Health care organisations should enhance strategies meant to address social, environmental, and economic factors that contribute to health outcomes—the drivers of health.
The root causes of disparate health outcomes include racism and bias, structural flaws in the health care system, and deep inequities within the drivers of health (DOH). To advance health equity, organisations should look outside of the traditional health care system and address these social, economic, and environmental factors that lead to healthy or unhealthy outcomes. This research focuses on the ways health care leaders can address inequities in the DOH in their patients and members, employees, and community, and through relationships in the larger ecosystem.
In 2017, the Deloitte Center for Health Solutions surveyed nearly 300 health system leaders and found that 80% said they were committed to establishing and developing processes to systematically address social needs as part of clinical care. However, the same survey revealed that much of the activity was ad hoc, and gaps remained in connecting initiatives that improve health outcomes or reduce costs. This time, as we relaunched the survey with health system leaders, we added health plan leaders.
The 2021 Drivers of Health Survey of 49 health plan leaders and 251 health system leaders revealed the following insights into areas in which health care organization leaders can impact DOH to achieve greater health equity:
• Most health care organisations are still screening their patients and members more than they are actively connecting them to services: As we saw in the prior survey, in nearly every DOH area, health care leaders say they are screening their patient and member populations for need. However, far fewer say they are acting on those identified needs by, for instance, establishing in-house programs or creating formal partnerships with community-based organisations (CBOs). For example, while 80% say they are screening their patients and members to determine whether they might need access to food banks or vouchers, only 35% have established community partnerships to address identified needs in that area.
• Many are not leveraging partnerships with CBOs enough:While 69% of health plan leaders and 63% of health system leaders say they have general partnerships with local community- and/or faith-based organisations to help address DOH, fewer than one-third of overall respondents say that they are leveraging community partnerships to address specific DOH needs in their patients and members or larger community.
• More ecosystem partners are needed to bolster DOH efforts: Fewer than half of health system leaders (49%) and health plan leaders (45%) say they have partnered with other health care organisations to address DOH needs. Just over half of health plan leaders (55%) and 44% of health system leaders say they partner with technology vendors that provide solutions like ride-sharing or digital financial literacy vendors.
• Health care organisations pay least attention to their own employees’ DOH needs: Fewer than half of health care organisations are screening or providing programs to their employee populations around economic or environmental DOH (e.g., 41% are screening their employees to identify whether they are able to pay their bills or whether they have stable housing versus 78% who say they are screening their patients). Education is the only DOH area where employees receive more attention than patients and members and the larger community.
• Growth in value-based care is leading more health systems to invest in DOH than four years ago: In 2017, 20% of health system leaders said that value-based models or initiatives that emphasise the integration of DOH into health care would lead them to increase their organisation’s investments in this area. By 2021, this increased to 58% of health system leaders.
Most of the survey respondents agree that improving health outcomes is a top goal underlying their DOH strategy (90% of health plan leaders, 74% of health system leaders).
Health care organisations and their leaders looking to impact their patients and members, community, and employee populations’ DOH should implement well-defined DOH strategies now. Leaders should consider:
• Creating accountability and governance for DOH initiatives
• Measuring and evaluating programs and initiatives
• Embedding DOH approaches into clinical care
• Ensuring their own employees’ needs are being addressed
• Strengthening relationships with CBOs
• Looking to new ecosystem partners
In Activating health equity: A moral imperative calling for business solutions, we outlined how health care organisations can intentionally and deliberately design and build systems that advance health equity as an outcome. One way to do this is by addressing social, economic, and environmental needs faced by their employees, patients and members, and larger community, and the ecosystem relationships and partnerships that can support these initiatives. With that in mind, we surveyed health care leaders on the activities and programs they have initiated to activate greater health equity across these different areas (figure 1).
To understand where health system and health plan organisations are building solutions and strategies to address the DOH for their employees, the people they serve, and their larger community, we surveyed 300 leaders from large health system and health plan organisations. We also talked to experts from academia, community organisations, and industry associations to understand the practical implications of these survey findings (see sidebar “Research methodology”). Throughout the survey and discussions, we referred to areas of need as the “drivers of health.” Many organizations may refer to these as the “social determinants of health.” We use this term because there has been a shift in parts of the health care system away from referring to these as “determinants” and rather as “drivers” to emphasise that nothing predetermines health (see sidebar “Words matter: Social determinants of health versus drivers of health”).
Executive survey: In June and July 2021, the Deloitte Center for Health Solutions surveyed 300 leaders at large health systems and health plans to understand how they are addressing the DOH. We aimed for participant variety among large health system and health plan leaders. As reflected below, responsibility for DOH initiatives and programs is held by many different titles/roles.
