For physicians, addressing social determinants of health can be difficult because they are set in motion long before a patient arrives for a visit and can undermine the best of medications and treatments.
“As physicians, we are trained in how to figure out and treat challenges in health for our patients,” said Waco family physician Tim Martindale, MD. “But sometimes it is the simple, practical things that limit our patients’ health. And [for most older physicians] there was no class on this in medical school.”
There’s no-one-size-fits-all way to address any social determinant of health, says Sandra Frasser, MD, a pediatrician who works at People’s Community Clinic in Austin. Simple-sounding questions from patients like, “Where can I get affordable food?” and “How can I pay for my prescription?” frequently prompt a complicated network of answers. The size and scope of those answers can change completely from patient to patient based on their income, housing situation, family size, immigration status, geographic location, whether they are insured, and other factors.
Websites that locate services can help both practices and patients identify the nearest assistance available. But even then, social services can be hard for patients to find or reach, especially in low-income and rural parts of Texas.
The availability of community services constantly shifts and changes, says Ricardo Garay, program manager for community engagement and health equity at the department of population health at The University of Texas at Austin Dell Medical School. Partnering with a local community health worker who keeps track of those changes can save physicians and their staffs time and money.
“A properly trained community health worker is very adept at knowing how to make [connections between patients and the appropriate services],” he said. “Community health workers are professionals who have to be paid, but they’ll sometimes do this work pro bono because they’re so invested in the health of their community.”
Physicians can make similar partnerships with lawyers and social workers to help their patients overcome social determinants.
“It’s easy to forget health has to be a collaborative effort: not just the patient and me, but also the resources of our community communicating and working together,” Dr. Martindale said.
Here are some practice tips for how physicians can address some of the most important social determinants.
Food insecurity
In Texas, 14% – one in seven – experience food insecurity, or lack of consistent access to enough food, according to Feeding Texas, the state’s largest hunger-relief organization. That’s 1.4 million Texas households and more than 4 million individuals. Texas is one of 15 states with a higher food insecurity rate than the national average, the organization says.
“[Food insecurity] is probably the biggest challenge for our families,” Dr. Frasser said.
Food assistance programs, such as the National School Lunch Program; the Women, Infants and Children program; and the Supplemental Nutrition Assistance Program help address food insecurity, but many families don’t know these benefits exist or are unsure how to apply, Dr. Frasser says.
Physician practices can help get them through that process, she says. So can social workers and community health workers.
Many immigrants don’t qualify for these programs, which means they must rely on one of Texas’ 21 food banks or local food pantries to obtain food when it’s running short. Medical practices frequently work with them as well to ensure patients have food.
“[Before the pandemic] we hosted a free lunch program in our community room for school-age children and their parents during the summer, to help make sure children were fed when school was out,” Dr. Frasser said. “After we saw the patient we would remind them, ‘Don’t forget to stop by downstairs and get a free lunch.’”
Food deserts also are a problem in Texas. The U.S. Department of Agriculture defines them as low-income areas where a significant number of residents live more than one mile in urban areas or more than 10 miles in rural areas from a supermarket, big-box supercenter, or other healthy grocery store.
Texas also has the greatest number of people living in food deserts, or “low-income and low-access (LILA)” areas – about 5 million, according to Feeding Texas. Texas ranks sixth in the nation for the highest percentage of its population living in LILA areas, at 20%.
In many cases, people who live in food deserts don’t understand how they can make higher-priced nutritious food work with their family’s budget, Dr. Frasser says. People’s Community Clinic offered cooking classes to help show them.
“The parents would sign up for a program and they would get all the food provided for those cooking classes to have and take home,” she said.
Cost of appointments
Physicians routinely hear from patients that prescriptions are too expensive, says Emily Briggs, MD, a New Braunfels family physician who sits on the Texas Medical Association’s Select Committee on Medicaid, CHIP, and the Uninsured.
“That is a factor in everyday patient care,” she said.
Most physicians first look at generic and older medications because newer ones still under patent with the pharmaceutical companies tend to be the most expensive, she says.
