Beyond The Office Walls: Here's How Employers Can Impact Social Determinants of Health

Healthcare policy experts generally agree, not enough attention has been paid to Social Determinants of Health (SDOH). Put simply these are the things other than seeing a doctor that have a meaningful impact on your health. Healthcare leaders often debate whether SDOH are responsible for 80% of all health outcomes, or a lower percentage, but can all together agree they play a major role. How you feel about the exact percentage may have to do with your own personal health journey, circumstances and socioeconomic status. Let's take a deeper dive into SDOH from an employer's perspective to learn how companies can build around this framework.

SDOH can be broken down into six unique categories; economic stability, education, neighborhood and physical environments, food, community and social context and healthcare system access.

We plan to address which SDOH is most important to employees, but before we do, let’s discuss definitions around healthcare outcomes. Healthcare outcomes are measured in a variety of ways, but can be placed into about six buckets. They are: mortality (deaths); morbidity (disease); life expectancy; healthcare expenditures; health status; and functional limitations.

The United States generally underperforms in all of the above measurements when compared to other wealthy developed nations. If we experimented by layering in the amount of money we spend on healthcare and the volume of pharmaceutical drugs Americans consume in oder to achieve better health outcomes, the disparities become even more noticeable.

We compiled this information primarily to help employers understand how they are in a unique position to be a proactive and influential social determinant of health for employees. Let's start by assuming certain SDOH like housing, education, food and health system access are more difficult to achieve for the unemployed and those living below the poverty line. Up until now, most of the attention around social determinants has focused on populations who don't have higher quality housing, living, education, etc. Government should play a bigger role in determining SDOH for these populations through tax-payer funded programs. Our aim, however, is to focus on health equity at the employer level and determine what employers can do to build a healthier and more productive workforce for the 150+ million employees in the US.

Let’s start by looking at each SDOH category and address how an employer influences a person's choices, access, ability, and situation both at work and outside the walls of the office:

Economic Stability:?employers offer employment opportunities to people who qualify to become an employee, but does that mean their job is done? A persons income is typically determined by what their employer is willing to pay them. Pay plays a major role in determining health outcomes (more on that later). Expenses play another role which dovetail with income, but for many American’s they struggle with expenses, namely medical bills. Medical debt is currently the leading cause of bankruptcy in the US, with 75% or greater filing reporting they have employer sponsored health insurance. Therefore, it’s very important that employers understand how their health plan affordability impacts their middle to lower wage earners, and to determine if any of those individuals are experiencing medical debt. The employee healthcare affordability struggle is a major equity issue that should not go unaddressed. Additionally, the benefits offered should be easy to access, understand and use and avoid stigmatizing frequent use and gaps. Lastly, if an employer wants to be a positive influence on SDOH, they should be prepared to offer employees support as they navigate their benefits to ensure they get the care they need at an affordable price. Fortunately Aon has developed a tool to help employers understand these issues better and address them with actionable insights. With a few census data points, their health, equity and affordability tool helps you connect and understand organizational relationships between healthcare costs and affordability, demographics, physical and mental health conditions, health habits, plan design, location, healthcare labor supply and work productivity. The tool leverages machine learning of healthcare expenditure and affordability predictors. The tool also provides insights related to affordability, social determinants of health through an area deprivation index, and care access, including primary care and mental health shortages. Additionally, it benchmarks these areas related to Aon’s broad client base and similar clients. For more: Health Equity and Affordability Tool | Aon

Neighborhood and Physical Environment:?prior to the pandemic most employees chose a neighborhood and housing type based on proximity to their employer and affordability. In a post pandemic world, many employees have greater flexibility, potentially meaning they can find more affordable housing, with greater access to safety, parks and playgrounds. No matter which type of housing an employee chooses, it’s safe to say their employer shaped their decisions and will continue influencing these decisions. Several reasons neighborhood and housing is considered an important SDOH is because lack of quality, affordable housing leads to stress and anxiety, and living in unsafe cities or towns can expose people to crime, violence and a long list of unhealthy threats. Attributes like walkability and parks are more likely to encourage an active lifestyle and promote health. Employers must now think about their work-from-home (WFH) policies, the location and design of their physical office environments and the programs they offer to support transportation, flexibility and even child care. Employees are seeking a sustainable working life, which means they want hybrid, flexible arrangements that provide the level of work-life-social balance needed to maintain optimal physical and mental health. This is especially true of healthcare workers, who compared to other industries and after fighting through years of a pandemic are burned out, depressed and feel a sense of depersonalization towards the profession.

