Speaker presentation from U.S. News Healthcare of Tomorrow leadership summit, Nov. 17-19, 2019 in Washington, DC. Find out more about this forum at www.usnewshot.com.

1. 0
Ethics of Addressing Social Determinants
of Health
Jean L. Raphael, MD, MPH
Section Head, Academic General Pediatrics
Texas Children’s Hospital

3. IF YOU DECIDE TO SCREEN FOR SOCIAL
DETERMINANTS….
• Clinical – cultural competency, quality improvement
• Research – root causes, intervention development
• Education – medical school, residency training
• Community Resources – appropriate funding
• Health Care Financing – alternative payment models
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4. PATIENT-LEVEL COSTS
• Potential of reinforcing stereotypes of racial/ethnic
minorities and vulnerable populations
• Patient discomfort with inquiries about SDH
• Patient abrasion
• Pursuit of resources that are difficult to obtain or
for which they may be ineligible
• No significant evidence screening improves patient
health
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5. PROVIDER-LEVEL COSTS
• Compromise of clinical productivity
• Consumption of personnel time
• Screening for factors for which there are no known
available resources
• Lack of resources to achieve incentives in alternative
payment models
• Change in patient expectations and potential
dissatisfaction
• Overburdening community resources
• Increase in disparities between those in and out of care
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6. COMMUNITY-LEVEL COSTS
• High volume of referrals
• Inappropriate referrals
• No formal mechanisms for feedback
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7. SYSTEM-LEVEL COSTS
• Return on Investment
• Unintended Consequences
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8. • Investment-benefit relationship mismatched in time,
especially in child health
• Investments made by payers and health systems may
lead to benefits and savings in other sectors
• Medicaid churn may undermine efforts
RETURN ON INVESTMENT

9. • Initiatives become victims of their own success and
eventually create longer-term disincentives to engage in
value-based payment programs
• Adjusting performance measurement by SDH could create
inappropriate incentives by artificially boosting
performance scores of providers treating vulnerable
individuals (i.e., acceptable to provide poor care and
forego improvement)
UNINTENDED CONSEQUENCES

10. ETHICAL IMPLICATIONS OF SDH SCREENING ARE COMPLEX

11. • Payers and health systems have the potential to address
SDH…and/or create long-term problems
• Evidence base for investment to address SDH evolving
• Partnerships between payers, health systems, and
communities are essential to resolving ethical dilemmas
CONCLUSIONS