February 15). How does health spending in the U.S. compare to other countries?. Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/

State of Homelessness: 2023 edition. National Alliance to End Homelessness. (2023, May 23). https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/

The Centers for Medicare and Medicaid Services . (2023, April 1). ICD-10-CM official guidelines for coding and reporting. https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf
 

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