Defined as “the conditions in which people are born, grow, live, work and age,”1 the impact of social determinants of health (SDoH) on individual and population health risks and outcomes is widely recognized. Categories of social determinants include:
 
  • economic stability
  • neighborhood and physical environment
  • education
  • food
  • community and social context
  • health care2

In the quest for improved population health and lower total cost of care, providers, payers, and public health agencies are developing ways to address SDoH. Small steps can result in noticeable improvements.

Health insurer Humana reported that by screening a group of members for food insecurity and offering Supplemental Nutrition Assistance Program (SNAP) benefits and an emergency food box to those who qualified, they were able to cut the members’ number of unhealthy days in half. Separately, Humana has found that food insecurity results in significantly higher rates of diabetes and heart failure as well as a somewhat higher rate of hypertension.3

Among providers, integrated health systems are ideally positioned to address SDoH. With broad and deep connections to their communities, health systems have the reach and the data to allow them to take specific steps for their populations, often in partnership with local health plans and public health agencies.

Ideally, these initiatives not only help manage chronic illnesses successfully and cost effectively, but in the long run actually reduce their incidence by changing health behaviors heavily affected by SDoH. Value-based care contracts add a sense of urgency, but long-term thinking is required.

Specialty pharmacy and social determinants
Specialty pharmacies are attuned to obstacles to initiating therapy and maintaining adherence, given the high cost of many specialty drugs and the potentially catastrophic consequences of non-compliance or non-adherence for their complex patients. In addition to the out-of-pocket cost—which can be prohibitive for many patients, not only those defined as low income—social determinants that can create obstacles include:
 
  • Transportation access for critical follow-up appointments.
  • Substandard housing or homelessness that makes correct storage of medications impossible.
  • Food instability or healthy food access, making it difficult to take medications correctly with food or to adhere to a modified diet.
  • Poor literacy, making it difficult to follow written instructions.
  • Language barriers, impeding communication with the care team.
  • Instability due to neighborhood safety or domestic violence.
  • Mental health challenges.
  • Stress related to day-to-day concerns, such as lack of childcare.

Any major social disruption will make certain social determinants of health more pronounced. The impact of the coronavirus disease 2019 outbreak will likely include growth in the uninsured, underinsured, and Medicaid-covered population, due to job losses, and exacerbation of chronic and complex conditions in individuals who delay care or cannot access care during the crisis.

Steps that health system specialty pharmacies are taking
Integrating specialty pharmacy staff into oncology, neurology, rheumatology, and other specialty clinics within their health systems is a growing trend with a range of beneficial outcomes. By providing assistance with prior authorization; financial assistance; direct patient care, such as medication counseling and disease state education; and care coordination, clinic liaisons ease the way for initiating and maintaining therapy for complex patients. They may also be able to refer patients to other resources within the health system, such as social workers.

Health system social workers can address multiple barriers to care, whether directly or by linking patients to social service organizations. For example, offering access to ride-share services helps patients get to appointments. Simply making the offer, even if it is refused, emphasizes the importance of the appointment.

Fairview Health Services, a founding member of Excelera, a nationwide network of health systems, provides comprehensive therapy management for Fairview Specialty Pharmacy patients. Some are referred to a health coach who can address complex patient needs and SDoH.

An evaluation of the program found that patients perceived that health coaching had a positive impact on their physical and mental health. Patient depression scores improved and 44% were referred to other resources, ranging from disease-state support groups to smoking cessation programs to end-of-life support.4

Integrated health systems put the patient at the center of care. Risk stratification for targeted interventions is a tool for lowering total cost of care. It also is a powerful tool for making a difference for individual patients and reducing disparities caused by SDoH.

For those health systems that are members of the Excelera Network, the proprietary Complex Patient Data Platform captures a wide—and increasing—range of longitudinal medical, pharmacy, and patient journey data for complex patients. The platform informs decisions around clinical best practices and it holds potential as a tool for insights into SDoH.

Health system specialty pharmacies, as integral providers of complex and chronic patient care, are key to developing innovative ways to address social determinants of health as a means to positively affect outcomes, population health, and total cost of care.

About the Authors
Jami Schell, PharmD, CSP is the Director of Pharmaceutical Accounts for ExceleraRx Corp.
Lana Gerzenshtein, PharmD, BCPS, CSP is Manager of Network Clinical Programs for ExceleraRx Corp.
Tim Paine is the Vice President of Pharma Strategy & Relations for Fairview Pharmacy Services.


References
  1. World Health Organization website. Accessed April 30, 2020. https://www.who.int/social_determinants/sdh_definition/en/
  2. Artiga, Samantha, and Hinton, Elizabeth. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation. Published May 10, 2018. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care. Accessed May 1, 2020.
  3. Sullivan, Tom. Social Determinants of Health and the $1.7 Trillion Opportunity to Slash Spending. Healthcare IT News. Published October 9, 2017. https://www.healthcareitnews.com/news/social-determinants-health-and-17-trillion-opportunity-slash-spending. Accessed May 1, 2020.
  4. Simonson, Dana & Wittenborg, Marj & Snyder, Mallory & Wiest, Holly & McNamara, Ann. (2019). Evaluation of a specialty pharmacy health coaching program. Journal of Drug Assessment. 8. 36-36. 10.1080/21556660.2019.1658316.