If you work in the healthcare world, “social determinants of health” (SDoH) is something you’re starting to hear everywhere. While it has long been a focus in public health, the healthcare industry and employers have been slower to make it one of their foci. Since half of Americans receive healthcare through their employer, this is a problem.
It has been easier for plan sponsors to focus on employees as individual actors, rather than thinking broadly about how employees are functioning overall with regard to the SDoH in their communities: economic stability, education, health and healthcare, neighborhood and built environment, and social and larger community context. In fact, most wellness programming and associated tools (i.e. fitness watches, reimbursements for gym use, and financial wellness seminars) are completely focused on changing an individual’s behavior notwithstanding the external forces beyond the company walls. But it hasn’t been working. The sick are sicker and healthcare prices continue to rise in part because we are not individual actors and health and wellbeing are much bigger than what happens within the company walls. If employers want to continue being the conduit to healthcare for most Americans, they need to understand how programming works both on the individual and how it fits into the local fabric of the community.
Wellness Programming Today
Large employers are expected to spend an average of $3.6 million on wellness programming for employees in 2019. This includes everything from gym membership subsidies, to in-house seminars, to Fitbits. Nevertheless, the CDC says that 6 in 10 adults have a chronic disease and 4 in 10 have two or more chronic diseases. This is not limited to the unemployed or underemployed. Our research of consumers with health insurance shows that at least half are overweight or obese, a condition linked with many chronic diseases.
Clearly the investment in wellness isn’t solving the problem on its own. In our conversations with healthcare consumers, we know that wellness programming doesn’t work for everyone. This is because most wellness programming is implemented on a company-wide scale, without taking into account the nuances of the members and communities that it serves. While some of the challenges cross cultures and people, that doesn’t mean that there is a blanket solution. Gym memberships and financial wellness classes alone will not change behavior if the employees are worried about where their next meal will come from, if they are in physical danger, or if they simply don’t understand the point of changing behavior. Wellness programming is currently focused on the individual or the company, not the broader context in which those individuals live – their community. There is opportunity for employers and their health partners to look beyond their walls, into the communities to which their employees belong.
Employers first need to cultivate a trust and consciousness with employees and the communities so that they understand their unique challenges and resources. Only then can wellness programming leverage this knowledge to actually change behavior. To do so, companies can partner with community leaders who can educate them about the particular challenges of the community and who can educate and encourage community members to make changes for the better. Thinking locally requires a decentralization of health and wellness thinking, but it will be far more powerful and effective than a one-size-fits-all healthcare approach.
Root Causes of Poor Health/Health Decision Making
What are the root causes of poor health and health decision-making and what can be done?
- Financially stressed consumers lack the bandwidth needed to plan for and to live a healthy life because they are too consumed with the day-to-day struggles of making ends meet. Our annual survey of employed healthcare consumers found that 1 in 3 financially stressed consumers put off medical treatments because of cost. Combined with consumer interviews that we’ve conducted on healthcare related issues, we know that when household finances are tight, consumers are not making good health decisions. Their priorities are first to ensure the basics (shelter, food, safety) and then worry about health. They prioritize convenient food over healthy food and ignore warning signs for mental illness. By providing employees a living wage and a good work/life balance, employers will see them dedicate more time and energy towards being healthy. They will take advantage of wellness programming more and become advocates of a healthy lifestyle that will have ripple effects across the community.
- Beyond a living wage and a work/life balance, many people simply lack access to food and safe areas to exercise. Food deserts restrict the amount of healthy foods available for people, which can especially affect those with young dependents or those with chronic diseases that require a healthy diet to manage adverse symptoms. Diabetics, for instance, who do not eat regularly can suffer from a drop in blood sugar which can cause everything from fogginess to more complicated outcomes. For employers, this means disengaged employees who are not performing to their potential or worse, employees with very expensive medical trips to the ER. Employers are uniquely positioned to make the lives of their most challenged employees easier, not by offering gym classes or yoga afternoons, but by subsidizing healthy lunches or by offering a food pantry and meals on wheels for those in need.
- Access to a trusted care provider – one that is both culturally and linguistically relevant to the patient – can mean the difference between whether people take part in preventative care, as well as in care plan and medication adherence. Access in this context goes beyond physical distance. The effectiveness of a doctor is in his or her ability to gain the trust of their patients and their community. Many organizations are now partnering with Uber, Lyft, or other ridesharing companies to provide increased ability to simply get to a doctor, but there is often a simple lack of available and trained medical professionals in the community who can gain their trust because they look like them and talk like them. Telemedicine is one solution, but only for those with access to the internet and who are willing to see a doctor this way. Another solution could come in the form of empowering trained nurses to help address community needs, but the feasibility of approach requires further research. Employers who find ways to partner with local organizations, hospitals, and healthcare professionals will see greater engagement from their employees in their own health.
What Can be Done?
Engagement of healthcare consumers requires us to scrap that one-size-fits-all approach of health initiatives today. It requires trust-building and engagement at the local level. Professor Raghuram Rajan, of The University of Chicago, calls the community “The Third Pillar,” and calls on us to practice “inspired localism,” where we engage with and energize communities to inspire real and lasting change. In this context, when community is engaged and energized, it will develop solutions to its healthcare problems.
Employers are often the biggest stakeholders in a community. They are dependent on the vitality and stability of the community in the same way that a community depends on them. Employers can take a good look at themselves and how well they are engaging with employees and their communities to empower them to take control of their healthcare and health expenses. To do so, they need an understanding of SDoH at each of their plants, offices, and other locations. Simply deploying libraries of information or wellness programming without understanding the root-level issues that might interfere with getting health and wellness mindshare is ineffective. For some companies, it might require a radical change of focus to recognize the value of potentially decentralizing some aspects of their benefits. Nevertheless, thinking this way will ensure that everyone will be better off.
 National Business Group on Health/Fidelity, https://www.businessgrouphealth.org/news/nbgh-news/press-releases/press-release-details/?ID=355
 CDC, https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm.
 Greenwald Research/EBRI, Consumer Engagement in Healthcare, Annual Survey. 2018 edition.
 Greenwald Research/EBRI, Consumer Engagement in Healthcare, Annual Survey. 2018 Edition.
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