“But for some patients, even $5 is too much for a prescription,” she said.
So, physicians employ a variety of other tactics to bring prices down, Dr. Martindale says. They include:
- Enlisting a specialist’s assistance in appealing for insurance companies and programs to pay for the prescription because a specialist’s voice sometimes carries more weight;
- Ordering pills that are twice the size needed and having the patient split them;
- Having the patient look into wholesale pharmacies or Canadian resources;
- Prescribing 90-day supplies when there is a price break for volume;
- Giving patients sample medications; and
- Getting patients enrolled in a prescription assistance program in which drug companies provide medications at no or very low cost to uninsured families.
While samples can be helpful, they should be thought of only as a stopgap measure, Dr. Briggs says. Pharmaceutical companies provide samples to get patients used to those medications. Once the samples run out, patients may be stuck with either discontinuing the medication or paying for a prescription that’s difficult to afford, she says.
Patients frequently must shop around to find the cheapest pharmacy available, Dr. Briggs says. One of the best ways to do that is to use a prescription discount app like GoodRx, she says.
“I’ve found that apps like that make the prescription even less expensive than the insurance [coverage] will be at any pharmacy,” she said.
Transportation to appointments
In 2017, 5.8 million people in the U.S. (1.8%) delayed medical care because they did not have transportation, according to a survey published in the June 2020 American Journal of Public Health.
“We found that Hispanic people, those living below the poverty threshold, Medicaid recipients, and people with a functional limitation had greater odds of reporting a transportation barrier after we controlled for other sociodemographic and health characteristics,” the survey said.
Transportation in Texas usually means cars. Mass transit is typically found only in large cities and frequently moves too slow to be of much use to patients. For those who qualify, Medicaid pays for car-service rides to and from medical appointments. In the past, patients had to schedule a ride 48 hours before their physician appointment. This made the service impossible to use for people who needed an appointment the same day, Dr. Frasser says.
House Bill 1576, signed by the governor in 2019 with support from the Texas Medical Association, now allows patients in Medicaid and some other state programs to schedule a ride the day of their appointment.
However, the transportation sometimes does not arrive at the scheduled time so patients cannot make it to their appointments, Dr. Frasser says. Also, many low-income patients are immigrants who cannot apply for this service.
Rideshare services like Uber and Lyft offer services that allow medical facilities to pay the cost of a ride for patients. When patients pay for those services, the rides can be inexpensive over short distances, Dr. Briggs says. But even a cheap ride often can be too much for some families, Dr. Briggs says.
“If $5 is too much to spend for a prescription, $5 is too much to spend on getting a ride to a doctor’s office,” she said.
A local church or faith community may provide the best hope of finding assistance with transportation – as well as other basic services like food and housing, Dr. Briggs says.
“We encourage patients who belong to a spiritual community to ask what services they might offer,” she said. “Because many of our spiritual communities have volunteers who are just looking for an opportunity to help out.”
In some ways, lack of transportation has become less of a problem because of COVID-19, Dr. Briggs says. The pandemic freed up physician offices to use telemedicine, which allows patients to avoid the cost and hassle of transportation. However, access to technology can present other barriers to care, she says.
Access to technology
Accessing telemedicine remains difficult for some patients. A survey of 25 large group practices conducted by TMA’s Council on Health Care Quality found the biggest challenges to telemedicine were patients’ lack of technical literacy (72%), problems with internet connections (68%), and lack of access to a telemedicine-compatible device (60%). (See “The Telehealth Initiative,” July 2021 Texas Medicine, pages 20-25, www.texmed.org/TheTelehealthInitiative.)
Getting around these requires providing patient education and, when possible, devices. TMA also provides materials that can help, like a quick reference guide that spells out what patients will need during a telemedicine visit. (See “Resources,” page 28.) Physicians also can provide introductory visits to patients that allow them to do a dry run with a staff member before their visit.
Overcoming the lack of technology is tougher, Dr. Briggs says. Large practices can loan out tablets or other internet-connected devices to patients. Even then, some patients need technical help to work the devices. Her practice looked into the cost of loaning tablets and found it too expensive.
