Chris Pope, of the Manhattan Institute, recently objected to policies allowing sociologically-oriented community-based organizations to tap into multiple Medicaid funds for the purposes of addressing social determinants of health / health related social needs (SDOH/HRSN).[Pope]
Contending that current evidence in SDOH/HRSN does not show causal relationships with health outcomes, Mr. Pope concludes that in the United States health policy should:
- Limit Medicaid funds to the program’s “core benefits” (presumably meaning per statute law),
- Limit provider compensation to incentive payments in Medicare Advantage plans, and
- Not use tax or payment incentives to hospitals, payers or providers in return for addressing SDOH/HRSN.
Though Mr. Pope criticizes “progressive scholars”, he thoroughly examines the overwhelmingly positive research evidence. Nevertheless, he concludes that doctors, hospitals and health systems are hard-pressed merely with delivering cost-effective medical care and are poorly positioned if not ill-prepared to address non-medical SDOH/HRSN.
I concur with this latter point, but for a different reason. Physicians in today’s American business model have become too valuable to spend much time on counseling.[Moore] A 2019 report from Merritt-Hawkins found that health system CFOs expect primary care physician employees to generate direct and downstream revenues in excess of $1000/hour (>$2M / year).[Merritt-Hawkins] For this reason, I favor physicians practicing medicine and allied health professionals addressing non-medical matters.
Annual wellness visits and transitional care visits are opportune moments to screen for SDOH/HRSN. Mr. Pope writes that “…use of Annual Wellness Visits for SDOH assessments…turns physicians into data-gatherers for a poorly designed social survey in which information is skewed by entanglement with provider payment incentives.” In an Annual Wellness Visit, the provider is required by statute to provide the patient with “personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote selfmanagement [sic] and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition”. [US GPO] It is improper, ill-advised and inefficient to provide such recommendations when there are SDOH/HRSN barriers to a healthier life.
Mr. Pope’s piece continues, filled with bias, false beliefs and unsubstantiated judgments. Among them, “Ultimately, social policies should not be pursued for the sake of their incidental impact on health.” On what basis must social policies be divorced from their impact on health?
Mr. Pope misapprehends the patient-physician relationship, stating “The medical profession gains its authority from the ability of patients to trust that physicians’ advice serves only the objective good of their health, with advice rooted in medical science”. Physicians – like clergy and lawyers – gain moral authority not merely from special knowledge and expertise, but also by a relationship ethos that holds them to refrain from passing judgment while honoring each individual’s privacy and to act solely in the individual’s interests.[Drahman]
Mr. Pope states “Although foreclosures and evictions are associated with adverse health outcomes in the short run, abolishing the ability of private owners to profit from investment in housing would inflict much greater harm in the long run.” The notion that it would be worse to cause private real estate investors to miss out on long-term gains, rather than using SDOH/HRSN funds to avert homelessness and improve health outcomes, is speculation not based in evidence.
Mr. Pope discounts the role of community in health. “Viewing health as socially determined downplays personal agency, and although positive externalities exist, health is a relatively internalized good. Insofar as lack of money is an obstacle to health, its greatest adverse impact is likely to be as an impediment to access purely medical services.” This statement reflects an inability to see the multi-generational effects between the wealthy and the destitute, of successive generations growing up with ample resources for one and of few resources for the other.
Critical of hospitals, he states that “the degree to which hospitals provide free or discounted medical care to the uninsured can be quantified, the open-endedness of SDOH concepts allows hospitals to claim tax credit for almost any spending classified as ‘community building activities.’” When did you last see a hospital resent making a health promotion investment?
“Making hospital systems responsible for the broader health and social welfare of local neighborhoods entrenches their market power over those communities. It is difficult to reconcile such power with vigorous competition over the provision of narrowly defined medical services.” Nothing prohibits hospital systems from competing in social domains. Indeed, this an advisable consumer-centric strategy.[Fusaro; Khan]
Mr. Pope’s biggest objection to SDOH/HRSN reveals his ignorance in holding that “the bulk of SDOH scholarship merely identifies correlation, without demonstrating causal effects by rigorously eliminating confounding factors”. Applying an incorrect standard of evidence, he is apparently unaware it has long been known that epidemiological research and behavioral interventions cannot be performed in randomized, controlled, double-blind protocols. While debated in social sciences, in epidemiology the Bradford Hill criteria are accepted in establishing causality.[Fedak] One would need to make a counterfactual argument as to why they should not be accepted.[Höfler]
Finally, Mr. Pope makes some egregiously outrageous statements.
