Social determinants of health (SDOH): Three trends to watch in 2023
By Maureen Hennessey, Ph.D., Jorge Font, Dominic Galante, M.D., Kris Kang, PharmD, and Cynthia Miller, M.D.
Healthcare ecosystem stakeholders, including pharmaceutical and device manufacturers, will continue to coalesce in support of the Quintuple Aim in 2023. In response to value-based reimbursement pressures, a dip in state-regulated health plans’ reported profit margins, and “pent up” demand with sicker populations, the healthcare sector is hastening adoption of population health approaches, including initiatives to improve outcomes by closing health disparity gaps. Private/public sector commitments galvanized by the White House provide further impetus to address food insecurity and diet-related diseases. CMS (i.e., the Enhancing Oncology Model) and the National Committee for Quality Assurance are also catalysts, with new standards and measures for providers and plans to identify and respond to adverse social determinants of health (SDOH), identify health disparities, and initiate plans to close disparity gaps. Employer organizations (the major funders of commercial insurance) are also supporting SDOH/Health Equity initiatives, with entities like Business Group on Health recognizing elite employers for excellence in health equity, and the Society for Human Resource Management (SHRM) urging HR professionals to ensure employers advance health equity. These factors will escalate momentum for healthcare stakeholders to expand their SDOH/Health Equity initiatives. Rapidly changing communication, environmental, and technological landscapes will also impel stakeholders to evolve their 2023 SDOH/Health Equity approaches to adapt to emerging challenges. The following is a preview of three SDOH trends that will expand in importance to take on pernicious challenges in 2023.
Mis/Dis/Information: Eroding Patient Trust
With nearly two-thirds of surveyed pharma communication leaders anticipating misinformation-generated crises within the year, most are evolving their strategies to protect brand value and company reputation. Public and private sectors are joining forces to address misinformation and disinformation (mis/dis/information), now recognized as an adverse SDOH leading to health disparities among diverse populations. The Surgeon General has called for a whole-society approach to combating misinformation, noting its severe impact on adherence with vaccines and effective therapies for cancer and heart disease. The American Medical Association (AMA) has adopted a policy to tackle disinformation, and the Commonwealth Fund’s recent report called for action to mitigate distrust caused by “a tsunami of misinformation and, when shared with bad intent, disinformation.”
Johns Hopkins Bloomberg School of Public Health estimates that COVID-19 vaccine mis/dis/information have cost the United States as much as $50 million– $300 million per day since mid-2021. Combined with the U.S. pharmaceutical industry’s estimated revenue losses of $250B/year due to non-adherence, and concerns about brand reputation, powerful social and financial motives are accelerating focus on this complex social risk factor. Declaring “information” as a SDOH, Google is joining forces with leading non-profits to advance health equity within historically marginalized communities, leveraging YouTube to deliver healthcare information, and amplifying credible voices. Johns Hopkins is partnering with health departments to launch AI chatbots, tackling COVID-19 vaccine misinformation within communities.
Look for experts across sectors including pharma to intensify collaborations utilizing behavioral technologies (social networking, psychological), marketing (social listening and messaging), public health methodologies (health literacy), AI and other digital technologies to innovate fresh approaches. Mis/dis/information messaging styles and strategies are evolving rapidly, creating an imperative for all health sectors to evolve their messaging strategies and styles to rebuild public trust.
Climate Health: A New SDOH
Climate health is receiving increased attention as a new SDOH. In addition to SDOH such as housing and food insecurity, the environment – particularly climate – can drive health outcomes. Extreme weather events cause life disruptions leading to delayed medical care, mental health challenges, and displacement. Historic practices, like redlining, have exposed people of color to more environmental risks (i.e., excessive heat, flooding, and pollution). Extreme weather can also worsen the health of populations with chronic diseases. For example, power outages can increase hospitalization rates for patients with COPD, and exposure to extreme heat can lead to chronic kidney disease.
Pharmaceutical companies have a significant incentive to focus on climate. With the evolution of value-based contracting and the need for real-world data, manufacturers will have the opportunity to see how the environment affects health outcomes. For example, if looking at the outcomes of a population on a heart failure drug, patients in locations experiencing extreme heat may have more hospitalizations than those who do not. This could skew outcomes such that a drug appears to be less effective. Mitigating the effects of heat, or at a minimum measuring the impact, can allow pharmaceutical companies to realize the efficacy of their products. Similarly in clinical trials, especially as the industry moves to decentralized trials, outcomes may be affected by local environmental effects. Pharmaceutical companies may be able to use mapping tools to determine areas of climate vulnerability to improve randomization accuracy. Mapping tools may ensure that one arm of a trial doesn’t have more climate- vulnerable patients than another, especially with diseases like heart failure and diabetes, which are more affected by weather changes. In 2023, look for more manufacturers, payers, and providers to acknowledge and address climate health – an SDOH that can impede favorable outcomes – beginning at clinical trials and beyond.
The Digital Divide: It’s More Than Access
The swift uptake of telemedicine during the pandemic has highlighted the “digital divide” as a significant SDOH, revealing underutilization of digital telehealth by under-resourced populations. Telehealth includes virtual interactions between patients and clinicians, other digital interactions such as text medication reminders, and remote monitoring (i.e., pulse oximeters, continuous glucose monitors) for chronic conditions. Now the fastest growing healthcare modality, concern exists that telehealth design and use factors are overlooked, resulting in exacerbations of healthcare disparities. Look for intensified, intentional focus by payers, health systems, and digital designers on digital inclusivity. Designers will seek to democratize digital use through greater emphasis on tailoring solutions to address barriers such as language access, readability, health literacy, and ease of use. Payers and health systems will support digital adoption through initiatives to better understand and respond to diverse patients’ motivations and trust in digital care, address access and connectivity gaps, and systemically support skills development to build digital literacy and user confidence.
Efforts to identify device performance limitations potentially contributing to health disparities will likely intensify, and greater examination of the role of AI and machine learning (ML) is underway, with at least one physician leader moving toward “augmented intelligence,” by training models on diverse data sets, to avoid scaling and exacerbation of health inequities caused by using inadequate data sets not representative of healthcare populations, potentially introducing systematic bias. Conferences like AI for Healthcare Equity and Health Equity in Clinical Trials Congress will continue to explore the use of AI to advance health equity, and multi-sector alliances will advocate for improved care in underserved populations using digital health technology.
The healthcare ecosystem will continue to intensify its efforts to close and prevent health disparity gaps, aligning around the Quintuple Aim in 2023. Pharmaceutical manufacturers are developing social and digital strategies to facilitate access to their therapies at clinical trials and beyond. Pharma communication leaders are taking action to address mis/dis/information threats to their brand and clinical adherence. Pharma is expanding its understanding of customers’ SDOH initiatives and unmet needs, and supporting them with technology, resources and capacity/coalition building initiatives. In 2023, those stakeholders who join forces to address current challenges, but also anticipate, plan, and innovate for emerging threats, will be at the vanguard of advancing health equity.