white paper: consumer perspectives on how social

Consumerperspectiveson how socialdeterminantsimpact clinicalexperience

WHITE PAPER:

Consumer feedback shows opportunity to improve engagement and address health challenges

© 2018 Waystar Health. All Rights Reserved.

IntroductionNumerous studies have demonstrated the impact of social determinants of health (SDoH) on health status, outcomes and total cost of care. As care teams, provider organizations and payers attempt to mitigate the impact of these non-clinical risk factors, understanding the consumer’s perspective on SDoH issues will be critical.

Survey methodology Waystar surveyed 500 consumers to understand their individual SDoH contexts and any impact on medical encounters at a hospital or physician office. The survey focused on recognized core SDoH categories: financial insecurity, social isolation, housing insecurity, addiction, transportation access, food insecurity and health literacy. To qualify for the survey, a respondent was required to live in the United States, be at least 27 years old and have had a healthcare encounter within the past 12 months.

2018 research highlightsAmong the findings in the 2018 survey of 500 random consumers:• Social determinant challenges are quite common: 68% of consumers have at least some level of SDoH challenge and

52% have moderate to high SDoH risk in at least one category. • SDoH risk is present across payer classes: Every payer class has a sizable high-stress population.• Government-funded insurance pools, Medicare or Medicaid, have the largest high-stress share: Nearly 60% of the

combined Medicare-Medicaid community have moderate or high stress in at least one category and 33% have high stress in three or more.

• Health status and SDoH challenges correlate: Those with high SDoH stress are nearly 50% more likely to suffer from chronic conditions and 2.3 times more likely to rate their health as “fair” or “poor.”

• SDoH prevalence impacts ability to get and stay healthy in tangible ways: Patients with high SDoH risk are over three times more likely to miss multiple medical appointments per year.

• Patients with SDoH issues prefer to discuss them with providers over payers: Patients with SDoH issues are 2.5 times more willing to talk about those issues with clinicians compared to payers.

• Efforts to engage patients on SDoH issues are misapplied: Most conversations about SDoH are occurring with patients that are least likely to have health issues and least likely to utilize support services, if available.

Demographics of survey respondents


SDoH prevalenceIn our population, 52% had some level of elevated stress – 25% were “moderate risk” with elevated stress in one to two categories and 27% were “high risk” with elevated stress in three or more categories. Minor levels of SDoH stress were present in 16% of the population (“low risk”), with the remaining 32% reporting effectively no SDoH challenges.

SDoH challenges are prevalent across all payer classes, although the composition and density varies. As expected, those on government sponsored insurance, Medicare or Medicaid, had greater SDoH stress. Among this population, 33% were “high risk,” compared to 21% of the commercial insurance population being “high risk.”

SDoH compositionThe most commonly reported SDoH issues are financial insecurity and social isolation. This was consistent across payer classes, although the prevalence and severity differed. Health literacy had the lowest self-reported prevalence among the Medicare/Medicaid population, while food insecurity was the least common issue for the commercial population.

Percentage of consumers experiencing SDoH challenges

SDoH risk prevalance by payer class

Frequency of SDoH challenges by payer class


Relationship between SDoH and health managementIndividuals with SDoH stress rate their overall health status much lower than the overall population and are significantly more likely to suffer from one or more chronic conditions. Interestingly, even in the healthiest categories, more than one in five self-report high SDoH risk.

Consumers also recognize the impact SDoH has on their ability to improve and maintain their health. Only 1% of the “low risk” population indicated that their issues caused them to miss at least one healthcare appointment per month. When looking at the “moderate risk” segment, that rate quadrupled to 4%, and among the “high risk” patients, that rate increased nearly another six-fold to 23%. SDoH stress is clearly an indicator for no-show reduction efforts.

Consumers with moderate to high SDoH risk are 42% less likely to rate their health as “excellent” or “very good,” and 2.3 times more likely to rate their health status as “fair” or “poor.”

Consumers with moderate to high SDoH risk are 44% more likely to suffer from a chronic condition.

Distribution of SDoH risk level by self-reported health status

Chronic condition prevalence related to SDoH risk

SDoH impact on how often patients miss medical appointments


Efforts to identify prevalence of SDoHTo understand the SDoH challenges patients are facing, providers and payers are beginning to utilize screening tools – typically a survey of approximately a dozen questions that is either completed by the patients themselves or administered by a member of the care team. This effort is far from universal due to issues of response and perception bias as well as resource limitations.

