opinion

COLUMN: Health systems should address the social determinants of health



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Imagine a physician who has seen the same man visit the emergency room 10 times in the past year. She treats him each time he comes, but he’s hard to track down, and she can’t help but wonder what’s going on in his home life to make him come to the ER this often. Would improving his home situation improve his health and reduce his visits to the ER?

The social determinants of health, as defined by the Centers for Disease Control and Prevention, encompass the “conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes.” In other words, they are the factors that determine our health that may not be obvious in the clinic or the hospital, such as education, food security, employment, housing and culture.

Because these factors show up in people’s everyday lives, not necessarily in hospitals or clinics, addressing social determinants of health from within the health care system has been difficult.

This could change. Last week, the American Medical Association and UnitedHealth Group announced a new initiative to address the social determinants of health in hospitals.

The AMA and UnitedHealth have created nearly two dozen ICD-10 codes, or billing codes, to track the social determinants of health. The AMA has previously emphasized that ICD-10 codes used with insurance billing should also be adopted to address social determinants of health.

In a press release, UnitedHealth stated that by “combining traditional medical data with self-reported SDOH data, the codes trigger referrals to social and government services to address people’s unique needs, connecting them directly to local and national resources in their communities.”

A move like this is hardly breaking news, but it has the potential to transform our entire health care system. In a climate where health care access is constantly threatened, this is a reminder that our health care system can also change for the better.

Access to health care is of increasing concern throughout the country. Just last month, IU students staged a rally to demand improved and affordable health care services. Moreover, the potential benefits of this policy are nontrivial: lowering health care costs, shifting towards preventative medicine and reframing our health care system within the context of communities.

But is this enough? Billing codes hardly seem to inspire action or change. UnitedHealthcare, the health insurance arm of UnitedHealth, is the largest single health carrier in the US. Is it warranted to be suspicious of insurance companies and what they stand to gain? I am curious about the efficacy of this top-down policy and worry that it will be clouded by bureaucratic tape and inaction.

These issues remind me of a course I took this semester on health information technology. We discussed how systems designed with the best of intentions often have unintended consequences, such as when a diagnosis of gender dysphoria automatically referred patients to mental health care services. Although people with gender dysphoria are more likely to have mental illness, it suggested that gender dysphoria itself was a mental illness. To avoid such scenarios, how can we mindfully use billing codes and electronic health records to address social determinants of health?

A 2018 paper from the New York University School of Medicine identified lack of standardization and actionable data as what makes it difficult to incorporate social determinants of health into care. The paper recommended creating national standards for documenting social determinants of health, which is reflected in the proposed billing codes.

On a related note, an article published last month in the AMA Journal of Ethics noted that many hospitals simply do not have the infrastructure and competencies to engage in community health initiatives.

Some are trying to change that. In California, Sutter Health and WellSpace Health have established a collaborative street nurse program for the homeless, bringing health care out of the hospital. In Indiana, the Black Barbershop Health Initiative provides free health screenings in black-owned barbershops.  

These community initiatives are exciting, concrete ways to address the social determinants of health, but large-scale change requires systems-wide policy changes. Billing codes and electronic health records may not seem that glamorous in comparison to community health initiatives, but they can carry greater impact.


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