Biopsychosocial vs. Biomedical Model
MedicalEconomics.com30 MEDICAL ECONOMICS ❚ DECEMBER 10, 2017
by TODD SHRYOCK Editor
aying doctors for outcomes in- stead of volume may seem to make sense, but what happens when patients can’t do their part to follow prescribed be- havioral changes or take their medications?
For some patients, their so- cioeconomic situation has a greater impact on their health
than anything their doctor is doing. A Min- nesota Department of Public Health study indicates that social determinants aff ect a larger proportion (40%) of health and well- being nationally than does clinical care (10%). Social determinants are typically de- fi ned as food insecurity, housing, transpor- tation, education, violence or community safety, social support, health behaviors and employment.
Richard Bryce, DO, a primary care phy- sician in Detroit, has seen the eff ects these challenges have on his patients at the com- munity clinic he oversees. “Unfortunately, a lot of these social challenges play a huge role in their health,” he says. “When you are a medical student, you spend so much time learning about diff erent drugs and surgeries to improve lives, but on a day-to-day basis, social determinants play a big role and their eff ect on outcomes is huge.”
For example, patients may want to ex- ercise, but are afraid to leave their house because the neighborhood isn’t safe, says Bryce. Poverty or lack of education can lead to poor food choices, even when healthier foods are readily available.
“Individuals who are unemployed or homeless can’t aff ord healthcare, and those living in unsafe neighborhoods with high rates of violence and/or experiencing transportation barriers can’t access care when needed, leading to untreated medical conditions and resulting in poorer health outcomes,” says Jay Bhatt, DO, MPH, FACP, a practicing internist and chief medical of- fi cer of the American Hospital Association. “Research has also indicated that many indi- viduals with food insecurity are at high risk for chronic diseases such as diabetes and obesity in some age groups.”
Bhatt is also former managing deputy commissioner at the Chicago Department of Public Health where he developed pro- grams addressing social issues in medical treatment.
So how does a physician who is respon- sible for keeping patients healthy deal with these socioeconomic challenges that stretch far beyond the walls of the practice, espe- cially when the fi nancial viability of their practice may be on the line?
HIGHLIGHTS
Physicians
need to understand
the problems their
patients are facing
before addressing
socioeconomic
challenges, and the
way to do that is to ask.
For patients who
need additional
assistance, smaller
practices can identify
local volunteers who
could serve as a
liaison between the
practice and the social
agencies.
Operations
BUILDING BLOCKS TO BETTER HEALTH Overcome socioeconomic obstacles to improve adherence
MedicalEconomics.com 31MEDICAL ECONOMICS ❚ DECEMBER 10, 2017
“You can either look at the problems faced by patients and ignore them or try to address them, even if you are not medically trained to address them,” says Bryce. “So- cial determinants make keeping patients healthy hard, but when you can fi nd solu- tions that are not always medical in nature, it can be really rewarding.”
IDENTIFYING THE PROBLEM Physicians need to understand the specifi c problems their patients are facing before ad- dressing social issues, and the only way to do that is to ask, experts say.
Jeremy Long, MD, MPH, an internist in Denver, runs a clinic for the underserved and says it’s necessary to build trust to get the patient to open up about nonmedical is- sues that may be aff ecting their health. “Try to build rapport with them and introduce them to the whole team to show them how invested you are,” says Long. “When they see that, it helps them let their guard down.”
Long’s clinic uses a seven-page intake form that not only covers the standard med- ical questions, but details about the patient’s life. Questions about substance abuse, em-
Social determinants of health Operations
Payer recognition of social determinants of health While physicians are keenly aware of the social issues that may affect patient adherence, payers
aren’t as quick to acknowledge these factors when it comes to quality metrics. Medical Economics
asked three policy experts to weigh in on what they think federal and commercial payers should do to
recognize social determinants of health when it plays a role in physician reimbursement.
“[The Centers for Medicare & Medicaid Services (CMS)] should
more adequately risk adjust the metrics
so that providers who are serving
patients with multiple social and
economic barriers to compliance are
not penalized. [The agency] needs to
partner with the U.S. Department of
Housing and Urban Development, the
U.S. Department of Agriculture and
the U.S. Department of Education to
actually address those barriers. CMS
has taken some well-informed steps
in that direction, but it has not gone far
enough.”
—Paula Braveman, MD, MPH
PROFESSOR OF FAMILY AND COMMUNITY MEDICINE
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
“It’s not necessarily [payers] paying for services. There are other human
service agencies paying for community-
based services and that’s their role. But
it is really: How can you pay to better
coordinate these services and for the
time and staff resources it takes to
more proactively coordinate the things
that we know make a difference in
improving care. That’s something that
could potentially help without being a
total, radical departure.
