"What is the biggest challenge to innovation when it comes to the social determinants of health?"

Thus began our panel discussion at the inaugural Reaching Outcomes conference, convened by ConsejoSano and moderated by the upstream movement's own godfather, Dr. Rishi Manchanda from HealthBegins.

I had the honor of fielding Rishi's questions and sharing my perspectives alongside an all-star panel of SDoH entrepreneurs, health system leaders, policy experts, physicians, and innovation veterans.

So what is the biggest challenge? Here was my answer:

"The biggest challenge to innovation when it comes to 'upstream going mainstream' is establishing consensus on where we are, and where we need to go."

With so many dire social issues plaguing America's most vulnerable communities, this may strike some of you as vague or wishy washy. But, as one of my fellow panelists Dr. Lisa Fitzpatrick is fond of saying: "Where you stand depends on where you sit." So let me explain where I'm coming from.

Our company's entire mission revolves around promoting social innovations in health. So, a big part of my day-to-day work involves reviewing literature, talking to really smart leaders at health plans, hospitals, venture funds, and startups, keeping track of the headlines, and trying to connect the dots in exploration of two big topics:

1. Where We Are Today (e.g. social needs screening, technology adoption, integration of SDoH initiatives into enterprise population health strategy, and so on)
2. Where We Ought to be Going (e.g. payment to support new care models, 'top down' versus 'bottom up' analysis of population needs, partnership strategies)

To me, the "delta," or change between those two goalposts represents the innovation opportunity that lies in front of us. And right now, any five year outlook remains murky at best. I shared a recent anecdote involving a conversation I had just last week (early October 2019) with an executive at a prominent national health insurer.

One of their state Medicaid plans was entering the homestretch of a yearlong project to screen over 70,000 patients for social needs, layering those data on top of claims and clinical data. Early analysis, he told me, confirmed his hypothesis: "Humans are humans." When I pressed him on what he meant, he elaborated that patients who reported lack of transportation tended to miss more appointments. Patients reporting greater instability with their income or employment tended to fare worse on measures of chronic disease management.

We briefly discussed how none of these 'insights' was really that groundbreaking given the last decade's advances in analytics and stratification, or the last few years' emerging consensus that unmet social needs drive clinical costs and outcomes. We stopped short of saying the mass social screenings represented a wasted effort, as that will ultimately depend on what happens afterwards. But it was clear that we remain upfield from definitive consensus on what's effective, value-adding, or #innovative.

Early Days for Upstream Innovation

My fellow panelists echoed the "early days" sentiment with examples that stressed the infrastructure-building phase even at the large, progressive integrated systems, the persistence of poor incentive alignment at hospitals, and a steady (and possibly growing) cultural disconnect between the communities where patients live and the places they are asked to go to receive care. Over the course of the day, similar themes emerged from numerous panel discussions:

• Basic communication and coordination between healthcare systems and their members remains suboptimal when it comes to culture, language, age, lifestyle, as well as socioeconomic considerations. The promise of "digital health" may still be lingering in the C-Suite, but as patients become accustomed to smartphone-driven everything, basic tasks like getting a ride to the doctor's office will drive engagement and access, as Kaizen's Mindi Knebel explained. On the other end of the spectrum, Tim Petrikin from Ampersand Health spoke to the value of brick-and-mortar community-building, pointing to their work in Philadelphia as an example of investing in trust, relationships, and practical help for communities with unmet social needs.
• Maternal and infant health remains woefully behind for Medicaid moms, due in large part to a lack of alignment between insurers, delivery systems, patients/mothers, and ancillary caregivers (lactation consultants, doulas, or even family members). Leah Sparks from Wildflower Health and Melissa Hanna from Mahmee were on hand to share how their platforms are filling in these gaps.
• A range of investors (Tufts Health Ventures, Acumen Fund, 7Wire, Kaiser Ventures, others) as well as coalition leaders (Molly Coye from AVIA and Adimika Arthur from HT4M) and other nationally-focused industry experts weighed in with various perspectives on progress and potential. The gist: While for the most part social interventions remain disconnected from broader enterprise strategy, signals from Silicon Valley to Wall Street indicate that SDoH will likely prove to be more than just a passing fad.

As evidence mounts that "we're not there yet" - it's equally important to continually define where the "there" is. This speaks to an even deeper challenge: Using the right language. Prior to our session, The American Medical Association's recently appointed Chief Health Equity Officer, Dr. Aletha Maybank, MD MPH stressed the importance of distinguishing between "social determinants of health" (as defined by the WHO) and "social determinants of care" - things that may range from coverage policy to urban planning to interpersonal bias (intentional or otherwise).

A similar dialogue was recently shared with us via twitter (h/t Andre Blackman of Onboard Health)

If you're anything like me, this 'language stuff' might be leaving you feeling somewhat conflicted: While we may carry the best of intentions - To try and nudge US healthcare towards more equitable, efficient, effective care - how can we make sure we're going about our work in the right way? Is it better to keep your mouth shut than to accidentally say the wrong thing, use the wrong language, mischaracterize an "SDoH" idea or initiative?

While a deeper analysis of our industry discourse is beyond the scope of this particular LinkedIn screed, my short answer is "No." If you're interested in the burgeoning social movement in healthcare, the plain truth is that we'll need all the help we can get. Getting it wrong is the first step towards getting it right. Getting excited is a good place to start; getting informed is a good place to go next.

The caveat: Intentions matter. This was my biggest takeaway from Consejosano's event: Finding the right tribe of passionate, intelligent people can provide a "safe space" to discuss the nuances of progress, ask tricky questions, and share perspectives, data points, and stories that will help us chart the course forward, together.

A very special thanks to Abner Mason and the Consejosano team for convening the event and inviting us to attend as speaker and sponsor.

What do you think? I'd love to hear your thoughts or questions: [email protected]

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