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December 8, 2020
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Allen Weiss
Outcomes System Dynamics

The Proof Case for Addressing the Negative Social Determinants of Health

Up to half of all premature deaths are preventable by modifying behaviors and exposures that occur in communities.[1] “The Case For More Active Policy Attention To Health Promotion” sharpens readers’ attention to policy changes directed at disease prevention and health promotion.[2] Rather than spending over 95% of the $3.5 trillion (2017) healthcare dollars on disease, wouldn’t moving upstream to prevent illness in the first place make more sense?[3] The nation has been focused on providing health care rather than creating health.

The Center for Medicare and Medicaid Innovation, a division of CMS (Center for Medicare and Medicaid Services), recently reconfirmed the critical role of the social determinants of health (SDOH) in health outcomes. “The Accountable Health Communities (AHC) Model addresses a critical gap between clinical care and community services in the health care delivery system by testing whether systematically identifying and addressing health-related social needs (HRSN) of eligible Medicare and Medicaid beneficiaries through screening for HRSN, referral to community resources, and community navigation services will impact health care costs and reduce health care utilization,” according to CMS’s Fact Sheet.[4]

This affirmation, while important, is insufficient alone. Analogously, when caring for a patient, obtaining a correct diagnosis is inadequate; prescribing an effective therapy and sharing an accurate prognosis are equally important to obtain a good outcome. Abundant, shared, anecdotal success stories make caregivers and receivers feel better; but moving whole communities and populations remains challenging. Effective short- and long-term solutions and metrics for large populations, previously lacking, are now available and valid utilizing the Sharecare Community Well-Being Index.[5]

The Accountable Health Communities Model, initiated in 2016 as a possible solution to reduce the negative influence of adverse SDOH, currently funds twenty-nine communities across the nation centered on individuals with high socioeconomic needs.[6] The altruistic five-year program screens beneficiaries to identify unmet, health-related social needs. It subsequently refers people to community services that address housing instability, food insecurity, utility inadequacies, interpersonal violence and transportation needs. This screening makes the “diagnosis,” while the community navigation services becomes the “therapy.”

The Accountable Health Communities Model Fact Sheet recently published a compilation of the first 750,000 completed screenings using the AHC Health-Related Social Needs Screening Tool.[7, 8] One third of the voluntary participants reported at least one core, health-related social need. Food insecurity was the biggest threat at 67%, followed by housing 47%, transportation 41%, utilities 28% and safety 5%. Sixty-three percent were Medicaid beneficiaries; the other 37% were Medicare beneficiaries including some dual-eligible people (Medicare and Medicaid).

The Accountable Health Communities program offered in-person community navigation services to individuals who had two or more emergency room visits in the last year or screened positive for inadequate SDOH. After in-depth interviews, 76% of eligible individuals accepted individual plans to address negative SDOH. And again, 76% of those receiving help were Medicaid recipients
with the remainder on Medicare. The personal assigned as a navigator assists recipients for up to one year until the health-related need is resolved or deemed unresolvable.

Health systems and insurers will benefit when they address negative SDOH as payment migrates from fee-for-service to payment-for-value, which encourages health and decreases the need for expensive care. Pharmaceutical firms and device manufacturers will be see reduced demands, but they will survive. Medicare Advantage, managed Medicaid, and self-insured employers will also benefit from reduced spending on acute treatment. Most importantly, people across the socioeconomic spectrum will enjoy better health.

The big question is: How to create and sustain a healthier population? Fortunately, effective programs with demonstrated success are progressing nicely. The Blue Zones programs alone serve 57 communities, helping 4 million folks across America. These communities range in size from the healthiest state in the nation, Hawaii, which started on the Blue Zones journey in 2015, to small, challenged farm areas like Immokalee in Southwest Florida. These communities have experienced objective benefits as shown by comprehensive, longitudinal, nearly contemporaneous metrics. The Sharecare Community Well-Being Index has consolidated the social determinants of health and well-being parameters as detailed below.[5]

Models designed for the most challenged are important, but preventing folks from becoming so challenged in the first place will require a mindset change. Reducing multigenerational poverty, chronic disease and social distress requires systemic assistance. The Blue Zones Project, well past the experimental stage, has effectively implemented a comprehensive plan for policy, places, and people objectively changing individuals, communities, organizations, and entire states. By decreasing the need for costly medical care, we can fund early childhood education, vocational training, and other entities that grow vibrant and robust societies.

America is in a globally competitive world. Redirecting precious resources, decreasing waste, and improving health will recharge and redirect the nation toward better outcomes.


  1. “Up to Half of Deaths of U.S. Premature Deaths Are Preventable; Behavioral Factors Key,” by Mark Mather and Paola Scommegna, Population Reference Bureau, September 2015.
  2. “The Case for More Active Policy Attention To Health Promotion,” by J. Michael McGinnis, Pamela Williams-Russo, and James Knickman, Health Affairs, March 2002.
  3. “Health Expenditures,” National Center for Health Statistics, Centers for Disease Control and Prevention, 2018.
  4. “Accountable Health Communities Model,” Fact Sheet, Centers for Disease Control and Prevention, 2020.
  5. “Sharecare Community Well-Being Index,” in partnership with Boston University School of Public Health, August 2020.
  6. “Accountable Health Communities Model,” Centers for Medicare and Medicaid Services, May 2020.
  7. “Accountable Health Communities Model Fact Sheet,” Centers for Medicare and Medicaid Services, May 2020.
  8. “The Accountable Health Communities Health-Related Social Needs Screening Tool,” Centers for Medicare and Medicaid Services, May 2020.

4sight Health contributors recognize that we can’t fix the broken U.S. healthcare system without reducing the causal negative social determinants of health. Here are some 4sight Health articles with different perspectives on this issue.

About the Author

Allen Weiss

Dr. Allen Weiss is Chief Medical Officer for the national Blue Zones Project. Having practiced rheumatology, internal medicine, and geriatrics for 23 years and been President and CEO for 18 years of a 716-bed, two-hospital integrated system, Dr. Weiss now has a national scope focused on prevention. After graduating from Columbia University’s College of Physicians and Surgeons and subsequently completing his training at both the New York Presbyterian Hospital and Hospital for Special Surgery of Cornell University, he had a solo practice in Rheumatology, Internal Medicine, and Geriatrics for twenty-three years. He is recognized both as a Fellow of the American College of Physicians and a Fellow of the American College of Rheumatology. Dr. Weiss’s national commitments and honors include: named as one of the Top 100 outstanding physician leaders of healthcare systems by Becker’s Hospital Review multiple times; chosen as a keynote speaker at numerous meetings; served five years on the Regional Advisory Council of the American Hospital Association; elected to the American Hospital Association Board in 2017; selected as Chairman of the Upper Midwest Vizient Board; and continues as a Director of American Momentum Bank. In 2005, he was invited to testify on information technology before the U.S. House Ways and Means Health Subsection. For the state of Florida, Dr. Weiss is past Chair of the Florida Hospital Association as well as its Quality Committee. The Florida Hospital Association presented Dr. Weiss with its highest award in 2019 for advancing healthcare, and he has received numerous other awards from Florida organizations. His wife, Dr. Marla Weiss, is a writer and educator. They have two daughters who are physicians, one a biomedical illustrator/educator and the other an adolescent medicine physician/educator.

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