Social Factors of Health Impacting Majority of US Families, Survey Says

It has now become commonplace for families in America to struggle with their ability to keep children as healthy as possible due to factors related to social determinants of health (SDOH), according to a new survey.

A majority of parents of US children under 18 (65%) report at least 1 factor of SDOH that are barriers to optimal health, according to the nationwide survey, which was commissioned by Nemours Children’s Health System. The report was accompanied by a frank letter from R. Lawrence Moss, MD, FACS, FAAP, president and chief executive officer of Nemours.

“We are paid for volume and complexity of service delivered,” he wrote. “This misalignment of incentives means that keeping children healthy and out of the hospital is financially unsustainable.”

Moss elaborated in an interview with The American Journal of Managed Care^®, saying that Nemours is “fundamentally committed to changing how America cares for kids” and said the 2 biggest opportunities to do that are changing payment systems, so healthcare systems are paid for treating health rather than treating disease, and addressing SDOH.

“Most evidence suggests that health is only due to about 15% of medical care and about 85% to all of these other factors," he said, referring to social factors such as substandard housing, food insecurity, or unsafe neighborhoods.

Two things are needed to change reimbursement, he said.

“One is to change the system from the current fee-for-service environment, where we’re paid for service delivered, to a system where we’re paid a fixed amount per patient per month and we’re fully accountable for that patient’s health, which therefore would transform the system such that health systems like Nemours would have a strong financial incentive, as well as an ethical and moral incentive, to keep kids out of the hospital and to keep kids and families healthy.”

The second part, Moss said, would be to take funds set aside for medical care and pair them with dollars allocated for social determinant factors, such as ones discussed in the survey, which was conducted by the Harris Poll last month. It found that 80% of parents believe that they have sufficient resources to raise healthy children, but a majority (68%) also cite serious obstacles, saying that at least 1 of these factors affected them in the past year:

• 32% were unable to pay 1 or more of their bills
• 32% skipped a doctor/dentist appointment because they couldn’t afford to pay for visits or find transportation
• 30% had trouble paying for or getting to a doctor/dentist appointment or paying for medicine
• 23% worried about running out of food
• 17% worrying about their/their family’s personal safety
• 17% had trouble finding work or affordable child care
• 10% were unable to access a grocery store with healthy food options

The report notes that value-based care (VBC) and SDOH have something in common: Both look at the bigger picture of health instead of just episodic care. For instance, addressing SDOH can reduce healthcare spending (by avoiding unnecessary treatments and hospitalizations) as providers working in VBC look for more effective ways at keeping people healthy.

VBC that incorporates SDOH has been shown to improve the health of children, since it means delving into the root cause of an illness.

As one example, Moss cited a 2012 project, funded by CMS’ Center for Medicare and Medicaid Innovation, to improve the health of children with asthma in Delaware by creating a team that included a social worker, case manager, psychologist, and community health workers, who would work with the families at home to examine and change, where possible, the environmental factors that are known to worse the disease.

However, Moss’ predecessor, David J. Bailey, MD, MBA, previously noted that such VBC—which produced a 44% reduction in asthma-related hospitalizations after 3 years—also meant that hospital services were not being utilized, which led to a loss.

Those kinds of projects take strong community partnerships and adding SDOH factors to the electronic health record, which Nemours is doing, he said.

Overall, about 58% of its patient population in Delaware are Medicaid beneficiaries, while 75% of its Florida population are (those are the states that each have a freestanding children’s hospitals); Moss said the percentage of Medicaid patients varies by market. Nemours also operates more than 80 primary, urgent, and specialty practices in those 2 states as well as New Jersey, Pennsylvania, and Georgia.

The 1000 online survey participants were a nationally representative sample, balanced by age within gender, region, race/ethnicity, child’s age, marital status, employment status, size of household, education, and annual household income, as well as propensity to be online, based on US Census Bureau targets. Demographics of the sample were 45% male and 55% female, with a mean age of 41. By income, 15% had household income under $35,000, 10% had household income between $35,000 and $49,900, 15% had income of $50,000 to $74,900, and 56% had household income of $75,000 and above.

In another finding, most parents or caregivers were unaware of how socioeconomic factors affected health; the majority (70%) mistakenly believed that prescription drugs have the largest role in preventing chronic conditions such as asthma and type 2 diabetes.

And ssome parents, especially those with lower incomes, were uneasy with the idea of talking with their provider about the social issues affecting their lives, such as money problems or being exposed to violence. But 56% said they would be comfortable with the idea if they knew they would not be judged or if they knew that telling them would improve their or their families’ health.

"We see an important role for us in partnering and educating families,” Moss said. “The way I interpret the information of families not understanding social determinants is not so much a gap on the part of families as the fact that they participate in a health system as we do, which is almost solely focused on medical care and not focused on other factors.”

It is up to Nemours to change that conversation with families, Moss said.