Editor’s note: This commentary is by Mark Crow, of Shelburne, who is a director of the Vermont Business Roundtable and the president of Tenth Crow Creative, a strategic creative agency that works with companies focusing on improving the social determinants of health within their communities.

We are all struggling through this pandemic but, unfortunately, some are struggling more than others. Recent studies show that there has been a significant disproportionate impact on Hispanic and Black Americans. The explanations for the difference vary and include: 

1. Many of our essential service workers are from these populations and, thus, have higher risks of exposure; 

2. These populations often live in generational groups and in apartment buildings and other types of multi-family housing where practicing social distancing is challenging; and 

3. These populations have higher incidence of underlying health conditions (e.g. diabetes) that make them more susceptible to contracting Covid-19.

But are these really reasons? In my mind, they are actually symptoms of a larger problem — the health inequities that exist as a result of differences in social determinants of health (SDOH) among communities. You don’t have to look too far upstream to see that, ultimately, the reasons stated are linked to access to better education, more affordable housing, preventive health care, and other SDOH affecting these populations. 

What are social determinants of health and why should we care? 

SDOH are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks — things like housing instability, food insecurity, utility needs, interpersonal violence, transportation, mental and physical health access, discrimination, and education.

Studies show that 80% of a person’s health is impacted by what goes on outside a provider’s office. Additionally, approximately 75% of aggregate health care cost in this country can be tracked to chronic diseases (e.g. heart disease, cancer and diabetes). Many of these conditions occur at higher rates in people of color. Further, these conditions don’t occur in isolation but, rather, are closely tied to the SDOH of communities. So, addressing SDOH is an important factor in improving population health overall and addressing health inequities in particular. 

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How do we address this? 

There are, of course, many organizations out there that have been working and will continue tirelessly to work to address a variety of SDOH. But, to effectively address health inequities among communities, we need systemic change. We need to implement community-wide infrastructures of coordinated care to identify and understand the root causes underlying health inequities in communities, and then develop the combination of health care, mental health, housing, education, transportation and other social interventions to address them. 

One possibility is through value-based care. Value-based care, in its narrowest sense, is designed to lower health care costs through transforming the health care compensation system. For years, compensation to providers has been based on the fee-for-service model, where providers are paid for every procedure they perform. So, revenue is driven based on how many procedures can be performed. Basically, the provider is paid for treating the sick and injured, which, of course, is not a bad thing. But what if the system incentivizes keeping people well? That’s the ultimate goal of value-based care. In essence, value-based care models assess the health and health needs of specific populations and then assign a dollar amount to caring for those patients. The providers responsible for caring for that population are then paid that fixed amount. If the providers are able to care for that population for less than that amount, then they can invest the difference in their organizations. If the cost to treat that population exceeds the amount paid, then the loss is borne by the providers. So, the incentive is to keep people well and out of the hospital, not just treat them when they are sick or injured. 

How do we keep people well? 

Given that 80% of a person’s health is impacted by SDOH, keeping people well must include addressing SDOH. Through value-based care models, health care is no longer just about hip replacements and other procedures. Rather, health care also requires addressing SDOH at community-wide levels through creating programs to educate people about positive lifestyle choices, investing in affordable housing, providing transportation services, creating food banks, and more. Value-based care models also address SDOH from the ground up through utilizing a system of coordinated care among providers, social support organizations, and community groups to assess, identify and provide patient-centered services. For example, a primary care provider who screens patients for SDOH may learn that a patient is also in need of mental health services, transportation, housing or other social supports. The provider then can work with other participants in the coordinated care network to provide the necessary services or social supports. Simply, it’s approaching patient care holistically – from a physical and environmental standpoint to keep them well. And, in so doing, value-based care health care becomes a powerful means for addressing SDOH. 

Vermont, among other states, has bravely started down this path with its all-payer model. This model includes an accountable care organization, OneCare Vermont, which is comprised of providers, payers, social support organizations and community collaborators. OneCare offers programs that pay for positive outcomes and healthcare activities. Providers are given access to data, resources, and tools to improve patient health. Resources and expertise are pooled to help Vermonters become healthier and stay healthier, with a focus on improving access to primary care and managing chronic illnesses. The model has been in existence for just a few years and, while we still have a way to go, there has been real progress. Systemic change like this takes time though. But, if we truly want to improve population health and address health inequities, all while reducing health care costs, the value-based care care approach seems most promising.