Inequity, Race, Social Determinants and Health Care: COVID-19 Provides a Call to Action

Editor’s note: Senior Director Rebecca Segel, Consultant David Mena, Associate Principal Karyl Kopaskie, PhD, and Vice President Yelena Bouaziz contributed to this post.

Three cultural influencing trends are colliding in the US: a global pandemic, a recession and a racial inequity awakening. Each of these is drawing more attention to what we already know in health care—that is, factors such as race, socioeconomic status, environmental elements and social structures influence health. Combined, these trends are a powerful force to promote change in society, as well as at the organizational level.

Is now the time to reevaluate an organization’s role in addressing social determinants of health (SDOH)? Sg2 believes all systems are well positioned to play some role—but not in single-handedly solving health inequity. It is too big for any one organization to “own” the outcomes, however, it is also too big to ignore. Instead, organizations must collaborate with community partners to stitch together disparate services and stakeholders.

Let’s look at the COVID-19 pandemic in isolation, using it as a case example of what could be—and should be—done by health systems to address the interrelationship of disease and social determinants. We must recognize, though, that this is compounded in today’s landscape, where a public health crisis is not only affecting the world at large, it is also disproportionately affecting underserved communities, many of whom are also being impacted by a COVID-19–driven recession (eg, those in the service industry), as well as lower-wage jobs and racial injustice.

COVID-19 Initial Surges: A Look Back

The current medical and economic crisis is exacerbating existing health inequities, with emerging data showing that low-income populations, already negatively affected by SDOH before the pandemic, suffer a disproportionate burden of disease and mortality due to the virus. The inherent vulnerability of low-income, homeless, incarcerated and impoverished populations to the economic downturn combined with their high prevalence of underlying complex chronic conditions means that the impact will extend well beyond the pandemic, with devastating long-term consequences on health disparities, costs and economic vitality.

During the initial surge, health systems and other stakeholders partnered with communities to develop and implement strategies to mitigate the short-term risks of infection and help “flatten the curve,” especially among the most vulnerable populations. Health systems must work with the greater community of stakeholders to address the aspects of the health system that were already broken and have now been laid bare by the pandemic.

COVID-19: Planning for the Next Phase

During the next phase of COVID-19, many organizations will pivot to focus on financial recovery, but this is not the time to lose sight of keeping communities safe or preparing for possible additional surges in the coming months.

  • Don’t just revert back to the status quo. Leverage the new care pathways and communications built during the crisis to address the needs of the nonpaying population—which will only grow during the recession.
  • Keep vulnerable patients out of the ED. Continue to provide care through virtual health modalities or direct uninsured and Medicaid patients to less-costly sites of care.
  • Collect data with compassion. Expand lessons learned in communicating to non-English speaking patients to increase cultural sensitivity and empathetic data collection. Accurate data on the social needs of a population is the first step in meeting those needs.
  • Partner and collaborate. Lead or participate in a coalition to share information and accountability with community-based organizations, payers and local government.
    • Work with community-based organizations, local governments, employers and payers to meet patients’ social needs. The vulnerable population and probable resource restraints on the side of the health system postpandemic will make this even more critical.
    • Develop closed-loop referral pathways for social services and share data with your partners where you can.
Long-term: Strategic Investments in Community Health

For community health improvement, the strategic investment opportunities of tomorrow look a lot like pre-pandemic ideas but with greater sense of urgency. Health systems are executing on short-term initiatives in record time, investing in housing, economic development and virtual health, demonstrating that where there is a will, there is a way. Don’t miss this opportunity to gain support for strategic long-term community initiatives. The biggest challenge SDOH programs need to overcome is financial sustainability.

  • Leverage the value-based care part of your portfolio. Providers paid through global budgets (like in state of Maryland) or capitation contracts are likely to weather the crisis more easily than their fee-for-service counterparts due to better cash flow.
    • Value-based arrangements promote population health management strategies aimed at improving baseline health. Consider taking the value-based route for Medicaid managed care organizations who are increasingly including social need benefits within their plans.
    • Broad acceleration toward prospective payment models could be on the horizon, particularly for nonprocedural care. Primary and medical care were not profitable prior to the COVID-19 pandemic—now is the time to explore ways to do better by the patient while also improving your balance sheet.
  • Shore up losses. Start by riding the current momentum toward value and integrate the “start where you are losing” strategy into your post-pandemic recovery plan.
    • Develop a risk contract with yourself for your nonpaying population (likely to grow in the coming months) and invest in social interventions and community health initiatives that will reduce financial losses on the back end due to overutilization. Shifting your focus to cost avoidance instead of top line revenue growth may more efficiently preserve your margin and support your organization’s mission.
  • Measure return on investment (ROI) differently. While making the case for investment in tough-to-measure community initiatives has always seemed risky, for once, the risk of not doing so couldn’t be clearer.
    • Develop a model for tracking ROI in the short-term for investments in social needs for your contractually defined, high-risk patient population, as well as for long-term investment in community health.

Now is the time to be proactive in defining your health system’s role in addressing social determinants of health. Reach out to Sg2 for help determining the extent to which you can or should contribute, as well as how to keep sustainability at the core of your efforts.

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Sources: Ray R. Why are Blacks dying at higher rates from COVID-19? Brookings. April 9, 2020; Melo F. Telemedicine from within a hospital or homeless shelter? M Health Fairview says it’s underway. Twin Cities Pioneer Press. June 22, 2020; Vaidya A. Chicago to rent out thousands of hotel rooms for people experiencing COVID-19 symptoms. Becker’s Hospital Review. March 23, 2020; COVID-19 Health Literacy Project website. Accessed July 2020; Landi H. COVID-19 is widening gaps in health equity. Here are some ways organizations are trying to address it. FierceHealthcare. May 11, 2020.

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