“Serve as a resource for providers to
look to for standardized screening tools
or other tools to connect to community-
based services. Those are useful roles
for CMS to take into account some of
the challenges physicians face.”
—Pamela Riley, MD, MPH
VICE PRESIDENT OF DELIVERY SYSTEM REFORM
THE COMMONWEALTH FUND
WASHINGTON, D.C.
“In the ideal world, what we would be saying is that we are expecting the
same quality outcomes regardless of
patients’ social context, but that we
provide additional support—fi nancial
support—to provide the kinds of
services that would mitigate those
social determinants of health. That is a
very diffi cult thing to do without building
the infrastructure around it.
“I think it sends the wrong message
of what we are expecting in the
healthcare system to say, ‘We are
taking these social factors as a given
and therefore not expecting the same
level of health outcomes.’ The goal
has to be equivalent health outcomes,
and I think we need to recognize that
some patients may need more intensive
surrounding and support services
and those need to be built into the
reimbursement system.”
—Jeffrey Levi, Ph.D.
PROFESSOR OF HEALTH POLICY AND MANAGEMENT
MILKEN INSTITUTE SCHOOL OF PUBLIC HEALTH AT
THE GEORGE WASHINGTON UNIVERSITY
WASHINGTON, D.C.
MedicalEconomics.com32 MEDICAL ECONOMICS ❚ DECEMBER 10, 2017
Operations Social determinants of health
ployment, insurance style of learning, goals of care and incarceration are all asked to gain a complete picture of the person’s life and the challenges he or she faces.
Bhatt says that physicians can start with screening questions that take the form of, “Do you have trouble getting here?”, “What kind of neighborhood do you live in?” and “Are you having diffi culty getting food for yourself or your family?”
“Th ough these questions are personal, they can help physicians build relationships
with their patients and give them insight to better understand factors aff ecting their health,” Bhatt says. Many professional orga- nizations off er screening tools and guide- lines, so that’s a good place to start.
Gail Cunningham, MD, FACEP, chief medical offi cer for University of Maryland St. Joseph Medical Center, oversees a program aimed at reducing the hospital’s readmission rates for patients struggling with psycho- social issues that aff ect their health. Th e hos- pital uses a nurse practitioner to interview patients about the nonmedical challenges in their lives and helps direct them to commu- nity resources and nonprofi ts that can help.
“Some patients are honest and some are a bit delusional about reality,” she says. “Some patients are fi ercely independent and don’t want help or don’t think they need help. Some may decline our service then get home and realize [dealing with their social issues is] harder than they thought and will call us back.”
While it can be challenging to get a full picture of the patient’s social challenges, experts agree that the more commitment physicians show toward the patient’s well- being, the more they are willing to open up. But Bryce says to be careful not to stereo- type, especially about income.
“Social determinants are not always just about income level,” he says. “If you are not getting the results you want, it’s important for the physician to look deeper at the care model and the patient and why they are not getting better. Sometimes when you dig deep, that’s when you’ll fi nd an answer in the challenges the patient faces.”
PROVIDING SOLUTIONS Treating patients with challenges that af- fect their adherence can be frustrating, but it starts with taking the right attitude. When a patient has been told multiple times to eat healthily and make sure they are taking their meds only to return having done none of it, the fi rst response from a doctor might be exasperation. But Bryce says it’s better to pause and focus on empathy.
“We don’t necessarily understand the life they live,” says Bryce. “If you try to under- stand it, it will allow you to better take care of the patient and decrease the pressure you put on yourself if you are not getting the re- sults that you want.”
Th e more doctors are able to understand
What to do with the nonadherent patient
S hould a physician dismiss a patient because of nonadherence alone, even if every attempt has been made to deal with not only clinical issues, but social
issues? Experts say in most cases the answer is no.
“What I hope not to see is rampant selection by physicians, discriminating for patients who are healthy,” says Ryan Nash, MD, FACP, an internist and director of the Center for Bioethics at Ohio State University. “Patient abandon- ment is a major problem, so you want to ensure there is a safe plan and some sort of transition to another healthcare professional. It should be done formally, in writing, and there should be a set time period for the transfer.” He recom- mends seeking legal advice on drafting a letter that will meet the requirements of the jurisdiction the physician is in.
Richard Bryce, DO, a Detroit- based primary care physician, says that having patients sign an informal contract that outlines expectations when they join the practice can help, but won’t work for everyone. Some- times a doctor’s attitude is the most important factor in patient adher- ence. “In most cases, if the doctor can be positive and instill motivation, the patient will do the best they can.”
