Efforts to spur hospitals to address the social determinants of health are 'asking physicians to do what we should ask housing officials to do,' says one health policy expert.


July 26—Hospitals are ramping up spending on the social determinants of health, according to a recent survey—even as some question the approach.

Hospitals spend a median of $200 per patient or individual (some initiatives include non-patient local residents) to address social needs each year, according to a recent Deloitte Center for Health Solutions nationally representative online survey of about 300 hospitals and health systems.

“Responses vary considerably. While a small percentage of hospitals report larger investments, most fall along the lower end of the long distribution tail,” the report stated.

Much of that spending goes to nurses, social workers, and care managers to address social needs, but less goes to behavioral health professionals and translators. For instance, 88 percent of respondents report that their hospital employs nurses to address health-related social needs, 71 percent employ behavioral health staff, and 50 percent employ translators.

“These figures indicate that most hospitals are following the more traditional clinical care model of having nurses address these needs,” the report said.

Hospitals are in the early stages of developing capabilities to address social needs, and these include:

  • having a well-defined process for connecting people to social needs resources (fully functional, 33 percent; limited availability, 42 percent);
  • measuring outcomes for some of their initiatives (fully functional, 24 percent; limited availability, 38 percent);
  • developing ties to community nonprofits or organizations that address social needs (fully available, 44 percent; limited availability, 30 percent).

Community health needs assessments (CHNA), which the Affordable Care Act requires tax-exempt hospitals to perform, play a leading role in identifying various unmet needs in local communities, upon which hospitals can focus their social determinants spending.

Hospital Goals

Among the research that appears to justify social determinants spending by hospitals was a recent study conducted in conjunction with Health Leads that found unmet health-related social needs are associated with nearly twice the rate of depression, a 60 percent higher prevalence of diabetes, and more than double the rate of emergency department visits.

“One of the things we’re learning is how important the social determinants are—how the non-healthcare-delivery issues affect health,” said Stuart Altman, PhD, an economist and chairman of the Massachusetts Health Policy Commission. “Most of the estimates suggest health care is just 20 percent of health.”

Altman said the healthcare system is not going to change the population’s health “unless we take a much broader view of what affects that,” including where people live, how they live, whether they have jobs, their mental health, and where they eat.

Despite such findings about the need to address social determinants, some continue to question whether hospitals are the right entities to address social needs like the ones identified by the Deloitte report, which include housing instability/homelessness, food insecurity, transportation, education, and social supports.

Darrell Gaskin, professor of health policy and management at Johns Hopkins University, said hospital spending on social determinants of health is a second-best solution because of the cost involved.

“The real sad part is the physicians and the administrators are the most expensive labor in our society, so we’re not going to save money that way,” Gaskin said. “Why should I ask a hospital system to do that? Why don’t I just improve the school system and put the money in the school system so that the people who are trained to teach people how to be educated have the money to do their jobs?”

However, he was resigned to demands that hospitals finance the social determinants of health until the United States finds a way to reduce health spending so it's below one-sixth of our economy.

“We’re going to be stuck in this place where we’re asking physicians to do what we should ask housing officials to do, or transportation officials to do, or education officials to do,” Gaskin said.

Charles Roehrig, founding director of the Altarum Center for Sustainable Health Spending, has long led studies about the effects of social determinants of health on productivity.

Roehrig worried that growing healthcare spending is crowding out spending on social determinants of health.

Overall federal healthcare spending will nearly double over the next decade from $1.2 trillion in 2017 to $2.2 trillion in 2017, according to the latest Government Accountability Office projections. While such mandatory spending will consume a growing share of the economy, nonhealthcare discretionary federal spending will shrink from 6.3 percent of GDP in 2017 to 5.5 percent of GDP in 2027.

“If you see the spending that is declining, it is all of the safety net stuff, like food stamps,” Roehrig said about federal spending. “If you spend more on health, you are going to spend less on social determinants, and you might have a worse effect on productivity by spending more on health and less on social determinants.”

Funding Sources

Ironically, hospitals reported that federal healthcare funding was their largest source of the funds they were spending on addressing social determinants of health. Forty-eight percent of hospitals said they received social determinants funding from federal sources, such as reinvestment of savings from 340B programs, federal Innovation grants, state innovation model grants, waiver funding, and Accountable Health Community grants. Twenty-five percent reported receiving no outside funding for their social determinants spending.

“Our qualitative interviews confirm that sustainable sources of funding to address social needs is a challenge for many hospitals,” the Deloitte study authors wrote. “One reason for this, interviewees say, is shifting priorities in federal and state government.”


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Thursday, July 27, 2017