Education:?depending on the type of industry, job and skills, education may or may not be required. For upper-end industries like law, accounting, finance, healthcare and insurance, it may be assumed that literacy, early childhood, and higher education are all pre-requisites. However, that may not be true in some trades, manufacturing and labor jobs, where a high level of illiteracy, language difficulties and lack of training exists. This is likely the least relevant SDOH for employers considering a large percentage of education decisions are made and influenced before an employee and employer ever meet. Despite this, there is an opportunity for employers to identify opportunities to advance the education of employees, especially in ways that help to lead to better health outcomes. Even if employers only focus on increasing health literacy for all employees but recognize that employees who struggle with basic literacy will experience increased difficulties understanding the complex language of medicine and benefits. A 2022 Gallup poll revealed that employees who 'strongly agree' their employer cares about their overall wellbeing, which includes education and literacy, are 3x more likely to be engaged at work and 69% less likely to actively search for a new job.

Food:?the term “food deserts” has gained attention over the past several years. This term refers to zip codes where access to healthy, whole foods is extremely limited. What food deserts typically have in abundance is fast food, processed food and mini-marts loaded with boxed, bagged and unhealthy options. Employers may ask: what role do we play in an employee’s access to food? The answer isn’t so simple. One way employers can impact food choices for employees is through wellness programs where they receive education on diet and nutrition. Additionally, a large number of employers have on-site food service; employers can carefully review the menu options, ensuring they are delivering access to healthy options. Lastly, employers can provide food vouchers for mail order services that deliver healthy foods and supplements to employees doorsteps. Some companies are building such benefits into their health and wellness spending programs, allowing employees to select from a menu of healthy options that will help them achieve healthier outcomes. Employers are starting to recognize that treating chronic disease consumes the majority of their health spending, and according to the National Institutes of Health, over 80% of chronic diseases are driven by diet, exercise and stress.

Community and Social Context:?this category may seem vague, but relabeling it makes it easier to understand. Things like social belonging, community, discrimination and stress all fall under this category. Certainly, employers are all now aware of the importance of diversity, equity and inclusion (DEI), but how many employers are tying these efforts back to SDOH? In our opinion one very important reason to evaluate DEI is to prevent discrimination, eliminate stress, enable social integration and drive engagement and inclusion. We could take a much deeper dive into these subjects, but the point we want to make is that employers have a very meaningful role in community and social aspects of employees lives. The more they purposefully evaluate and improve support systems that in this category, the greater results they will achieve in health outcomes. As employers design benefits programs, they must evaluate whether there are discrepancies that may have overlooked minorities, or the LGBT+ community. A quick example is related to fertility treatments, where such plans are typically designed around heterosexual couples. Are those same benefits clearly spelled out for same-sex couples? HR and executive leaders need to take themselves out of the status-quo comfort zone and imagine scenarios where certain individuals or groups could feel alienated by such policies. A 2022 MetLife employee benefit trend study ranked the top three DE&I actions employees expect. Ranked number two was "offer a wider range of benefits that address DE&I."

Health Care Systems:?healthcare coverage has to be the most important aspect of this category. Without coverage an employee has some alternative options, like paying cash for care, but coverage is generally accepted as the key to unlocking and accessing care. We addressed coverage affordability above, however it remains important to understand how plan designs, networks, deductibles, cost sharing and other caveats impact the outcomes for employees. Beyond coverage, it is important to address doctor and hospital availability and quality of care. There is a national shortage of primary care doctors to meet current demand. Employees may experience friction in the system that prevents them from getting timely care and reaching optimal outcomes. Employees should be prepared to explore emerging concepts like direct primary care, and on-site clinics that deliver better primary care options to employees. Again, this is an area where Aon's proprietary Health Equity and Affordability Tool can map where employees experience the biggest burden to afford and access healthcare.

In Closing:

Now that we explored how our health is influenced by more than just our genetics and individual behaviors, we can begin to understand that employers have the ability to influence almost every aspect of SDOH. We can emphatically say employers across America are a major factor, if not the most influential factor in SDOH for 158 million employed people. Their impact and influence extends far beyond the office walls, into employee’s family lives, and they choices they make in life. Employers should strongly consider SDOH when setting their healthcare strategy, as following this framework helps maintain a focus on health outcomes, which in the end drive cost increases or decreases, along with productivity, profitability and a host of other benefits. If you are an employer or insurer and want to learn more about this framework, let’s start a conversation.

By: Nick Gaudiosi - Senior Healthcare Strategy Executive