When all else fails, “a lot of people are using their phones because they don’t have a computer,” Dr. Frasser says.
But that also poses problems. Telehealth platforms often drop calls if other apps are running or if a patient has a poor internet connection. And if the physician needs to see something like a rash or a wound, that means the patient must email photos – a potentially time-consuming process.
“There are definitely a lot of hiccups there,” she said.
Cost of visits
Patients who can’t pay for prescriptions and transportation almost certainly have difficulty paying for physician visits. That’s uncomfortable for the doctors determined to treat them, Dr. Briggs says.
“As a person who is the president and owner of my practice, I very much tread a fine line of demanding that my patients obtain equal care, no matter what their social determinants of health be, and balancing that with my office manager saying we need to keep the doors open,” she said. “It’s a very difficult line to walk.”
Most physician offices use a sliding fee scale based on a patient’s ability to pay. Many allow patients to set up payment plans and encourage quick payment by giving prompt payment discounts.
But there’s little flexibility for physicians in private practice who take Medicare patients, Dr. Martindale cautions. That agency won’t allow him to charge rates any lower than the lowest rates Medicare pays.
“I often offer the lowest rates I legally can, give patients discounts on injections, pass on the … discount price I can get from labs for labs I draw, and make sure I do everything the patient needs in one visit instead of making them come back for additional care.”
Physicians who are employed usually have an even harder time giving patients discounts because their rates are dictated by their employers and can include facility fees, he says. Many low-income patients are charged the full amount but then have the debt forgiven after filling out paperwork showing need. That process can affect their credit rating, he says.
Medicaid covers many of these patients, so they may just need help getting enrolled, Dr. Briggs says. Sometimes, local programs also can help offset or cover the cost.
“In New Braunfels, we have an indigent care program that covers visits like Medicaid that is specifically for people who don’t qualify for Medicaid but don’t have insurance,” she said.
Language and literacy
One of the best ways to get around language barriers is to have bilingual written instructions. But that doesn’t always work, says Tyler pediatrician Valerie Smith, MD.
This was highlighted for her by a young Spanish-speaking mother who was giving formula to her baby for the first time. The baby kept losing weight, despite the formula, and it turned out she was diluting the formula too much because she didn’t understand the written instructions.
“She had instructions in Spanish, but she could not read in Spanish,” Dr. Smith said.
Accurate communication is vital for personal health literacy. Texas medical offices routinely hire Spanish-speaking staff as medical translators. For instance, Dr. Frasser, who is bilingual, has no problem talking to patients in Spanish.
But her clinic sees patients who speak many other languages, including Vietnamese and Burmese, she says. In those cases, she uses translation services. Often the translators are excellent, but the quality can be uneven.
Regardless of the language, physicians should work to boil down medical instructions to an easily understood format, Dr. Martindale says.
In doing so, they should not overestimate patients’ health literacy, which is defined as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others,” according to the U.S. Department of Health and Human Services.
The COVID-19 pandemic has highlighted the need for improved health literacy, John Hellerstedt, MD, commissioner of the Texas Department of State Health Services, has emphasized. (See “A Healthy Knowledge,” May 2021 Texas Medicine, pages 32-34, www. texmed.org/HealthLiteracy2021.) For instance, despite widespread education efforts, many people never understood the need for face masks, physical distancing, hand washing, and other nonpharmaceutical interventions, he says.
Physicians can simplify written instructions by following plain-language guidelines and using pictures or drawings instead of words for printed instructions.
For verbal instructions, they can use the “teach-back” technique, in which the patient repeats back the physician’s instructions in the patient’s own words, Dr. Martindale says. And physicians should not be shy about repeating instructions to make sure they sink in.
“One of my mottos is ‘redundancy builds clarity,’” he said. “So I don’t mind repeating things three to five times in a visit, maybe with different words and examples, to be sure the patient understands what they are facing, and what is our strategy.”
Tex Med. 2021;117(9):24-29
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