Markian Hawryluk
The Bulletin

Oregon’s efforts to improve the health care of its residents are being undermined by the social factors that affect health outcomes, according to a new state health assessment issued last month by the Oregon Health Authority.

The assessment is conducted every five years and is used to set priorities for the state’s health improvement plan.

“What we know is that a person’s health is inextricably tied to educational outcomes, employment and wages, and access to affordable housing,” said Dr. Katrina Hedberg, state health officer and epidemiologist with the health authority’s Public Health Division. “These are all areas where we found Oregon fell short.”

According to the assessment, Oregon made progress in reducing opioid overdose deaths, HIV infections, teen pregnancies and smoking rates among adults and teens. But the state has lagged on measures such as graduate rates, housing affordability and food insecurity.

As a result, the state’s ranking in the United Health Foundation’s America’s Health Rankings fell from eighth in 2011 to 20th in 2017. Developed in partnership with the American Public Health Association, the rankings downgraded Oregon due to low high school graduation rates and poor performance on a number of measures related to vaccinations.

The state health assessment concluded that Oregon lags far behind other state in measures of the social determinants of health, areas such as housing, education and other social services that have been shown to have significant impact on a person’s health.

Those areas have typically been the purview of social service organizations rather than health entities.

But many in the health field have seen a growing understanding that health plans, hospitals and clinics won’t get ahead of the demand for health services unless more investment is made to keep people in healthier environments where they are less likely to get sick.

“I think that all vested interest parties are finally leaning in to the opportunity after years of conversation and have an implicit desire to get there,” said Dan Herman, CEO of 211info, a social services referral hub serving Oregon and Southwest Washington.

The organization has recently partnered with a technology firm, Unite Us, to provide care coordination for patients referred for social services and to report back to providers so they know their patients have received that help.

Herman said commitment to social determinants of health remains “pocketed” in Oregon, with some health care organizations more involved than others. That’s, in part, because of a lack of research to show that investing in social determinants will keep patients healthier and reduce costs.

“I think we’re all struggling with the metrics,” Herman said. “The data that support it, it is spotty.”

Jennifer Stoll, vice president of government affairs and public relations for OCHIN, a Portland-based nonprofit health care innovation center, agrees.

“Although the concept is one that everyone has bought into,” she says, “the data isn’t really there.”

OCHIN helps community health clinics implement electronic health records and those systems now have screening tools that allow clinics to capture data on social determinants during appointments. But groups need more information to really understand whether referring patients to social services actually works, and what interventions prevent people from getting sick and save money.

OCHIN and several other organizations have projects underway to answer that question, but early work has already provided some lessons. OCHIN found, for example, that screening tools only help if providers have an easy way to connect those patients with social services.

“If there’s not a next step, it actually leads to provider burnout,” Stoll said. “It’s just another thing they have to capture in the documentation process.”

The state health assessment relied on some of the standard data that health care organizations track, but state officials also held community meetings around the state to get public input.

“The biggest thing that came through to me,” Hedberg said, “is that while we can measure a lot of these diseases, conditions and outcomes, that social determinants are what we talk about.”

Oregonians, she said, talked about the impact of living in poverty, food insecurity and lack of education on their health. Those issues are likely to be addressed primarily through the regional coordinated care organizations, which provide care to people covered by Medicaid. The Oregon Health Authority is making social determinants of health an area of focus in the next round of contracting with those organizations.

In Central Oregon, the coordinated care organization is run by PacificSource Health Plans in conjunction with the Central Oregon Health Council. As part of the arrangement, PacificSource has agreed to cap its profits at 2 percent. The council can then reinvest any leftover funds into projects to help improve community health, including initiatives involving social determinants of health. This year, those include funding projects to improve housing options and kindergarten readiness.

“If people aren’t food insecure, if people aren’t homeless, if people have the proper social supports they need, if we’re doing a real good job at that, we will have very minimal disease,” said Donna Mills, the council’s executive director. “But we can’t ignore the management of disease because there are a number of people who are already sick.”

While many health organizations believe that addressing social determinants of health may pay off in the long run, finding the money to do so while still meeting annual budgetary goals has been difficult.

Some efforts may have more immediate payoffs in reducing emergency room visits or hospitalizations, but other initiative may take years to show any return on investment.

“This health care ship turns very slowly,” Mills said.

— Reporter: 541-633-2162,