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Disrupting the social determinants of health: From exponential medicine to exponential health

The year was 1989. I was an undergrad at Columbia University. I had a lot more hair than I do now and odd glasses – which by the way are now back in style. Seinfeld made its big debut on television and the Berlin Wall came down.

New York City had been experiencing a crisis throughout the 70s and 80s and there was a full-fledged epidemic of homelessness. One day, I decided to count how many people asked me for money or help of some kind during the walk from my dorm to my first class.

What’s your guess? How many people?

It wasn’t three …or ten…or twenty.  It was thirty five. Thirty-five individual people asked for help during the course of a twenty-minute walk. More than one per minute. This was the day I decided I needed to do more, so I found a homeless shelter near campus and volunteered there several times each week. The program grew to the point where we were serving 300 meals a day on our busiest days.

The world has changed a lot since 1989, thanks in large part to an explosion in technology. But that shelter is still there and today – 28 years later – is still serving 300 meals a day on its busiest days.

I spoke earlier this week – along with Lee Sanders and Dr. Gloria Wilder – on this topic at Exponential Medicine, a conference I look forward to each year because I think it’s one of the best gatherings in the world for people who are driving the disruption of our health care system. The focus of the session was on the move from exponential medicine to exponential health, which has a lot to do with social issues driving health outcomes, or the “social determinants” of health – like the ongoing problem of homelessness in the US. To illustrate the need for this shift in thinking, let me tell another quick story about a patient that we’ll call “Linda.”

Meet Linda.

Linda is a 43 year old diabetic mother of two. Her doctor has prescribed a care plan to help her manage her diabetes, and her son’s pediatrician has prescribed medications for her son to manage his asthma. But Linda’s apartment has lead paint, and the public health department has threatened her landlord with legal action for lead abatement, leading him to evict Linda. This leads her to use up her emergency cash on temporary housing, to miss her job interview, and while much of her treatment is covered, the spacer required to administer her son’s albuterol is not. He struggles in school because of his asthma. Their access to healthy food is cut short. It is only a matter of time before the family will find themselves in the ER, and possibly on their way to larger, life-threatening health conditions. This is an example – one of many – of the social determinants of health in action.

Social determinants of health – which include housing, food, transportation, employment, education, emotional support, freedom from violence, among others – are a nation-wide problem. Up to 80 percent of health outcomes are driven not by how clinicians treat the body, but by how life factors impact health.1 Despite spending more money than any other country on health care, we have some of the worst outcomes.2 We spend over $9,000 per person per year 3, yet rank last in industrialized nations for well-child births, obesity, cardiovascular, cancer, and more. 4

If we are spending so much, why are we so unhealthy?

I think this statistic might have something to do with it: While we spend 40 percent more on clinical care than the average country, we spend 40 percent less on public health.5 And, in the US, while hospital leadership seems committed to the social determinants of health, most activity around this area is ad-hoc, according to Deloitte Center for Health Solutions research. According to our survey of 300 hospitals and health systems, 80 percent report that their leadership is committed to addressing social determinants of health. However, 72 percent of surveyed hospitals do not have dedicated funds for social determinants of health for all of the populations they want to target, and nearly 40 percent of hospitals report having no capabilities to measure outcomes. Clearly, there is work to be done to get our hospitals to a better place where not only is this a priority, but one that is incorporated into broader value-based care initiatives.

How do we move forward? Why are we doing this?

There are amazing programs and innovations being developed and implemented across the country right now, but it’s fragmented.  And it’s incremental. There’s no blueprint. What is it that we’re building? What is this going to look like? How does MY piece connect to YOUR piece? And most importantly, how is this thing we’re building really going to work for PEOPLE?

In my job as a Strategy Consultant, I’m usually trying to answer one key question:  “Why are we doing this?” So going forward, as a community of leaders, innovators, and stakeholders in health care, I think we need to continually ask ourselves, “Why are we doing this?” And even if we like the answer we have for ourselves, or our company, or our university, or venture fund, or organization … how do we feel about the collective answer? What are we building? How will we scale it? Why are we doing this?

Addressing social determinants is still outside the core of health care.  And until it becomes part of the core…until we have exponential health…we will only have exponential medicine. My hope is that we can create the blueprint that forces this shift to a system that actually creates, protects, and sustains health.

  1. RWJF County Health Rankings
  2. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective
  3. Common Wealth Fund; OECD Current Expenditure on Health per Capita 2016
  4.  http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective;OECD Health Rankings: https://data.oecd.org/healthres/health-spending.htm
  5. E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More is Getting Us Less. Public Affairs. 2013
Author bio

Josh is a Partner with Deloitte Consulting LLP, leads the firm’s Healthcare Provider Strategy Practice. He holds extensive experience in strategy formulation, large-scale transformation, operations and organization strategy in the global healthcare industry.