How Transformative Primary Care Addresses the Social Determinants of Health

By Mary Chen

America claims to have the world’s best healthcare system; and if you have a complex disease and money, the care you get is remarkable. But 70 percent of medical outcomes are based on lifestyle – including where you live, what you eat, and whether you have a ride to your medical appointments. This statistic raises a critical question – “What good is living in the country with the world’s best health care if you can’t get to your doctor’s office?

Millions of Americans struggle with social determinants of health. These factors can reduce life expectancy. Not far from our medical centers in New Orleans, people live 10-15 years longer than the people in our neighborhoods. The only difference? Minority and lower-income senior citizens live in our communities, while wealthy seniors live in the more affluent zip codes a few miles away.

A closer look at the lives of these seniors paints an unflattering portrait of the social inequities that impact their health.

Seniors living with economic instability are more likely to have poor nutrition and eating habits. These bad habits can lead to higher blood pressure and blood sugars, congestive heart failure, depression and emotional issues, lack of energy, cognitive decline, and physical instability. 

Seniors living in over-crowded, run-down conditions are more likely to have unreliable water, gas and electricity service, poor insulation and ventilation, dirt, mold, and pests. These factors can lead to infections, chronic respiratory conditions, mental and emotional health challenges, falls, infectious diseases, and neurological issues. 

These seniors also suffer from poor or non-existent transportation options and inadequate health literacy. Both factors lead to chronic stress and create inflammation and high cortisol levels which ultimately cause disability, disease, and mortality. 

Improving the social determinants of health for all Americans is simply the ethical thing to do—but it’s also crucial to securing the nation’s economy. It’s well documented that failing to control social determinants of health will continue to push American health care costs higher as more people need emergency and inpatient hospital care. But solving this systemic inequality will require many primary care doctors to approach healthcare differently. 

Determining the causes of chronic conditions

The fee-for-service providers that dominate our national health care system do not have the time to address chronic conditions effectively. They see anywhere from 25 to 35 patients per day. They spend approximately 15 minutes with each patient – and that includes the time it takes to write notes and update charts! All these doctors can do is address the problem in front of them. They don’t have time to truly get to know their patients and determine how underlying social challenges impact health.

ChenMed, on the other hand, has smaller patient panels that give their doctors the time to build trusting relationships with their patients and unearth the factors driving their chronic conditions. A ChenMed physician may ask a care team member to help connect a patient facing food insecurity with a grocery delivery service. If a patient doesn’t have access to reliable transportation, a care team member will arrange transportation so the patient doesn’t miss a doctor’s appointment. 

Full-risk capitation emphasizes well care

Some people believe the fee-for-service system is “broken” because it is expensive and ineffective. The truth, however, is fee-for-service works perfectly – it generates the revenue and profits it is designed to generate. The system profits from sick care and rewards providers based on how many tests and procedures they order. 

Unfortunately, there is no billing code to order an Uber to get the patient to an appointment. Billing codes don’t exist for connecting patients with social services either. 

ChenMed’s full-risk capitation model makes it easier to provide services that fee-for-service providers cannot. 

In full-risk capitation, health care plans pay providers a lump sum, and the providers assume all the financial risk associated with the patient’s care. If providers keep the patient healthy, they make money. If they fail and the patient needs a costly hospitalization, the providers lose money. 

This approach allows providers to invest the time to build trust and influence patient behavior. They may also offer on-site medication pickup to patients who have no way to get to a pharmacy or social services to help patients eat healthier. Most of all, they can see patients as often as needed to prevent little problems from becoming big ones. 

According to research, this approach to care gets results. A 2017 report highlighted by the American Journal of Managed Care showed that ChenMed patients had 33.6 percent fewer ER visits and 28 percent fewer hospital admissions when compared with the average among Medicare beneficiaries. During the pandemic, a study published by the American Journal of Preventive Cardiology in September 2020 showed that ChenMed patients who contracted COVID-19 had a 40 percent lower mortality rate than high-risk patient cohorts in other studies. 

An equitable approach to health care saves lives

Ignoring the social determinants of health robs the neediest and most vulnerable seniors in America of healthy lives. 

These seniors are hurting and have nowhere to turn – except the emergency room. But the fee-for-service hospital-based healthcare delivery system is failing them. 

If we can empower and incentivize clinicians to incorporate social determinants of health into their exams, they can meet these seniors where their needs exist – and that includes food, housing, and transportation needs. Everyone will compete to improve health through transformative primary care, and we will inspire others towards a much more ethical healthcare delivery system.

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