One of the issues with a nonadherent patient is fi guring out where that patient should go if they are dismissed from a practice. “It’s easy to say it’s not working out at this end, but it’s incumbent on us as physicians to work out another place for that patient,” says Jeremy Long, MD, MPH, an internist in Denver. Many nonadherent patients struggle with behavioral health problems, which complicates treatment, especially for the small practice with limited resources.
The American College of Physi- cians’ Ethics Manual states in part that “Continuity of care must be assured. Abandonment is unethical and a cause of action under the law.”
But no matter how complicated the case, physicians must put in their best effort. “It is important to provide patients with enough information regarding their condi- tion and your treatment recom- mendations, and to provide it in a format that is easy to understand,” says Jay Bhatt, DO, MPH, FACP, a practicing internist and chief medical offi cer of the American Hospital Association. “Stressing the signifi cance of the condition and the need for timely follow-up should help with patient compli- ance.”
MedicalEconomics.com 33MEDICAL ECONOMICS ❚ DECEMBER 10, 2017
OperationsSocial determinants of health
the challenges patients face in life, the more that can be used to create a positive attitude from both the doctor and the patient, he adds. “Th ere is not a pill out there that is go- ing to fi x someone who doesn’t have enough food to eat.”
Patients facing these challenges often are not in a position to help themselves, so physicians need to do part—and sometimes all—of the work to help them. Experts say to start by researching what resources exist for the social challenges a practice sees the most.
“Connecting to resources in the commu- nity requires some initial eff ort, but many partnerships and activities are already un- derway,” says Bhatt, adding that reaching out to the public health department, local hospitals and social organizations is a good place to start.
EDUCATING PATIENTS Bryce says part of the role of the doctor is to educate patients on help that is available. For instance, Detroit has a program where food stamps can be used to buy double the face value of fresh fruits and vegetables. Many patients have access to the market, but just don’t know about it. He adds that education eff orts aren’t always perfect, but putting patients in touch with the right re- source can make a big diff erence.
Some patients will require more hand- holding than others, but Long says it’s of- ten ineff ective to just scratch out a name or phone number of a community resource on a slip of paper and hand it to the patient. “If you are in a small practice, I think you have to start sitting down with people doing the social services that work in the area and start networking in a meaningful way.”
Cunningham agrees, noting that time invested with a representative from a social service agency may yield a list of services and contacts for a variety of types of help. For those patients who need additional as- sistance, she suggests smaller practices try to identify local volunteers who could serve as a liaison between the practice and the so- cial agencies, helping them fi ll out forms or setting up interviews.
“Also, ask questions of your patients dur- ing the visit to identify issues that may have been missed—‘I’m writing a prescription now, do you have a way to pick it up and a way to pay?’” says Cunningham. A call to the pharmacy may reveal programs to help with
adherence through medication remind- ers via text message or phone calls, but the practice may have to do some of the work on the patient’s behalf.
Long says that his offi ce practices a model where the patient is shown how to do something once, with the expecta- tion the patient can do it the next time. For example, a patient need- ing transportation assistance would be given help fi lling out the applica- tion and getting the initial appoint- ment set up. After that, about 80% of the patients have the knowledge to continue on their own.
“You have to meet the patient where they are at,” says Bryce. “For some patients, you can show them a program for free food and they take it from there, but for others, you have to take it step by step. You don’t always get the outcomes you want, but you just do the best you can.”
Th e trust established between the physician and the patient will also go a long way toward helping address any socioeconomic chal- lenges the patient may face. Th e more the patient trusts the doctor, the more open he or she will be to receiving referrals to help them ad- dress their needs, says Bhatt.
“Additionally, developing trust- ing relationships with community partners is also important,” he says. “In the partnership, practices should defi ne roles and responsibilities and deliverables for each team member.”
Checking up on patients after their consultation with social servic- es can help patients feel connected and cared for, Bhatt adds.
Addressing social determinants of health is not the job of one phy- sician alone, but an eff ort must be made if patients are to overcome their challenges and if physicians are to maximize their reimbursement under val- ue-based care.
“Start off small, build resources and skills within your team to address these issues,” says Bhatt, “then start collaborating with other physicians, local community orga- nizations, local businesses etc., to help the most prominent health needs in the com- munity.”
LOOKING FOR HELP Practices with limited
resources don’t have to solve
patient social issues on their
own. Many existing public and
private agencies are willing
to help, but physicians may
need to do some research to
learn where their patients
can obtain assistance. Good
starting points include:
❚ Public health departments
❚ Local hospitals
❚ Pharmacies (for medication adherence help)
❚ Social organizations
❚ Philanthropic organizations (such as United Way)
❚ Food banks
❚ Religious organizations
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