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.”