• Health plans (N = 49)
o Size: All respondent organizations had more than 500,000 member lives. More than three-fourths of organisations had more than 2 million member lives.
o Respondent titles: Director/VP/SVP—strategy (45%), population health (20%), and chief medical officer (18%), among others.
• Hospitals and health systems (N= 251)
o Size: All respondent organizations had revenue of more than US$1 billion. Approximately half of them had revenue of more than US$5 billion.
o Respondent titles: Administrator (34%), chief medical officer (23%), director/VP/SVP of strategy (12%), and chief clinical officer (10%), among others.
We asked respondents to answer questions on their initiatives to screen and connect specific populations to services: their patients, members of their larger community, and their employees. We also asked them about their capabilities, investments, and barriers around DOH initiatives.
Executive panel discussions: We also conducted small group discussions in August 2021 to review the survey findings with external subject matter experts. We consulted a total of 11 experts in the DOH and health equity fields from academia, community organisations, and industry associations. The panelists reacted to the survey results and added their perspectives on various aspects of DOH screening and interventions, capabilities, investments, and barriers to overcome.
As a recent Health Affairs blog emphasised, “Now more than ever, it is crucial that we use language that speaks to the realities of peoples’ lives and illuminates, rather than obscures, our shared understanding of and responsibility to act on all the factors that drive health.”1
When we conducted the original survey in 2017, most health care leaders were addressing what they then called the social determinants of health (SDOH). As the national conversation around this imperative has matured, we have seen a shift away from the word determinants toward the term drivers of health. This shift occurred as health care organizations and CBOs gained more evidence around and experience with supporting patients’ and members’ needs outside of health care. Indeed, while for many years the discussion centred on what elements outside of clinical care determined the health of an individual, the discussion now centers on what support and programmes can aid and drive better health outcomes. These factors drive health outcomes—whether good or poor—but are not predetermined. In addition, beyond just “social,” these drivers also include economic and environmental factors. Finally, this shift toward drivers helps turn the focus toward building up the ways that health care organisations can support individual agency.
Our 2017 survey found that most hospitals (88%) were screening for social needs at the time. However, only 33% of them reported having a well-defined process for connecting people with social-needs-related resources for their entire target population. The 2021 survey revealed that this gap still exists. For example, while most health care leaders (79%) say they are screening the populations they serve to understand whether they face challenges paying bills, only 35% say they have formal partnerships with community organisations to help patients address need in this area. Few health care leaders (29%) say they are screening patients and members for education level or connecting them to community partners who could help advance their education (18%) (figure 2).
"There are some real structural and trust issues in working with public and private organisations, period. It can be a convoluted process to forge the right public-private partnerships to work with large organisations and nonprofits … And then, you have a failure, quite honestly, in public health, which should really be a trusted convener in our communities to bring it all together."
—Joe Wilkins, managing director, JW Health Insights and board director, Black Directors Health Equity Agenda
"It's great to see some [health systems] conduct food insecurity screening or transportation using frameworks like the PRAPARE assessment or the Accountable Health Communities (AHC) model assessment. However, we've found that the percentage of the patient base getting screened for social needs remains very low, which then impacts referrals out to the community. In the future, more consistent programs that also leverage analytics on need look to be the right approach to ensure the majority of a patient base has health-related social needs captured."
—Manik Bhat, founder and CEO, Healthify Inc.
There is increasing evidence on how insights into their communities can help health care organisations identify patients’ and members’ health needs in a timely manner.5 About two in three respondents say they have general partnerships with local community- and/or faith-based organisations to help address DOH needs. But, fewer than one-third of overall respondents say that they are leveraging community partnerships to address specific DOH needs in their larger community. For example, a little more than half (54%) of health care leaders say they are screening their larger community for access to stable housing, and only 29% say they have formal partnerships with community organisations to address housing needs in the community or communities they serve (figure 3).
Extending relationships to new partners, including organisations traditionally considered competitors, could help organisations address DOH needs. Many health care leaders already recognise this: Nearly half of health system leaders (49%) and health plan leaders (45%) say they have partnered with other health care organisations to address DOH needs. Nontraditional players are increasingly playing a role in addressing needs, too. More than half of health plan leaders (55%) say they partner with technology vendors that provide solutions like ride-sharing or digital financial literacy vendors (figure 4).
