Paying doctors for outcomes instead of volume may seem to make sense, but what happens when patients can’t do their part to follow prescribed behavioral changes or take their medications?
For some patients, their socioeconomic situation has a greater impact on their health than anything their doctor is doing. A Minnesota Department of Public Health study indicates that social determinants affect a larger proportion (40%) of health and well-being nationally than does clinical care (10%). Social determinants are typically defined as food insecurity, housing, transportation, education, violence or community safety, social support, health behaviors and employment.
Richard Bryce, DO, a primary care physician in Detroit, has seen the effects these challenges have on his patients at the community clinic he oversees. “Unfortunately, a lot of these social challenges play a huge role in their health,” he says. “When you are a medical student, you spend so much time learning about different drugs and surgeries to improve lives, but on a day-to-day basis, social determinants play a big role and their effect on outcomes is huge.”
For example, patients may want to exercise, but are afraid to leave their house because the neighborhood isn’t safe, says Bryce. Poverty or lack of education can lead to poor food choices, even when healthier foods are readily available.
“Individuals who are unemployed or homeless can’t afford healthcare, and those living in unsafe neighborhoods with high rates of violence and/or experiencing transportation barriers can’t access care when needed, leading to untreated medical conditions and resulting in poorer health outcomes,” says Jay Bhatt, DO, MPH, FACP, a practicing internist and chief medical officer of the American Hospital Association. “Research has also indicated that many individuals with food insecurity are at high risk for chronic diseases such as diabetes and obesity in some age groups.”
Bhatt is also former managing deputy commissioner at the Chicago Department of Public Health where he developed programs addressing social issues in medical treatment.
So how does a physician who is responsible for keeping patients healthy deal with these socioeconomic challenges that stretch far beyond the walls of the practice, especially when the financial viability of their practice may be on the line?
“You can either look at the problems faced by patients and ignore them or try to address them, even if you are not medically trained to address them,” says Bryce. “Social determinants make keeping patients healthy hard, but when you can find solutions that are not always medical in nature, it can be really rewarding.”
Identifying the problem
Physicians need to understand the specific problems their patients are facing before addressing social issues, and the only way to do that is to ask, experts say.
Jeremy Long, MD, MPH, an internist in Denver, runs a clinic for the underserved and says it’s necessary to build trust to get the patient to open up about nonmedical issues that may be affecting their health. “Try to build rapport with them and introduce them to the whole team to show them how invested you are,” says Long. “When they see that, it helps them let their guard down.”
Long’s clinic uses a seven-page intake form that not only covers the standard medical questions, but details about the patient’s life. Questions about substance abuse, employment, insurance style of learning, goals of care and incarceration are all asked to gain a complete picture of the person’s life and the challenges he or she faces.
Bhatt says that physicians can start with screening questions that take the form of, “Do you have trouble getting here?”, “What kind of neighborhood do you live in?” and “Are you having difficulty getting food for yourself or your family?”
“Though these questions are personal, they can help physicians build relationships with their patients and give them insight to better understand factors affecting their health,” Bhatt says. Many professional organizations offer screening tools and guidelines, so that’s a good place to start.
Gail Cunningham, MD, FACEP, chief medical officer for University of Maryland St. Joseph Medical Center, oversees a program aimed at reducing the hospital’s readmission rates for patients struggling with psycho-social issues that affect their health. The hospital uses a nurse practitioner to interview patients about the nonmedical challenges in their lives and helps direct them to community resources and nonprofits that can help.
“Some patients are honest and some are a bit delusional about reality,” she says. “Some patients are fiercely independent and don’t want help or don’t think they need help. Some may decline our service then get home and realize [dealing with their social issues is] harder than they thought and will call us back.”
While it can be challenging to get a full picture of the patient’s social challenges, experts agree that the more commitment physicians show toward the patient’s well-being, the more they are willing to open up. But Bryce says to be careful not to stereotype, especially about income.
“Social determinants are not always just about income level,” he says. “If you are not getting the results you want, it’s important for the physician to look deeper at the care model and the patient and why they are not getting better. Sometimes when you dig deep, that’s when you’ll find an answer in the challenges the patient faces.”
Treating patients with challenges that affect their adherence can be frustrating, but it starts with taking the right attitude. When a patient has been told multiple times to eat healthily and make sure they are taking their meds only to return having done none of it, the first response from a doctor might be
exasperation. But Bryce says it’s better to pause and focus on empathy.
“We don’t necessarily understand the life they live,” says Bryce. “If you try to understand it, it will allow you to better take care of the patient and decrease the pressure you put on yourself if you are not getting the results that you want.”
The more doctors are able to understand the challenges patients face in life, the more that can be used to create a positive attitude from both the doctor and the patient, he adds. “There is not a pill out there that is going to fix someone who doesn’t have enough food to eat.”
Patients facing these challenges often are not in a position to help themselves, so physicians need to do part—and sometimes all—of the work to help them. Experts say to start by researching what resources exist for the social challenges a practice sees the most.
“Connecting to resources in the community requires some initial effort, but many partnerships and activities are already underway,” says Bhatt, adding that reaching out to the public health department, local hospitals and social organizations is a good place to start.
Bryce says part of the role of the doctor is to educate patients on help that is available. For instance, Detroit has a program where food stamps can be used to buy double the face value of fresh fruits and vegetables. Many patients have access to the market, but just don’t know about it. He adds that education efforts aren’t always perfect, but putting patients in touch with the right resource can make a big difference.
Some patients will require more hand-holding than others, but Long says it’s often ineffective to just scratch out a name or phone number of a community resource on a slip of paper and hand it to the patient. “If you are in a small practice, I think you have to start sitting down with people doing the social services that work in the area and start networking in a meaningful way.”
Cunningham agrees, noting that time invested with a representative from a social service agency may yield a list of services and contacts for a variety of types of help. For those patients who need additional assistance, she suggests smaller practices try to identify local volunteers who could serve as a liaison between the practice and the social agencies, helping them fill out forms or setting up interviews.
“Also, ask questions of your patients during the visit to identify issues that may have been missed—‘I’m writing a prescription now, do you have a way to pick it up and a way to pay?’” says Cunningham. A call to the pharmacy may reveal programs to help with adherence through medication reminders via text message or phone calls, but the practice may have to do some of the work on the patient’s behalf.
Long says that his office practices a model where the patient is shown how to do something once, with the expectation the patient can do it the next time. For example, a patient needing transportation assistance would be given help filling out the application and getting the initial appointment set up. After that, about 80% of the patients have the knowledge to continue on their own.
“You have to meet the patient where they are at,” says Bryce. “For some patients, you can show them a program for free food and they take it from there, but for others, you have to take it step by step. You don’t always get the outcomes you want, but you just do the best you can.”
The trust established between the physician and the patient will also go a long way toward helping address any socioeconomic challenges the patient may face. The more the patient trusts the doctor, the more open he or she will be to receiving referrals to help them address their needs, says Bhatt.
“Additionally, developing trusting relationships with community partners is also important,” he says. “In the partnership, practices should define roles and responsibilities and deliverables for each team member.”
Checking up on patients after their consultation with social services can help patients feel connected and cared for, Bhatt adds.
Addressing social determinants of health is not the job of one physician alone, but an effort must be made if patients are to overcome their challenges and if physicians are to maximize their reimbursement under value-based care.
“Start off small, build resources and skills within your team to address these issues,” says Bhatt, “then start collaborating with other physicians, local community organizations, local businesses etc., to help the most prominent health needs in the community.”