“Much SDOH scholarship appears to be a methodologically sloppy attempt to claim the objective superiority of lifestyle preferences characteristic of urban academic liberals. Farmers’ markets, mass transit, and bike paths each have their charms, but there is little scientific basis for the SDOH literature’s focus on them at the exclusion of traditionally red-state pursuits such as hunting, fishing, or golf.”
The notion that “blue-state citizens” favor farm-to-market programs, mass transit and bikeways while “red-state citizens” fancy fishing, hunting and golf is preposterous if not bigoted. Are not America’s worst traffic jams in “deep blue” cities? I myself have friends and family, some of them liberal some conservative, residing in red-states and in blue-states, some fish and hunt while some don’t, some are farmers while some are metropolitan, some ride bikes, many play golf, all with no discernible link between political preference and their recreational pursuits. Indeed, one long-honored tradition of sport and outdoor recreation is that people can enjoy a common pursuit as a diplomatic bridge.[Krislov]
And, “Policies to promote marriage, control recreational drugs, and prosecute low-level, ‘broken window’ crimes might each substantially improve the health of communities, but references to them are nowhere to be found in the SDOH literature.” As a clinical investigator, I find it quite presumptive to critique researchers for topics they haven’t been funded to examine!
In sum, Mr. Pope and I disagree on whether or not primary care is the most logical place to identify SDOH/HRSN. My apologies for the length of this blog, but Mr. Pope’s views overflow with bias and misconception. Where he and I agree, however, is that it's a mistake to "medicalize" all matters affecting health. Next time, I’ll address my view on how to address SDOH/HRSN.
Citations
Pope, C. Is everything health care? The overblown social determinants of health. Manhattan Institute, New York, NY, July 2024. https://manhattan.institute/article/the-overblown-social-determinants-of-health
Moore, G.E., et al. Implementation of exercise management services among sports medicine physicians in the United States. Clin J Sports Med, February 8, 2024. doi:10.1097/JSM.0000000000001209
Merritt-Hawkins. 2019 Physician Inpatient/Outpatient Revenue Survey. Merritt-Hawkins, Dallas, Texas; 2019. https://www.amnhealthcare.com/blog/physician/perm/new-survey-shows-physicians-are-key-revenue-generators-for-hospitals/
Drahmann, M., Cramer, C. (2021). The Professional Ethos of Teachers, Doctors, Lawyers, and Clergy: A Comparison of Ethos in Different Professions. In: Oser, F., Heinrichs, K., Bauer, J., Lovat, T. (eds) The International Handbook of Teacher Ethos. Springer, Cham. https://doi.org/10.1007/978-3-030-73644-6_24
US Government Publishing Office. Public Law 111-148: The Patient Protection and Affordable Care Act, Section 4103. March 23, 2010. https://www.healthcare.gov/where-can-i-read-the-affordable-care-act/
Fusaro, R., Rahilly, L. What’s new in consumer wellness trends? McKinsey & Co., 2024.
Khan, R. et al. Rising expectations among health care consumers: How to lead the consumer-centric transformation. Optum, Inc., July 2024.
Fedak, K.M., et al. Applying the Bradford Hill criteria in the 21st Century: how data integration has changed causal inference in molecular epidemiology. Emerg Themes Epidemiol 2015, 12:14 doi:10.1186/s12982-015-0037-4
Höfler, M. The Bradford Hill considerations on causality: a counterfactual perspective. Emerg Themes Epidemiol 2005, 2:11 doi:10.1186/1742-7622-2-11
Krislov, M. Harnessing the power of sports for global diplomacy. Forbes, July 9, 2024. https://www.forbes.com/sites/marvinkrislov/2024/07/09/harnessing-the-power-of-sports-for-global-diplomacy/
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