Only 22% of consumers with SDoH stress indicated having discussed these issues with their physician. Of those who discussed their issues, 64% are in the “high risk” segment and another 20% are in the “moderate risk” segment.

Although roughly one in five patients with SDoH stress will have the conversation, the data suggests many risky patients are slipping through. Of all patients in the “high risk” segment, 60% never discussed their issues with a provider or their insurance company.

Preference for physicians over payers, but still a sensitive topicAcross all payer groups, patients were 2.5 times more likely to prefer discussing SDoH concerns with a physician/nurse as opposed to an insurance company representative. This isn’t surprising, but should be considered as providers take on more of a payer role in the form of ACOs, bundles or simply a greater number of “at-risk” contracts.

Interestingly, 10% of respondents with commercial insurance and 20% of the respondents on Medicare or Medicaid prefer not to discuss SDoH challenges at all, highlighting the need for tactful, unobtrusive strategies for gathering social determinant insight.

Within the group of consumers that do not want to discuss SDoH issues, the share with “moderate” or “high” SDoH risk remains significant.

Physician conversation targeting for those with self-reported SDoH stress

Who patients prefer to discuss SDoH issues with

Risk distribution of consumers that do not want to discuss SDoH issues


Risk mitigation and program uptakeOnce SDoH risks are identified, the next step is to mitigate them. Many organizations haven’t yet developed the necessary programs, services or community partnerships required to address the needs of their patients. Even for those with resources at their disposal, it can be challenging to get patients to engage. While 83% of patients being offered programs and services to help address their SDoH challenges have “moderate” or “high risk,” 46% decline to accept assistance.

Of note, the uptake of programs and services was considerably higher for patients who discussed SDoH challenges with their physician/nurse compared to those who had a discussion with an insurance representative. This suggests patients have a higher level of comfort or trust when they work with clinicians to address SDoH issues.

Opportunity for improved targetingSDoH risk is present across all age groups, but the influence of those risk factors is felt more acutely by the older populations. Almost 60% of those age 27 to 39 rate their health as “very good” or “excellent,” compared to only 37% and 28% for those age 40 to 64 and 65+, respectively. Only 11% of these younger consumers rate their health as “fair” or “poor,” compared to 24% and 20% for those age 40 to 64 and 65+, respectively.

Surprisingly, younger consumers are nearly twice as likely to have been engaged in a discussion of their SDoH challenges by their provider or insurance company. Unfortunately, they are also less receptive to assistance than the older segment.

In short, providers are more often focusing their SDoH mitigation efforts on patients whose health status is less affected by SDoH issues and who are far more likely to decline support programs or services when offered.

Program uptake distribution for those offered services to mitigate SDoH stress

Differences in program uptake following clinician vs. insurance rep discussion


ConclusionClearly, SDoH issues are daily barriers as consumers try to get and stay healthy. Payers and clinicians are making efforts to understand the sociodemographic context of their patients and offer programming. However, the activity is still limited and appears unevenly applied or done in a manner that consumers choose to reject today. Better methods are needed to target highest risk patients who would most benefit from assistance programs.

A recent study in the Annals of Family Medicine1 showed that manual SDoH data collection in the EMR was quite burdensome for staff and had substantial barriers to adoption. New technologies utilizing predictive data analysis are showing promise in their ability to segment patient populations without manual survey efforts, enable pre-arrival preparations and suggest more appealing methods of program presentation. Figuring out how to engage patients in their SDoH challenges is core to successful, cost-effective and high-value population health management.

1Gold, Rachel; Bunce, Arwen; Cowburn, Stuart; Dambrun, Katie; Dearing, Marla; Middendorf, Mary; Mossman, Ned; Hollombe, Celine; Mahr, Peter; Melgar, Gerardo; Davis, James; Gottlieb, Laura; Cottrell, Erika (2018, September/October). Adoption of Social Determinants of Health EHR Tools by Community Health Centers. Retrieved from http://www.annfammed.org/content/16/5/399.full.pdf+html

Health status by age group

Age influences discusstion targeting and uptake rates

white paper: consumer perspectives on how social

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