Upping our social investments for health

We’ve known for years that there is a strong connection between social factors (such as income, housing, and education) and health. Lower educational attainment is associated with lower life expectancy, worse reported health, and higher rates of infant mortality. Higher income levels, on the other hand, are linked to better reported health status
and lower incidence of chronic disease. Most early deaths are attributable to behavioral and social factors, rather than healthcare access and quality.

Given the outsized impact of social factors on health, doctors and health systems are addressing the problem by going upstream. A recent article in the Boston Globe profiles doctors who are “prescribing” social supports like financial assistance to improve health. A concept that was controversial a few years ago (“Giving patients money? That’s unprofessional!”) is now seen as an important element of addressing overall health.

“We have clinical tools we use on the front lines for a host of other health issues. So I thought, let’s do the same for poverty.”

Dr. Gary Bloch, St. Michael’s Hospital and Inner City Health Associates, Toronto

For example, what started out as a small movement in Canada to screen and treat poverty has become commonplace; most Canadian doctors now prescribe some sort of social support. But while some US hospitals are screening for social needs, it’s still underutilized. Fewer than a quarter of US hospitals currently screen for social risks, according to a 2019 study.

Why aren’t more hospitals implementing social supports for patients? Part of the problem is that there aren’t always social supports available to refer patients. In 2020, a promising program to address social needs for the sickest patients in Camden, NJ did not reduce hospitalizations compared to a similar patient group. One reason why the program failed was a lack of resources in the community to help patients who received the referrals in the hospital.

“The bottom line is, we built a brilliant intervention to navigate people to nowhere.”

Dr. Jeffrey Brenner, founder of the Camden Coalition, in Kaiser Health News

Another issue is that the way hospitals are funded provides little incentive for hospitals to that address the upstream determinants of health. With the exception of Maryland hospitals and integrated systems like Kaiser and Geisinger, most hospitals are paid for volume rather than value. High-tech elective procedures give hospitals the greatest payout while preventive care like addiction services and mental health are poorly reimbursed.

However, that doesn’t mean that hospitals are powerless. Nonprofit hospitals are granted significant tax benefits worth billions, but few pay this back in full to their communities. And programs to address social determinants of health are the lowest funded category of spending for hospitals, despite being arguably the most important. On average, hospitals spend less than 1% of their total expenses on these programs, while the value of their tax exemption is estimated at 5.9% of their expenses. We should hold hospitals accountable for spending their fair share on programs that do the most for community health.