"There's a push from the payers, systems, and health and human services to work more with our type of organisation … It is usually a formal relationship, but months go by and we don't receive any type of referrals. But there has been a shift. There's a big difference between 2016 and today. I think a lot of community organisations would prefer if we were embedded into discharge systems more."
—Sue Daugherty, CEO, MANNA
In earlier research, health care CEOs we surveyed identified improving the health of their workforce through DOH as a top focus area. However, this survey revealed that gaps remain in making progress toward that priority. Respondents indicated that, compared with patients and members and their larger community, employees are the least likely group to be screened for DOH or be connected to services to address those needs. For instance, fewer than 50% respondents say their organisations screen employees’ food, housing, transportation, and financial needs, and even fewer act on those needs (in-house programs, community partnerships) (figure 5).
Multiple studies have tied employee health and well-being with organisational productivity, engagement, and profitability.10 Low attention to the employees' DOH prove to be a blind spot for organisational growth.
"There are a good number of employees who are on Medicaid that don't have access to good benefits … How many of these health leaders are paying a living wage? How many of their employees get access to full benefits? That's going to tell you more about need in the employee population."
—Therese Wetterman, project lead, Shaping the Future of Health and Healthcare, World Economic Forum
North Carolina-based Atrium Health is one of the largest employers in the region, with more than 70,000 “teammates” (as Atrium prefers to ascribe its employees). Recognising teammates as its “most valuable asset,” the organisation takes a comprehensive view of its teammates’ well-being. Through several programs, it not only promotes and incentivises three aspects of well-being—physical, financial, and personal—but also supports teammates who face hardships on these aspects. For instance, under the “HOPE” (housing opportunity promoting equity) initiative, it provides affordable housing to teammates who face higher need. In addition, through the “Help NOW” initiative, the organisation has partnered with several local community organisations to give teammates direct access to support for food, housing, economic assistance, and internet access.11
Health care organisations appear to be shifting away from launching DOH initiatives just because it “feels good” or “we do it because we know it is good for patients.” Instead, more leaders are seeing a business case for this investment. Indeed, the survey revealed significant increases in two areas among health systems,12 compared to 2017:
• A 12 percentage-point increase (from 13% to 25%) in the number of health system respondents that said a top goal around their DOH initiatives was to meet new market expectations or adjust to changes in the market
• A 10 percentage-point increase (from 16% to 26%) in the number of health system respondents who said improving financial performance was a top goal
This likely is explained at least in part by an increase in focus on value-based care since the last survey. In 2017, 20% of health system leaders said that value-based models or initiatives that emphasised the integration of DOH into health care would lead them to increase their organisation's investments in this area. This increased to 58% of health system leaders this year.
The Centers for Medicare and Medicaid Services (CMS) has launched several initiatives focused on shifting care into nontraditional settings. For example, it launched the AHC model out of the Center for Medicare and Medicaid Innovation (the Innovation Center). AHC programs aim to promote collaboration between clinical health care services organisations and CBOs. As of 2021, there are 28 active organisations participating in the program. Initial evaluations show that individuals who qualified for services through these programs are disproportionately likely to be low income, racial and ethnic minorities, and, among Medicare beneficiaries, disabled, and that the most common health-related social need reported was food insecurity.13 As CMS tests more of these models and increasingly shifts payment away from fee-for-service and toward paying for outcomes, more health care organisations may see a business case for investing in DOH initiatives. For now, these programs are small-scale.
Another area where CMS is pushing health care organisations to think beyond the four walls of the hospital is in Medicare Advantage (MA). As we described in Leveraging digital solutions to engage, attract, and retain Medicare Advantage members, regulatory changes, combined with market pressure from COVID-19, have led many MA plans to stand up services and benefits around the DOH. Almost all MA health plans offer supplemental coverage—benefits above traditional services offered to fee-for-service beneficiaries. In 2019 and 2020, CMS expanded the definition of these benefits to include nonhealth benefits that may impact health, such as in-home support services, meal delivery, and nutritional food.14 While only 1% of MA health plans included in-home support services for the 2019 benefit year, more than 845 MA plans offered special supplemental benefits for the chronically ill (SSBCI), including pest control, transportation, meals, and even pet support in 2021 (the number was 245 in 2020).15 Indeed, our 2019 study of 14 managed care organisations (MCOs) and MA plans found that most of the executives interviewed plan to continue their DOH investments because they align with their mission to improve the health of the communities they serve, and because they have faith that the savings derived from better health outcomes and lower health care utilisation will eventually exceed the cost of those interventions.16
Our nation has long faced a health equity crisis rooted in structural inequities. Racism and bias, disparities in the DOH, and structural flaws in the health system have led to quantifiable differences in health-related outcomes, disproportionately affecting racially and ethnically diverse communities.
“Disparities in outcomes, should not, and do not have to, be driven by racism and bias.”
—Kulleni Gebreyes, principal and executive director, Deloitte Heath Equity Institute, Deloitte Consulting LLP
Tackling health equity takes a multipronged approach. Organisations should acknowledge all of the ways in which they can do this:
• Dismantling the overt and covert racism and bias built into the foundation of the health care system over centuries
• Expanding access to coverage and care for communities and populations that have historically lacked it
• Looking outside of the traditional health care system to address the social, economic, and environmental factors that lead to healthy or unhealthy outcomes
Previous research we published aims to tackle the first two areas.17 In this study, we focus on implications for the last area in more detail, which broadly align with four domains of health equity (figure 6).
Create accountability: Organisations should put DOH at the top of leadership priorities
Only one-third (31%) of respondents say they have a dedicated leader or team committed to establishing and developing processes to systematically address the DOH as part of clinical care. Moreover, fewer than one-third (28%) say they have defined teams with accountability for connecting their entire patient population (versus just a targeted population) to community-based resources. Effectively linking DOH initiatives to health equity strategy, as well as the strategy for the larger organisation, will likely require assigning accountability and teams with oversight into and responsibility for creating efficiencies across the organisation. Creating clearly defined strategies dedicated to addressing health equity and the DOH should be clear priorities for these roles. Only one in four organisations we surveyed have defined health equity or DOH strategies.
Measure and evaluate: Programs and investments need clear goals—and goals should look beyond traditional financial and health outcomes
Fewer than one in five (19%) respondents say they are measuring outcomes or results from DOH activities for their entire population. Investing in data, technology, and capabilities can be a way to reveal new insights and activate solutions based on findings. As services and programs are implemented, organisations should ensure that metrics and goals are focused not only on financial improvements, but on health outcomes and individual patient or member priorities. For example, focusing on metrics such as increasing the number of children in a given community who show up and are ready to learn on day one of kindergarten could help shift the focus away from typical clinical measures and toward measures that align to the larger DOH.
Expand offerings: Embed DOH approaches into clinical care
Health care organisations can look at all the ways they can address DOH through the products and services they deliver. Leaders could consider offering “farmacies” or care management approaches that account for broad needs. Education and training for clinicians should extend beyond traditional medicine and into areas like social work and public health. Beyond that, organisations should consider taking steps to address environmental factors that are within their control, such as working with local, state, and/or federal governmental agencies to support infrastructure enhancements and performing climate assessments for their communities.
Look inward: Ensure your own employees’ needs are being addressed
According to estimates from 2017, nearly one in five employed women (18%) and nearly one in four (23%) employed Black women work in the health care field. A significant portion of those workers, however, make less than US$15 an hour—34% of all female workers and nearly half of Black and Latina female health care workers. Moreover, a significant portion of those populations lack access to health insurance and or are on Medicaid (7.1% and 10%, respectively).18 As large employers, health care leaders should ask themselves questions such as: Is the pay for my employees equitable and is it sufficient to support their needs for food, shelter, transportation, and even health care?
Extend a hand: Diversify and expand community-based partnerships
Health care organisations should continue to create new relationships, including with community-based partners. Leaders can look beyond organisations that touch directly on health outcomes to ones that are investing in infrastructure critical for equitable health, (e.g., developers, community investment funds).
Reach outward: Create relationships with ecosystem partners that help further DOH goals
Extending the reach of DOH initiatives into the larger community will likely require leveraging relationships beyond existing partners. For example, this may mean building and sharing free operational tools or technology resources to help organisations across industries take more effective action to address the DOH. Beyond that, it may require leveraging new datasets, like employment data or local data on homelessness rates, which will likely come from new partners as well. Less than half (49%) of health system leaders and 59% of health plan leaders say they’re using health data from sources other than claims (e.g., census, local public health data) to understand their community’s needs. Moreover, only 38% of health system leaders (59% of health plan leaders) are using nonhealth data like access to transportation or data on homelessness to understand their community’s needs.
Innovation starts with insight and seeing challenges in a new way. Amid unprecedented uncertainty and change across the industry, stakeholders are looking for new ways to transform the journey of care. Deloitte’s US Life Sciences & Health Care practice helps clients transform uncertainty into possibility and rapid change into lasting progress. Comprehensive audit, advisory, consulting, and tax capabilities can deliver value at every step, from insight to strategy to action.